BOSTON
MEDICAL LIBRARY
8 THE FENWAY
:
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4
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7
THE
MEDICAL RECORD
A Weekly Fournal of Medicine and Surgery
EDITED BY
GEORGE F. SHRADY, A.M., M.D.
| SURGEON TO ST. FRANCIS HOSPITAL, NEW YORK; CONSULTING SURGEON TO THE NEW YORK CANCER HOSPITAL, AND TO THE HOS-
PITALS OF THE HEALTH DEPARTMENT OF THE CITY OF NEW YORK
Wolume 36
JULY 6, 1889 — DECEMBER 28, 1889
NEW YORK
WILLIAM WOOD & COMPANY
= 1889
Éra
1S] til 6 1
.-ceame so
DA ASG
N a “ye
Trow’s
PRINTING AND BOOKBINDING COMPANY,
201-213 Zast 12th Street,
New YORK.
LIST OF CONTRIBUTORS TO VOL. XXXVI.
ABBOTT, Dr. GEORGE E., New York.
ACKERMAN, Mr. G. K., New York.
ALLEN, Dr. CHARLES W., New York.
ALLEN, Dr. DuDLEy P., Cleveland, O.
ALLPORT, Dr. FRANK, Minnesota.
ANDERSON, Dr. J. HARTLEY, Pitts-
burg, Pa.
ANDERSON, Dr. WILLIAM, Brookiyn,
| N. Y.
| AuLTz, Dr. A. E., Richmond, Ky.
RasBcock, Dr. Joun Lorp, St. Louis,
Mo.
- Baroy, Dr. J. M., Philadelphia, Pa.
Baran, Dr. J., New York.
Barclay, Dr. Rosert, St. Louis, Mo.
; Barucn, Dr. S., New York.
| Basuorg, Dr. Harvey B., West Fair-
view, Pa.
Beane, Dr. Frank Duprey, New
York.
Beck, Dr. W. M., Kensington, Kan.
BELT, Dr. W. A., Kenton, O.
BENJAMIN, Dr. D., Camden, N. J.
_ Berc, Dr. Henry W., New York.
Bıuincs, Dr. Joun S., U. S. Army.
BLACKWELL, Dr. E., New York.
BoERSTLER, Dr. S. W., Lancaster, O.
' Bocert, Dr. E. S., U. S. Navy.
' Boone, Dr. H. W., Shanghai, China.
Boone, Dr. J. J., Mount Victory, O.
Bow gs, Dr. F. J., New York.
BRaDLEy, Dr. ALFRED E., U. S. Army.
sia Dr. N. Roe, Philadelphia,
a.
BREWER, Dr. GEORGE E., New York.
Bropir, Dr. WiLL1aM, Detroit, Mich.
BROTHERS, Dr. A., New York.
Brown, Dr. Moreau R., Chicago, Ill.
BROWNING, Dr. A. G., Maysville, Ky.
BryanT, Dr. JosEPH D., New York.
Bucuman, Dr. A. P., Fort Wayne, Ind.
Buck, Dr. ALBERT H., New York.
Butt, Dr. CHARLES STEDMAN, New
York.
BuTLer, Dr. C., Shepherdstown, W.
Va.
Butter, Dr. F. W. P., Edgefield, S. C.
een ee n
- m
amaa e
CAMMANN, Dr. D. M., New York.
CANFIELD, Dr. WILLIAM BUCKINGHAM,
Baltimore, Md.
CARPENTER, Dr. A. B., Cleveland, O.
CARREAU, Dr. JOSEPH S., New York.
CHAPMAN, Dr. J. MILNE, Inverness,
Scotland.
CHEESMAN, Dr. T. M., New York.
CHETWOOD, Dr. CHARLES H., New
York.
CLAIBORNE, Dr. J. HERBERT, Jr.,
New York.
Cor, Dr. Henry C., New York.
‘Couns, Dr. A. N., Detroit, Mich.
Couns, Dr. G. M., Tipton, Ind.
Co.uins, Dr. JosepH, New York.
Coox, Dr. GEORGE J., Indianapolis,
~ Ind.
COPELAND, Dr. W. P., Eufaula, Ala.
CroTHERS, Dr. T. D., Hartford,
Conn.
Curtis, Dr. B. FARQUHAR, New
York.
Dana, Dr. CHARLES L., New York.
Davis, Dr. N. S. Jr., Chicago, Ill.
DawesaRy, Dr. RoBERT H. M., New
York.
DeBecx, Dr. Davin, Cincinnati, O.
DELAFIELD, Dr. Francis, New York.
DENNIS, Dr. FREDERIC S., New York.
Dotson, Dr. J. S., Hornellsville, N. Y.
Draper, Dr. WILLIAM H., New York.
DuKEMAN, Dr. WILLIAM H., Los An-
geles, Cal.
Duxes, Dr. W. CLAYTON, Memphis
Tenn.
DuNHAM, Dr. Epwarp K., New
York.
EARL, Dr. Georce H., Wareham,
Mass.
EDEBOHLS,
York.
Epson, Dr. Cyrus, New York.
Ecan, Dr. P. R., U. S. Army.
Erus, Dr. R. Peekskill, N. Y.
Ery, Dr. JOHN S., New York.
EmMET, Dr. Tuomas Abppis, New
York.
Dr. GEORGE M., New
FigeLp, Dr. MATTHEW D., New York.
Forest, Dr. W. E., New York.
FowLER, Dr. GEORGE R., Brooklyn,
N. Y.
FREDIGKF, Dr. CHARLES C., Chicago,
Gipsons, Dr. RicHARD H., Scranton,
Pa.
GIBNEY, Dr. V. P., New York.
GILLETTE, Dr. A. A., Westernville,
N. Y.
GoLDping, Dr. J. F., Brooklyn, N. Y.
Gott, Dr. WILLIAM A., Viroqua, Wis.
GREENE, Dr. J. L., Red Cliff, Col.
GRIFFIN, Dr. E. HARRISON, New
York. l
Grove, Dr. B. F., Baltimore, Md.
GRUENING, Dr. E., New York.
Hart, Dr. B. F., Sweet Springs, Mo.
Hawes, Dr. Joun B., Reichenberg,
Bohemia.
Hay, Dr. C. M., Morris Plains, N. J. -
Heap, Dr. G. P. po
Henry, Dr. Morris H., New York.
Hircucock, Dr. De Witt, Long Isl-
and City, N. Y.
Hosss, Dr. A. G., Atlanta, Ga.
Hopkins, Dr. Howarp H., New Mar-
ket, Md.
Jackson, Dr. J. HuGuuincs, London,
England.
Jacosi, Dr. A, New York.
Jupxins, Dr. WILuIaAM, Cincinnati, O.
KAMMERER, Dr. FREDERIC, New York.
KeLsey, Dr. CHARLES B., New York.
Kemper, Dr. G. W. H., Muncie, Ind.
KENNEDY, Dr. Tuomas C., Shelby-
ville, Ind.
Kme, Dr. J. W., Fort Dodge, Ia.
Kinc, Dr. CLARENCE, Machias, N. Y.
Kirk, Dr. T. T., Pittsburg, Pa.:
KREIDER, Dr. GEORGE N., Springfield,
Ill.
Lanc, Dr. CHARLES L., New York.
LATHAM, Mr. ‘THomas, New York.
Leer, Dr. RosBERT, London.
LEVISEUR, Dr. FREDERICK J., New
York.
Lewis, Dr. BRANSFORD, St. Louis, Mo.
Lewis, Dr. DANIEL, New York.
Liceaca, Dr. E., Mexico.
LISTER, Sir JOSEPH, London, England.
Loomis, Dr. Henry P., New York.
Lowman, Dr. WILLIAM R., Orange-.!
burg, S. C. tere
Lypston, Dr. G. FRANK, Chic<fsi& 6}
ur-ceame so
iv
CONTRIBUTORS TO VOL. XXXVI.
McADir, Mr. ALEXANDER, New York.
McCaskey, Dr. G. W., Fort Wayne,
Ind.
McCoy, Dr. Juan W., New York.
McLean, Dr. MALcotm, New York.
McMurtry, Dr. L. S., Danville, Ky.
MACPHATTER, Dr. NEIL, Denver, Col.
Mayer, Dr. NATHAN, Hartford, Conn.
MEIcs, Dr. ARTHUR V., Philadelphia,
Pa.
MENDELSON, Dr. WALTER, New York.
MERRILL, Dr. O. H., Corinna, Me.
MELTZER, Dr. S. J., New York.
Meyers, Dr. S. Oscar, Mount Ver-
non, N. Y.
MILLER, Dr. JOHN A., Salt Lake City,
Utah.
MITCHELL, Dr. S., Jr., Hornellsville,
N. Y.
Morcan, Dr. Joun C., Philadelphia,
Pa.
Morcan, Dr. W. F., Leavenworth,
Kan. :
Morton, Dr. DANIEL, Missouri.
NaGLE, Dr. Joun T., New York.
NELSON, Dr. WOLFRED, Arkansas.
Newcome, Dr. JAMES E., New York.
NEWTON, Dr. RICHARD COLE, Mont-
clair, N. J.
NICOLSON, Dr. WILLIAM PERRIN, At-
lanta, Ga.
Nites, Dr. H. D., Salt Lake City,
Utah.
Nose, Dr. GEORGE H., Atlanta, Ga.
O’Dwyer, Dr. JosePpH, New York.
O’Han ton, Dr. PuiLir F., New York.
Oris, Dr. FESSENDEN N., New York.
Otis, Dr. WILLIAM K., New York.
PATTON, Dr. JosePH M., Chicago, Ill.
PARKER, Dr. WM. THORNTON, New-
port, R. I.
PETERSON, Dr. FREDERICK, New York.
PoLK, Dr. WILLIAM MECKLINBURG,
New York.
PorcHER, Dr. F. PEYRE, Charleston,
S. C.
Post, Dr. SARAH E., New York.
POTTER, Dr. THEODORE, Indianapolis,
Ind.
RACHEL, Dr. GEORGE W., New York.
RANDOLPH, Dr. Rosert L., Balti-
more, Md.
Reep, Dr. BOARDMAN, Atlantic City,
N. J.
Rey, Dr. J. H., Fair Haven, Vt.
REMINGTON, Dr. FREDERICK, Roches-
ter, N. Y.
Rice, Dr. E. P., Chicago, Ill.
RICHARDSON, Dr. CHARLES H., New
York.
Ripon, Dr. Jonn, New York.
RIvey, Mr. Henry A., New York.
RosBerts, Dr. Joun B., Philadelphia,
Pa.
RopENHURST, Dr. Dewitt C., Phila-
delphia, N. Y.
ROOSEVELT, Dr. J. WEST, New York.
Roses, Dr. A., New York.
RuMBOLD, Dr. THomas F., St. Louis,
Mo.
Sacus, Dr. B., New York.
Scuaprs, Dr. Joun C., Brooklyn,
N. Y.
Searcy, Dr. J. T., Tuscaloosa, Ala.
SHIMER, Dr. Henry, Mount Carroll,
Ill.
SHRADY, Dr. GEORGE F., New York.
SMITH, Dr. ANDREW H., New York.
SmiTH, Dr. Howarp, Paris, France.
SMITH, Dr. J. R. N., Milltown, Me.
Snow, Dr. Irvinc M., Buffalo, N. Y.
STARK, Dr. HENRY S., New York.
STEDMAN, Dr. THOMAS L., New York..
STEVENS, Dr. GEORGE T., New York.
STOCKTON, Dr. CHARLES G., Buffalo,
N. Y.
Stout, Dr. Henry R., Jacksonville,
Fla.
STRAUGHN, Dr. J. H., Lexington, Mo.
Stupy, Dr. JOSEPH N., Cambridge
City, Ind.
TarBox, Dr. O. C., Princeton, Mich.
TEALE, Mr. T. Pripcin, Leeds, Eng-
Jand.
Tuomas, Dr. J. D., Pittsburg, Pa.
THOMPSON, Dr. James B., Rathburee,
Siam.
THOMPSON,
York.
Titus, Dr. E. C., New York.
TuRNER, Dr. S. S., U. S. Army.
Dr. W. Giman, New.
UpELL, Dr. P. G., Spencerport, N. Y.
Van Dyxe, Dr. F. W., Grant’s Pass,
Oregon.
WALKER, Dr. Henry F., New York.
Wattace, Dr. T. C., Cambridge,
N. Y.
WASHBURN, Dr. W., New York.
Watkins, Dr. T. J., Chicago, Ill.
WEBER, Dr. LEONARD, New York.
Weeks, Dr. Jonn E., New York.
aes Cs ae GEORGE T., Keyport,
WE cu, Dr. WiLLiam H., Baltimore,
WENDT, Dr. Epmunp C., New York.
WETHERBY, Dr. B. J., Arlington,
Kan.
Wiixinson, Dr. J. R., Greenville,
S. C.
WiıLuiamĮs, Dr. CHarLes E., Houlton
Me.
Wiliams, Dr. HAMILTON, Brooklyn,
N. Y.
Wiliams, Dr. W. W., Wichita, Kan.
WricHT, Dr. J. W., Bridgeport,
Conn.
Wraicnt, Dr. Jonn W., Columbus, O.
WRIGHT, Dr. JONATHAN, Brooklyn,
N. Y.
WYETH, Dr. Joun A., New York.
Younc, Dr. James K., Philadelphia,
Pa.
Societies from which Reports have
been received.
AMERICAN ASSOCIATION OF OBSTE-
TRICIANS AND GYNECOLOGISTS.
AMERICAN DERMATOLOGICAL ASSOCIA-
TION.
AMERICAN MEDICAL ASSOCIATION.
AMERICAN NEUROLOGICAL ASSOCIA-
TION.
AMERICAN OPHTHALMOLOGICAL SOCI-
ETY.
AMERICAN ORTHOPEDIC ASSOCIATION.
AMERICAN OTOLOGICAL SOCIETY.
AMERICAN PADIATRIC SOCIETY.
AMERICAN PuBLiC HEALTH Associ-
ATION.
AMERICAN RHINOLOGICAL ASSOCIA-
TION.
ASSOCIATION OF AMERICAN PHYSI-
CIANS.
BRITISH MEDICAL ASSOCIATION.
CANADIAN MEDICAL ASSOCIATION.
GERMAN CONGRESS OF INTERNAL
MEDICINE.
INTERNATIONAL CONGRESS UF DERMA-
TOLOGY AND SYPHILOGRAPHY.
KENTUCKY STATE MEDICAL SOCIETY.
MEDICAL SOCIETY OF THE COUNTY OF
New YORK.
MEDICAL SOCIETY OF VIRGINIA.
MEDICAL SOCIETY OF WEST VIRGINIA.
MISSISSIPPI VALLEY MEDICAL ASSOCI-
ATION.
NATIONAL ACADEMY OF SCIENCES.
NEW JERSEY SANITARY ASSOCIATION.
New YORK ACADEMY OF MEDICINE.
New YORK NEUROLOGICAL SOCIETY.
New YORK STATE MEDICAL ASSOCIA-
TION.
NORTHERN Kansas MEDICAL Soci-
ETY.
Nova Scotia MEDICAL SOCIETY.
ONTARIO MEDICAL ASSOCIATION.
PRACTITIONERS’ SOCIETY OF NEW
YORK.
SOUTHERN SURGICAL AND GYNECO-
LOGICAL ASSOCIATION.
TRI-STATE MEDICAL ASSOCIATION.
WASHINGTON STATE MEDICAL SOCI-
ETY.
‘The Medical Record
A Weekly Journal of Medicine and Surgery
‘Vol. 36, No. 1
Original Articles,
THE THERAPEUTIC VALUE OF OXYGEN IN-
HALATION, WITH EXHIBITION OF ANIMALS
UNDER HIGH PRESSURE OF OXYGEN.’
By W. GILMAN THOMPSON, M.D..
PROFESSOR OF PHYSIOLOGY IN THE NEW YORK UNIVERSITY MEDICAL COLLEGE ;
PHYSICIAN TO THE PRESBYTERIAN AND NEW YORK HOSPITALS.
Mr. PRESIDENT AND FELLOWS OF THE ACADEMY: The
subject of my paper this evening is: “ The Therapeutic
Value of Oxygen Inhalation,” with experimental de-
monstration of the effects upon animals of continued
inhalation of oxygen under very high pressures.
With regard to the therapeutic use of oxygen, I present
nothing especially new ; but I have been impressed by the
fact that this agent, which is by many considered invalua-
ble, by other equally competent observers is rated as
worthless, und by others, again, is employed from time to
time in an indefinite way, with but little thought as to the
real nature of its effects. For example, it is given for
anzemia for five or ten minutes, two to three times a day,
greatly diluted, and it is given pure for consecutive hours
in dyspncea arising from very diverse causes.
It is the object of my thesis to discuss briefly the
physical and physiological problems associated with
oxygen inhalation, and to suggest certain points for dis-
cussion which may enable us to formulate more definite
views than at present prevail.
The experiments to be directly recounted are as yet in-
complete, and the conclusions which they beget may pos-
sibly require modification in the light of additional trial.
The fundamental facts bearing upon the problem of
absorption of oxygen gas are familiar. I will, therefore,
merely sum them as concisely as possible.
1. The normal atmospheric pressure is (practically)
15 pounds to the square inch.
2. ‘The gases, oxygen and nitrogen, exist in the atmos-
phere, each under a “partial pressure” by which the
oxygen represents 3 pounds, and the nitrogen 12
pounds, corresponding to their normal admixture in the
air in the proportion (in round numbers) of one part of
oxygen to four of nitrogen. If oxygen be allowed to
completely replace the nitrogen of the air, it, of course,
exerts the entire pressure of 15 pounds.
The question arises, Does such an atmosphere, namely,
15 pounds to the square inch of pure oxygen, really cause
more oxygen to be absorbed by the blood? In answer to
this question, the following statements have long been ac-
cepted by physiologists as positively proven :
1. The hemoglobin of the red blood-disks has a re-
markable affinity for oxygen.
2. In addition to the oxygen, which forms a fixed part of
its composition, hæmoglobin carries a varying quantity of
“ respiratory oxygen ” in loose chemical combination, which
is readily absorbed froin the air in the lungs, and which is
parted with in equal readiness in the systemic capillaries.
3. The blood, while passing through the lungs under
normal conditions, subjected to a pressure of one atmos-
phere of air, becomes very nearly—fully |4— saturated
with respiratory oxygen.
4.-The plasma carries but very little oxygen—not over
two per cent. by volume.
i Read before the New York Academy of Medicine, May 16, 1889.
New Vom Jury 6, 5, 1889
Whole No. 974
———— — . $ N eager Sy _—_——— —-
5. The saan air, in saturating haenoeistin with
oxygen, forming oxy-hzemoglobin, loses (in round num.
bers) 5 parts of oxygen out of the 21 parts per roo
which it contains, returning, therefore, 16 parts of unused
oxygen by exhalation. In breathing pure oxygen, will
the hzmoglobin still appropriate but 5 parts of that gas,
leaving 95 parts per roo unused? It will; therefore, if
more oxygen is taken into the blood when the oxygen ex-
ists under a total pressure of 15 pounds, it must enter
the plasma, and not the hæmoglobin.
Reduced hæmoglobin absorbs oxygen a little quicker
in pure oxygen gas than in air; but the difference is in-
considerable, and the quantity absorbed is ultimately the
same in experiments outside of the body.
Can the blood plasma absorb more oxygen in an atmo-
sphere of pure oxygen exerting 15 pounds of pressure ?
Let us for a moment admit that it may. Obviously, one
of two results must occur: first, the additional oxygen
may remain in the plasma so long as the tension of oxygen
inhaled is maintained at the increased rate, producing no
special effect, and it would be exhaled again as soon as
the tension of the inhaled oxygen is lowered to the nor-
mal ; in the same manner that nitrogen is known to be ab-
sorbed in small amount (two per cent.) by the plasma, to
be eliminated again unaltered.
Or, secondly, the increased amount of oxygen absorbed
might oecasion greater oxidation in the tissues, with in-
creased metaboiism, represented by larger quantities of
CO., H,,, and other products.
Very careful experiments have been made to determine
whether these waste materials are increased by continued in-
halation of pure oxygen at 15 pounds of pressure, and it has
been conclusively shown that they are not increased to any
appreciable extent. Moreover, it has been proved that the
blood plasma really absorbs but very little additional oxygen
under any pressures which are compatible with mainte-
nance of life. Bert. in his classical work upon “ La Pres
sion Barométrique,” has shown that at 1 atmosphere the
blood absorbs 20 volumes per cent. of oxygen; at 2 atmcs-
pheres it absorbs 0.9 volume per cent. additional; at 3 at-
mospheres, 0.7 volume per cent.; at 8 atmospheres only
0.1 volume per cent.; and the total additional oxygen ab-
sorbed under a pressure of ro atmospheres amounts to
only 3.4 volumes per. cent.
All experiments upon blood removed from the body
unite in demonstrating that in pure oxygen, under one at-
mosphere of pressure, the blood takes up scarcely any more
of the gas than it appropriates from common air. Quir-
quand found that in the dog arterial blood contained only
1 volume per cent. more oxygen after inhaling pure oxygen
at a pressure of one atmosphere, and venous blood gained
24 volumes per cent. of oxygen.
Is it possible that the simple problems of absorption of
oxygen by the blood, when shaken in a retort, are modified
when the gas has to reach the plasma through the medium
of the lungs? Let us consider the latter condition.
‘The amount of any gas absorbed by a liquid through a
membrane depends upon: 1, the specific nature of the
gas and of the liquid ; 2, the temperature ; 3, the density
of the membrane ; 4, the gas-pressure.
It is possible that slight variations in the composition of
the plasma may influence to a small degree the amount of
oxygen absorbed. The change in temperature of oxygen on
entering the lungs, even under compression, 1s not sufficier ^2
to materially affect the rate of absorption. ‘he density 6}
the membranes, namely, the epithelium of the air-ceame so
2 THE MEDICAL RECORD. [July 6, 1889
especially the walls of the pulmonary capillaries, mav con- | comfort. An interesting fact has been demonstrated by
, Bert, that, under an air-pump, animals can withstand a
ceivably vary with the amount of blood present, and influ
ence the gas absorption.
In some of the older text-books of physiology the state- |
ment is made that animals cannot live in an atmosphere of
pure oxygen, because it rapidly burns up their tissues as it
burns a candle; ¢.¢., their greatly increased metabolism
causes rapid tissue waste, convulsions, and death. ‘This
is a still prevalent popular fallacy. Later experimenters
have claimed that the convulsions, etc., were due to re-
tention of CO, and other waste products (possibly vola-
tile ptomaines), which are reinhaled. Dr. Andrew H.
Smith showed, by a series of most instructive and exhaustive
experiments, made in 1869-70, that so long as the exhaled
CO, and nitrogenous waste are removed, animals live for
many hours in pure oxygen under ordinary atmospheric
pressure, without any symptoms or appreciable change.
soyi pea TTT ty
-a
P
JUN
itis] {II |
f
I have repeated many s'milar expe:iments, and demon-
strated that the same is true wit’) regard to inhalation of
oxygen under pressures not exceeding 14 or 2 atmospheres.
Beyond this pressure the mechanical effects upon the cir-
culation and the interference with proper gas diffusion in
the lungs become manifest late or soon, according to the
degree of pressure employed.
The only effects experienced by those in health who have
inhaled oxygen freely are vague and inconstant, and many
of these effects may be due to the gas not being absolutely
pure. Some describe a sensation of freedom about the
chest, as if respiration were easier, or they speak of a
feeling of warmth beneath the sternum, or of coolness,
slight vertigo, warm hands and feet. More blood flows to
the surface of the body sometimes, and there may be slight
formication. Some incline to drowsiness, others to increased
muscular activity. ‘There is often increased appetite and
consequent gain in weight. The pulse may or may not
be accelerated. The temperature is usually unaltered.
Uric acid is said to be diminished (Kohlmann and Eck-
ard). I have sometimes noticed an increase in the rate
of breathing while inhaling pure oxygen, but this has always
been due to voluntary suction effort on the part of the
patient, and it can be easily avoided by giving proper in-
s ruction. |
Several deep voluntary inspirations of oxygen produce
condition known as apnoea, in which the breath can be
or several seconds longer than usual without dis-
|
|
f ‘
J TR || |e) ae
-
|
greater reduction of pressure in an atmosphere of pure
rarefied oxygen than in an atmosphere of rarefied air.
Quinquand describes uniform reduction of the pulse in
| animals inhaling pure oxygen amounting to from 10 to 15
beats, and a corresponding reduction of 4 or 5 respira-
tions, and 4—1° C. reduction in temperature. Bert found
increased sugar in the blood of animals kept under in-
creased oxygen pressure. From the foregoing summary
of the physics of oxygen absorption it appears that, under
given conditions of healthful circulation and respiration,
but very little additional oxygen can be made to enter
the blood by any degree of pressure short of that which
mechanically interferes with those functions. In con-
firmation of this statement, and before considering the
effect of oxygen upon abnormal circulation and respir-
ation, I will cite a few of the
experiments recently made with
the apparatus here presented.
The apparatus, which was
made for me by the Delamater
Iron Works in this city, is of
very simple construction. It
consists of an iron locomotive
cylinder with one removable
head. A window of -inch
plate-glass is inserted jn either
end of the cylinder, so that the
animals can be constantly ob
served. A steam-gauge records
\ the pressure of the gas, which
|| is admitted through a valve con-
| nected by a strong tube with an
/ ordinary oxygen cylinder, pur-
chased from the oxygen manu-
facturer. The oxygen in these
cylinders is sold unde: a press-
ure of 225 pounds or more,
and as the ċylinders are approxi-
mately the size of my own tank
(36,700 c.c.) I readily get a
pressure of roo pounds by
simply opening the valve. The
tank has an exhaust valve for
quickly releasing the pressure.
It is painted white within, and
furnished with an electric light.
A wire grating is arranged to keep the animal off the
floor and allow room for urine, and for materials used
to absorb waste products. Food can be put in, and the
animal may be left comfortable for any desired period.
The exhalations may be tested at any time by collecting a
little of the air from the exhaust valve. ‘The removable
head is so large that a good-sized dog can be put in through
the opening. It is screwed on by many bolts, and leakage
is prevented by rubber packing and red-lead. The ap-
paratus is practically air-tight, for all the pressures at
which I have used it. The character of the breathing,
tracheal rales, cries, etc., can be very well auscultated
through the iron wall of the tank and dense air within.
(Many interesting details of the following experiments
are omitte1 for the sake of brevity.)
Experiment 1.—\wo pigeons and a monkey were to-
gether placed in the tank and oxygen was added, 5 pounds
at a time, at intervals of 5 minutes, until 30 pounds were
reached, z.e., 2 atmospheres of oxygen + 1 of air already
present—three atmospheres in all. Up to this pressure
no effect at all was produced except that the pigeons
seemed drowsy, while the monkey was lively and playful.
The monkey then showed moderate dyspnoea with mouth-
breathing, and respiration rose from 35 to 70. The oxygen
pressure was raised to 35 pounds, and in 5 minutes the
monkey had a slight convulsion. ‘The pigeons remained
unaffected.
The pressure was gradually blown off, the convulsions
aoe)
July 6, 1889]
ceased, and after remaining 45 minutes in the tank the
animals were released and appeared normal. ‘lhe mon-
key’s temperature had fallen 14° F. The temperature of
one pigeon fell 44° F.; that of the other 6° F. No evac-
uation of urine or fæces. Hemoglobin normal.
This experiment merely shows what has been demon-
strated by others, that animals can exist comfortably
in an atmosphere composed of more than two-thirds
oxygen, under moderately increased pressure, without any
discernible alteration in their functions or demeanor, until
the pressure exceeds three atmospheres.
Experiment 2.—A second monkey was kept in the
tank for 1} hour under 11 pounds of additional oxygen
pressure. No effect, except that he appeared sleepy and
rather bored. On removal the rectal temperature had
fallen 14° F. As the tank air was blown off a pigeon was
placed in a jar of it, and in 6 minutes it had convulsions,
although a candle burned brightly in the same jar. A
counter-test was made by placing another pigeon in fresh
air in another jar of the same size. In the same time, 6
minutes, the second pigeon had no dyspnoea, yet a candle
was extinguished at once in the jar.
The fact that the first pigeon had a convulsion in an at-
mosphere that relighted a paper, is probably due to poison-
ing from the monkey’s nitrogeneous waste.
Experiment 3.— A guinea-pig, a dog, and an alli-
gator were together placed im the tank, and oxygen was
rapidly added, until in 15 minutes a total pressure of 5 at-
mospheres was reached. ‘The dog then had a convulsion.
The pressure was released slowly, and after 4o minutes
it registered 20 pounds. ‘The animals all seemed com-
fortable, so oxygen was added again upto 45 pounds, or 4
atmospheres in all. After a few minutes the valve was
slowly opened and the animals were released, having re
mained 14 hour in the tank. The pig and dog both died
in 3 minutes in convulsions. Autopsies showed great
pulmonary congestion in both animals, and over-distention
of the right heart. The other viscera were exsanguinated.
The venous blood was nearly black. The dog’s temper-
_ ature had fallen 9 ” F., and the pig’s 14 ’ F. T he alligator’s
rose from 51}° (external air 66°) to 75° or 23ł° F.
The alligator survived.
This experiment, with several others, shows that the
higher animals are sooner affected by pressure than the
lower. The monkey was asphyxiated before the pigeons,
the dog before the guinea pig.
The remarkable fluctuation in temperature observed in
nearly all these experiments is interesting, but I do not
attribute it to the influence of oxygen. I have never no-
ticed a rise of temperature in these experiments except
in cold-blooded animals, and this fact alone argues against
increased tissue oxidation.
In warm-blooded animals the normal temperature. aver-
ages considerably higher than in man, and fluctuations of
6” or even 10° F., which are occasioned by trivial causes,
may occur without any serious attending phenomena. I
have often seen a dog’s temperature fall 3° or 4° from
simply inhaling ether. The heat-regulating mechanism of
the lower animals is far less perfect than our own. ‘They
have a greater range of temperature in individual cases.
In these experiments the fall of temperature noted is un-
doubtedly produced merely by the profound disturbance
in the circulation and consequent increased heat-loss or
diminished heat-production. Moreover, the rapid release
of the pressure abstracts heat from the surface of the
body. The fall of temperature is equally decided in at-
mospheres of compressed air and of compressed oxygen.
It is greatest when the pressure has been very high, where
it has been suddenly removed, and when convulsions and
dyspnoea have been intense. I have often noticed a sim-
ilar loss of temperature produced by asphyxiating an ani-
mal under an air-pump. Therefore this remarkable heat-
loss is in nowise associated with an increase in oxygen ab-
sorbed.
Experiment 4.—A monkey was kept in the tank for
24 hours, under a pressure which was gradually increased
THE MEDICAL RECORD. 3
— ode —— cat!
up to 45 Beaudet shes oxygen, and then slowly diminished.
The animal during all this time played about, and
seemed perfectly normal. When the pressure reached
zero it was suddenly raised again in 8 minutes to 51 pounds
of oxygen, nearly 44 atmospheres in all. He was kept at
nearly this pressure for 45 -minutes more, without ap-
preciable effect of any kind. Just before removal, after
spending 34 hours in the tank, the animal had a slight
convulsion. ‘The rectal temperature fell 14°.
Experiment 5.—Is a repetition of the preceding ex-
periment. A monkey and pigeon were kept for over two
hours in the tank under a pressure of oxygen which
registered 30 pounds during most’ of that time. Very
shght dyspnoea occurred toward the end, but no other
symptoms resulted. The monkey’s temperature fell 4.2°,
the pigeon’s only 1° F.
Experiment 6.—A cat was placed in the tank, and
oxygen pressure was rapidly added until, at the end of an
hour, it registered go pounds—in all 7 atmospheres. No
convulsions occurred until 7o pounds of pressure was
reached. After 14 hour in all the animal was removed,
and it soon died from pulmonary congestion and dilatation
of theright heart. Some emphysema was found in the
thinner portions of the lungs Bert states, as a result of
his experiments, that at 34 atmospheres of oxygen, animals
die from asphyxia and convulsions. In this experiment,
twice that pressure was borne for some time, although it
ultimately proved fatal.
Experiment 7.—Three pigeons were’ kept for 14 hour
under a pressure of 40o pounds of oxygen, nearly 4 atmo-
spheres in all. One of them alone had convulsions, and
on removal it remained for some days with the muscles
in-a curious condition of rigidity and contracture, and all
attempts at moving it threw it into violent convulsions.
The bird lay on its back for four days, with neck and legs
strongly flexed. ‘The animal had had its cerebellum re-
moved some weeks before, and I think the peculiar symp-
toms were due to the pressure affecting the surface of
the brain unduly through the opening in the skull, rather
than to any influence of the oxygen. The two other
pigeons survived, and were normal.
Experiment 8.—A dog was kept for an hour at a
pressure of 4 atmospheres, composed of three-fourths
oxygen. ‘There were a few convulsions, but the dog re-
covered. The rectal temperature fell 5.4° F.
Experiment 9.—A cat and dog were kept alive for
an hour under an additional atmosphere of oxygen in a
confined space, where the ordinary air would have been
fatal to either animal alone in less than half that time.
Experiment 1o.—A similar experiment was repeated,
using compressed air instead of oxygen, with a like good
result. Havifig determined the effect of high pressures
of oxygen, I next tried to learn to what extent the con-
vulsions which are common above 4 atmospheres, are
caused by the pressure alone, or to what extentthey might
be due to somespecific action of oxygen. In all the ex-
periments thus far described, the convulsions were im-
mediately relieved by blowing off 5 or 10 pounds of press-
ure. Itis also noticeable that, while the pressure was being
either increased or diminished, the animals evinced a cer-
tain amount of restlessness, which was usually greater
when the pressure was falling, and which promptly sub-
sided. In the following experiments the animals were
subjected to exactly the same conditions upon successive
days, with the exception that compressed air was used on
one day, and oxygen on the next. The pressure was
added or released at the same rate in each case, and the
exhaled CO, was removed by a solution of KOH.
Experiments 11 and 12.—A dog weighing 224 pounds,
was subjected to rapidly increasing air pressures. <A
total pressure of 8 atmospheres was reached (inside of 26
minutes) before the animal had a convulsion, or even ap-
peared discomforted. When oxygen was given the next
day, at the same rate, convulsions occurred when th:
total pressure had reached 5 atmospheres, and when 64
atmospheres were reached the convulsions became so
4 THE MEDICAL RECORD.
violent as to shake the heavy tank and threaten imme-
diate death. It was with difficulty that he was rescued
by releasing the pressure, and whereas on coming out of
8 atmospheres of compressed air the dog appeared nor-
mal, on coming out of 64 atmospheres of oxygen he had
tremors, incoirdination, salivation, staring eyes, and
jerky dyspneeic respiration. There were no rales in the
chest. Ether was given to control the convulsions which
persisted after his liberation, and he survived.
Experiment 13.—A further test was made the next day
by allowing this dog to remain in the closed tank, breath-
ing common air under 15 pounds pressure, until he be-
came decidedly asphyxiated in 27 minutes, with mouth
breathing and respiration, 120. ‘len pounds of oxygen
pressure were added, and the respiration fell to 38, with
great relief of the dyspnoea. ‘The oxygen pressure was
finally raised to 45 pounds, when convulsions occurred.
Experiments 14 and 15.—A cat and dog were together
placed in the tank and allowed to remain until, after 20
minutes, both animals were decidedly asphyxiated. When
both animals were on the verge of convulsions, the dog’s
respiration being 120 and the cat’s 80, 5 pounds of
oxygen pressure was added, with instant relief; the dog’s
respiration fell to 40 and the cat’s to 60. When the
dyspnoea again returned after an interval, it was always
relieved by adding a little oxygen until 30 pounds press-
ure had been reached. After 50 minutes the animals
were released in good condition. The exhaled air, col-
lected at intervals, contained a very large percentage of
CO,, yet a candle burned brightly in it. ‘The next day
the same animals were replaced in the tank and 22 pounds
of oxygen pressure were added at once, which they bore
for 45 minutes, with but slight dyspnoea toward the end.
Experiments 17 and 18.—A large cat was placed under
a pressure of 55 pounds of oxygen or 4% atmospheres in
all, and in 2 minutes severe convulsions resulted. ‘The
next day the same animal was kept for 35 minutes under
the same pressure of atmospheric air without any ill effects
at all.
The day following, the animal was left in the tank for
20 minutes, when it showed intense dyspnoea (the cat’s
body filled J; of the capacity of the tank); 10 pounds of
oxygen pressure were then added with immediate relief,
which lasted for one hour. At the end of this time the
oxygen pressure was increased to 30 pounds, and the cat
remained comfortable for 3% hours in all. On removal
a convulsion occurred, but the animal was restored by
chloroform. KOH was used to absorb the CO,. The
rectal temperature fell 5}° F. during the experiment.
All of the experiments thus far reported were made
with perfectly healthy animals. They prove that: 1.
When the breathing is normal, oxygen and atmospheric
air do not differ materially in effect up to about two
atmospheres of pressure. 2. Both oxygen and air under
pressures between } and 2 atmospheres relieve the dysp-
noea produced by inhaling vitiated air, and oxygen has a
distinctly greater effect in this regard than air. 3. The
effect seems to be exerted through the respiratory centre,
diminishing the rate of breathing, and improving the
rhythm of the respiration.
4. Above 2 or 3 atmospheres a much greater pressure
of air can be borne than of oxygen without inducing convul-
sions.
The cause of the convulsions is still undecided.
‘The cause of the ordinary normal respiratory impulses
is believed, by the great majority of experimenters at the
present time, to be the lack of oxygen in the blood conveyed
to the respiratory centre in the medulla. Others, how-
ever, believe that the presence of excess of CO, in the
blood is an equally potent factor; and there are a few
physiologists who claim that the lack of oxygen excites in-
spiration, and that the presence of excessive CO, may
excite forced expiration.
Convulsions are produced by suddenly withholding oxy-
gen, and convulsions of a somewhat different type may be
produced by inhaling a large percentage of CO... It is pos-
[July 6, 1889
sible that they may be alsu produced by nitrogenous
waste matters (probably volatile ptomaines ?), which are
either re-inhaled, or which cannot be exhaled. Which-
ever theory we adopt, the fact remains that the convul-
sions are precipitated when the pressure of the inhaled
atmosphere reaches a certain maximum. I submit the
following theory regarding these convulsions: That they
are due to the physical law that “ the diffusion constart
of two gases is inversely as the pressure,” and, therefore,
the higher the pressure the less the rate of diffusion. In
normal breathing the air in the upper part of the lungs
only is exchanged mechanically, as we know. The air of
the more deeply seated air-vesicles, which contains. an
excess of CO, is changed by diffusion at a definite rate
for ordinary atmospheric pressure. If the pressure of the
inhaled atmosphere, be it oxygen or common air, is greatly
increased, it is more difficult, and it requires more time for
the CO, to diffuse from the blood into the air-vesicles,
and from the air-vesicles into the tidal air in the wider
portions of the air-passages. As a result, €O, tends to
accumulate in the blood, and, further, by its retarded dif-
fusion from the residual air in the vesicles, it tends to
keep back the oxygen of the tidal air from closer approach
to the capillaries. Hence the blood is prevented from tak-
ing up sufficient oxygen, and at the same time its CO, ard
volatile nitrogenous waste matter accumulate, and convul-
sionsresult. The fact that increased oxygen pressure causes
convulsions sooner than increased air pressure may po--
sibly be due to the greater difficulty that CO, experiences
in diffusing into pure oxygen highly compressed, as com-
pared with common air ; but this is at present purely hypo-
thetical. Another very important consideration is the
fact that, with greatly increased pressure the solubility of
CO, in the blood is much increased, and it therefore tends
to diffuse out less readily into the air-cells.
Pure oxygen under slightly increased pressure is bene -
ficial, because it mixes readily enough with the CO, present
in the lungs, and a very little more of it may be absorbed
by the plasma. But under greatly increased pressure dif-
fusion becomes too slow and difficult, and convulsions
ensue.
The next problem is the discussion of the influence, upon
abnormal respiration, of oxygen, inhaled under increased
pressure. For the present purpose, without going deeply
into the manifold exciting causes of dyspnoea, we may
classify its principal varieties as follows :
I. Dyspncea due to abnormal conditions of the air,
especially to diminished oxygen supply from obstruction
to the entrance of air, to increased CO, or nitrogenous
waste, or to other poisonous gases.
II. Dyspnoea due to abnormal conditions of the blood,
either diminished number of red disks, or diminished oxy-
gen carrying power of the red disks—.¢., diminished hæ-
moglobin.
III. Dyspnoea due to obstructed circulation, arising
from a feeble heart, pulmonary congestion, etc., which re-
tard the blood-current.
IV. Dyspnoea due to diminished surface of aération for
the blood, from compression of the lung by fluid, from
consolidation, or other cause—as feeble expansion of the
chest.
V. Dyspnoea of purely neurotic character, with normal
lun
Regusding the latter, it may be said that there seems
to be a general “ respiratory sense,” corresponding to the
general sense of hunger, thirst, etc. We mentally refer
dyspnoea to the chest, as we mentally refer thirst to the
throat ; yet in cases of gastric fistula, thirst is relieved by’
injecting water into the stomach. ‘Thirst may also be re-
lieved by immersing the body in water.
It is a matter of common observation, to see certain
cases of pneumonia or of phthisis in which the patient,
while perfectly conscious, feels no distress in breathing,
yet the rhythm and rate of respiration are wholly abnor-
mal. On the other hand, there may be decided subjec-
tive dyspnoea without discoverable lesion in the respiratory
I am at present engaged upon a series of new experi-
ments by which some of these varieties of dyspnoea are
artificially induced, and then the effect of inhalation under
pressure of oxygen is studied.
A few of these experiments I will report :
Experiments 19 and 20.—In a cat with both vagi cut,
there was no appreciable dyspnoea so long as the animal
remained quiet and had plenty of air. The cat was shut
in the tank, breathing confined air, uncompressed, until
intense dyspnoea resulted of the well-known cut-vagus
type. Inspiration became very deep and prolonged, the
nares and mouth were wide open, every accessory respira-
tory muscle was called into action, and an exaggerated
pause occurred between the end of inspiration and begin-
ning of expiration, the latter being sudden and forcible. In
addition there were tremors of the head and legs; 7 pounds
of oxygen pressure were then added, with instant relief
of all the symptoms. ‘The cat was removed after fifteen
minutes, and allowed to rest until the next day, when it
was still alive with quiet respiration. The animal was
then urged to walk a few steps until intense dyspnoea oc-
curred as before. On being placed in the tank in this
condition, compressed air was added under the same
pressure as the oxygen used on the previous day. Instead
of producing relief the dyspnoea was augmented, and when
the pressure was increased to three atmospheres the dysp-
nœa became most intense. ‘There were loud tracheal
rales audible through the wall of the tank, which transmits
respiratory sounds with remarkable clearness. Restless-
ness and weakness became extreme. On releasing the
animal it was restored to its previous condition of com-
fort. In these experiments the pressure effects were very
decided.
Experiment 21.—It took forty minutes for the same ani-
mal to acquire marked dyspncea, with both vagi cut, in con-
fined air at one atmosphere, whereas two atmospheres of
air produced immediate severe dyspnoea. ‘The interesting
feature of these experiments is that the dyspnoea which
occurred in an exaggerated form after section of both
vagi and poisoning by confined air, was relieved by add-
ing seven pounds press::re of oxygen to the already foul
air.
Experiment 22.—A young but large dog, with a cannula
4-inch in diameter inserted in right pleural cavity. When
the cannula was closed with a cork, respiration was normal ;
when it was open there was great dyspnoea, and respir-
ation was increased to 66 and shallow. The dog was
placed in the tank with the cannula open, and 15 pounds
pressure of oxygen were added. In twenty minutes res-
piration fell from 66 to 32, and became deep and very
labored. The oxygen was blown off and the respiration
rose to 47. Then 40 pounds pressure of common air
were added. The animal again became very uneasy and
the respiration slower and deeper. In fifteen minutes
more he was liberated, and the cork was replaced.
This experiment demonstrates that, when an animal is
deprived of half the normal breathing-space by collapse
of one lung produced by a free opening in the pleura,
both compressed oxygen and compressed air reduce the
frequency of respiration, but add greatly to the distress of
the animal from the mechanical effects of the pressure.
If there was any specific difference between the oxygen
and common air in this case, it was obscured by the
evil mechanical effects of the increased pressure.
Experiment 23.—In another experiment I produced ex-
treme dyspncea from local pulmonary congestion from in-
jection of AgNO, solution into the lung tissue. The ani-
mal (a cat) was placed in the tank when the respiration
was 150 and very shallow; there was great prostration,
the animal being scarcely able to stand. ‘Ten pounds of
oxygen pressure were added, and in three minutes respir-
ation was slowed to 80 and became much fuller, and
the animal seemed greatly relieved and stronger. On
increasing the oxygen pressure to 20 pounds the respir-
X
THE MEDICAL RECORD. 5
ation fell to 64, the cat stood up, licked her paws, and
moved about in a natural manner. After an hour under
this pressure the cat was liberated, and she became im-
mediately worse. ‘The respiration increased, and the cat
again became so feeble as to constantly lie down. In
this case of acute pulmonary congestion the inhalation of
oxygen under pressure gave remarkable relief to the
dyspnoea and general distress. Autopsy showed only one
lobe to be congested on the side of the injection.
Experiment 24.—Dog, weight 16 pounds. I inject-
ed 550 c.c. of water into a dog’s right pleural cavity to
compress the right lung and diminish the space for aération
of the blood. Respiration became very deep and labored,
and while at rest the rate was 35. While exercising, respir-
ation became 100 and shallower. The animal was placed
in the tank, and 10 pounds were added of a mixture of
4. oxygen + 1(N,O). In three minutes respiration fell
from 60 to 48, and the dog seemed much relieved and very
drowsy. After 15 minutes the pressure was gradually in-
creased to 45 pounds, when a violent convulsion occurred
in four minutes. This was controlled by releasing the
pressure slowly. After remaining one hour in the tank,
the animal was removed. ‘The temperature had fallen
44° F. ;
Se this experiment, where the area for aérating the
blood was diminished by one half, the respiration became
much more natural on inhaling a mixture of 4. oxygen +
1 (N,O) under pressure. No different effect was noticed
in using this mixture from that obtained by pure oxygen.
Experiment 25.—A puppy weighing 144 pounds was
bled to the extent of 24 ounces. Respiration became
very irregular, and the animal appeared very weak. He
was given the same mixture of 4. (O) + 1 (N,O) under
various pressures. At pressures under ro pounds he was
much relieved, but under three atmospheres the dyspnoea
was greatly increased, and he became too feeble to stand.
Experiments 26 and 27.—A dog weighing 16} pounds
was bled to the extent of ro ounces. ‘The resulting
dyspnoea was relieved by adding 4 pounds of pressure
of the mixture used in the previous experiments. Sub-
sequently the dyspnoea returned, and being again placed
in the tank under 10 pounds of oxygen pressure added to
the air already present, his condition improved in a marked
degree. But when 30 pounds of oxygen pressure were
added, the dyspnoea became intense. It was again relieved
by reducing the pressure.
These experiments have not been performed with high
pressures because we can make any clinical use of such
pressures. but in order to find the limits of the maximum
effect of oxygen, as an aid to inferring the clinical results
which are possible under one atmosphere of pure oxygen,
i.e., in which the oxygen tension is increased to 15 pounds.
The experiments, although as yet incomplete, certainly
demonstrate that oxygen under moderately increased ten-
sion does aid certain types of dyspnoea.
We now come to the second division of my subject,
the Therapeutic Value of Oxygen Inhalation.
It is not very feasible to give oxygen to man under pres-
sures above tnat of the atmosphere. My own experience
in this regard is confined to the use of compressed air in
a few severe cases of spasmodic asthma, which were
greatly improved, I think, rather by the general air-press-
ure, than by the slignt increase in oxygen tension pro-
duced by an additional atmosphere.
Dr. Valenzuela, in a paper read before the Royal Acad-
emy of Medicine of Madrid, two years ago, reports the
use of oxygen inhaled under 7 times the ordinary oxygen
tension of the air (7.¢., 14 atmosphere of pure oxygen).
Several cases of pneumonia in man were greatly benefited.
At the end of an hour in one case the temperature fell 1.7° |
C. He also speaks of reducing the temperature of rab-
bits having septicemia, by inhalation of oxygen under in-
creased tension. For reasons given earlier in this paper,
I believe that the reduction of temperature was due to
pressure effects, and that it would have occurred equally
had compressed air been used instead of oxygen.
6 THE MEDICAL RECORD.
[July 6, 1 889
‘The inhalation of oxygen is no new remedy. Its aea]
peutic use was suggested by its discoverer, Priestley, in
1774. But it has suffered much from the extolment of
quacks, who take advantage of the popular knowledge that
without oxygen there is no life, and the belief that, conse-
quently, the more oxygen is given, the more vigor results,
and that ozone is a public boon even beyond oxygen in
power. Whereas, it is a physiological impossibility to take
ozone into the blood through the lungs, and even were it
possible, its presence there is incompatible with the con-
tinuance of the circulation (Oertel).
The legitimate clinical use of oxygen is, however, con-
stantly advancing, not after the manner of so many new
remedies that spread throughout the country, offering
fame to all who first report their trial to-day, and which
pass into oblivion to-morrow ; but the advance is steady
and convincing.
_ Until recently, oxygen could only be obtained from illu.
minating companies, and those who have given it trial in
impure forms, and without system, have generally mis-
judged it. ‘To-day it is prepared by many manufacturers,
exclusively for medical use, with guarantee of its purity,
and many of our hospitals have oxygen generators of their
own.
Oxygen is employed therapeutically, 1, as a curative
measure in diseases of the blood, circulation and respira-
tion ; and, 2, as a palliative measure in extreme subjective
and objective dyspnoea.
The therapeutic use of oxygen is now very prevalent i in
the United States, and in Continental Europe. Two or
three hundred thousand gallons are inhaled yearly in this
city alone. During the cholera epidemics of ‘Toulon and
Marseilles, in 1886, it proved a most useful adjunct to
other treatment. It is employed with success in many
cases of opium narcosis, coal-gas asphyxia, chloroform
poisoning, etc.
Decided success is claimed for its use in anzemia, chlo-
rosis, leukzemia, slow convalescence, and in wasting dis-
eases.
Hundreds of cases of dyspnoea and cyanosis compli-
cating pulmonary diseases, have been reported in the jour-
nals of the past few years, as benefited by oxygen inhala-
hon.
In 1888 it was ordered in Paris that oxygen be kept in
readiness at each of the 16 pavilions erected on the
banks of the Seine for the resuscitation of the drowned
(Lancet, June 16, 1888, p. 1273), and it was further ad-
vised to keep it at all the police and fire stations. The
literature of the therapeutic use of oxygen shows decided
improvement in the intelligence and care with which it is
given, besides affording such convincing evidence of its
value in certain classes of disease, that no consideration
of expense or trouble should weigh against it.
Adopting the previous classification of dyspnoea, I will
refer to a few illustrative cases within my own experience.
I. Oxygen in anaemia, chlorosis, etc.—Oxygen is given for
these affections often in a greatly diluted form, for 5 or
IO minutes, two or three times a day. If those cases be
excluded which will recover anyway, and those which
are simultaneously under other treatment, there is little
evidence of any specific advantage of oxygen over good
fresh air. In casesof this kind in which I have used oxygen,
I have never employed it alone, but I have failed to note
any benefit from it as an adjunct to iron and other remedies.
It does not seem quite rational to suppose that enough
oxygen can enter the system in this way, in so brief a time,
to produce anything more than a momentary effect. Lit-
tle or no additional oxygen enters the plasma under these
conditions (of dilution, etc.), and the red corpuscles which
are at fault have, in the ordinary air, more oxygen than
they can appropriate. Besides, at least 10 inspirations
are required to completely change the air in the lungs.
II. Blood-poisoning.—In diseases in which blood-poison-
ing of some kind was the occasion for the use of oxygen, I
have uniformly failed to find any improvement in the con-
dition of cyanosis, although I have watched for it with
eae care; but I fai frequently seen the abae
dyspnoea relieved.
To illustrate. ‘Two years ago, I treated a case of malig-
nant diphtheria in which great prostration early occurred,
with very rapid respiration (50), marked subjective dysp-
nœa and cyanosis. ‘There was not enough membrane to
cause any obstruction, and the lungs at the time were
perfectly clear and well filled with each inspiration. ‘There
was no time to examine the blood, but it seemed to be a
case in which the blood became suddenly overwhelmed
with the diphtheritic poison, and either the red disks
themselves, or their hemoglobin, was destroyed. Oxygen
was vigorously administered for several hours, without the
slightest improvement in cyanosis or rate of respiration,
although the patient, an. intelligent adult, said he felt
greatly relieved by the gas. Death soon followed from
pulmonary oedema and heart-failure.
Last March, a robust adult entered the Presbyterian
Hospital, as a case of illuminating-gas poisoning. On
admission he was unconscious, and he remained so. His
lungs were clear at first. Later, he developed pneumonia,
from which he died on the third day. During the entire
time his respiration continued at 72. Oxygen was freely
given, almost continuously. It produced no effect whatever
upon either the rate of breathing or the cyanosis, which
occurred during several attacks of. pulmonary cedema.
Cupping the chest, and venesection to relieve the right
heart, produced decided temporary improvement where
oxygen completely failed. In these cases, as is well known,
carbon-monoxide forms a compound with hæmoglobin
which permanently replaces oxygen in the red disks ; and
in the instance cited, oxygen inhaled nearly pure was evi-
dently not appropriated by the plasma in sufficient quantity
to be of benefit.
III. Affections of the circulation.—In cardiac diseases,
or in failure of the heart to maintain the pulmonary cir-
culation at its normal velocity, oxygen is reported to be of
considerable value. My own experience with it in cases of
this class has not been so encouraging. For example, in
a recent case of malignant endocarditis, with extensive
valvular disease and dilatation, I found oxygen of no avail
in relieving the dyspnoea, either before or after there
were any physical signs of obstruction to the entrance
of air to the lungs. When the circulation is feeble, and
the blood-current through the lungs is impaired, the
blood, while in the lesser or pulmonary circulation, has
all the more time to appropriate oxygen and be relieved of
.CO,; but the blood in the greater or systemic circulation
reaches the lungs less promptly, and it accumulates more
CO,. It seems doubtful whether inhalation of oxygen in
this condition can be of much avail.
IV. Diminished surface for aération.—In pneumonia,
with very rapid respiration, dyspncea, and cyanosis, I have
often found oxygen to give very great relief. It is even
possible for the dyspnoea to be decidedly relieved, while the
cyanosis disappears in a few seconds, and the rate of res-
piration becomes slower, and its character improves. ‘The
same is true of capillary bronchitis and of asthma, es-
pecially when accompanied by extensive bronchial secre-
tion. Where the thorax is poorly expanded from enfeeble-
ment of the respiratory muscles, thoracic pain, or ob-
struction to the air-passages, etc., it may be impossible to
inflate the lungs normally, or to have as complete an inter-
change of gases within them as should take place.
Under these conditions increase in the amount of oxygen
present in the inhaled air ought to allow a larger propor-
tion of oxygen to reach the deeper air-cells in a given time.
V. Neurotic dyspnaa.—Oxygen gives decided relief to
certain forms of neurotic dyspnoea, t.c., dyspnoea occurring
where the lungs are perfectly normal, but from some cause
the respiratory sense suffers greatly. I have found it very
beneficial in uremic dyspnoea. In one such case with
normal lungs, the most pronounced I have ever witnessed,
very intense dyspnoea lasted for three days, and during this
time oxygen was almost continuously used day and night.
After inhalation for fifteen or twenty minutes, the respira-
July 6, 1889]
tion became slower and more tranquil, the cyanosis (which
occurred later on with pulmonary cedema) was slightly im-
proved, and the patient was greatly eased. ‘The dyspnoea
soon returned if oxygen was discontinued, and improved
when it was resumed. In cases of this nature, which so fre-
quently occur, I have come to regard oxygen as an invalu-
able therapeutic agent, not for any curative effect—for the
condition may be hopeless from the start—but as a prompt
and easy aid to one of the worst forms of suffering—the
continual sense of impending suffocation. It is possible
that in some cases the benefit is psychic, but it does occur.
Much has yet to be decided regarding the effects of oxygen
inhalation. We should have more careful experiments
to determine whether the exhalation of nitrogenous waste
(volatile ptomaines ?) is increased by oxygen inhalation, and
to determine whether more oxygen is conveyed to the blood
by diluting it with some still more diffusible respirable gas,
or by administering it pure. Experiments of this nature,
combined with careful study of the body temperature and
pressure effects, will, no doubt, throw more light upon
the relation of oxidation processes to fever, etc. In
conclusion, the following summary of the therapeutic
value of oxygen inhalation is offered :
Oxygen is of value—
1. Ip neurotic dyspnoea, for the relief of the distressing
subjective symptoms.
2. Where there is diminished surface for aération of
the blood, oxygen improves the cyanosis, lowers the rate
of breathing, and relieves the subjective dyspncea.
3- Oxygen is of value where there is diminished infla-
tion of the lungs from many causes.
4. It is especially beneficial in the dyspnoeas of chronic
Bright’s disease and urzemia, pneumonia, capillary bron-
. chitis, asthma, and catarrhal bronchitis, and sometimes in
pulmonary congestion, and the early stage of cedema.
5. Great care should be taken to secure chemically
pure oxygen.
VI. Oxygen may be given freely and abundantly in cases
of emergency, without fear of any injurious consequences.
Ordinarly it is sufficient to give it pure by one nostril,
while the other inhales atmospheric air; but it is often best
to give it for a few moments by the mouth or both nostrils,
without admixture of air.
It is impossible to separate completely the causes of
dyspnoea, which may often exist in combination, but in
order to focus somewhat the discussion invited, Mr. Pres-
ident, I would suggest, that it would be interesting to hear
_ the views of those present regarding the value of oxygen
inhalation :
1st. In general diseases of defective nutrition, without
regard to dyspnoea.
2d. In dyspnoea due to altered condition of the nerves,
or of the circulation, altered composition of the blood
(poisons, etc.), diminished surface for aération, or feeble
expansion of the lungs.
In performing my experiments I have received valuable
aid from Dr. John C. Cardwell, Assistant to the Physio-
logical Laboratory at the New York University Medical
College, as well as trom several students of the College.
BIBLIOGRAPHY.
Smith, Andrew H.: Oxygen Gas as a Remedy in Disease. Prize
Essay. New York, 1870, and New York Medical Journal, 1870.
Beigel on Inhalations. l
Solis-Cohen on Inhalation. Philadelphia, 1876.
Loysel: Journal de Médecine de Bruxelles, August, 1884, and Thèse
e Paris, 1883.
Fave: Oxygen in Eclampsia, London Medical Record, June 15,
1885.
Richardson : Oxygen Inhaled at Different Temperatures.
Science Monthly, November, 1878.
Wallian: New York M#DICAL RECORD, October and November,
1383; do., 1834, pp. 233-287; 313-316 ; do., October 3°, 1885.
Wallian: Suggestions to Users, Philadelphia Medical Bulletin, 1886,
pp. 272, 307.
Robinson, Beverley: Oxygen in Pneumonia. New York MEDICAL
RECORD, 1889, p. 40.
Smith, An jrew H.: New York MEDICAL RECORD, 1889.
Oertel: Ziemssen’s Handbook of General Therapeutics, vol. iii., pp.
233-246.
Valenzuela: Inhalation of Oxygen Under Pressure.
4. 1887.
Popular
Lancet, June
THE MEDICAL RECORD. 7
Bert, Paul: La Pression Barométrique. Paris, 1878. Comptes Kendus
de la Société de Bnoiogie, 1885, vol. ii., p. 537.
pronon Oxidation by Drugs. St. Bartholomew's Hospital Reports,
1882.
Birch : Oxygen Inhalation. British Medical Journal, 1859, pp. 1033.
1053.
Hackley: Oxygen in Phthisis. New York Medical Journal, vol. ix.,
P- 597.
Mackey: Practitioner, vol. ii., p. 278.
Vanderbeck: Oxygen in Therapeutics. Philadelphia Medical Bul-
letin, 1886, pp. 73, 106.
Ehrlich: Use in Organism of Oxygen.
1885, vol v., pp. 431-434.
Priestley : Experiments on Different Kinds of Air. London, 1774.
Dumarquay : Pneumatologie Médicale. Paris. 1866.
Laborde; Intravenous Injections of Oxygen. Comptes Rendus de la
Société de Biologie, 1885, vol ii., pp. 598-6or.
Kellogg: Oxygen Enemata. Therapeutic Gazette, September 15,
1887. .
Revue de Médecine, Paris,
Humphrey : Oxygen Enemata. Medical Age, April, 1888.
Bert, Paul : Rarefied Oxygen. Comptes Rendus de la Société de
Biologie, vol. lxxviii., p. QII.
Ehrlich: Revue de Médecine, 1885, vol. v., p. 431
Quinquaud : Mémoires de la Société de Biologie. 1885.
Regnault et Reisset: Annales de Chimie et de Physique, 3me série,
vol, xxvi., 1849.
Arsonval: Mémoires de la Société de Biologie, 1887, p. 43.
Rosenthal: Die Athembewegungen.
Schmidtborn: Ursachen der Athembewegungen.
ALCOHOLIC TRANCE IN CRIMINAL CASES.'
By T. D. CROTHERS, M.D.,
SUPERINTENDENT WALNUT LODGE, EDITOR '‘JOURNAL OF INEBRIETY,”
HARTFORD, CONN.
THE frequent statement of prisoners in court, that they
did not remember anything about the crime they are ac-
cused of, appears from scientific study to be a psycho- `
logical fact. How far this is true in all cases has not
been determined, but there can be no question that crime
is often committed without a conscious knowledge or
memory of the act at the time.
It is well known to students of mental science that in
certain unknown brain states memory is palsied, and fails
to note the events of life and surroundings. Like the
somnambulist, the person may seem to realize his surround-
ings and be conscious of his acts, and later be unable to
recall anything that has happened. ‘lhese blanks of
memory occur in many disordered states of the brain and
body, but are usually of such short duration as not to
attract attention. Sometimes events that occur in this
state may be recalled afterward, but usually they are
total blanks. The most marked blanks of memory have
been noted in cases of epilepsy andinebriety. When they
occur in the latter they are called alcoholic trances, and
are always associated with excessive use of.spirits. Such
cases are noted in persons who use spirits continuously,
and who go about acting and talking sanely although giv-
ing some evidence of brain failure, yet seem to realize
their condition and surroundings. Some time after, they
wake up and deny all recollection of acts or events for a
certain period in the past. This period to them begins at
a certain point and ends hours or days after, the interval
of which is a total blank, like that of unconscious sleep.
Memory and certain brain functions are suspended at this
time, while the other brain activities go on as usual.
In all probability the continued paralysis from alcohol
not only lowers the nutrition and functional activities of
the brain, but produces a local palsy, followed by a tem-
porary failure of consciousness and memory, which after
a time passes away.
When a criminal claims to have had no memory or rec-
ollection of the crime for which he is accused, if his state -
ment is true, one of two conditions is probably present,
either epilepsy or alcoholism. Such a trance state might
exist and the person be free from epilepsy and alcoholism,
but from our present knowledge of this condition it would
be difficult to determine this fact. If epilepsy can be
traced in the history of the case, the trance state has a
pathological basis for its presence. If the prisoner is an
inebriate, the same favoring conditions are present. If
ETC.,
1 Read before the International Medico-legal Congress, at New
York City, June 5, 1889.
8 THE MEDICAL RECORD.
————.
the prisoner has been insane, and suffered from sun- or
heat-stroke, and the use of spirits are the symptoms of
brain degeneration, the trance state may occur at any time.
The fact of the actual existence of the trance State is a
matter for study, to be determined from a history of the
person and his conduct ; a grouping of evidence that the
person cannot simulate or falsify; evidence that turns
not on any one fact, but on an assemblage of facts that
point to the same conclusion.
The following cases ate given to illustrate some of these
facts, which support the assertion of no memory of the
act by the prisoner in court :
The first case is that of A——, who was repeatedly ar-
rested for horse-stealing, and always claimed to be uncon-
scious of the act. This defence was regarded with rid-
icule by the court and jury, and more severe sentences
were imposed, until, finally, he died in prison. The evi-
dence offered in different trials was, that his father was
weak-minded and died of consumption, and his mother
was insane for many years, and died in an asylum. His
early life was one of hardship, irregular living, and no
training. At sixteen he entered the army, and suffered
from exposure, disease, and sunstroke, and began to
drink spirits to excess at this time. At twenty he was
employed as a hack-driver, and ten years later became
owner of a livery stable. He drank to excess at intervals,
yet during this time attended to business, acting sanely,
and apparently conscious of all his acts, but often com
plained he could not recollect what he had done while
drinking. When about thirty-four years of age he would,
while drinking, drive strange horses to his stable, and
claim that he had bought them. ‘The next day he had no
recollection of these events, and made efforts to find the
owners of these horses and return them. It appeared
that while under the influence of spirits the sight of a good
horse hitched up by the roadside alone, created an intense
desire to possess and drive it. If driving his own horse,
he would stop and place it in a stable, then go and take
the new horse, and after a short drive put it up in his own
stable, then go and get his own horse. The next day all
this would be a blank, which he could never recall. On
several occasions he displayed reasoning cunning, in not
taking a horse when the owners or drivers were in sight.
This desire to possess the horse seemed under control,
but when no one was in sight all caution left him, and he
displayed great boldness in driving about in the most
public way. If the owner should appear and demand his
property he would give it up in a confused, abstract way.
No scolding or severe language made any impression on
him. Often, if the horse seemed weary, he would place it
in the nearest stable, with strict orders to give it special
care. On one occasion he joined in a search of a stolen
horse, and found it ina stable where he had placed it
many days before. Of this he had no recollection. In
another instance he sold a horse which he had taken, but
did not take any money, making a condition that the buyer
should return the horse if he did not like it. His horse-
stealing was all of this general character. No motive was
apparent, or effort at concealment, and on recovering
from his alcoholic excess he made every effort to restore
the property, expressing great regrets, and paying freely
for all losses. ‘The facts of these events fully sustained
his assertion of unconsciousness, yet his apparent sanity
was made the standard of his mental condition. The
facts of his heredity, drinking, crime, and conduct all sus-
tained his assertion of unconsciousness of these events.
This was an alcoholic trance state, with kleptomaniac im.
pulses.
The next case, that of B——, was executed for the mur-
der’ of his wife. He asserted positively that he had no
memory or consciousness of the act, or any event before
or after. The evidence indicated that he was an inebriate
of ten years’ duration, dating from a sunstroke. He
drank periodically, for a week or ten days at a time, and
during this period was intensely excitable and active.
He seemed always sane and conscious of his acts and
[July 6, 1889
jay ns a —— ee ae ee -_—— paper ar eee
surroundings, although intensely suspicious, exacting,
and very irritable to all his associates. When sober he
was kind, generous, and confiding, and never angry or
irritable. He denied all memory of his acts during this
period. While his temper, emotions, and conduct were
greatly changed during this time, his intellect seemed
more acute and sensitive to all his acts and surroundings.
His business was conducted with his usual skill, but he
seemed unable to carry out any oral promises, claiming
he could not recollect them. His business associates
always put all bargains and agreements in writing when
he was drinking, for the reason he denied them when
sober. But when not drinking, his word and promise was
always literally carried out. He broke up the furniture
of his parlor when in this state, and injured a trusted
friend, and in many ways showed violence from no cause
or reason, and afterward claimed no memory of it. After
these attacks were over he expressed great aların, and
sought in every way to repair the injury. Finally he
struck his wife with a chair and killed her, and awoke
the next day in jail, and manifested the most profound
sorrow. While he disclaimed all knowledge of the cnme,
he was anxious to die and welcomed his execution. ‘This
case was a periodical inebriate with maniacal and homi-
cidal tendencies. His changed conduct, and unreason-
ing, motiveless acts, pointed to a condition of trance.
His assertion of no memory was sustained by his conduct
after, and efforts to find out what he had done and re-
pair the injury.
The third case, that of C———, was aman of wealth and
character who forged a large note, drew the money,
and went to a distant city on a visit. He was tried
and sentenced to State prison. ‘The defence was no
memory or cor.sciousness of the act by reason of exces-
sive use of alcohol. ‘This was treated with ridicule. Al-
though he had drank to excess at the time of, and before,
the crime, he seemed rational and acted in no way as if
he did not understand what he was doing. Both his
parents were neurotics, and he began to drink in early
life, and for years was a moderate drinker. He was a
successful manufacturer, and only drank to excess at
times for the past five years. He complained of no
memory during these drink paroxysms, and questioned
business transactions and bargains he made at this time.
On one occasion he went to New York and made foolish
purchases which he did not recall. On several occasions
he discharged valuable workmen, and when he became
sober took them back, unable to account for such acts.
‘These and other very strange acts continued to increase
with every drink excess. At such times he was reticent,
and seemed to be sensible and conscious, and did these
strange acts in a sudden, impulsive way. ‘The forged
note was offered boldly, and no effort was made to con-
ceal his presence or destination. When arrested he was
alarmed, and could not believe that he had done so
foolish an act. This was a clear case of alcoholic trance,
in which all the facts sustained his assertion of no con
sclous memory of the crime. In these three cases the
correctness of the prisoners’ assertions of no memory was
verified by all the facts and circumstances of the crime.
The mere statement of a person accused of crime, that
he had no memory of the act, should lead to a careful
examination and be only accepted as a fact when it is sup-
ported by other evidence.
The following case illustrates the difficulty of support-
ing a prisoner's statement of no memory when it is used
for purposes of deception :
An ‘inebriate, case D , killed a man in a fight, and
was senténced to prison for life. He claimed no memory
or recollection of the act. I found that when drinking he
seemed conscious of all his surroundings, and was always
anxious to conceal his real condition, and if anything had
happened while in this state he was very active to repair
and hush it up. He was at times quite delirious when
under the influence of spirits, but would stop at once if
anyone came along that he respected. He would, after
July 6, 1889]
THE MEDICAL
acting wildly, seem to grow sober at once, and do every-
thing to restore the disorder he had created. ‘The crime
was an accident, and at once he attempted concealment,
ran away, changed his clothing, and tried to disguise his
identity ; when arrested, he claimed no memory or con-
sciousness of the act. ‘This claim was clearly not true,
and contradicted by the facts.
In a recent case E— shot his partner in business while
bo:h were intoxicated, and displayed great cunning to
conceal the crime and person ; then, after elaborate prep-
arations, went away. He made the same claim of de:
fence, which was unsupported by any other evidence or
facts in his previous life. He was executed. Of course
it is possible for the trance state to come on suddenly,
and crime be committed at this time; still, so far, all the
cases studied show that this condition existed before, and
was the product of a growth beginning in brief blanks of
a few moments and extending to hours’ and days’ dura-
tion. Unless the facts indicated the trance state before
the crime was committed, it would be difficult to establish
this condition for the first time, followed and associated
with the crime.
I think, in most of these cases, where this defence is set
up, there will be found certain groups of cases that have
common physical conditions of degeneration. ‘These groups
of cases I have divided from a clinical stand-point, the
value of which will be more as an outline for future studies.
Probably the largest number of criminal inebriates who
claim loss of memory as a defence for their acts are the
alcoholic dements. This class are the chronic inebriates
of long duration; persons who have naturally physical
and mental defects, and who have used spints to excess
for years. ‘This, with bad training in early life, bad sur-
roundings, and bad nutrition, has made them of necessity
unsound, and liable to have many and complex brain de-
fects. Such persons are always more or less without con-
sciousness or realization of their acts. They act auto-
matically only, governed by the lowest and most transient
impulses. Crimes of all kinds are generally accidents
growing out of the surroundings, without premeditation
or plan. They are incapable of sane reasoning or ap-
preciation of the results of their conduct. The crime is
unreasoning, and general indifference marks all their acts
afterward. The crime is always along lines of previous
conduct, and never strange or unusual. The claim of no
memory in such cases has always a reasonable basis of
truth in the physical conditions of the person. Mania is
very rarely present, but delusions and morbid impulses of
a melancholic type always exist. The mind, like the body,
is exhausted,. depressed, and acts along lines of least re-
sistance. l
The second group of criminals who claim no memory
are those where the crime is unusual, extraordinary, and
unforeseen. Persons who are inebriates suddenly commit
murder, steal, or do some criminal act that is foreign to
all previous conduct. In such cases the trance condition
may have been present for some time before, and escaped
any special notice, except the mere statement of the per-
son that he could not recollect his acts. The unusual
nature of the crime, committed by persons who never
before by act or thought gave any indication of it, is
always a factor sustaining the claim of no memory.: ‘The
explosive, unreasoning character of crime always points to
mental unsoundness and incapacity of control.
A third group of criminals urge this statement of no
memory, who, unlike the first group, are not imbeciles
generally. 'Ihey are positive inebriates, drinking to ex-
cess, but not to stupor, who suddenly commit crime with
the most idiotic coolness an | indifference, never manifest-
ing the slightest appreciation of the act as wrong, or likely
to be followed by punishment. Crime committed by this
class is never concealed, and the criminal’s after-conduct
and appearance give no intimation that he is aware of
what he has done. These cases have been termed moral
paralytics, and the claim of the trance state may be very
likely true.
RECORD. 9
A fourth group of cases where memory is claimed to
be absent occurs in dipsomaniacs and periodical inebriates,
who have distinct free intervals of sobriety. This class
begin to drink to great excess at once, then drink less for
a day or more, and begin as violently as ever again. In
this short interval of moderate drinking some crime is com-
mitted which they claim not to have any recollection of.
Other cases have been noted where a condition of men-
tal irritation or depression preceded the drink explosion,
and the crime was committed during this premonitory
period and before they drank to excess. ‘The strong prob-
ability of trance at this period is sustained by th2 epileptic
character of such conduct afterward. The trance state
may be justly termed a species of aura, or brain paralysis,
which precedes the explosion.
In some instances, before the drink storm comes on,
the p2rson’s mind would be filled with the most intense
suspicions, fears, delusions, and exhibit a degree of irrita-
tion and perturbation unusual and unaccountable. In-
tense excitement or depression, from no apparent cause,
prevails, and during this period som2 crime may be com-
mitted ; then comes the drink paroxysm, and later all the
past is a blank. ‘Trance is very likely to be present at
this time.
In these groups the crime is generally automatic, or
committed in a manner different from other similar crimes.
Some governing centre has suspended, and all sorts of
impulses may merge into acts any moment. The con-
sciousness of acts and their consequences is broken up.
The strong probability is that these trance blanks begin
in short periods of unconsciousness, which lengthen with
the degeneration and mental feebleness of the person.
The obscurity of these conditions, and the incapacity of
the victims to realize their import, also the absence of
any special study, greatly increases the difficulty. It will
be evident from inquiry that trance states among inebriates
are common, but seldom attract attention, unless they
come into legal notice. ‘The practical question to be
determined in a given case in court is the actual mental
condition of the prisoner, who claims to have no recollec-
tion of the crime. ‘This is a class of evidence that must
be determined by circumstantial and collateral facts,
which require scientific expertness to gather and group.
The court can decide from the general facts of the crime
and the prisoner whether his claim of no memory may
possibly be true, and order an expert examination to
ascertain the facts. This should be done in all cases
where the prisoner is without means, in the same way that
a lunacy commission is appointed to decide upon the in-
sanity. The result of this expert study may show a large
preponderance of evidence sustaining the claim of no mem
ory, or the opposite. If the former, the measure of the
responsibility must be modified, and the degree of punish-
ment changed. While such cases are practically insane
at the time, and incapable of realizing or controlling their
acts, they should be kept under legal and medical surveil-
lance for a lifetime, if necessary. Such men are danger-
ous, and should be carefully watched and deprived of
their liberty for a length of time depending on recovery
and capacity to act rationally and normally. ‘They are
dangerous, diseased men, and, like victims of contagious
disease, must be housed and treated.
The future of such cases depends on the removal of
the causes which made them what they are. The possi-
bility of permanent restoration is very promising in most
cases. How far alcoholic trance exists in criminal cases is
unknown, but the time has come when such a claim by
criminals cannot be ignored, and must be the subject of
serious inquiry. Such a claim cannot be treated as a
mere subterfuge to avoid punishment, but should receive
the same attention that a claim of insanity or self-defence
would. This is only an outline view of a very wide and
most practical field of medico-legal research, largely un-
known, which can be seen in every court-room of the land.
These cases appeal to us for help and recognition, and
the highest dictates of humanity and justice demand of
10
us an accurate study and comprehension of their nature
and character. |
The following summary of the leading facts in this
trance condition will be a stand-point for other and more
minute investigations :
1st. The trance state in inebriety is a distinct brain con-
dition, that exists beyond all question or doubt.
2d. This brain state is one in which all memory and
consciousness of acts or words are suspended, the person
going about automatically, giving little or no evidence of
his real condition,
3d. The higher brain centres controlling consciousness
are suspended, as in the somnambulistic or hypnotic state.
The duration of this state may be from a few moments
to several days, and the person at this time may appear
conscious and act naturally, and along the line of his or-
dinary life.
4th. During this trance period crime against person or
property may be committed without any motive or apparent
plan, usually unforeseen and unexpected. When accu-
rately studied such a crime will lack in the details and
methods of execution, and also show want of conscious-
ness of the nature and results of such acts.
5th. When this condition passes away the acts and con-
duct of the person show that he did not remember what
he had done before. Hence his denial of all recollection
of past events, and his changed manner, confirm or deny
_ his statements.
6th. When such cases come under judicial inquiry the
statement of the prisoner requires a scientific study before
it can be accepted as a probable fact. It cannot be sim-
ulated, but 1s susceptible of proof beyond the comprehen-
sion of the prisoner.
7th. In such a state crime and criminal impulses are
the result of unknown and unforeseen influences, and the
person in this condition is dangerous and an irresponsible
madman. :
8th. This condition should be fully recognized by court
and jury, and the measure of responsibility and punish-
ment suited to each case. ‘They should not be punished
as criminals, nor should they be liberated as sane men.
They should be housed and confined in hospitals.
FLAT-FOOT, OR PES VALGUS ACQUISITUS.
By JAMES K. YOUNG, M.D.,
YHILADBLPHIA.
INSTRUCTOR OF ORTHOPEDIC SURGERY, UNIVERSITY OF PENNSYLVANIA ; ATTEND-
ING ORTHOPADIC SURGKON, OUT-PATIENT DEPARTMENT, UNIVERSITY HOSPITAL,
ETC.
THE orthopedic surgeon is frequently consulted about a
painful deformity of the foot which, as an acquired affec-
tion, is very common, and, as such, has not generally re-
‘ceived the attention it deserves. It is the so-called “ flat-
foot,” or talipes plantaris.
Flat-foot is characterized by a falling down or giving
way of the normal plantar arch, so that the inner side of
the sole rests upon the ground, or is turned completely
backward. It has been variously described as talipes val-
gus, pied-bot valgus of the French, and platt-fuss of the
German writers. Like other forms of talipes or club-foot,
it may be either congenital or acquired. As a congenital
affection, in its mildest form it is often found at birth, but
seldom in such a degree as to be considered pathological.
It is, moreover, a well-accepted fact that all infants on
commencing to walk are flat-footed, and do not acquire a
perfect plantar arch until they have exercised some time
and the leg-muscles have become developed. l
It is most common as an acquired affection from in-
fancy to adolescence, seldom becoming a serious deform-
ity until the latter period, and always occurring in one
of two forms, as pes valgus paralytica, resulting from
poliomyelitis anterior; or as pes valgus acquisitus, from
simple muscular relaxation, as associated with rachitis; or
as a sequala of burns, traumatism, osteitis of the tarsus,
or ankle-joint disease.
THE MEDICAL RECORD.
-alus and ankle-joint.
[July 6, 1889
It may be instructive here to review briefly the anatom-
ical construction and mechanism of the natural foot.
The foot includes all that portion of the inferior extremity
below the tibio-tarsal articulation consisting of the tarsus,
metatarsus, and phalanges, and in the adult has the form
of two arches, an antero-posterior and a transverse, each
with its convexity or dorsal surface above, and its con-
cavity or plantar surface below.
The antero-posterior, the most important, is supported
upon two piers or pillars, and has its summit at the astrag-
This has been still further divided
into two arches, an outer and an inner, by an imagi
line drawn posteriorly between the third and fourth meta-
tarsal bones. The inner portion of the antero-posterior
arch is much more curved than the outer, and forms the
instep.
The posterior pier, formed by the posterior parts of the
astragalus and os calcis, is shorter, more curved, has but
one joint, and is more solid, receiving the greater part of
the weight of the body. The anterior pier, composed of
the scaphoid, three cuneiform, and three inner metatarsal
bones, is longer, less curved, has many joints, and is more
elastic, serving to diminish the force of shocks transmittéd
to the arch. The head of the astragalus, fitting into the
concave surface of the scaphoid, and its postero-inferior
surface, articulating with the anterior surface of the os
calcis, may be regarded as the keystone, though differing
in many respects from such bodies as usually employed.
The weak part of the arch is strengthened by the inter-
osseous ligaments, particularly the inferior calcaneo-sca-
phoid, which supports it from below, while beneath the
inner portion of the plantar fascia adds additional strength.
The outer portion of the antero-posterior arch consists of
the outer portion of the os calcis, cuboid, and the two
outer metatarsal bones. It is strengthened by the calca-
neo-cuboid ligaments and the outer portion of the plantar
fascia. Both arches are still further maintained by the
tibialis posticus and peronei muscles, particularly the P.
longus. The transverse arch, formed on the inner and
outer sides by the bones entering into the inner and outer
antero-posterior arches respectively, varies in degree of
curvature in different portions of the foot, being most
marked across the cuneiform bones. It affords protection
to the soft parts of the sole, and adds to the elasticity.
The weight of the body is received by the astragalus as
the highest part of the arch, and transmitted to the ground
through the two piers of the antero-posterior arches. The
foot in extension rests normally upon the heel, the tips of the
metatarsal] bones, and the outer side of the sole, the weight
of the body in standing, walking, running, or dancing be-
ing transmitted through the heel, the ball of the great toe,
and that of the little toe—the natural tripod of the foot
—in the order named.
Thus the direction of the weight upon the arches is
constantly changing, and it is only through the action of
certain muscles that the normal arches are conserved.
Thus in flexion the antero-posterior arch is increased by
the action of the tibialis anticus, peroneus tertius, and
extensor longus digitorum ; and in extension, by the ac-
tion of the gastrocnemius, soleus, plantaris, and peroneus
longus, both the curves are diminished, and the foot flat-
tened. ‘Then, also, when the foot is markedly flexed the
foot 1s adducted, and when markedly extended it is ab-
ducted, in which positions the arches are respectively in-
creased and diminished. In this connection, Mr. Le Gros
Clark says: “ In reviewing the action of the various mus-
cles around the foot, it is obvious that their attachment
is designed to preserve the plantar arch, and that such
healthy condition must depend in great measure on the
evenly balanced action of those muscles upon their several
attachments. Thus the peronei and tibial muscles antag-
onize each other, and the expanded insertion of two of
them into the tarsal bones is very instrumental in preserv-
ing the transverse as well as the antero-posterior arch.”
Three degrees or stages have usually been recognized,
a mild. an intermediate, and a severe stage. ‘Thus Lit-
July 6, 1889]
tle ' describes three varieties, of increasing intensity: rst,
those “in which the displacement is transient during the
erect position only ;” 2d, those “in which the displace-
ment is permanent, and deformity is present ;” and, 3d,
those characterized by an aggravation of all the symptoms,
to a marked degree.
A very good division, also, is that of Roth,’ who de-
scribes three varieties: “ (1) Cases in which it is possible
to restore the foot completely to the normal shape by
passive manipulation, . without any force exerted by the
surgeon, or by making the patient stand with the heels
raised ; (2) cases where the tarsal bones have become
more or less fixed in their displaced positions by shortened
ligaments and tendons, osseous deformity of the articula-
tion surfaces, and fibrous or osseous anchylosis, which re-
quire forcible manipulation under anæsthetics to restore
more or less of a normal arch ; (3) intermediate cases, in
which a partial restoration of the tarsal arch is possible
without drisement force.”
The division, however, which I prefer is that into, rst,
slight; 2d, medium; and, 3d, severe; which corresponds
to that of - Reeves.’
Numerous theories have been advanced as to the mode
of production of flat-foot. The muscles, tendons, liga-
ments, bones, fascias, and even an improper mechanical
construction, have each been considered the chief factors
in its production.
Thomas, of Liverpool, and Roth,‘ of London, believe
that the normally constructed human foot is incorrect an-
atomically, because “ the lower end of the tibia is placed
too much toward the inner border of the foot,” and that
this is the primary cause. Stromeyer* believed that
atony of the plantar fascia, and the tarsal interosseous
ligaments were at fault.
H. von Meyer ° considered it due to a rotation of the as-
tragalus inward, and pressure atrophy of the bones; while
Reismann‘ considered it due to muscular contraction, first
of the extensors and then of the pronators; but Volkmann
and Lorenz" have disproved this, the latter supporting
the view of Henke,’ who announced that muscular insuffi-
ciency and body pressure were the chief factors; an ex-
planation first proposed by Duchenne (of Boulogne), who
considered the peroneus longus particularly at fault.
Of these theories the last has always appeared to me
the most satisfactory, that it is a muscular affection from
the first. Thus muscular relaxation, either from debility
or paralysis of the peroneus longus, leads to an improper
distribution of the body-weight upon the tarsal arches,
which, by undue pressure upon the interosseous ligaments,
especially the inferior calcaneo-scanhoid and calcaneo-
cuboid ligaments and plantar fascia, induce their sub-
sequent relaxation, stretching, and obliteration of the
normal arch.
The symptoms differ in the two varieties—pes valgus
acquisitus and pes paralytica—but in each are character-
istic; but it is more particularly with the former—the so-
called “ splay foot,” “ talipes valgus spurius,” “ inflamma-
tory flat-foot,” or “ tarsalgia of adolescents,” with which
we are concemed.
Patients suffering from this affection have an attitude
and walk that is characteristic. They stand with the
feet everted, resting on the inner side of the sole, with the
knees in a fixed valgoid position, and walk with a difficult,
heavy gait, the knees flexed and the feet placed everted
and flat upon the ground in an uncertain, careful manner.
Such patients have an expression of anxiety, tire easily,
1 Little: On Deformities, 2d edition, p. 233. London, ace
2 Roth: New York MEDICAL RECORD, March, 1888, p. 51.
? Practical Orthopzdics, 1885, p. 185.
‘New York MEDICAL RECORD, March, 1888, p. 53; also Lat.
Curv., etc., H. K. Lewis, London, 1889.
5 Beitrage zur operativen Orthopadik, 1838.
* Ursache und Mechanismus der Enstelung des erworbenen Platt-
fusses, 1883.
7 erworbene Plattfuss, Langenbeck's Archiv, B. 2, Heft 3,
I
* Die Lehre vom erworbenen Plattfusse, 1883.
* Zeitschrift fir rationelle Medicin, 3d series, vol. v., 1859.
THE MEDICAL RECORD. TI
and complain of great pain of a dull, aching character,
or sharp, excruciating in nature, about the inner malleo-
lus, instep, or ball of the great toe, accompanied in some
cases with swelling. On inspection the external appear-
ance varies with the degree. .In the mild variety the
plantar arch is depressed, the inner malleolus lowered and
prominent, the foot is cold, bluish, and perspires freely,
and an outline taken to ascertain the angle of deflection `
is found reduced from thirty-four degrees normal to about
twelve degrees in mild, to eight degrees in severe cases.
The patient cannot raise himself on his toes, but the
deformity can be readily restored by manual pressure.
In the medium variety all these conditions are exagger-
ated, the foot is completely flattened and somewhat
everted, the inner side presents two prominences below
and anterior to the internal malleolus, the head of the
astragalus, and the tubercle of the scaphoid; and on
taking an outline the angle of deflection is found reduced
to probably eight degrees. ‘The pain is common about
the inner lower portion of the astragalus, and may be so
severe as to render exercise intolerable. The arch can
still be restored, and the deformity is not prominent.
In the severe variety the foot is more everted, making
an angle of deflection in severe cases as low as five de-
grees. ‘This is due to functional paresis of the pero-
neus longus, and increased reflex contraction of the
peroneus brevis, tertius, and extensor communis digi-
torum. The pain is increased by the unbalanced action
of muscles, giving a painful spot at the base of the first
metatarsal bone, by the direct pressure upon the liga-
ments, giving a point over the calcaneo-cuboid and astrag-
alo-scaphoid articulations, and from direct pressure upon
the plantar nerves referred to their distribution. Fibrous
and osseous changes have occurred, and the arch cannot
be restored without some operative procedure.
The pathology of the affection was for some time ob-
scure, especially the non-paralytic valgus, it being sup-
posed at one time to be inflammatory. Such cases have
frequently been mistaken and actively treated for inflam
matory lesions of the bones or ligaments ; complete in-
flammation with effusion of lymph, serum, or pus, never,
however, occurs. All the inflammatory symptoms are
simply the result of pressure.
The extensors, particularly the peroneus longus, from
some cause become relaxed. This is followed by stretch-
ing and elongation of the plantar muscles and tendons,
the long and short plantar ligaments, the calcaneo-cuboid
and astragalo-scaphoid ligaments, and the plantar fascia,
and a giving way of the inner antero-posterior arch. The
astragalus is pushed downward, forward, and inward ; the
scaphoid is rotated, the internal surface downward and
the external surface upward; the ligaments, generally on
the inner and plantar surfaces of the bones, are stretched,
the joint surfaces separated on the plantar and crowded
together on the dorsal aspect. This may become so
great that the bones entering into the medio-tarsal
(Chopart’s) joist divide, the anterior portion resting
upon the ground and the posterior portion drawn up by
the extensors so that the heel does not touch the floor,
making the so-called ‘‘ canoe-shaped sole.” ‘The articular
surfaces become eroded from the continued pressure, and
osseous anchylosis renders the deformity permanent. The
diagnosis in many cases can readily be made, but in others,
especially the inflammatory variety, with which we are
most concerned, very careful attention will be required ts
avoid confounding it with other conditions.
From the congenital forms of valgus it can be dis-
tinguished by the latter being always bilateral and the
“peroneus responding to electrical stimulus. (The slight
normal tendency to flat-foot observed in infants has
already been referred to.) Its occurrence about the
period of adolescence, the previous history of rheumatism,
knock-knee, bow-legs, lateral curvature, traumatism, bone
or joint disease, should all be carefully inquired into.
1 Rohmer: ‘Les Variations de Forme normales et pathologi.jues
de la Plante du Pied. Thèse. Nancy, 1879.
12 - THE MEDICAL RECORD.
[July 6, 1889
It is most commonly mistaken for rheumatism, of
which it may be a sequela, and for inflammatory con-
ditions of the tarsal or metatarsal joints or ligaments. Its
angle of deflection, determined from the outline, will be
the best single symptom to distinguish it from the former ;
and the same with reflex muscular contraction, or a col-
lection of inflammatory fluid, from the latter.
The lesions from which it would be most difficult to
distinguish it are the early stages of perforating ulcer,
and such neuropathies as Charcot’s joint disease. From
these in the earlier stages a differential diagnosis cannot
be made, but the subsequent course would soon decide
the true nature of the affection.
The prognosis will depend on the cause and general
condition and surrounding of the patient, and degree of
the deformity. If advice is sought early, and the disease
is still in the first or even second degree, the prospects,
under appropriate treatment, of great improvement or
even complete cure are good. Certainly entire relief
of pain may be expected. If, however, ligamentous or
osseous anchylosis have occurred, some relief may yet be
hoped for, but resort must be had to brisement forcé, or
tarsectomy, before the deformity can be overcome.
The treatment of pes valgus acquisitus varies with
its cause and degree. Any diethetical tendency must
be corrected by appropriate remedies. The mild va-
rieties yield readily to the use of electricity to the af-
fected muscles, massage, and removal from the exciting
cause, with properly fitted metallic sole plate. For this
purpose numerous devices have been recommended—
pads of leather, felt, rubber, and other material attached
to the inner or outer side of the sole, steel bars, springs,
etc., added to specially constructed shoes, etc. I have
attained the best results with the improved plate spring
of Dr. A. Sydney Roberts, figured in Medical and Sur-
gical Reporter for April 6, 1889. It consists of a tem-
pered steel plantar spring so constructed as to supply an
artificial arch.. )
In describing it, ' he writes :
“ An outline of the patient's foot is first taken on stencil-
board, the tracing being extended upward on the inner
side of the foot. The elevated, corresponding to the
depressed, arch of the foot, can be tempered to the ex-
tent required by the particular case. The lateral pres-
sure brought to bear by the elevated flanges is such that,
while giving support to the arch to a certain extent,. the
artificial arch also prevents further displacement of the
astragalus and scaphoid. Again, in place of giving only a
limited amount of support to the inner side of the foot,
this appliance supports the foot as a whole.”
After the use of this spring in upward of sixty cases, in
hospital and private practice, I am much gratified with
the results obtained.
In severe cases, after the restoration of the arch by
Operative measures, the spring may with advantage be
su plemented by an ankle support—two lateral steel up-
rights connected with a band extending to the calf, and
an internal oval ankle-pad over the medio-tarsal articula-
tion.
As a symptomatic condition in osteitis of the tarsus
and ankle-joint disease, the valgus generally yields to the
treatment employed for the primary osseous or articular
lesion. |
In severe cases, before resorting to extreme operative
measures, all contracted tendons should be divided.
Those most frequently requiring division will be the
tendo Achillis, peronei, and extensor longus digitorum,
and they are best divided into two stages—the peronei and
extensor longus digitorum, first, to correct the valgus,
and the tendo Achillis subsequently, to correct the equi-
nus, which in severe cases is present. Failing in the
worse cases to restore the arch by such means, accom-
panied with manual force—brisement forcé, with either
a Bradford or Thomas wrench, should be attempted, and,
1 Medical and Surgical Reporter, vol. ix., No. 14, p. 420.
as a last resort, Ogston’s’ operation should be resorted
to ; or, if much anchylosis be present, a regular tarsectomy,
1.¢., removing a wedge-shaped piece of the tarsus from the
inner side of the tarsus without reference to the bones or
portions of bones removed, and the restoration of the
foot. These severe operations should only be resorted to
when milder measures, after due trial, have failed; for
comparative reliet will, in the greater majority of cases,
be obtained by the milder remedies in about six or eight
weeks, whereas several months are required after any cut-
ting operation upon the tarsal bones.
222 SOUTH SIXTEENTH STRERT.
Clinical Department.
HYSTERECTOMY FOR LARGE FIBROMYOMA.
By D. BENJAMIN, M.D.,
SURGEON TO THE COOPER HOSPITAL, CAMDEN, N. J.
H. M——, aged thirty, living in the southern part of New
Jersey, came to me, March 24, 1888, suffering from a large —
abdominal tumor which, she stated. her physicians called an
ovarian tumor. I obtained the following history: Her
mother died of erysipelas; one sister died with cerebro-
spinal meningitis. Patient’s past condition was stated to
have been moderately healthy until last summer, when
she commenced to lose flesh; at this time there was
noticed a slight enlargement of the abdomen, which was
attributed to dropsy. In October, 1887, she was examined
by a physician, who stated that there was a tumor in the
left ovarian region, then about the size of a fist. Two
months afterward she was subjected to another examina-
tion, and the tumor was found to have increased in size
to that of a child’s head. No history of any injury to
this region could be obtained. Her menstrual flow had
been regular, sometimes profuse ; had skipped one month,
which she attributed to a cold. She began to suffer from
vomiting, and constipation, and occasional abdominal
pains ; these symptoms had constantly grown worse, until
almost every meal was vomited, and constipation became
more and more obstinate, so that powerful purgatives had
to be administered, but were losing their effect, and symp-
toms of obstruction were becoming marked.
She had lost fifty pounds in weight within a few months,
but as she had been previously inclined to embonpoint,
her emaciation was not extreme. On palpation through
the abdominal wall, the tumor appeared symmetrical and
mobile; did not feel so hard as is common with fibroid
tumors, nor so soft as a cyst; was not nodular, and felt
very much like a pregnant womb in the early part of the
ninth month. Fluctuation could not be positively demon-
strated. Percussion sound dull, except a small area in
each flank.
Vaginal examination showed the cervix drawn up, and
an enlargement in Douglas’ pouch about the size of a
retroverted womb. Rectal touch gave no additional in-
formation. A flexible urethral sound passed into the os
uteri about two inches, taking a forward direction. Preg-
nancy having been eliminated by the examination, a diag-
nosis of solid, or semi-solid tumor involving the womb
could be made, but the exact relation of the ovaries to
this tumor was not clear, and exploratory incision was
advised, with a view of ascertaining the exact relation of
the tumor to the pelvic organs, and the possibility of “its
removal, with the understanding that any beneficial opera-
tion that would seem feasible should be proceeded with.
Accordingly, March 2gth, patient was etherized; the
usual incision was made in median line. ‘The tumor was
wedged so tightly in the superior strait of the pelvis, that
only one ovary could be reached—the left, which was en-
larged. Adhesion being slight, the incision was extended
upward, with scissors, sufficiently to enable the upper part
1 London Lancet, January 26, 1884.
July 6, 1889]
of the tumor to be reached, which was free, but in contact
with the stomach and liver.
The incision was then extended upward and downward
sufficiently to enable the tumor to be delivered forward
through the abdominal incision. The right ovary was
found crowded down into Douglas’ pouch, and was en-
larged to about the size of a hen’s egg, and roughened on
the surface. The nght Fallopian tube was much enlarged,
and the left tube was about double the normal size, and
adherent. Both ovaries, and both Fallopian tubes were
carefully ligated and cut away. ‘The exact relation of the
base of the tumor to the womb could now be clearly
mace out, and it was apparent that room enough could
be made above the insertion of the vaginal wall, into the
cervix, to remove the tumor and body of the womb with-
out necessanly wounding the ureters, bladder, or other
pelvic organs. I then determined to remove the entire
tumor and womb, since to return it to the abdominal
cavity would have been to have left the patient in almost
as bad a condition as before the operation, with respect
to the obstruction and other difficulties which the tumor
caused, and at the same time be little less dangerous to
the patient’s life than complete hysterectomy. I then car-
ried the incision downward as closely to the pelvic bone
as the bladder would permit, ligated each of the round
ligaments in two places, and cut between, applied Koe-
berle’s clamp, and cut away the tumor. The stump was
at least three inches in diameter. The tumor was about
thirty inches in circumference. After all bleeding points
had been properly secured, and all clots removed from
the abdominal cavity, the bowels and peritoneum were
thoroughly washed off. The omentum, which had been
lying on a towel, was returned and arranged over the
bowels. The pedicle was fixed in the lower angle of the
womb, and the incision closed with silk sutures at inter-
vals of less than half an inch. Wound was dressed anti-
septically, and the patient placed in bed.
The patient constantly improved without any untoward
symptoms, and was discharged in six weeks after the
operation. The clamp came off on the twenty-third day.
The patient has not vomited since the operation, and has
had no pain. All functions are normal. She states that
it is the first time she has felt well in four or five years.
In determining the value of the operation of hysterec-
tomy to humanity, it is important that all cases should be
reported, as I found the literature on the subject so
meagre at the time of the above operation, that reliable
data could not be obtained in this country. The opera-
tion has never, so far as I can learn, been performed in
New Jersey; butas hysterectomies are becoming more
frequent and successful, ample statistics will soon be
forthcoming.
A CASE OF STRANGULATED HERNIA MIS-
TAKEN FOR ONE OF UREMIA IN A PA-
TIENT KNOWN TO BE SUFFERING FROM
CHRONIC INTERSTITIAL NEPHRITIS—AU-
TOPSY. |
By FREDERICK REMINGTON, M.D.,
ROCHESTER, N. Y.
N. F—, sixty years of age, married and housekeeper
by occupation, entered the Monroe County Insane Asylum
suffering from chronic mania. The family and personal
histories were negative; the habits unknown; and the
previous health good. She was well developed and nour-
ished. Heart enlarged to left. Accentuation of second
aortic sounds. Some cedema of hands and feet and some
puffiness of eyelids. Examination otherwise negative.
Urine—Amount varied from 70—go ounces in 24 hours.
Specific gravity, 1.010-1.008. Albumin ras of one per
cent., and the sediment contained a relatively large num-
ber of small hyaline and fine granular casts. During the
patient’s stay in the asylum she frequently suffered from
slight urzemic attacks, as was evinced by some cedema of
THE MEDICAL RECORD. : 13
feet and eyelids, vomiting, and vertigo. From these at-
tacks she usually recovered after a rest of a day or two in
bed.
The patient’s appetite had been poor for several days,
and she had been losing weight rapidly. One day she
had some swelling of feet and vomiting; there was also
diarrhcea. Morphine, gr. + by stomach, was given to re-
lieve the vomiting. ‘The urine was passed involuntarily
and its amount cannot be estimated. During the next
two days the patient’s symptoms grew rapidly worse, and
she died three days later at noon. No new symptoms
having developed.
Autopsy.—The heart-walls were greatly thickened, and
showed evidence of granular- degeneration. There was
calcification of the aortic flaps. The mitral orifice ad-
mitted five, and the right auriculo-ventricular seven,
finger-tips. The weight of the heart was twenty-two
ounces.
The kidneys were decreased in size, their surface was
uneven and capsule adherent; surface granular; cortex
is very much decreased and dense on section ; pyramids
injected ; weight of both kidneys five ounces.
Projecting through the internal inguinal ring on the
right side, into the inguinal canal, there was a hernia
of the middle portion of the small intestine. The intes-
tines were agglutinated to the hernial sac. ‘The included
knuckle of gut was gangrenous and leathery, and easily
broken through. ‘The hernial sac contained about two
ounces of a yellowish stercoraceous material. It was im-
possible to reduce the hernia. Below the constriction,
the intestines were empty, while above they were filled
with gas and semi-fluid, yellowish, not especially feculent,
fæces. ‘There was absolutely no tumor produced by the
hernia, and there was no symptom which was not in
keeping with a urzemic attack. Of course, the patient was
unable to give satisfactory subjective symptoms, and under
the circumstances a more rational conclusion could not
have been arrived at than the opinion formed by everyone:
who saw her, that she was suffering from uremia.
SUBCORACOID DISLOCATION OF THE HU-
MERUS REDUCED BY KOCHER’S METHOD.
Dr. S. W. BOERSTLER, of Lancaster, O., writes: “ P.
M—, a stout, muscular man; was brought to my office
with a subcoracoid dislocation of the left humerus, pro-
duced by a fall on the hand and forearm, a few hours be-
fore I saw him. Several attempts at reduction had been
made by manipulation, extension outward and down-
ward with the heel in the axilla, but all failed. Having
read the account of Kocher’s method in THE MEDICAL
Record of March 3oth, by Dr. Charles Powers, of New
York, I concluded to give it a trial. ‘The patient was
placed on the floor, the well shoulder steadied by an as-
sistant, and the position of the arm, with the different
movements as shown in Dr. Powers’ article, strictly carned
out. The first attempt was successful, and those present,
as well as myself, were astonished with what ease and
facility the reduction was accomplished. I had never
heard of Kocher’s method, and I believe it is not generally
known to the profession. Our text-books on surgery do |
not speak of it. Hamilton, in his work on ‘ Fractures and
Dislocations,’ recommends reduction by manipulation, but
the different movements of the arm are unlike those of
Kocher. This simple, easy, and effective procedure, I
advise every one to try who may have a case of subcora-
coid dislocation. It is unnecessary to aneesthetize the
patient.”
THE BROOKLYN ACADEMY OF SCIENCE, a society incor-
porated August 22, 1888, has opened a free reading-room
in its rooms in Warner Institute, Willoughby Avenue
and Broadway, Brooklyn. The various scientific journals
will be upon the tables, and there is absolutely no charge
to the public. Donations of papers will be greatly ap-
preciated.
14 : THE MEDICAL RECORD.
[July 6, 1889
THE MEDICAL RECORD:
A Weekly Fournal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., EDITOR.
PUBLISHED BY
WM. WOOD & Co., Nos. .56 and 58 Lafayette Place.
New York, July 6, 1889.
THE WORKINGS OF THE LAW AGAINST
SUICIDE.
Does prohibition prohibit? is a question frequently asked,
in these days, by those interested in temperance matters,
and is variously answered according to the bias of the one
to whom it is addressed. A similar question was pro-
pounded a few years ago when a law was passed in this
State making suicide a crime, and many inquired, doubt-
ingly, whether the attempted prevention of suicide would
prevent it. If it is allowable to form a conclusion from
the statistics of suicide in this city, we might say that it
does prevent, or rather restrict, self-murder. Previous to
the enactment of this law the average number of suicides
in New York City was 144 per 1,000,000 inhabitants, and
since that time, although there has been an increase in
the number of suicides, the increase has not been in pro-
portion to the growth of population, so that, relatively,
tnere has been a slight falling off.
The punishment prescribed for attempted suicide is
not very severe, and would not be likely to deter one who
was really bent on self-destruction. The section of the
Penal Code bearing upon this point reads as follows:
‘Every person guilty of attempting suicide is guilty of a
felony, punishable by imprisonment in State prison not
exceeding two years, and bya fine not exceeding one
thousand dollars, or both.”
Tne fact that such a mild penalty has had the effect of
reducing the number of suicides relatively to the popula-
tion suggests the query whether, in a certain proportion of
cases, the success of a suicidal attempt is not accidental ;
whether of those that perish a certain number did not
make a feint at suicide without really intending or wishing
to end their lives, led to their foolish act perhaps by a
desire to create sympathy, or in the hope of calling back
an offended lover, the feigned attempt becoming, unfort-
unately, only too real in its fatal issue. This supposition
is strengthened somewhat by the statistics of the Board of
Health in respect tothe class in whom the greatest
falling-off in suicide has been noted. It is shown that
the decline is most notable in women, and it is among the
weaker ones of this sex that we would most naturally look
for these pretended attempts at self-destruction. Having
no intention of killing themselves, they would be more
likely to be deterred from making a pretence of so doing
by the threat of a punishment held over them, whereas
those who really wished to end their existence would be
little influenced by a penalty which they would take care
to escape by insuring a successful termination to their
attempt.
THE LESSONS TAUGHT BY RARE DISEASES.
A VERY instructive address was recently delivered by
Jonathan Hutchinson (Lancet, May, 1889) before the
Medical Society of London, in which he urged upon his
hearers the importance of careful and systematic study of.
rare diseases. There are no isolated maladies, all diseases
are the result of pathogenetic influences, and careful study
will often show the relation between widely differing ap-
pearances. A large number of diseases ranked as “rare ”
are simply exaggerated or overgrown examples of those
which are common—more striking, it is true, but present
ing nothing really novel. The zeal which we often -vitness
for “nominal” diagnosis, the anxiety to place every case
under some recognized name, leads sometimes to forget-
fulness of the fact that the nature of the disease is of far
more real importance than its name. In the early stages
of most maladies, the ulterior development is by no means
certain, but depends rather upon the—as yet undeter-
mined— incidence of a variety of contributory causes. It
is not the fact that the human body is ever taken posses-
sion of by some seed-like principle, destined in future in-
fallibly to evolve a certain definite form of disease. The
form which results is the outcome of a complex chain of
causes. The order of events which has in any given case
ended in the production of certain of these rare maladies,
might have failed at any point, or might have been broken
by art.
As illustrations of this truth, he cites a number of in-
teresting diseases. ‘The starting eyes, the throbbing caro-
tids, the swollen thyroid, the irritable heart, the general
failure of strength in exophthalmic goitre, mark the ex-
treme development of the disease ; but every day we see
women with failing health, and irritability of circulation
in head and neck—shown by want of control of temper
and proneness to flushing—who, in all probability, are suf-
fering from the same disease in its mildest form. Change
of climate is, probably, the only specific: in the former
case, giving the greatest relief to symptoms, in the latter,
cutting the disease short in its earliest stages.
In myxcedema, we have a slowly insidious change in
structure, pervading almost all parts, and leading, without
any tendency to spontaneous amelioration, to gradual ab-
olition of all the higher endowments of humanity, and,
finally, to destruction of life itself. But who does not
see frequently in the flabby, thickened skin, the feature-
less face, the general obtunding of intellect of certain
patients, the milder forms of this disease, which, we may
be tempted to suspect, is, in reality, but one of the ordinary
forms of premature senility to which many women are, to
a greater or less degree, liable.
While some of the diseases accounted rare are simply
exaggerated specimens of what is common, it is also true
of others that they reveal individual idiosyncrasies of ex-
aggerated intensity. In xeroderma pigmentosum, for ex-
ample, the affected children are born with apparently
healthy skins, but in a few years freckles develop on ex-
posed parts in a most unusual degree, and these may
coalesce, become inflamed or ulcerated, destroy the feat-
ures, produce neoplzsms, or even become cancerous.
July 6, 1889]
But this disease is essentially the same as common freck-
lng, only intensified by the family peculiarities of the
patient.
This doctrine of exaggeration, as explanatory of rare
diseases, is very well illustrated by the phenomena of Rey-
naud’s disease. All the changes that are essential to it
are experienced by the person who gets a “ dead ” finger
from keeping his hand in cold water, or a blue nose from
exposure to a cold wind.
Again, xerostoma is but a more pronounced and per-
sistent example of that temporary dryness of the mouth
which is so often induced by emotion.
In one case under his own observation, a patient, after
an ordinary operation for piles, had immediate, complete,
and permanent paralysis of the anus and urethra. In his
opinion similar disabilities of the rectum and bladder cen-
tres, in less degree, occur in all cases of retention after
operations.
It is important that we should understand that no dis-
eases are unique. When like causes are brought to bear,
like results must necessarily ensue. If we but look around
us enough, and reflect upon what we see, we shall discern
the great laws which underlie all disease processes. ‘The
transformation of the “ black freckles” of the aged into
cancer and similar phenomena but illustrate two great
laws—that in the piocesses of old age, all local disturb-
ances tend toward cancerous action, and that the precise
form of malignancy will depend on the tissue attacked.
In this connection, the condition termed “ granuloma
fungoides ” deserves mention. ‘The skin is first attacked
by inflammatory thickening, and then, gradually, large
fungating growths develop, which are in all clinical feat-
ures malignant, and which cause the patient’s death.
These are neither epithelial nor sarcomatous, but seem to
be connecting links between inflammatory and truly ma-
lignant affections. Some of them may possibly have de-
rived their peculiarity in the first instance from individual
idiosyncrasy as regards drugs.
Several of the many rare diseases quoted in his address
illustrate strikingly, in his opinion, the important doctrine
that all inflammatory products are infective, much in the
same way that the products of malignant growth are so;
and further, that the process of malignant new-growth is,
after all, nothing but a modification of that of chronic
inflammation.
THE TRUE STATUS OF HOMCEOPATHY.
THe New York Graphic recently wandered from the easy
paths of contemporaneous picture-making, and made some
remarkable statements regarding the status of homceopa-
thy. Commenting on Professor H. C. Wood's address at
the Yale Medical School, it says: “ At atime when quite
one-half of the medical practice of the world is governed
by the philosophic discoveries of Hahnemann, it seems
something more than an anachronism to have a member
of the Faculty of the Pennsylvania’ University stigmatize
homoeopathy as quackery on the plane of faith-cure.”
The Graphic critic adds: “ Considering that there are
monuments to Hahnemann, the discoverer of homceopa-
thy, in many of the great cities of Germany—that the
science he taught is a recognized branch in most of the
great medical schools in Europe, Professor Wood's ex-
traordinary doctrine, must be regarded as the zeal of igno-
THE MEDICAL RECORD. 15
rance and does no credit to the great university he com-
promises by such intemperate judgment.”
Such stupid and blundering criticism as this is of im-
portance and interest only as it shows how prevalent is the
ignorance regarding the true status of homceopathy even
among men who are undoubtedly well-informed as to the
world’s progress in most directions.
The facts are simply these. In the United States there
were in 1885 twelve homceopathic and eighty-eight regular
medical colleges with one thousand and eighty-eight and nine
thousand four hundred and forty-one students, respectively.
At the most liberal estimate the homeeopathic practition-
ers of this country form one-eighth of the total number.
There is no homceopathic medical college in the country
which can be said to be even fairly well equipped and
endowed, as compared, for example, with the leading
regular medical colleges of New York, Boston, and
Philadelphia. The only school which really flourishes
numerically is in Chicago. |
The statement that “homceopathy is a recognized
branch in most of the great medical schools of Europe”
is absolutely untrue. Homoeopathy has no place what-
ever in any of the universities of Germany or France, nor
has it a school of its own anywhere in Germany. There
is a small homceopathic hospital of one hundred beds in
London, with a small medical school attached.
‘There are said to be only about two hundred and
seventy-five homceopathic physicians in all Great Britain
and Ireland. ‘The number on the Continent is proportion-
ably even less.
OLD-TIME FEES.
THE recent centennial celebration of our city seems to
have stimulated considerable delving into the past, and
medical matters have had their share of investigation.
Chiefly among these, aside from the questions of modes
of prescribing and treatment, fees have claimed no little
attention. One fact, at least, is patent, that, as a rule,
they have not increased, and in very many instances have
perhaps fallen below the stationary plane. At best, to
the general practitioner, upon whom the burthen of earnest
and continuous work mostly falls, the consideration of
what is a proper recompense for services is of paramount
interest. For his consolation, we may say that in the
golden days of our continent medicine, no more than
theology and law, yielded no princely incomes. Perhaps
medical societies here and there may have attempted to
regulate the scale of remuneration by imposing rates with
carefully shaded details, but these were not uniformly
operative, and very likely represented only the maximum.
The ancient practitioner, almost invariably “ expected to
be at home very shortly,” dealing with long distances and
precarious meals, and facing storms of every derege of
s2verity, even if he charged more than his descendant of
the towns of to-day, was compelled to balance his time
against competition. Then, again, barter more frequently
than money was the basis of settlement, so that shifting
values exercised a baneful influence in more ways than one.
Dr. J. M. Worthington, of Annapolis, Md., has sent to
the writer of “ Medical New York in 1800” a bill of Dr.
James Murray’s against an estate, studded with various
dates from April, 1788, down to its legal settlement in
August, 1790.
16 | THE MEDICAL RECORD.
The comments of our antiquarian friend Worthington
upon this bill will explain themselves. He says, in his
note to Dr. John Shrady, that the said Dr. Murray, who
belongs to the family of that name resident in Maryland
many years before the Revolution, collected about five
dollars for each visit. “ His charges,” says he, “for
compounding prescriptions, from one shilling to seventeen
shillings each, were by no means unreasonable, and yet
they would make the average apothecary of to-day
wealthy, while the patients might be reduced to despair.
As will be seen, all kinds of medicaments figured among
the items of this bill; to wit, pills, powders, boluses, blis-
ters, mixtures, infusions, cordials, purges, decoctions, and
juleps.”
All these things were possible in the days of no coal,
no artificial light but candles, no transportation except by
horse or sail, and no cheap postage ; when, to say noth-
ing about a medical periodical, even a newspaper was a
luxury.
The Dr. Murray to whom allusion is made was a man
of acknowledged social standing, skill, and learning : he
had an extensive patronage among the large land-owners.
The recent Surgeon-General of the Army belongs, as we
are informed, to this stock.
Hews of the Wileek.
AN ACCESSARY THYROID GLAND AT THE BASE OF THE
Toncue.—Herr R. Wolf, of Hamburg, reported a unique
case of this kind. A girl, aged eighteen, otherwise healthy,
complained of a feeling of a foreign body being in the throat.
The speaker found a tumor at the back of the tongue, dif-
ferent in color from the other parts. It was firm and
solid to the touch ; its posterior border was lost in the gul-
let. Treatment with iodide of potash and painting with
iodine was successful at first, but the tumor suddenly be-
gan to grow, difficulty of swallowing came on, and extir-
pation was determined on. He first performed tracheot-
omy, and later on (February 6th) removed the tumor.
The cavity left was filled with a tampon, and recovery
was rapid.
PREVENTING ‘TUBERCULOSIS BY MILITARY ORDERS.—
The German War Minister has decided that the chest of
every soldier shall be examined once a month. If the
chest does not reach a certain breadth and does not de-
velop with drill and athletic exercises, the soldier will be
disqualified, and regarded as being predisposed to phthisis,
and, moreover, likely to infect his comrades.
NoOvEL TREATMENT OF ABDOMINAL ANEURISM. — A
novel procedure has just been attempted by Mr. Keetley
in a case of large abdominal aneurism which is under his
care at the West London Hospital. The tumor, which
mainly occupies the epigastric region, and projects prom-
inently forward, has thrust the liver into the right lumbar
region, and Mr. Keetley, in order to control if possible
the pulsation in the aneurism, devised and carried out the
following procedure. An incision was made below the
ribs on the right side, and the peritoneal cavity opened ;
a specially constructed instrument with a handle, a curved
stem, and a thickened extremity was then passed into the
wound and through the foramen of Winslow, between the
liver and the tumor, and made to compress the aorta
[July 6, 1889
above the origin of the coeliac axis. Upon the first occa-
sion the stem was of copper, and unfortunately bent under
the pressure to whick it was subjected. The operation
was repeated with an instrument constructed of steel. It
was found that the object aimed at could be obtained,
but not entirely. Although the aorta was by this means
partially compressed, it was not- possible to control the
circulation sufficiently to render it justifiable to continue
the attempt.— Medical Press.
IDENTITY OF FUNCTION OF THE Two OCCIPITAL LOBES.
—M. Dupuy has recently shown a patient before the
Société de Biologie who has two good non-strabismic eyes,
but who only sees with one ata time. The moment she
attempts to use both together she becomes very dizzy ;
hence, says M. Dupuy, there must be identity of function
in the visual centres of each cerebral hemisphere. We
do not know that there is any place but the city of Paris
in which it would be necessary to prove so old and wel-
established a fact as that upon which M. Dupuy thinks
he has thrown such brilliant light.
AN ATTEMPT TO ORGANIZE AN INFIRMARY FOR ELEC-
TRO-THERAPY AND ‘“ SUGGESTION-THERAPY ” (Electricity
and Mind-cure) was recently made at Munich, but so far
has not succeeded.
THE MEDICAL ASSOCIATION OF ALABAMA forbids its
members to do contract practice. Dr. W. C. Cross con-
tracted to practise with the Blocton Iron & Coal Com-
pany, and sent in his resignation as a member of the Asso-
ciation. The resignation was not accepted, and Dr. Cross
was dropped for “ unprofessional conduct.” Thereupcn
he sued the Association for $50,000 damages. We trust
that the Association will not be mulcted in so large a
sum ; but it seems from the facts before us as if its action
was decidedly arbitrary, and a good deal of the Knights-
of-Labor order.
SALOL AND CHOLERA.—Professor Löwenthal, who has
lately made experiments on the action of salol on cholera
bacilli in Professor Cornil’s laboratory in Paris, of which
an account was given in these columns in “ Medical Paris
of To-day,” has received a special mission from the French
Government to proceed to ‘Tonquin, in order to study the
effects of salol on cholera patients. Professor Löwenthal
is for this purpose nominated a navy medical officer å
titre déranger, but is allowed full liberty of action. This
is the first time that the French Government has selected
a member of another nation for such a post, and it well
indicates the tendency of science to draw nations nearer
together.— Lancet.
LADY KortTRIGHT, formerly of Philadelphia, but now
living in England, has presented $100,000 to the Presby-
terian Hospital at Philadelphia, to found a Convalescents’
Retreat. She has also given to the same hospital $40,000
to build a male surgical ward, and $10,000 to endow two
perpetual free beds.—Aedical News.
A CURE For Snorinc.—Dr. John I. Brinkerhoff, of
Auburn, N. Y., writes: “ I notice in THE MEDICAL REC-
ORD a serious request for cure for snoring, and a facetious
reply to ‘bite the nose, gently, but firmly.’ Still, there is
a cure for snoring, used by my comrades in the army, viz.,
tie a band or handkerchief over the mouth if the subject
can breathe easily through the nose. We found this to be
very effective.”
July 6, 1889]
THE MEDICAL RECORD. 17
THE EYESIGHT OF AMERICAN SCHOOL CHILDREN.—Dr.
J. L. Minor, of Memphis, Tenn., reports (Memphis Jour-
nal of the Medical Sciences) the results of his examination
of 682 pupils in the public schools of Memphis. ‘The
refraction was normal in 523 out of 682; the refraction
was hyperopic in 128, and myopic in 32. The myopia,
therefore, amounts to less than five per cent., and the my-
opes were all in the fourth class, where they constituted
fifteen per cent.
Dr. CHARLES F. Srittman, of New York City, who
has attained considerable prominence during the last eight
years in the field.of medical examination for life insurance,
- naving been elected to fill the first chair on that subject
ever created (in the University of Vermont), and who is
also the author of the latest and most thorough text-book
on hfe insurance examinations—besides having been con-
nected with the Travellers’ and other prominent com.
panies in this city, as medical examiner—has recently
given up this portion of his work, and is now devoting
himself to the practice of his specialty.
THE DEATH OF Dr. CHARLES W. WOLFERTZ.—Charles
W. Wolfertz, M.S., M.D., of 231 East Eleventh Street, died
suddenly of heart failure, on June roth, at Orange, N. J.,
where he had gone the week previous to regain his health.
He was a graduate of the College of the City of New York
of Class of 1883, taking degree of B.S. He graduated
from College of Physicians and Surgeons in 1886, winning
the first Harsen Prize for best Report of Medical and
Surgical Clinics held at New York Hospital. He was an
inspector of vaccination on Board of Health for three
years, and had a promising career before him. He leaves
a widow and one child, and a host of sympathizing
fnends.
For Drasetes Dr. Dujardin-Beaumetz says: Into a
glass of Vichy water, sweetened with saccharin and flav-
ored with a little rum or kirsch, I dissolve one of the
following powders, and order the whole to be taken at
one dose : Antipyrin, 3 v.; divide in chart. No. xx. One
powder three or four times a day. I have never seen any
ill results from this medicine, however long continued ;
nevertheless, Albert Robin affirms that at the end of a
week albumen will appear in the urine. He adds: The
most simple way of prescribing Martineau’s remedy is:
Take before each meal, in a tumbierful of Vichy or Vals
water, one of the following powders, adding to the mixture
two drops of Fowler’s solution of arsenic: Carbonate of
lithia, 3 ijss. ; divide in chart. No. xx.
PROPOSED EXTENSION OF COLLEGE TERM IN CANADA.
—At the recent meeting of convocation of the University
of Toronto, the President of the Medical Faculty urged
upon the Minister of Education, who was present and
who largely controls educational legislation in the pro-
vince of Ontario, the desirability of having the college
term extended to nine months instead of six months, dur-
ing each of the four years required before graduation.
‘This proposed change is now exciting considerable com-
ment among the profession, and is generally received with
favor. ‘The standard of medical education in Canada
has steadily increased for many years, and the suggestion
of a nine months course, coming as it does from the head
of one of the leading institutions, has much to support it.
There is no doubt that the present course favors the
usefulness of the student. If the course be changed from
six to nine months in each of the four years, there is no
doubt it will add to the thoroughness of the work done,
and will be profitable for the student as well as of advan-
tage to the public, for whose service he will be all the
better qualified. While it may seem hard to impose on
the student an attendance on college lectures of thirty-six
months before being allowed to be presented for gradua-
tion, yet few are found willing to dispute the fact that the
change would be a most desirable one, and in every way
conducive to the interests of the profession in Ontario.
THE Last INTERNATIONAL MEDICAL CONGRESS, which
met in Washington in 1887, unanimously selected Berlin
as the next place of meeting in 1890. Professors Vir-
chow, Von Bergmann, and Waldeyer, to whom was con-
fided the preliminary direction of the next congress, have
already taken active steps to make it-a success. All the
medical faculties and other medical bodies in Germany
have been invited to nominate delegates to confer to-
gether on the subject this year, at the time of the Heidel-
berg meeting of the German Scientific Association in
September. It is proposed that the congress of 1890
should commence its proceedings on August 6, 1890.
THE GYNECOLOGIST’s FIELD.—The Fallopian tubes are
found diseased in one-third of all female cadavers, accord-
ing to Winckel. The gynecologist has, therefore, always
one chance out of three of finding something the matter
with the ovaries and tubes, if he only cuts down upon
them.
VERMONT STATE MEDICAL SOcIETY.—The semi-annual
meeting of this society will be held at Brattleboro, Vt.,
on Tuesday and Wednesday, July 9th and roth.
THE PRINCE OF WALES’ LEPER.—The chief sensation
of the week, telegraphs the London correspondent of the
New York Times, has been over what has come to be
called the Prince of Wales’ leper. By some curious freak
London took exceptional interest in the circumstances
surrounding Father Damiens’ death. After his death the
photographer who owned a negative of the devoted priest
coined money, and the agitation began for a moment.
The Prince took charge of the matter, and then the
doctors who had views on leprosy joined it, and by the
time the meeting was held a full-grown project of found-
ing a leper hospital in London had taken shape. Unfor-
tunately, to have a good leper hospital one needs lepers,
and so a search was instituted, and the discovery made
that there are two much needed specimens in London.
The Prince, put up to make a speech, declared that there
was a leper in London employed in a large meat market.
At this a tearful outcry was raised by the butchers, and.
columns of protest were crowded into the papers until the
identity of this man was revealed. He turns out to be a
native Englishman who was never out of the country, and
who peddled ox-tails, etc., on his own account, and is an
undoubted leper.
HYPNOTISM IN ArT.—The novelists who have been of
late years working hypnotic and trance phenomena into
their productions are being followed by the painters. A
Munich artist has recently painted the picture of a beau-
tiful woman lying in a cataleptic state, with the title
“ Hypnotized.”
18 THE MEDICAL RECORD.
[July 6, 1889
Society Reports,
American Medical Association.
FORTIETH ANNUAL MEETING,
Held at Newport, R. 1., Fune 25, 26, 27, 28, 1889.
(Continued from page 727.)
SECTION ON SURGERY AND ANATOMY.
THIRD Day, THURSDAY, JUNE 27TH.
Dr. THomas S. K. MORTON, of Philadelphia, read a
paper entitled
ABDOMINAL SECTION FOR TRAUMATISM,
in which he carried his original statistics and observations
of two and one-half years ago up to date.
He excluded all cases where section for traumatism was
not done as a measure of primary relief—that is, at latest,
when not more than two or three days have elapsed.
Those operated upon after such lapse of time were termed
“ secondary section,” etc.
Of the first class Dr. Morton presented tables of 234
cases, with a general mortality of 58.97 per cent.
Ninety-seven American surgeons operated upon 165
cases, with a mortality of 65.45 per cent.; 64 foreign
surgeons operated upon 69 cases, with a death-rate of
47.82 per cent.
-Thirty-two operations were performed in Philadelphia,
25 in New York, 22 in St. Louis, 22 in London, and 13
in Chicago.
A feature of the paper were the remarks upon the
causes of death after operation. Forty-three cases died
from peritonitis, due to delayed operation ; 16 from peri-
tonitis arising after operation ; 11 from overlooked per-
forations ; 4 from inefficient suturing of wounds; 3 died
upon the table, 10 immediately after leaving it, and 40
within 12 hours.
Eighteen cases were opened, and no intraperitoneal
injuries requiring treatment found, 2 of which died : 1, of
Opium-poisoning ; the other, cause not stated.
Of the 234 cases there were: Gunshot wounds, 110,
mortality, 67.2 per cent. ; stab-wounds, 79, mortality, 39.2
per cent. ; ruptured bladder, 27, death-rate, 62.9 per cent ;
ruptured ‘and contused intestine, 18, with an 88.8 per
cent. mortality.
Resection of intestine was performed 17 times in 15
cases, with but two recoveries. The writer stated his
belief that these, as well as many other figures, would be
reversed by the employment of Senn’s improved methods
of intestinal anastomosis and suture, which he described in
their relation and application to wounds of the class under
consideration.
Senn’s hydrogen test was used in 11 instances. It
proved the presence of wounds in 8 cases, their absence
in 2 cases, one of which died of subsequent violent peri-
tonitis. In one case it entirely failed to show perfora-
tions, two of which were discovered when the abdomen
was opened to control hemorrhage. The author assigns
the hydrogen test to an extremely narrow field of useful-
ness.
He emphasizes that, under fair surroundings, every case
where penetration can be proved should be opened and
searched—many even without such evidence, as in rupt-
ure of the bladder, bowel, etc.
He further insists upon median incision, early opera-
tion, systematic search for lesions, irrigation, thorough
drainage, preliminary washing out of the stomach, and the
treatment of subsequent peritonitis with active cathartics
and, perhaps, reopening the wound.
Hydrogen insufflation as a test of rupture of the bladder
was suggested, and a number of successful experiments to
that end cited. |
Josera W. Price, of Philadelphia, read a paper on
PELVIC SURGERY BY ABDOMINAL SECTION.
The introduction of Listerism, which was fundamentally
correct in idea, wrought death by chemicals instead of dirt.
Even now this opinion may be disputed. But ere long it
will be the rule to keep harmful disinfectants as far away
from the abdomen as fetid pus or other filth. It stands
proven that cleanliness may be and constantly is obtained
without the aid of any chemicals whatsoever. ‘This opin-
ion I have always held, and have never, in any operation
of my own, used chemical disinfectants in any form what-
soever. Cleanliness, water, and good surgery are the very
best of all antiseptics.
The author then made astrong plea for early operation,
and against the use of electricity.
Dr. J. M. Baroy, of Philadelphia, read a paper on
THE TREATMENT OF PERITONITIS.
That peritonitis is a disease distinct, and is idiopathic in
its origin, is boldly disputed zn ¢ofo by many, their opinion
being based on not only clinical and post-mortem evi-
dence but on data obtained by an opening into the peri-
toneal cavity during life and during the progress of the
attack itself. That peritonitis is absolutely never idio-
pathic in its origin he was not, as many others were, fully
prepared to say, but of this, at least, we are sure: that in
the vast majority of cases there is a ‘distinct lesion as the
exciting cause, and, personally, in quite a large experience
with this disease, he had never seen a case in which a defi-
nite cause was not probably present. If we accept this
view of the etiology of peritonitis, as he thought we needs
must, it is perfectly clear that, even from a theoretical
point of view, we must find some other treatment than by
narcotics.
In place of the treatment by opium large doses of the
salines are advised. And this, taken together with open-
ing of the abdominal cavity, put into the hands of the
profession remedial agents to which the vast majority of
cases of peritonitis should succumb.
Pure traumatic cases, of course, demand operative
measures ; and chronic peritonitis is best treated by the
surgeon. Tubercular cases are no exception to this rule.
_ After every abdominal section for peritonitis, whether
the cause is found or not, the necessary complements of
the operation are free irrigation and drainage.
Dr. N. B. Carson, of St. Louis, read a paper on
CHYLOUS CYST OF MESENTERY, WITH A REPORT OF A CASE.
The patient was first seen three years ago, then thircy-nine
years of age ; had a cyst about the size of a foetal head.
The tumor was aspirated, and several ounces of chyle
withdrawn. During the following three months there was
no change in the size of the cyst. He was not seen again
until February, 1889, when there was found inflammation
about the tumor, which had increased in size to that of an
adult head. Laparotomy was performed on March 3,
1889, the sac incised, and emptied of five pints of pure
chyle.
Analysis by Dr. Bremer, of St. Louis: Specific gravity,
1.014; alkaline ; contained albumen, but no fibrin. Mi-
croscopically, large granular cells in abundance, in some
of which the protoplasm showed various degrees of degen-
eration. ‘The chief elements were fat-globules, resembling
in size those of milk, and also crystals of sodium chlo-
ride, carbonates, and sulphates.
Dr. Bremer considers the fact that cells containing fresh
and intact protoplasm were found would go to prove that
the cyst from which the fluid was taken was in some way
connected with the canal carrying fresh cells, probably
with the lacteals or the cisterna mesenterica.
This is the first case in American literature, and the
largest of all cases recorded to date. These cysts may
originate from five different sources: From the thoracic
duct, from the receptaculum chyli, from the lacunz mesen-
terice, and from a rupture of the chyle-ducts within the
mesenteric folds.
July 6, 1889]
The case resulted in a complete cure. The conclusions
are: Removal of these cysts is advised so soon as they
begin to inconvenience the patient or interfere with his
nutrition or health, by incision and drainage, instead of
extirpation, as it is believed that the latter operation is
not only difficult but endangers the life of the individual.
yDr. AppDINELL Hewson, of Philadelphia, read a paper
entitled
THE USE, TWENTY-FIVE YEARS AGO, OF POLARITY, FOR LO-
CATING THE WHEREABOUTS OF A LEADEN BULLET DEEPLY
EMBEDDED IN THE BODY.
The bullet was located by the agitation of the needle of
asmall compass-charm when held in the immediate neigh-
borhood.
Dr. THomas H. Maney, of New York, reported a
RARE CASE OF FRACTURE OF THE EXOSTOSIS OF THE PU-
BIC BONE.
The patient had been well up to three wecks before first
seen, and he was able to walk when he was admitted to
the hospital. The history was that he had felt something
in the groin give way, and the disability followed. A col-
lection of pus presented along the upper inner border of
the thigh. This was opened. Ata later operation there
was found a reduplication of the pubic bone, which had
become separated from its base of attachment, and was
acting as a foreign body and pressing on the femoral artery.
It is the opinion of the writer (the patient having died of
pyemia on the fifteenth day, and a post-mortem examina-
tion having been obtajned) that the condition was one of
congenital reduplication of the pubic bone.
Dr. RoBERT NEwMAN, of New York, read a paper en-
titled
=LECTROLYSIS IN THE TREATMENT OF STRICTURE OF THE
RECTUM.
Twelve cases were reported in detail ; the first had been
treated by him in 1871. ‘The modus operandi is virtually
the same as he uses in urethral stricture, applying a
metal bulb as negative pole to the stricture with a gal-
vanic current of from five to fifteen, or even twenty, milli-
amperes, according to the seat of the stricture, the nature
of the neoplasm, the size of the electrode, and other con-
ditions. The seances are of from five to fifteen minutes,
and under some circumstances thirty minutes, and are
repeated in one or two weeks. No force should be
used. The electrode should be kept steadily against the
stricture and only guided until the electrolytic action does
the work of enlarging the calibre and the instrument
passes the obstruction.
It seems that females are more inclined to have rectal
stricture, as out of the twelve only two were males. Their
ages were mostly between thirty and forty; the youngest
was twenty-four, the oldest sixty-two years of age. ‘The two
males were comparatively young men, twenty-three and
twenty-six years of age. Eight cases were single strictures,
and four had multiple strictures. The duration of the mal-
ady was from six months to twenty years. The causes va-
ried, but hemorrhoids and constipation were important
factors ; other causes were syphilis, venereal enteritis, and
dysentery. It is believed that rectal stricture may follow any
inflammation of the rectum. One case was complicated
by five fistula, which ‘healed without further treatment
after the stricture had been cured. Eight cases had had
previous treatment ; of these, six had had operations with
the knife. In none had the previous treatment been suc-
cessful. Of the twelve cases reported, nine are claimed
to be cured, and three temporarily improved. ‘The nine
cured cases had shown no relapse during the time they
were under observation—from one to ten years. Other
successful cases were referred to, treated by Dr. Samuel
Benton and Dr. W. T. Whitmore, of London, and Dr. S.
T. Earle, of Baltimore.
The conclusions drawn were as follows :
Electrolysis in the treatment of stricture of the rectum is
THE MEDICAL RECORD. 19
not a panacea ; failures may occur, and may be expected
if the stricture be due to carcinoma.
Electrolysis will give improvement to rectal strictures
when other means have failed.
Electrolysis will cure a certain percentage of cases,
without a relapse, better than other modes of treatment,
and without the necessity of using bougies or any after-
treatment.
The best chances for a cure are with the fibrous inflam-
matory strictures. The best mode of treatment is by a
metallic bulb as negative pole, with weak currents at in-
tervals of four days to two weeks.
FourtH Day, FRIDAY, JUNE 28TH.
Dr. Frank Woopsury, of Philadelphia, presented a
new model inhaler for administering ether or chloroform,
made by E. A. Yarnall, of Philadelphia, in which the an-
esthetic is dropped into a funnel-shaped opening at the
top and falls upon absorbent cotton confined in a cham-
ber beneath, where it is confined by a perforated, hinged
diaphragm. ‘The advantages are cleanliness, convenience,
and cheapness.
Dr. CHARLES DENISON, of Denver, Col., exhibited
A NEW RIB CUTTER,
and narrated
A CASE OF RESECTION OF RIBS FOR DRAINAGE OF A PUL-
MONARY CAVITY.
The lung-cavity was treated by washing out with anti-
septic solutions, The case terminated favorably. The
rib-cutter was devised with the end in view to make as
small an opening as possible, and to leave the periosteum
Intact.
Drs. W. Barton Hopkins and C. B. PENROSE, of Phil-
adelphia, read a paper on the
ORGANIZATION AND ABSORPTION OF STERILIZED DEAD-
BONE DOWELS,
in which were shown the effects of retaining for various
periods ox-bone dowels in contact with living bone. The
experiments were performed upon dogs, and demonstrated
that organization of the dead bone, as evidenced by the
presence of blood-vessels continuous with and extending
from the living bone, readily occurs. After five weeks
bone dowels lose their power to give support to fragments
or extremities of bone in which they have been introduced,
begin to undergo absorption in the medullary cavity, and
active organization in the shaft of the bone.
From these experiments we base the following deduc-
ne
That when sterilized dead bone is placed, under
tävorabie circumstances, in contact with living bone, it
undergoes organization. When, on the other hand, it is
acted upon by periosteum itis absorbed, and when placed
in the medullary cavity, in not too large bulk, organization,
combined with absorption, takes place.
2. That these processes go on perhaps most actively
between the fifth and eighth week, and are not necessarily
associated with any inflammatory action.
3. That, therefore, where these dowels are employed to
pin together fragments of bone after fracture, to fix the
extremities of bone after resections, or for any other me-
chanical purpose in surgery to which they are adapted,
they may be relied upon to do their work for a period of
one month or six weeks, and hence to give ample time,
as a rule, for union to occur. After this, their presence
being no longer required, they gradually lose their iden-
tity in surrounding bone, and disappear.
Dr. CHARLES DENISON, of Denver, Col., presented
A CASE ILLUSTRATING THE DRAINAGE OF A PULMONARY
CAVITY.
The case, taken from the writer's records, was that of
a man, twenty-six years of age, first examined, November
3, 1888. The previous April he had had a pneumonia of
20
THE MEDICAL RECORD.
[July 6, 1 889
the left lung, and softening was determined to be present
in the left axillary space. ‘Though his stay in Colorado
was accompanied with increased weight and strength, yet
the signs of tubercular infection and breaking down of the
living tissue continued, as shown by the afternoon-hectic
and the daily expectoration of half a pint of purulent
sputa, night-sweats, etc. January 14, 1889, pulse, 110;
respiration, 40; temperature, 1014° F. at 2 P.M.
Permanent drainage was advised, and the operation
performed on January 22d; portions of the sixth and
seventh ribs were resected. A new treatment of the cavity
was devised: that of daily injection of a ten per cent.
solution of salol in liquid vaseline. This was carried out
by the patient, as well as the antiseptic cleansing of the
cavity.
March 16th, pulse, 92; respiration, 28; temperature,
984° F. at 4 P.M.; weight increased thirteen and a half
pounds since the operation. Discharge from the tube re-
duced to one ounce a day, and expectoration as well as
cough had ceased since the operation. Symptoms all im-
proved.
On May roth the drainage-tube was shortened from
four and a half to three and a half inches, and it lay along
the bottom of the pulmonary cavity, which was one and a
quarter by three and a half inches in size, extending along
the left side of the sternum, from the clavicle downward
and outward toward the left nipple, being situated beneath
the front wall of the chest. Air was then found to enter
around the cavity, above and outwardly. No fever; and
arrest of lung disease assured. Since then the patient has
done well.
The rib-cutter, suggested to the writer by the difficulty
of resecting the ribs because of their overlapping in this
case, was presented. It is composed of a periosteum
separator, curved at the point, upon which a sliding, cut-
ting blade is forced by a toggle-joint which gives the oper-
ator great power in making a clean, even section of the
bone. ‘This was illustrated in a satisfactory manner to
those present. By this instrument a portion of a rib can
be first denuded of its periosteum, and then one and a
third inch, or more, of it can be excised, and removed
through an external opening only large enough to admit
the instrument, ¢.¢., one and a quarter inch long.
Dr. J. G. CARPENTER, of Stanford, Ky., read an ex-
haustive paper on the
PATHOLOGY AND TREATMENT OF CHRONIC SCIATICA,
and reports two cases of operative nerve-stretching.
The first patient had chronic sciatica of the right nerve.
The trunk was inclined to the lett ; the vertebral column
described a curve with its convexity to the right ; the left
hand descended much lower than the right; the right
lower extremity was semi-flexed ; the buttock of this side
presented a flattened appearance, the gluteal fold being
elevated ; finally, the heel of the right foot did not touch
the floor. The limb was atrophied and cold, one and one-
half inch smaller from the hip to the foot than the left,
and the patient was unable to sit on the right buttock.
The condition of the nerve on exposure, before stretching,
was this: The neurilemma was found to be thickened,
congested, and numerous reticulations of small blood-
vessels ramifying the sheath. The latter had lost its
opacity and was a pinkish, yellow color, had many nodular
deposits, and many adhesions to the adjacent tissues,
showing plainly that the case was one chronic sciatic peri-
neuritis,
Attitude of second case, left sciatic nerve being affected :
Trunk inchned to the right ; the vertebral column curved
to the left, when the pain was great; the left lower ex-
tremity partly flexed, except when walking on the street ;
the left buttock flattened, and the gluteal fold elevated ;
and the heel of the affected side can be made to touch the
ground only with pain. In the recumbent posture the
left limb was flexed, and pads or pillows had to be placed
under the knee and back to remove pressure from the
tender points ; otherwise the patient could not lay on
the back or left side. The hmb was one and one-half
inch smaller from hip to foot than the right, and cold
and atrophied ; the patient could not sit on the left thigh
and buttock. On cutting down there was found to be
some fibro-cystic tumors and nodular deposits on the
nerve (perineuritis nodosa chronica), and bands of lymph
and adhesions between the sheath and adjacent tissue.
The neurilemma had lost its normal appearance and
showed signs of fatty degeneration, and was traversed by
many small blood-vessels.
Dr. J. WILLIAM WHITE presented a communication on
THE SURGERY OF THE SPINE.
Dr. White divides the spinal troubles which may neces-
sitate surgical interference into three classes: trauma-
tisms, caries, and neoplasms. He reviewed the history of
the surgery of these conditions, gave the details of two
cases in which he performed resection of the spine, and
reached the following conclusions :
1. The objections urged against operative interference in
spinal traumatisms were partly theoretical (hemorrhage, fre-
quency of absolute destruction of the cord, pressure from
inaccessible fragments of bone, etc.), and have been shown
to be unsupported by clinical facts. They were largely
due to a well-founded dread of (a) the shock, in the cases
operated on in pre-anæsthetic times; and (4) consecutive in-
flammation, suppuration, and pyzemia in pre-antiseptic pe-
riods. The later results, which now constitute our only
safe basis for generalization, are distinctly encouraging,
and resection of portions of the vertebrz in fractures,
possibly even in dislocations, shoud be recognized as an
eminently proper operation and, in suitable cases, alto-
gether warranted by the facts in our possession; and
further, such cases are by no means rare or exceptional.
2. There can be still less doubt that the testimony of
both pathologists and practical surgeons indicates that the
cause of the paralysis of Pott’s disease is, in many in-
stances, an extra-medullary proliferation of connective
tissue, assuming the density and proportion of a neoplasm,
occupying the space between the dura and the interior
surface of the lamine, not apt to be associated with intra-
medullary changes or with destructive degeneration of
the cord, and very frequently removable by operation.
3. Every case of focal spinal lesion, thought to depend
on a tumor, and not distinctly a malignant and generalized ©
disease, should be regarded as amenable to operative in-
terference, no matter how marked the symptoms of press-
ure may be, nor how long continued.
4. The method of extension, as recently revived, is well
worthy of preliminary trial in the first two classes, and in
obscure cases thought to belong to the third class. It
has not yet been tried in a sufficiently large number of
cases to establish its exact limitation, but it is unquestion-
ably a therapeutic measure of vast importance in spinal
injury and disease.
It is customary and proper, in deciding upon any serious
surgical procedure involving risk to life, to consider well
the prospects of the patient in the event of non-interfer-
ence, and to be largely influenced by them. Looked at in
this light, the operative surgery of the spine as regards
traumatisms, caries, and neoplasms may fairly be said to
have a rapidly widening field, and to deserve more serious
and careful consideration by practical surgeons than it has
received for many years.
The following papers were read by title: “ The Sur-
gery of the Lateral Ventricles of the Brain,” by W. W.
Keen, of Philadelphia ; ‘‘ Arthrectomy of Knee-joint,” by
E. H. Bradford, of Boston; “ Epicystic Surgical Fistula
for Relief of Vesical Catarrh,” by J. D. S. Davis, of
Birmingham, Ala.; “ Drainage in Abdominal Surgery,” by
Charles B. Penrose, of Philadelphia; “ A Plea for Early
Abdominal Work,” by M. Price, of ‘Philadelphia ; “ Wir-
ing the Patella ‘in Old Ununited Fracture,” by W. C.
Wile, Danbury, Ct.; “' The After-treatment in Cases of
Abdominal Section,” by L. S. McMurtry, of Louisville ;
“ Cranial Surgery,” by H. O. Walker, of Detroit; “ Fis-
July 6, 1889]
a
tula in Ano,” by J. M. Mathews, of Louisville; “ ‘The
New Improved Aseptic Surgical Pump,” by Elmer Lee, of
St. Louis; “Incomplete Inward Dislocation of the Ra-
dius and Ulna of the Elbow,” by Albert Stifel, of Wheeling,
West Va.
SECTION ON DISEASES OF CHILDREN,
THIRD Day, THURSDAY, JUNE 27TH.
A PAPER by Dr. Marcus P. Hatfield, of Chicago, on
“ The Value of Hydrogen Dioxide in the Treatment of
Children,” was read by title. A paper by Dr. David S.
Booth, of Sparta, Ill., on “ Penal Rule in Public Schools,”
was read by title.
Dr. S. P. DEoHOoFE, of Potsdam, O., read a paper on
POLIO-MYELITIS ANTERIOR ACUTA.
The author related the histories of five cases he had
seen. He thought the diagnosis not always easy. He
believed that in treatment the effects of electricity are not
brilliant. ‘The first treatment should be always rest.
Dr. Kina, of Chicago, had seen three cases in adults.
Pain was a symptom in adults, but was not found so readily
In his experience the bladder was always
paralyzed, but was all right at the end of two or three
days. In one of his cases the atrophy was extreme at the
end of three weeks. Considered electricity harmful in the
in children.
early stages.
‘THE CHAIRMAN thought that electricity never did good.
Dr. Hooper agreed with the Chairman.
Dr. I. N. Love, of St. Louis, read a paper entitled
ONE YEAR OF ACETANELIDE IN PADIATRIC PRACTICE.
The author stated that he considered acetanelide su.
perior to any of the carbolic-acid series. He believed
it better to use the name given at the head of the paper
in preference to the patented one of “antifebrin.” He
regarded the drug as three times more effective than
antipyrin and less depressing. If it diminished the red
bluod-cells, it required a long administration to do so.
The depressing effects resulted from poor makes of the
drug. He agreed with Widowitz in his view of the safe
and steady action with children. He did not believe the
disagreeable cyanosis was of special importance, and it
could be overcome by combining with alcohol. He made
mention of the advantage of the use of the drug in scarlet
fever, measles, and congestive fevers. The author spoke
of the treatment of fifty cases of whooping-cough by
acetanelide, and thought it a valuable remedy. In con-
clusion the writer of the paper stated the following :
Acetanelide, carefully guarded and properly used, is a
safe and reliable remedy in the diseases of infancy and
childhood. It is preferable to antipyrin, because it
does not cause so much depression, and its effects last
longer. The cyanosis is not a dangerous, though it is a
disagreeable, feature. It is of value in controlling tem-
perature in fever caused by the typhoid germ. It serves
almost as a specific in whooping-cough, by mitigating the
discomforts and controlling the paroxysms of the disease.
Dr. Dixon, of Kentucky, did not think thé acetanelide
equal to antipyrin, except as a febrifuge. Had had
alarming effects following its use. In malarial fevers
gave it, and followed it with quinine.
Dr. Hitt, of New Hampshire, gave eight- or ten-grain
doses in asthma.
Dr. Kino, of Chicago, had seen relief by twenty-grain
doses in a case of cerebral tumor.
Dr. W. P. Watson, of Jersey City, did not advise its
use in self-limited fevers.
Dr. ATKINSON, of Baltimore, had not seen the impure
drug. Did not think we could modify fever, but could
contribute to the comfort of the patient.
THE CHAIRMAN advised the use of the drug in hyper-
pyrexia with pale skin, to dilate the capillaries.
Dr. OSLER, of Baltimore, had given acetanelide in the
cold stage of fever, but had found it useless.
THE MEDICAL RECORD. 21
Dr. Woopsury, of Philadelphia, did not believe in
prescribing patented drugs, and therefore did not use it.
Dr. Love, in closing the discussion, reiterated that the
cyanosis was not dangerous, but the drug could be com-
bined with alcohol.
Dr. J. C. Wilson, of Philadelphia, read by title a paper
on “ Visceral Neuralgias in Children.”
Dr. WILLIAM P. Watson, of Jersey City, read a paper
entitled
ATROPINE IN ENURESIS.
The author had treate1 thirty cases by atropine, and
cured twenty-seven. He gave one drop, for each year of
the child’s age, of a solution made by adding one grain of
atropine to one ounce of water. l
The paper was discussed by Drs. DIXON, LARRABEE,
HILL, JEFFRIES, and KNAPP.
Dr. William Osler, of Baltimore, read by title a paper
on “A Further Study of the Cardiac Relations of
Chorea.”
The following papers were read by title : “ Adherent
Præputium Clitoridis as a Cause of Chorea, with Report
of a Case,” by C. Henri Leonard, M.D., Detroit; “ ‘The
Treatment of Heart Disease in Children,” by» J. A. Rob-
inson, M.D., Chicago; ‘The Physical Education of
Children,” by H. P. Leuf, M.D., Philadelphia ; “ The
Treatment of Tubercular Bone Lesions before the Joint
is Invaded,” by V. P. Gibney, M.D., New York ; “ Notes
on Surgical Diseases of Children,” by Edward Brock,
M.D., St. Louis ; “ Spina Bifida,” by Norman Teal, M.D.,
Kendallsville, Md. ; “ Trismus Nascentium,” by A. V.
Williams, M.D., Frankfort, Ky.
SECTION IN DERMATOLOGY AND SYPHILOGRAPHY.
THIRD Day, ‘THURSDAY, JUNE 27TH.
Dr. HENRY FLEISCHNER, Of New Haven, read a paper
on
PRURITUS.
The author described in an interesting manner the clini-
cal difference between the pain of pruritus and ordinary
pain, and mentioned the many unsettled questions connect-
ed with etiology, pathology, and therapy. ‘The treatment
had to be adapted to the individual case, was largely em-
pirical, and when successful proved so by accident. He
had most frequently found menthol useful. Results from
electricity he thought were largely imaginary. Acetic
acid had been of value in many cases, also resorcin and
kainn. Results from sulfonal had not encouraged him to
continue its use.
Dr. Cor.etT had obtained most benefit, according to
the class of cases, from tepid baths, menthol ointment or
solution in alcohol, carbolic acid, and tar applications.
CLINICAL STUDY OF ECZEMA SEBORRHOICUM.
The paper was sent by Dr. GeorGE T. ELLIOT, of New
York, and was based on the observation of 208 cases the
past eighteen months. ‘They constituted twenty-nine per
cent. of all cases of eczema seen during that time. ‘Thirty-
six of the cases were seen during the three summer
months. Of the 208 cases 134 were in females. All
ages were affected. The majority of cases occurred be-
tween the tenth and thirteenth year. The scalp w
affected in all the cases.. In 118 the eruption was limitéd
to the head and face. The progress of the eruption was
slow. The author thought it was a purely local affection,
not being affected by constitutional conditions or treat-
ment. In only a few cases was itching severe. Some pa-
tients stated that the eczema had been present even as
long as ten years, perhaps changing location. The scale
was unusually branny, the area of red or yellow, bare,
greasy, from size of a pea up. The skin between the
patches might be normal, greasy, or covered with scales.
Dr. BULKLEy did not believe as large a proportion of
cases of eczema fell under the division of eczema sebor-
rhoicum as appeared from Dr. Elliot’s paper ; that other
22
THE MEDICAL RECORD.
[July 6, 1889
forms of eczema had been confounded with this late divis-
ion made by Una. He also differed from the author in
the view that it was purely local, requiring only local
treatment.
Dr. CORLETT expressed essentially the same views en-
tertained by Dr. Bulkley, and said the subdivision made
by Una was accepted with more or less reserve in Paris,
Vienna, Berlin, and London.
Dr. J. ABBOTT CANTRELL, of Philadelphia, reported a
case of
PAINFUL SUBCUTANEOUS NEUROMA.
It occurred in a man, aged twenty-eight, the tumor be-
ginning to grow in the region of the deltoid fourteen years
ago. Others had appeared since, and numbered about
six, on either arm, inthe same region. ‘The largest was of
the size of a pea. At first they caused itching, afterward
they became painful, the pain being paroxysmal, and ex-
cited especially by contact of clothing and blows. It was
at times extreme, and like the cutting of a knife. He
had been disappointed in exsecting a tumor for examina-
tion, but presumed it to be neuro-fibroma.
Dr. Louis WICKHAM, of Paris, sent a paper entitled
NOTES ON THE PARASITIC THEORY OF ALOPECIA AREATA.
So long, he said, as a specific parasite for this affection
was not found and proven beyond doubt, the parasitic
theory would encounter many adversaries. But in favor
of this theory, in default of discovery of the parasite, there
were facts of contagion which seemed clearly proven. In
the Hospital St. Louis they had met with different ways
of transmission of variable importance. For instance (1)
a small girl affected with alopecia, a sister sleeping in the
same bed was frequently attacked with the same affection.
(2) Three children of the same family had taken alopecia
at short intervals from each other. (3) A small girl
coming from the country to stay with relatives where a
child has alopecia, one month later shows plaques of alo-
pecia. (4) A young man had alopecia over the right
temple, a place which was rubbed by the rim of his hel-
met. He had worn about two months the helmet of a
friend who had alopecia. The plaque corresponded ex-
actly to the part rubbed by the helmet. (5) Four men
working together in a small room were affected, one after
the other, within some months, with plaques of alopecia.
They sought advice how to protect their fellow-workmen
from the disease, which they were convinced was conta-
gious. They frequently exchanged hats, which doubtless
served as agents of transmission. ‘There were other strik-
ing examples of contagion in French medical literature.
The author was far from denying the existence of an
alopecia of neurotic origin, but the facts given, which came
under his own observation, and others quoted, proved, he
thought, the existence of a contagious form. Some ob-
jections to the theory were discussed. ‘They were alike
applicable to most diseases known to be contagious, but
in which the parasite had not yet been discovered.
The following papers were read by title : “‘ Eruption pro-
duced by Internal Use of Rhubarb,” by Dr. H. Golden-
burg, New York; “ General Points in the Treatment of In-
flammatory Diseases of the Skin,” by Dr. Oscar Lassar,
Berlin.
eSECTION ON LARYNGOLOGY AND OTOLOGY.
First Day, TUESDAY, JUNE 25TH.
W. H. Dary, M.D., CHAIRMAN.
Dr. Jonn O. Roe, of Rochester, N. Y., read a paper
on
GLANDULAR HYPERTROPHY AT THE BASE OF THE TONGUE,
AND ITS TREATMENT.
Until recently the importance of this condition was not
recognized. He referred to it under the usual name of
“lingual tonsil.” ‘The lingual and the faucial and pharyn-
geal tonsils are the same in structure and function—their
chief function being the secreticn of mucus. The lingual
tonsil is liable, from its position, to irritation by the passage
of food, etc. and the blood-vessels in and about them seem
subject to all the variations of the temperature of solids and
liquids which pass over them, and very naturally the
glands frequently take on an abnormal condition asa con-
sequence. An abnormally distended condition of the blood-
vessels is found in these hypertrophies. ‘These vary ac-
cording to the conditions of local irritability, but also with
the plethoric condition of the general system, and may,
as Mr. Lenox Brown has pointed out, be symptomatic of
mitral disease or hepatic engorgement, or even cerebral
tumors. Small ruptures over these glands may be the
origin of blood-spitting. ‘They are often associated with
the same condition of the other tonsils, and the symptoms
often resemble those of hypertrophy of the faucial tonsils,
causing changes in the voice and inarticulation, and the
sensation of a foreign body in the throat, as of a hair, etc.
Attacks of asthma are not infrequent from this cause, and
globus hystericus is often observed in this association in
females.
Diagnosis is easily made by inspection on drawing the
tongue forward.
Treatment has two objects to accomplish: 1, removal of
all hypertrophies ; and 2, obliteration of all varicosed blood-
vessels. ‘The first is best accomplished by abscissions with
a curved knife or scissors, is easily done, and unattended
by much hemorrhage or soreness. ‘The galvanic cautery
is also useful. Corrosive substances are also recom-
mended, as chromic and nitric acid, Vienna paste, etc. In
cases of moderate enlargement, caustics may prove effi-
cient. In using the galvano-cautery the hypertrophy may
be burned away by a flat cautery, applied from the summit
downward, by cutting off at the base with the cautery knife,
or by transfixing through the base with a very slender
cautery point. For destroying the enlarged vessels the
last instrument should be used, applied longitudinally to
the trunk of the vessel at the point from which they arise,
as near as possible. Before any of these operations cu-
caine should be applied.
Dr. SoLIS-CoHEN objected to the term “tonsil ” applied
to collections of lymphoid tissue, other than those existing
between the arches of the palate. He approved of the
author’s method of getting rid of the growths. In case
of slight enlargement he found that a solution of creosote,
or carbolic acid and iodine in glycerine, sufficient topical
treatment.
ELECTION OF OFFICERS.
Dr. John O. Roe, of Rochester, N. Y., was elected
President, and Dr. Frank H. Potter, of Buffalo, N. Y.,
Secretary.
Dr. E. FLETCHER INGALLS, of Chicago, read a paper
on
ELECTROLYTIC TREATMENT OF CYSTIC GOITRE.
The author referred to the various conventional methods
of treatment, and especially to that of Sir Morell Mac-
kenzie, first published in 1872, and which is pronounced
in Holmes’ “System of Surgery” to be the most efficient.
This consists of injecting into the cyst a solution of per-
chloride of iron, and allowing the cannula of the trocar,
tightly plugged, to remain in place for three days. If, on
removing it, suppuration does not take place, the same
procedure is repeated, this being followed by poulticing.
The author claims for electrolysis that it produces more
rapid results, is less dangerous, and has other advantages
over other methods, and gave the history of two cases in
support of his views, which had been treated by him by
electrolysis.
In the first case, after several tappings, followed each
time by rdpid reaccumulation of fluid, electrolysis was
used, and after three or four applications, for ten minutes,
of from six to ten Leclanche cells, the cysts ceased to
refill, and remained cured. ‘The tumor had been found
to be about one-third solid tissue. ‘This remained, bu:
July 6, 1889] .
did not increase. A needle was passed into the cyst and
the other pole of the battery applied over the tumor.
‘The second case was one which had existed for several
years, and had been injected with iodine and other fluid
but continued to remain of about the same size. Elec-
trolysis was first employed on February 23d, and after
four or five applications, on March 23d, it had ceased to
refill and the cyst was completely eradicated. The
strength of the current was regulated by the patient’s abil.
ity to bear it.
Dr. D. Bryson DeEtavan, of New York, then read a
paper on °
ADENOID HYPERTROPHY OF THE VAULT OF THE PHAR-
YNX ; ITS PATHOLOGY AND TREATMENT.
The author stated that there were two principal vari-
eties of the disease. In one the growth was soft, friable,
and rich in lymphoid elements ; in the other there was an
excess of fibrous tissue. ‘The first was removable with ease
and little pain—the other was exceedingly tough and re-
moval caused much pain. ‘The methods of operation were
alluded to, and it was insisted that in the more severe cases,
even in young adults, the use of anzesthetics is of the
greatest importance and that removal should be completed
if possible at one operation. The author also insisted upon
the great importance of the proper after-care of pa-
tients thus operated upon, and recommended that they be
put upon a course of tonic treatment, and that the mouth-
breathing habit be corrected by special attention thereto ;
that deformity of the chest, if present, be remedied by
proper physical exercise, and finally, that errors of pro-
nunciation be eradicated. ‘The paper was illustrated by
numerous instruments and by several fine colored draw-
ings.
Dr. LAWRENCE TURNBULL, of Philadelphia, then read
a paper on
THE VALUE OF ANTISEPTIC TREATMENT AND PROTECTION
OF THE MEMBRANA TYMPANI IN PERFORATIONS THE
RESULT OF OTORRH@A.
He stated that it was not necessary to dwell upon the
absolute importance of antiseptic surgery. Its latest and
most brilliant results have lately been seen in brain sur-
gery. It is not only possible to reach and drain abscesses
in the temporo-sphenoidal lobe of the cerebrum, but it is
considered possible to save life by opening into the cere-
bellar fossæ and remove pus from the neighborhood of
the lateral sinus. The antiseptic treatment of chronic
purulent disease of the middle ear was a natural sequence,
and was soon followed by the use of boracic acid in pow-
der and solution, later by bichloride of mercury, alone
and in combination, then by the use of antiseptic wool and
gauze, with the protecting agency of ol-silk, which pro-
tectors act as artificial membranes and prevent the en-
trance of disease-germs from the air.
‘fhe author then referred to the various causes prevent-
ing the cure of chronic discharge from the ear, also the
treatment of perforations of the membrana tympani by
means of grafts of skin, lining membrane of the chicken’s
egg, skin of the frog’s foot, and nictitating membrane of
the frog’s foot. ‘The paper concluded by reporting a few
cases in illustration of the subject.
Dr. F. H. Potter, of Buffalo, N. Y., then read a paper
on
THE USE OF MENTHOL IN THE UPPER AIR-PASSAGES,
with the results of its use by him during the past three
years by local application. These results indicate that
the drug controls superficial inflammation ; that it is
an analgesic, and second application can be made in in-
creasing strength without discomfort ; that it is destructive
of some of the low forms of life, especially the bacillus
tuberculosis, and that it is a valuable antiseptic in nasal
surgery. It has an important place in the treatment of
atrophic conditions. It can be used in strength of from
one to fifty per cent. dissolved in oil. ‘The oleum petrolia
the author considers the best for the purpose of dissolving '
THE MEDICAL RECORD. 23
the drug. It can be applied directly by cotton applica-
tion, or by means of the spray or by vaporization. The
direct method answers best in the pharynx, the spray and
vapor for the nose and larynx. Five cases of laryngeal
phthisis following upon disease of the lungs were also re-
ported,-in which the menthol treatment gave satisfactory
results, the local conditions improving rapidly under its
use.
Dr. CHARLES H. KNIGHT, of New York, read a paper
on
MENTHOL IN LARYNGEAL PHTHISIS.
Twenty cases, most of them of a severe type, treated
with menthol applications, furnished the author ground
for believing that this is a valuable agent in tubercular
laryngitis. ‘The drug was dissolved in fluid cosmolene in
the proportion of a drachm or a drachm and a half to the
ounce, and applied by means of a laryngeal syringe, or in
the form of spray, by a nebulizer or vaporizer. In nearly
all cases the subjective symptoms and the local appear-
ance improved. In no case did complete healing of an ulcer
take place. In this respect the author's experience does
not bear out the representations of Rosenberg and others.
Three propositions are offered : (1) Spontaneous cure of
a tubercular ulcer of the larynx may occur ; (2) a simple
erosion or ulceration may be mistaken for a tubercular
ulcer; (3) the best results from local treatment of the
larynx may be expected in cases of incipient or iimited
pulmonary disease and in primary laryngeal tuberculosis.
Dr. H. Hotsrook Curtis, of N. Y., then read a paper
entitled
ANAMIA AND ITS RELATION TO NASAL STENOSIS.
By a tabulation of cases he demonstrated that nearly all
patients with stenosis were anzmic, the percentage of oxy-
hemoglobin being only about one-half that of normal
blood. In his experiments he had used the hzmato-
scope of Hénocque, and had again tested the blood after
several weeks had elapsed. The conclusions arrived at
were that the increase of oxyhzemoglobin in the blood after
operation on the septum is directly proportional to the
relief afforded an impeded nasal respiration. ‘This in-
crease is constant, and averages about two per cent. in the
six weeks immediately following operation, in which the
stenosis is about fifty per cent., or in which the nose is
doing one-half its work.
Cases should not be operated on whose blood shows by
spectrum analysis less than six per cent. of oxyhzemoglobin,
as profound hemorrhage is apt to occur. Records had
also been kept in regard to body weight, chest measure-
ments, and capacity of the lungs by the spirometer. ‘These
factors also exhibit improvement after operation.
Dr. F. S. CrossFIELD, of Hartford, Conn., read a paper
on
EPILEPSY CAUSED BY INTRANASAL DISEASE.
The author stated that the first case that came under
his notice, in 1886, had all the appearance of some grave
lesion of the lungs — emaciation, hacking cough, more
severe at night, headache, night-sweats, and anorexia.
Had epileptic convulsions, the first six years, twice a
month, or oftener. Associated with this condition was
marked nasal hypertrophy of both cavities, with deflected
septum to left side, and exostosis, whose sharp angle
pressed against the hypertrophied turbinated body; marked
adenoid growth of the naso-pharynx ; slight changes m
the larynx. Epilepsy entirely disappeared when this patho-
logical cause was removed, and the patient is now entirely
well.
The second case was much like the first, only with slight
enlargement of the pharyngeal tonsil. The epileptic
seizures were much more frequent. ‘This case hkewise
fully recovered on removal of the local cause.
Dr. J. G. CARPENTER, of Stanford, Ky., read a paper
entitled
INTERNAL EAR DEAFNESS.
. The author said that many of the cases of internal ear
deafness were due to nasal disease, and by curing the
eb tee ee ee
a
24 THE MEDICAL RECORD.
[July 6, 1889
latter the former is relieved. Nasal disease should be
treated before structural jesions have taken place in the
internal ear. Two cases were reported in illustration of
his subject by the author.
Dr. J. A. Lippincott, of Pittsburg, Pa., reported a
case of i
SCLEROSING MASTOIDITIS,
occurring subsequently to primary purulent mastoiditis
interna ; opening of mastoid ; exposure of dura mater ;
recovery.
In September, 1885, the mastoid had been opened by
another surgeon, and an abscess found and carefully
cleansed. ‘lhe wound had healed, and severe pain was
relieved for six months, when it recurred, gradually be-
coming very severe, until July, 1886, when it came under
the author’s observation. Other measures failing, in Octo-
ber a considerable opening was made in the mastoid,
which accomplished nothing, immediately. The con-
dition became more and more serious. Convulsions
finally set in. In May, 1887, a second operation was per-
formed with the intention of making the opening suffi-
ciently large and deep to give relief. In this attempt the
dura mater was exposed to the extent of one-fourth of an
inch in diameter at the bottom of the wound. The pain
disappeared immediately. Convalescence wasrapid. An
examination a few days ago showed exemption from pain.
Extreme pain had been the chief symptom, there having
been no inflammatory appearances about the ear or the
mastoid region. ‘The patient was a young woman.
THIRD Day, ‘THURSDAY, JUNE 27TH.
Dr. D. N. Rankin, of Pittsburg, Pa., read a paper
entitled
EFFECTS OF NATURAL GAS UPON THE UPPER AIR-PASSAGES.
Natural gas was introduced to use in Pittsburg in 1883.
It at first gave rise to great complaints. It made the air
too dry to breathe; it ruined furniture by cracking the
joints; it was repudiated by many who had tried it, and the
apparatus for its use removed from their dwellings. Ex-
plosions also occurred. But it is a very cheap fuel and
light, and experience taught how to use it without pro-
ducing these effects. Chemical analysis shows it noxious
to breathe. The pipes were at first made of too porous
metal and leaked ; now it is used without these defects,
and is no longer breathed by the users, and no deleterious
_ effects are produced upon them.
Patients suffering from its inhalation will complain at
first of dryness of the throat and nares. This is followed
by free discharge of naso-purulent matter from these
cavities. After this the dryness recurs, sometimes thé
symptoms extending to the larynx and producing hoarse-
ness. Mirror examination shows congestion in the nose
and pharynx, and great sensibility exists in these parts,
promptly relieved by a four per cent. solution of cocaine,
followed by vaseline to the nose and throat.
Dr. GEORGE A. RICHARDS, of New York, read a paper
on
EMPYEMA OF THE FRONTAL SINUSES.
‘The author reports a case of empyema of the frontal
sinuses due to obliteration of the infundibulum by a polypi
which had existed fifteen years. ‘lhe empyema had pro-
duced absorption of the lower wall of the sinus, and a
s.aal] tumor had appeared at the root of the nose about
eight months before the patient presented himself for
treatment. An opening was made into the swelling, and
a tube passed through into the nose, after about twenty
polypi had first been removed. After thorough cleansing
thrice daily for about a month, the patient completely re-
covered. Sight improved at once, and complete relief to
a very marked anorexia, and great improvement in the
general health as well as in breathing and smell.
Of forty-eight cases collected by the author from litera-
ture, only fourteen were the result of injury, and but
seven the result of obstruction. Some cases occur many
years after injury. The majority occur without known
cause. The symptoms are more or less those of an ordi-
nary coryza, together with a feeling of distention, exoph-
thalmus, diplopia, failure of eyesight, and the appearance
of a tumor over the superciliary ridge or at the root of
the nose; hard at first, this soon becomes soft and fluc-
tuating.
The only treatment is to make an extensive opening
into the nose through which a perforated rubber tube
shoufd be passed. Cleanliness and free drainage are most
important. Of twenty-five cases so treated cure resulted
in twenty-three ; in two result was not stated ; while when
drainage into the nose was neglected the results were not
nearly so good. Death occurred in six cases; in four
from secondary cerebral abscess ; in one from meningitis,
and in one from albuminunia.
Dr. C. W. RICHARDSON, of Washington, D. C., read a
paper on
POSSIBLE DANGER OF INJURY TO THE MIDDLE EAR BY THE
USE OF NASAL ATOMIZATION.
The author anticipated criticism as to the reality of such
dangers being very great. He wished especially to call
attention to the danger to the middle ear from the use of
such spray instruments as Davidson’s and Snowdon’s
atomizing tubes because of the direct pressure exerted.
The first case was thatofalady. The author was spraying
the nose to remove crusts with Dobell’s solution. An
acute pain was experienced jn the ear ; spray was cut off
at once. This was followed in a few hours with typical
acute middle-ear inflammation. The other two cases
were similar ones.
The author thought it a common experience with
rhinologists in spraying the nose to have the patient re-
mark that he felt the spray go into his ear. He did not
wish to decry the spray, a very useful means of treatment,
but simply to point to the possible danger it involved and
to caution against the indiscriminate prescribing hand-
sprays to be used by the patient upon himself.
Dr. JosePH A. WHITE, of Richmond, Va., read a paper
entitled
THE SO-CALLED THIRD TONSIL.
The author believed that glandular hypertrophy in the
post-nasal space, even when slight, is an active agent in
keeping up a catarrhal condition of these and neighboring
parts, and causing extension to the ear. ‘To get rid of the
catarrhal condition these growths must first be destroyed
—the same treatment must be applied also to removal of
the faucial tonsils for the same reason. We do not know
the exact function of these tonsillar tissues, but we do
know that their removal does no harm. Perhaps the third
tonsil plays a greater part in the production of secondary
disease than the faucial, and this is easily understood
when their relation to obstructed respiration and ventila-
tion of the Eustachian cavity is considered. Marked im-
pairment is present in these cases.
Besides the mulberry-like growths there may be round
projections or conical ones, or several knob-like swellings,
or flat, cushion-like masses, etc. ‘These growths are some-
times soft and easily removed, at others compact and
tough, and hard to get nd of. The Eustachian tubes are
apt to be especially infringed upon by the latter, from
pressure. Statistics are unreliable, because careful exami-
nation and noting as to deafness is not often made by
rhinologists. ‘There is always more or less deafness
where these growths exist. Out of 565 cases of private
practice in eighteen months of naso pharyngeal affections,
the author had found 197 had disease of the middle ear.
Of these 134 had hypertrophy of the third tonsil—twenty
per cent. of the whole number treated.
An interesting point is the large number of voice defects
in these cases. This is scarcely understood, knowing as we
‘do, in our experience with professional singers and others
who habitually use the voice, the necessity of perfectly clear
July 6, 1889}
arching of the naso-pharynx to secure perfect resonance
and timbre.
The presence of these growths causes an increase of
catarrhal secretion which can only be removed by eradica- |
tion of the hypertrophies—-the only local means which
proves effective in treating the catarrh. Neglect of this
may lead to more serious troubles; for example, anterior
turbinated hypertrophy ; another is the occasional paraly-
sis of the alæ of the nose, causing serious impediment to
breathing. © :
The method of removal is unimportant, provided ‘it is
thorough. Large masses are best removed with the gal-
vano-cautery snare or cutting forceps, the latter is pain-
ful even with cocaine anesthesia. Galvano-cautery points
are best, perhaps, for soft, smooth masses.
The author had found his palate-retractor of great help
in these operations. ‘The paper was illustrated by reports
of cases.
Dr. W. K. Simpson, of New York, reported a case of
ACUTE RHEUMATIC LARYNGITIS OF GONORRHCEAL ORIGIN.
The author remarked upon the extreme rarity of the
case, not having been able to find reference to a similar
one. Seen first on February 23, 1888. ‘The patient gave
the history of previous attacks of gonorrhoea, the present
attack being of five weeks’ duration. ‘The rheumatic pains
and stiffness had existed three weeks in both knees and
hips, for three days in left thumb and wrist, presenting at
this time typical swelling of acute rheumatism. Laryn-
geal symptoms began three days ago, with painful degluti-
tion. On the following day there was a painful swelling
of the lower external portion of the larynx. In the evening
the patient became very hoarse, and talking was very painful.
February 23d, examination of the throat revealed painful
deglutition, pain on pressure over right side of larynx, and
absence of cough. Internally, both arytenoids swollen
and red, right much in excess, and somewhat oedematous ;
the nght vocal cord immobile on phonation, all of interior
of the larynx more or less hyperzemic, the nght vocal cord
being of a deep purple color and considerably swollen.
The treatment consisted of the use of salicylic acid,
which did not prove entirely effective. Laryngeal swelling
increased, embarrassing respiration. On February 2oth
a blister was applied to external larynx, and iodide of
potash administered. On March 6th he had greatly im-
proved, but there still remained little motion of the right
arytenoid and cord, and they were both still very red.
Dr. A. B. THRASHER, of Cincinnati, O, read a paper on
MORBID PERFORATIONS OF THE NASAL SEPTUM.
The author reported sixteen cases of morbid perfora-
tion of the septum narium, having special reference to
the syphilitic theory of the origin of the disease. ‘Three
of the cases occurred in syphilitics, eleven where syphilis
had not been present, and two cases were doubtful. In
syphilitic cases the vomer, or at least one of the turbinates,
was invariably attacked, and pain was always felt when
this was the case. In the non-syphilitic cases the per-
foration, as a rule, gave rise to no symptoms; at times it
seemed to have been caused by picking the nose with the
finger-nail. ‘There was localized anesthesia in the ulcer-
ated area. ‘The application of the galvano-cautery pro-
duced no pain. ‘The treatment consisted locally in deter-
gents, caustics to the ulcerated area, and mild ointments;
and internal remedies addressed to the underlying dys-
crasia.
Dr. J. E. ScHapb.e, of St. Paul, Minn., read a paper
on
COUGH IN ITS RELATIONS TO MORBID STATES OF THE
NASAL PASSAGES.
The symptomatology of morbid processes seldom fur-
nish a more perplexing subject: for analysis as to its prim-
ary cause than that of cough. A chronic cough which
does not yield to ordinary treatment, and whose origin
is obscure, is apt to excite extreme anxiety in the sufferer.
The subject is interesting from its practical relations.
THE MEDICAL RECORD. 25
Three cases were reported, in which chronic cough of
long standing was cured by directing proper measures
of treatment to removal of existing nasal disease, consist-
ing in one of posterior hypertrophies of the inferior tur-
binated bodies ; another, of nasal stenosis caused by de-
formity of the nasal septum ; and a third, of chronic nasal
catarrh.
The author maintained that when cough is thus pathologi-
cally connected with morbid states of the nasal passages
it is usually produced by reflex nervous influences or pare-
sis of the vaso-motor blood-vessels of the intranasal mu-
cous membrane.
Dr. CHARLES DENISON, of Denver, Col., read a paper
entitled
A NEW MOUTH-GAG, TOGETHER WITH THE CONSIDERA-
TION OF OTHER POSSIBLE AND BETTER RESULTS FROM
INTUBATION OF THE LARYNX.
The acthor presented a table of his twenty-five cases of
intubation with seven recoveries. They were shown to
be a severe class of cases. He had experimented to con-
struct a better gag than those in use, and exhibited four of
the new varieties made. One of these especially men-
tioned is so constructed as not to get out of place during
the operation. A new feature of these gags is to have
the teeth trough made somewhat swivel, so that they will
fit any angle of the jaw—a child of any age.
The author thinks that he has discovered an indication
for early operation. In two successful cases he was led
to operate early, from noticing that the tension of the
pulse was less during inspiration than during expiration,
showing that there was suction of blood back into the
pharynx during inspiration, because of the laryngeal
constriction. This the author believes to be the first
warning of danger and indication for intubation. In nine
| of his eighteen fatal cases death came at an average of
twenty-six hours after intubation, and was attributable to
the so-called aspiration pneumonia.
Dr. E. L. SHURLEY, of Detroit, Mich., presented a
paper on
THE HOT-AIR TREATMENT OF PHTHISIS.
The paper was intended to simply report progress in
the use of the Weigart apparatus. The author had used
the apparatus in about twenty cases, but in only eight with
that constancy and exclusiveness that would serve as a
test.
Case I.—Obliged to discontinue treatment from pain
caused to throat and lungs by the inhalations of hot air.
Case II.—Administered three or four times a day for
fifteen minutes at 120° to 200° F., the latter only three
times; 130° and 190° F. on several occasions. Immediate
improvement followed.
Case III.—Caused nausea and vomiting, but hectic
fever decreased and strength and flesh increased.
Case IV.—Febrile movement caused by treatment, also
pain in the chest, with breathlessness and nausea ; discon-
tinued after ten days.
Case V.—Pulmonary and laryngeal phthisis.
istered for aweek. Could not bear it longer.
Case VI.—Advanced stage of pulmonary phthisis.
Given three times a day; could not bear it; discontin-
ued.
Case VII.—Good effects.
Case VIII.—After fourteen days had to be stopped ;
apparently causing loss of appetite.
The author had found it impossible to apply the method
for such a length of time as is reported to have been done
in Germany.
Dr. CARL SEILER, of Philadelphia, read a paper en-
titled
CLINICAL OBSERVATIONS ON SOME CASES OF A PECULIAR
CHARACTER,
Admin-
in which he described the symptoms of a disease not yet
well known, and which has as yet received no name. ‘The
26 THE MEDICAL RECORD.
[July 6, 1889
author had not seen the paper which he had recently
learned that Dr. W. C. Glasgow read before the American
Laryngological Association in Washington, at its late
meeting, he therefore confined the paper to his own per-
sonal observations. :
The run of symptoms of the cases observed by the
author were summed up as follows :
1. Neuralgic muscular pains, usually in the back and
chest, and often in the head, ears, and limbs.
2. Extreme debility.
3. Mucoid infiltration of the submucous tissues, and
the formation of thin, white, pseudo-membranous patches
on the surface of the mucous membrane. |
4. Absence of febrile symptoms at first, and later, high
temperature and low rate of pulse relatively.
5. Absence of albumen in the urine, and liability of
heart failure.
6. Gradual melting away of the pseude-membrane and
the absence of any odor from it.
7. The wide geographical distribution in this country,
and the infectious but not contagious nature of the dis-
order.
8. Finally, the specific action of benzoate of soda in
relieving the symptoms promptly.
Dr. E. CUTTER, of New York, reported the following
two cases :
A case of
THYROTOMY FOR THE REMOVAL OF A SARCOMA,
operated on in 1886, was presented. ‘The patient on
whom the operation was performed could phonate. Ref-
erence was made to Dr. Hoffa’s late paper, giving the sta-
tistics of thyrotomy since 1879, which were so successful
as to justify the more frequent resort to this too-much.
dreaded operation. The case presented here was done
without tracheotomy. ‘The youngest case the reader had
operated on was a child of twenty-two months—voice re-
stored.
A case of
FIBROID OF THE RIGHT ARYTENOID,
operated on in 1868, by scarification, by a simple knife of
the wnter. Present state—permanent cure after twenty-
one years.
A second like case of enlarged arytenoid, on an Irishman,
was not successful. ‘Tracheotomy tube inserted with
relief. Patient visited Ohio. While there a physician
removed the tube as useless, and the man died soon
after.
Dr. Cutter propesed to change the name of the ven-
tricular bands to “ breath bands,” on the ground that the
false vocal cords are as true in their function as the true
vocal cords, said function being the control of the
breath in expiration, as seen in the laryngeal demonstrations
by the author. ‘The writer has waited five years for the
systemic writers to rename these bands, with no response ;
hence this name is suggested.
(To be continued.)
ASSOCIATION ITEMS.
ENTERTAINMENTS —On ‘Tuesday afternoon, June 25th,
an excursion was made to the torpedo station. ‘The visit-
ors were received by Dr. J. C. Wise, of the Navy. A
demonstration was made of the explosion of torpedoes,
two being set off, and the guests were also instructed in
some other of the mysteries of defensive warfare.
In the evening there was a reception in the Music Hall.
The platform was tastefully decorated with flowers and
potted plants, and some excellent music was furnished by
the artillery band. An address of welcome was made by
Mayor Coggeshall, on behalf of the citizens of Newport,
and one by Dr. H. E. Turner, on behalf of the Newport
physicians. Dr. ‘Turner's address was devoted chiefly
to sketches of the famous physicians of Newport, be-
ginning with “the old French doctor,” Norbert Félicien
Vigneron, who came to the city and married one of its
daughters in 1704. An oration on Dr. John Clarke, who
procured the charter of Rhode Island from King Charles
Il., in 1663, was then delivered by ex-Senator W. P.
Sheffield.
On Wednesday afternoon an excursion was made to
Coasters’ Island, to inspect the training-ship New Hamp-
shire, and to witness a battalion drill of the boys of the
Training School. ‘The visitors were introduced by Dr. J.
L. Neilson, of the Navy. In the evening there was a con-
cert at the Opera House.
On Thursday afternoon the members of the Association,
with their wives, visited Fort Adams and witnessed a light
battery drill. They were introduced by Dr. S. M. Hor-
ton, of the Army. in the evening of the same day a re-
ception was held ’in the parlors of the Ocean House.
The music was furnished by the naval band.
On Friday afternoon the members went off for a clam-
bake and a sail on N set Bay, upon the invitation
of the Rhode Island Medical Society.
Much credit is due the physicians of Newport for hav-
ing made a success of the meeting in spite of many diffi-
culties. The only complaint was of the lack of hotel ac-
commodations, and this was, of course, unavoidable.
The Rush Monument Committee is having the experi-
ence of most other monument committees, and almost de-
spairs of raising the needed $40,000. At the inception of
the idea it was thought that this amount could be raised
immediately by one-dollar subscriptions, but as yet the
appeal has been responded to by only a fraction of the forty
thousand.
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, May 16, 1889.
A. H. SmiruH, M.D., In THE CHAIR.
Dr. W. GILMAN ‘THOMPSON read a paper (see p. 1) on
THE THERAPEUTIC VALUE OF OXYGEN INHALATION, WITH
EXHIBITION OF ANIMALS UNDER HIGH PRESSURE OF OXY-
GEN.
Dr. J. West ROOSEVELT thought one explanation for
convulsions occurring in animals sooner when under press-
ure of oxygen than under pressure of ordinary air was
the fact that carbon dioxide was less soluble in compressed
oxygen than in compressed air. He also thought that the
amount of oxygen which the blood-plasma was capable of
taking up was sufficiently variable to account for certain
results in oxygen treatment of disease. The few cases of
pneumonia in which benefit was supposed to have resulted
from inhalation of compressed oxygen were not to be
taken as conclusive, for in an equal number of cases other
methods might have been, and frequently were, quite as
successful.
In neurotic dyspnoea, referred to by the author, he
thought benefit was to be derived from oxygen or any
other forced form of inhalation. ‘The treatment was
useful from two stand-points : first, by calling the patient’s
attention to the process he breathed better, deeper ; sec-
ond, the moral impression led him to feel that he was
suffering less from dyspneea.
In simple anzemia of girls he had found patients do
better under the use of oxygen in connection with the ad-
ministration of iron than under ironalone. ‘The explana-
tion might not be ready, yet he could hardly avoid the-
conclusion that the diminished hemoglobin was enabled,
under oxygen pressure, to take up more oxygen, which
amounted practically to breathing more pure air. It was
not to be assumed that the blood-plasma was always
saturated with oxygen. Like Dr. Thompson, he had seen
markedly beneficial results in some cases belonging to the
class of patients referred to, in whom the lung-surface ex-
posed to the air was diminished.
July 6, 1889]
Dr. GEORGE L. PEABovy thought it was a matter of
extreme difficulty to arrive at a conclusion as to the real
value of a given therapeutic procedure when applied with
others, especially in chronic diseases. Ofcourse, reference
was made to curative results, and not to immediate effects
upon symptoms. The earlier attempts to impart more
oxygen than usual to the body were made by placing
materials which originated it into the alimentary canal,
especially the chlorate of potassium, But materials which
readily gave up their oxygen in the animal organism when
introduced in any considerable quantity, must act as
caustics at the site of application. Later it was sur-
mised that the blood could take up unusual quantities of
oxygen through the lungs. ‘This might be possible if oxy-
gen were simply absorbed, but such was not the case ; it
entered into chemical combination with the hemoglobin
of the blood. Under high pressure, ten atmospheres for
example, the arterial blood did become somewhat richer
in oxygen, but practically the amount of oxygen taken up
depended upon the amount of hæmoglobin. In attempt-
ing to administer ozone in water it lost its character by
chemical union with substances on the mucous surfaces,
and might thus do actual harm, instead of proving to be
a therapeutic measure. Dr. Peabody said he was among
those who believed there was grave reason to doubt the
therapeutic value of oxygen in the vast majority of cases
in which it was used. He could not help believing that
its efficacy in many symptomatic states was not greater
than that of pure air administered in the same way. Ox-
ygen inhalation seemed to be most justifiable in certain
maladies attended by dyspnoea in which the blood was
overcharged with carbonic acid. In diseases of the re-
spirato;ry apparatus, with extreme dyspnoea and obstruction
of the passages, as in severe catarrhal bronchitis, emphy
sema, asthma, pleuritic effusions, etc., relief might be ob-
tained by oxygen inhalation.
His own experience with oxygen in illuminating-gas
poisoning was the same as Dr. Thompson’s. He had re-
peatedly used it in numerous instances for a long period
without relieving the patient subjectively or objectively.
He believed there was no justification for the use of
oxygen in such affections as gout, uric acid diathesis, in
which there was presumably imperfect oxidation. The
benefit which had been claimed was probably due to pul-
monary gymnastics, which the treatment necessitated. As
to its value in anemia and chlorosis, it must be remem-
bered that patients with these affections frequently got well
under most varying treatment.
Dr. BEVERLEY RoBINSON thought he had seen absolute
proof of the direct, immediate, therapeutic action of the
inhalation of pure oxygen in the treatment of certain dis-
eases. He had seen in numerous cases of simple anemia
much more marked improvement from the use of oxygen
in combination with the use of iron than from other
methods. He had also seen benefit from oxygen in albu
minuria in atrophic nephritis. In a very large number
of cases the oxygen treatment improved the digestion and
assimilation, and in as far as it did that it seemed to Dr.
Robinson to have a very wide field of utility. In phthisis
he believed it had no direct curative effect, but he thought
it proper to use it, because, first, it forced patients to ex-
pand their lungs; second, because there was reason to
believe it might act in some degree as an antiseptic;
third, it was useful in improving the nutrition. The
amount of oxygen which the blood-plasma could appro-
priate was said to be limited, but the use of oxygen might
stimulate the formation of hæmoglobin, and in that way
be of benefit. He did not think the physician should
allow himself to be guided in an absolute way in the
oxygen treatment by the results „of experimentation on
animals.
Dr. WALTER MENDELSON was inclined, so far as con-
cerned the clinical use of oxygen, to agree with Dr. Pea-
body. In cases of anzemia he had certainly seen some
very marked results. For instance, in the case of an old
man in the hospital various remedies were tried without
THE MEDICAL RECORD.
27
effect until they began administering ten gallons of oxyge
a day, when the improvement was marked. This might,
however, have been due to the systematic exercise which
the patient underwent during the inhalation, and the fact
that he felt something active was being done. In dysp-
noea from various causes he had generally seen immediate
relief, although sometimes it was not very striking ; but,
as he recalled the cases, all the patients finally died,
usually of the cause which had produced the dyspnoea.
Still, he believed that in their last moments they were
rendered more comfortable by the use of oxygen.
Dr. PuTNAM-JACoBI stated that in various forms of as-
phyxia it was observed that the amount of oxygen which
the hemoglobin carried was being continually diminished,
although its physiological capacity might have a maxi-
mum limit. It was in these cases that Dr. ‘Thompson
had found evidence of benefit from oxygen inhalation,
and it was in just such cases that one would expect the.
agent to have a therapeutic value. Here clinical experi-
ence coincided with physiological law. On the other
hand, in the form of anzemia spoken of there was a re-
versed condition ; the amount of hæmoglobin was dimin-
ished, and for that reason the system suffered want of
oxygen. The way to increase the capacity of the blood
for oxygen was to increase the metabolism in the tissues ;
this latter was stimulated by the presence of an increased
amount of albumen.
THE PRESIDENT confessed to a good deal of pleas-
ure in finding that the paper and the discussion in
the main confirmed the worx which he hai done in
this direction t.veaty years ago. One point he thought
deserved more emphasis, namely, that the blood in differ-
ent conditions might not be fully saturated with oxygen,
for the point of saturation corresponded to the full ex-
treme physiological demand. If one’s blood were fully
saturated with oxygen under ordinary circumstances, how
would it be when he took his place in the university boat-
crew? He thought there was a margin, and a pretty wide
one, between the conditions which ordinarily existed in
life and the extreme provisions which nature had made
for extraordinary conditions, and it was, perhaps, just
within this margin that an additional supply of oxygen
might be appropriated by the blood. For example, if
there were a pathological condition present in which the
demand for oxygen was not supplied with ordinary respi-
ration, and might be supplied if the patient breathed
thirty or forty times a minute with twice the usual exer-
tion, the physician might tell the patient to breathe in
that way, but he would know that ordinarily that would
not be possible. ‘To save the patient extreme respira-
tory effort to expand the lungs under ordinary conditions
of the atmosphere, the object might be accomplished
by giving him oxygen to inhale. It seemed to him that
this very nearly marked the limit of benefit to be derived
from oxygen treatment, except in those conditions pointed
out by previous speakers, in which there was diminished
surface exposure of oxygen within the lungs. ‘The condi-
tions in which most benefit had resulted in his experience
had been, on the one hand, catarrhal troubles, as suffocat-
ing bronchitis, and opium-poisoning on the other. In
opium-poisoning he had at one time supposed the benefit
from oxygen inhalation was due to the fact that in the or-
dinary atmosphere the diminished number of respirations
failed to supply the blood with sufficient oxygen, a diffi-
culty which was overcome by supplying the agent in a
pure state. But subsequently he had seen patients suffer-
ing from profound opium narcosis, with the respiration
not diminished notably in frequency or amplitude, yet
markedly benefited by oxygen inhalation. The inference
was that for some reason the blood in opium-poisoning
did not take up as much oxygen from ordinary air as
from air containing oxygen in excess.
When it came to the question of inhaling oxygen under
pressure, there were so many points to be considered of a
mechanical nature that it was difficult to say how much
the results were to be attributed to the influence of the
28 eee MEDICAL RECORD. _
oxygen itself. ‘He thought the convulsions, or even sud-
den deaths which were observed to take place after re-
moval of the person or animal from compressed air, could
be accounted for by the marked change in the distnbution
of the blood.
Dr. THOMPSON, in closing the discussion, said some of
the questions raised belonged to another department of
the subject, which time did not permit him to fully con-
sider. He would say, in reply to the President’s remarks,
that under ordinary respiration the arterial blood, as it left
the lungs, had been found nearly saturated with oxygen.
With regard to its taking up more oxygen under muscular
exercise, here other questions, relating to rapidity of heart-
action, etc., arose for consideration. In merely referring
to the phase of the subject discussed by Dr. Putnam-
Jacobi. he might say, as showing the importance of the un-
known quantity, that animals suffering from asphyxia, after
being deprived of a certain amount of oxygen, yet had
more oxygen in their blood than some anzmic patients
who did not appear to suffer from asphyxia in the least.
Dr. Robinson having alluded to Brown-Séquard’s asser-
tion that pure oxygen was more irritating to the respira-
tory surfaces than nitrogen monoxide, Dr. ‘Thompson said
he had found, as had also other observers, no specially ir-
ritating effects, or burning of the tissues as it were, from
pure oxygen.
THE PRESIDENT remarked that he had kept an animal
four days in pure oxygen without any change in its con-
dition.
Medica iene
CONTAGIOUS DISEASES—WEEKLY STATEMENT. — Re-
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending June 29, 1889:
Cases. | Deaths.
Typhus fevel 5645 Wessels mees wate a ein o o
Typhoid fever 6656 ds scot ke eee we neser sorsun 9 2
Scarlet fevers seco rsari vei nwuse ns aseeksi we base 70 7
Cerebro-spinal meningists.................0ceeee | 3 3
Measles 025 505 ese cies iraa aee in a se Se Tae 86 6
Diphtherlaves dics cocus Pew ess ane E EE ER IOI 32
Small-põx h.ssscgease ses aaee de ine in atai Oe I o
Vellow feret sii cite rreren eaa ESARTE o | o
Cholet eeta sane n a EE o | o
ASSOCIATION OF ACTING ASSISTANT SURGEONS.—The
Association of the Acting Assistant Surgeons of the United
States Army held its first annual meeting at Newport, R. I.,
on Monday evening, June 24th. Seventy-seven members
have been enrolled. The following list of officers was
elected for the ensuing year: President—A. Reeves
Jackson, M.D.; Vice-Presidents—J. L. Ord, M.D.; A. J.
Comfort, M.D.; D. S. Lamb, M.D. TZreasurer—R. J.
Dunglison, M.D. egtstrar— Benjamin L. Holt, M.D.
Recorder—W. Thornton Parker, M.D. Councii—H. M.
Deeble, S. S. Turner, W. E. Saben, H. R. Porter, J. P.
Pratt, H. E. Turner, S. B. Stone, John S. Warren, S. O.
_L. Potter, E. W. Thompson, John T. Nagle. Applications
for membership should be addressed to W. Thornton
Parker, M.D., Narraganset Pier, R. I.
AMERICAN MEDICAL EDITORS’ ASSOCIATION.—A meet-
ing of this association was held at the Casino, in Newport,
on Monday evening, June 24th, Dr. Wile, President, in the
chair. In the absence of the Secretary, Dr. I. N. Love
was elected Secretary pro fem. Dr. Wile read the address
of the evening on “ Our Duties as Journalists and the Re-
forms we should Persistently Advocate.” ‘The paper was
discussed by Dr. Dulles, of Philadelphia, Dr. Conners, of
Detroit, Dr. Davis, of Chicago, and Dr. Love, of St. Louis.
The following officers were elected for the ensuing year:
President—I. N. Love, of St. Louis; Vice-President—-C.
W. Dulles, of Philadelphia; Secrefary—J. L. Gray, of
Chicago.
[J ay 6, I 889
—_— zs
THE Lare W. BARKOD M. D., ETO nee
SURGEON, UNITED STATES ARMY. —At the Annual Meet-
ing of the Association of Acting Assistant Surgeons,
United States Army, held in the Casino, at Newport, R. I.,
June 24, 1889, the following resolutions were adopted :
Resolved, ‘That the Association of Acting Assistant Sur-
geons, United States Army, has learned with sincere
regret of the decease of the late W. Barbour, M.D., late
Acting Assistant Surgeon, United States Army. The
Medical Department of the Army has, by the death
| of Dr. Barbour, lost a faithful and valuable officer, the
medical profession a worthy member, his many friends a
sincere and manly companion. Dr. Barbour had been
long in the service, and had made an honorable record.
He died at the post of duty from disease contracted in
efforts to save human life, and his faithfulness is a bright
example of professional honor.
Resolved, That a copy of these resolutions be sent to
the New York MEDICAL REcoRD, and also to the Surgeon-
General’s Office for transmission to his family.
Henry E. Turner, M.D.,
RICHARD C. Moore, M.D.,
W. THORNTON PARKER, M.D.,
Committee.
RESOLUTIONS ON THE DEATH OF DR. JAMES B. HUNTER.
—At the recent meeting of the New York Obstetrical
Society, the following preamble and resolutions were
adopted :
Whereas, It has pleased Almighty God, in His infinite
wisdom, to remove from our midst our friend and col-
league, James Bradbridge Hunter, in the prime of his life
and in the morning of his usefulness ; therefore, be it
Resolved, ‘That while we bow in submission before His
supreme will, we recognize in His fiat the loss of one be-
loved and honored by us all for his gentle virtues and
manly qualities ; of one who will long be regretted, and
whose place will forever remain unfilled among us.
Resolved, That in his removal the entire profession of
medicine in America suffers a loss which cannot fail to be
appreciated by all connected with it.
Resolved, ‘That the kind sympathy of this Society, for
which he has done so much, and its sincere condolence
be tendered to his bereaved family; and that it cause a
copy of these resolutions to be spread upon its minutes,
published in several of the daily and medical journals of
the city, and transmitted to his immediate relatives.
T. GAILLARD THomas, M.D.,
CLEMENT CLEVELAND, M.D.,
Henry CLARKE Coe, M.D., Committee.
At a meeting of the Faculty of the New York Poly-
clinic, held June 20, 1889, the following preamble and res-
olutions were adopted :
Whereas, This institution has been called upon to
mourn the loss of its President, the late Dr. James B.
Hunter ; therefore, be it
Resolved, That in the death of Dr. Hunter the Faculty
of the Polyclinic has lost an active, efficient, and con-
scientious leader, and the Institution a teacher of rare
experience, untiring devotion, and distinguished success.
Resolved, That we recognize that in the abrupt termina-
tion of his laborious, able, and worthy career, the medical
profession has lost one of its most accomplished and
honored members, one whose death we profoundly de-
plore, and whose memory we venerate.
Resolved, That we extend to his family our heartiest
sympathy, assuring them that we too have lost a trusted
companion and a loyal frend.
Resolved, ‘That a copy of these resolutions be presented
to the family of Dr. Hynter, and that they be published
in the New York Medical Fournal, Tue MEDICAL Rec-
ORD, and the American Fournal of Obstetrics.
(Signed) } PauL F. Munpk,
E. B. BRONSON,
D. B. DELAVAN,
Committee.
The Medical Record
A Weekly Fournal of Medicine and Surgery
Vol. 36, No. 2
é — a m he Sai abs
Original Articles,
YELLOW FEVER.’
By WOLFRED NELSON, C.M., M.D.,
MEMBER OF THE COLLEGES OF PHYSICIANS AND SURGEONS, PROVINCE OF QUEBEC,
CANADA ; LATE STATE BOARD OF HEALTH, PANAMA, SOUTH AMERICA, ETC.
Mr. PRESIDENT AND GENTLEMEN: With your kind per-
mission I shall read a brief paper on yellow fever, a theme
at once interesting to all students of medicine, and pre-
sumably of marked interest to my confrères in the “ Sunny
South.”
In what follows, I shall refer to my own experience of
this dread disease at Panama, on the Pacific, and Colon, on
the Atlantic, both ports of the Isthmus of Panama; my
studies and observations on the West coast of Mexico,
where I studied and traced its epidemics of 1883 and
1884; my experience in the hospitals of Cuba; and
finally my visit to Florida, in the fall of 1887, when I de-
liberately forecast the epidemic that swept Jacksonville in
1888. My letter of warning to the people of Florida
was published in the Zémes-Union, of Jacksonville, No-
vember 30, 1887, and was recalled when the disease was
upon them.
Now, to return to the Isthmus of Panama, where I
lived and practised from 1880 to 1885. I was back there
twice in 1886, and twice in 1888, thus, to use an expres-
sive phrase, bringing my knowledge down to date.
The yellow fever of the Isthmus of Panama I describe
thus: It is an acute infectious disease, a specific fever,
ordinarily not contagious ; but under certain atmospheric
conditions, not yet fully explained, the disease undoubt-
edly develops contagious properties and epidemics re-
sult.
Yellow fever is ushered in in a variety of ways. It
may be preceded by languor or malaise. ‘The invasion
may be abrupt. Generally characterized by a chill, often
very severe, lasting one, two, or three hours ; the duration
of the chill having a marked significance, severe chills
marking nearly all fatal cases. Again, the disease may be
ushered in by sudden nausea and faintness, without any
warning, as in my own case during the Isthmian epidemic
of 1880. Headache is always met with. I know of no
exception to this statement. Frontal headache, a flushed
face, and gastric irritability in new-comers within the yel-
low fever zone, is always very suspicious, a fact specially
referred to in Dr. Belot’s admirable book, “La Fièvre
_ Jaune a La Havane.” Generally the headache is frontal ;
it may be bi-parietal and occasionally occipito-frontal,
but, to repeat, marked headache always. In dealing with
specific yellow fever of the Isthmus of Panama, which,
if respectability depends on its antiquity, is the oldest, most
respectable, and fatal variety known—a history of consti-
pation obtains in nearly all cases. I can recall but a sin-
gle case as an exception to this well-known rule, and it
was a case in my practice where the disease had been
preceded by a malarial diarrhoea. No condition of health
gives immunity. It aims at all, be they healthy or un-
healthy. It has a specific rôle. “From early youth to
advanced age it pursues its death-dealing mission. It is
true that the mortality among children is less than at pub-
! Being a paper read before the State Medical Society of Arkansas
Pine Bluff Meeting, May 28, 1889.
New YORK, JULY 13, 1889
— e — a OS te =- ——
Whole No. 975
erty and beyond. Pains in the legs and sacral region, the
latter often intense and agonizing. I shall never forget
my own experience. It seemed as if a legion of fiends
were trying to dig out—if I may use the expression—my
sacrum with red-hot pincers. The pain is excruciating
and indescribable. In the majority of patients, the face
was red, just like the face is in scarlet fever—the boiled
lobster color. ‘The eyes at first were clear, providing that
there had been no antecedent hepatic disease ; later they.
became suffused, injected. The skin was hot and dry.
In many cases a peculiar biting heat was felt (like the
calor mordax of pneumonia). It produced a strange sen-
sation, resembling a current of electricity playing over the
extended head. Pulse hard and slow, varying from sixty-
five to eighty. Temperature, first stage, 100° to 103°;
where the cases proved fatal, in the first stage, rising to
104°, 106°, and 107°, the latter being the highest temper-
ature noted by me in my practice ; t9 fall slightly just be-
fore death. In the second stage, or “ period of calm,” as
it is termed, it feels a remission only. At the beginning
of the third stage, or the stage of ‘secondary fever,” it
rises again. Respiration, as one would expect during the
“hot stages,” is hurried. At times a peculiar moaning
respiration of indescribable sadness. It fills the room and
the vicinity. The respirations varied from thirty to forty
per minute, and at the close of the third stage fifty to
sixty, becoming less with the fall of the temperature just
before death. Great thirst, nothing appeases it. Rest-
lessness, no position giving any ease. Urine, at invasion,
normal but high-colored. In the majority of cases on the
Isthmus of Panama the patients died during the first stage,
such was the blood-destroying intensity of the disease
when all, or nearly all, of the symptoms detailed and to
be detailed, appeared. ‘They do not appear in any steted
orcer.
Within twenty-fours hours of invasion all the symp-
toms are intensified. Sacral pain and headache increas-
ing ; gastric disturbance and epigastric tenderness devel-
oping early in many cases, the slightest pressure over the
stomach causing intense pain and eliciting sharp cries. In
cases where the brain symptoms were very marked, in
some where patients were unconscious, the slightest press-
ure produced a contortion of the face and body. If
deep-seated pressure was made they wnthed on their beds,
but the instant that it was removed they became quiet
again. Next, nausea and vomiting, at first a clear fluid,
well named “ white vomit ” by Surgeon-General Blair, of
British Guiana, South America. ‘Tongue at first slightly
coated. I am dealing with complicated cases. In pa-
tients who had suffered from intermittents, or bilious re-
mittents, what is termed the characteristic tongue of
yellow fever was not found. As stated it was slightly
furred, later the fur increases from behind forward, the
tips and edges take on a deep red. Gums also become
a fiery red, also the mucous membrane of the mouth and
throat. The whole mucous tract suffers. Later, in the
majority of cases, sore throat is complained of, due to
stripping of the mucous membrane. Blood oozes from
the denuded tongue and gums, giving an indescribable
fetor to the breath ; at times it collects on the teeth. In
some cases a peculiar and characteristic odor is exhaled
from the patient’s body. Once recognized, it never will
be forgotten. It somewhat resembles fodeur du cadavre
of French authors. The late Dr. Stone, of Louisiana,
was the first American writer, I believe, to recognize it.
As he states, it is a very bad omen.
30 THE MEDICAL RECORD,
[July 13, 1889
When patients die in the first stage, the urine always
shows a large amount of albumen. The temperature re-
mains high, 104° to 107° F. Delirium, often quiet,
‘ marks the latter temperature. In some cases extending
over more time—beyond the fourth or fifth day—the
albumen does not appear until the close of the second or
the beginning of the third stage. Albumen is a sine gua
non. I know of no yellow fever without it, nor do any
of my many friends practising within the tropics. It
never was absent in Isthmian cases. I never have seen
or heard of a case of specific yellow fever without it ;
never, either in the practice of Dr. L. Girerd, late Surgeon-
in-Chief Panama Canal Company, in that of Dr. Didier,
of the same service, or in the cases seen by my brother,
the late Dr. George W. Nelson, at one time my partner,
and later Resident Surgeon at the Canal Hospitals,
Huerta Galla, Panama, giving a combined experience of
hundreds and hundreds of cases. During an epidemic at
Colon, in the fall of 1883, it swept the shipping, over one
hundred and fifty cases, nearly all fatal. Again albumen
in all cases. Suppression of urine is a late, and generally
among the last symptoms. Where it is marked, they sel-
dom recover. ‘lhe bowels, if freely acted upon by the
sulphate of soda, to be referred to, may not furnish any
early information, diarrhceal motions produced by the
soda being followed by “ black vomit motions” in many
fatal cases. ‘These motions may precede or follow black
vomit. No rule is ahsolute, or such material, well named,
may only be seen at the autopsy. Black vomit follows
the constant retching and the “ white vomit” of Blair.
Black vomit is happily named, and shows innumerable
fine particles or flocculi named black vomit or “coffee
ground vomit,” or the marc de café of the French writers,
whose books on yellow fever are among the latest and
very best. Frequently patients, without the slightest
warning, commence violent vomiting. It pours forth from
mouth and nostrils, often threatening to choke them. I
have seen a patient resting quietly on his back after the
subsidence of the gnawing sacral pain, when a perfect
flood of black vomit has spurted from his mouth and
nostrils up into the air, over bedding, mosquito curtains,
and the nurse. An old and intelligent writer on yellow
fever, Dr. Dowell, has been singularly happy in his re-
mark, that it is per saltum. So it is.
Here, I must pause and divide my yellow fever cases
into two classes, and shall state that such are met on the
Isthmus of Panama. One class I took the liberty of nam-
ing “ uncomplicated,” the other * complicated.” By un-
complicated, I mean the disease occurring in new-comers.
In these, brain symptoms and delirium were common.
Such, almost without the classic exception, died. I never
knew one to recover. ‘The possession of full health
meant rich blood and a better culture-fluid for the germs
that destroy it—the absolute destruction of the blood
being but a matter of three or four days. I can best illus-
trate this by a case in the practice of my valued friend,
Dr. L. Girerd, to-day a retired practitioner living ın Paris.
In the case referred to, on the fourth day of the disease,
he failed to get a single red corpuscle in the blood—not
one. The heart was driving a fluid through the vessels—
one incapable of nourishing the brain tissues. A fluid
wholly devoid of the life-sustaining oxygen carried the red
corpuscles. His crucial microscopic work revealed a
fluid, and in it the débris of corpuscles; or, to use the
old time word that I have applied to this condition in
yellow fever, a necremia, or death of the blood. His pa-
tient, a titled foreigner, a magnificent specimen of man-
hood, who stood six feet four inches in his stockings, died
a few hours later. The “ complicated” cases occurred in
those who had been on the Isthmus from six months to
sixteen years, and of course were profoundly malarious.
I say of course, as no man, woman, or child there escapes
intense paludal poisoning. Sixteen years had failed to
give the so-called acclimation to an American, Captain
Dean. Specific yellow fever cut him off ; he was my pa
tient. An elderly Italian, M. Georgetti, after thirty-seven
years’ residence at Panama, died of specific yellow fever,
I personally know a French gentleman in Guaymas,
Mexico, who has spent over forty years on both coasts of
Mexico. He went through epidemic after epidemic un-
scathed, but in the thirty-sixth year of his residence, after
passing through the Guaymas epidemic of 1883, he came
down with the disease in 1884, when a few cases appeared,
as is usual following al? epidemics within the tropics, and
just escaped dying. He in person related his experience
to me. Acclimation is only so-called; it is a myth, but
quite in keeping with a lot of our gross ignorance regard-
ing yellow fever. Nothing, absolutely nothing, protects
against specific yellow fever, except having had the dis-
ease, a fact well known to all close students of the disease
within the tropics.
With this digression as a preparatory statement I shall
next consider the second stage, or “ period of calm,” as it
is termed. ‘There is a marked fall of temperature, but
merely a remission, and most deceptive and dangerous it
is. I can best illustrate this by actual cases. In two
cases, both mine, during the epidemic of 1880; new ar-
rivals; just married; he a Frenchman and Consul for
France ; she a Portuguese, aged seventeen. They had
passed the first stage. His temperature had ran up to
106” F., hers to 105° F. ‘Then came the deceptive “ pe-
riod of calm ;” they felt so well that, despite my emphatic -
orders, they got up and walked about. He was in one
room and she in another. In the woman’s case, the sec-
ondary fever came on that night, together with a copious
“ vaginal hemorrhage,” practically the equivalent of black
vomit. She died within twelve hours of her walking about
her rooms. His temperature again ran up. He died the
next day. She, poor girl, was laid out in her wedding
finery. They occupy a single grave in the Foreign Cem-
etery at Panama. Such, gentlemen, is malignant yellow
fever as I know it.
As I have stated, yellow fever may be a disease of a
single “access” or paroxysm. When it is so, the patient
dies or enters on convalescence, such being the milder
cases in Panama. ‘Thus, it resolves itself into a sharp,
clearly defined fever of a single paroxysm, or “ access,”
as the French so expressively term it. As nearly all at-
tacked died, the milder cases were the exceptions. In
the gieat majority the “ period of calm” was deceptive,
the slightest imprudence on the part of the patient ending
in death later, the remission — I have seen the temper-
ature as low as 99 °F.—lasting from twenty-four to thirty-
six hours; in cases marked by long chills, but twenty-four
hours to merge into the third stage of the disease, or that
of “ secondary fever.” I have faced three epidemics of
small-pox, one at home, in Montreal, and two at Panama.
The severe chills in that disease, initiating the severe and
confluent cases, the high primary fever, the second stage,
to merge into the high temperature of the secondary
fever, consequent blood changes, and death. ‘These cases,
so familiar to me, have caused much thinking in connec-
tion with my studies in yellow fever and its blood changes.
In a fatal case of confluent small-pox at Panama, without
the slightest warning, I have seen a fluid that to the eyes
was identical with black vomit, spurt from the mouth,
high in air, over everything, staining the bedding just like
black vomit ; it was fer saltum. ‘To our life-currents we
must look for information.
In the “third stage” the albumen appears, that is, if
absent at close of “ period of calm,” it is invariably met
here. Black vomit and black vomit motions, suppression
of urine, brain symptoms, etc., in cases ending fatally in
this stage, all the symptoms crowd each other, and death
closes the scene.
In “uncomplicated ” cases, or where violent delirium
may be met, many painful scenes result. A young Eng-
lishman, the picture of health, as attested by his magnifi-
cent physique and rosy cheeks, was stricken on landing.
He was my patient. ‘lhe case closed with furious delir-
ium. Four men had to take turns in holding him, until
death closed one of the saddest of sights.
July 13, 1889] THE
A few remarks regarding the “ ei of acclimation ” of
some writers. ‘Chis, mark you, is generally preceded by a
shght chill, a rapid pulse, a flushed face, suffused eyes,
with a trace of albumen in the urine—in a word, it is a
very, very mild form of yellow fever, the febnle movement
lasting twenty-four to thirty-six hours, the mildest type of
an “access.” Failing a trace of albumen, it is not a
fever of acclimation—that is, to a tropical physician—and
without the other symptoms, no subsequent protection
may be expected. In fact, some profound students of the
disease within the tropics consider it but a temporary pro-
tection ; that in seasons of epidemic, while such are ex-
posed in a lesser degree, still they are liable to contract
the severe i
Such, briefly told, is yellow fever on the Isthmus of Pan-
ama. I have seen and attended it, in both cities, Colon
and Panama. I wish to add that it and other tropical
diseases have caused, at a low estimate, fully 20.000
deaths on the line of the Panama Canal. ‘The New York
World of May 18, 1889, credits the French Consul at
Colon with saying that 1 5,000 Frenchmen have died. ‘This
probably is a mistake. I believe 20,000, all told, will be
a generous estimate. The heaviest dying known to me
was in 1884, during that epidemic at Colon, in the ship-
ping and on the Isthmus. In an article in Harpers
Weekly of July 4, 1885, I placed the death-rate for that
month at 653 officers and men of the Canal Company.
I obtained the figures from an inside source. ‘The Canal
Company’s statements, as published in Le Bulletin du
Canal Interocéanique, were aS mendacious as they were
misleading. De Lesseps’ last ditch, that absurd creation
of a man in his second childhood, has cost 20,000 lives,
over $200,000,000 in gold, has ruined hundreds of
thousands of petty investors in France. Up to the hour
of the crash, De Lesseps in person, while knowing the full
truth, unblushingly told his fictions. Since 1884 he has
known the whole truth. He is a wicked old man, who
should be buried alive under his fictions.
Many of our confréres have fallen in the Isthmus.
Some noble fellows are buried there—yellow fever, dys-
entry, and pernicious fever. Yellow fever must be seen
and studied in its own habitats. The Isthmus is one of
the earliest.
My visit to Tampa in November, 1887, impressed me
in many ways, but what greatly interested me was to hear
of cases of non-albuminuric yellow fever. ‘These cases of
so-called yellow tever, I believe, furnish that class of
people who have had yellow fever two and three times.
As may be inferred, I have no faith in any ‘yellow fever
without the invariable presence of albumen in the urine.
I have yet to meet with or read of a well-authenticated
case of secondary yellow fever. Nor do I know a single
physician who has seen one.
Now I come to the subject of treatment ; and here I
most emphatically state that yellow fever has no treat-
ment properly so-called. ‘The host of so-called treat-
ments justify my statement. How can a disease, accord-
ing to the old view, characterized by the symptoms
described by me, have one? Four centuries seem to have
taught the profession nothing, or next to it. All that has
been known with absolute certainty is that people got
yellow fever and died ; the world heard of the dying, and
that from Cuba it makes periodic invasions of the Sunny
South. The treatment of yellow fever is purely symp-
tomatic, my early treatment up to 1884, and was that of
the “ Old School.” May God forgive it for its ignorance
and charlatanism! Many authors have made a rechauffé
or rehash of the experience of others, they never having
seen a case themselves. They are responsible for much
ignorance, /f uot worse. Having tried all the so-called
orthodox treatments, I, previous to the fall of 1884, set-
tled on the following : On being called to see a patient at
the outset, I played a trump card and made quinine the
diagnostic agent. We must bear in mind that a few hours
in such cases may mean a life saved or lost. The follow-
ing was the mixture :
MEDIC AL RECORD. 31
owe ee ee
R. Quin, sulph . E E EA EPEE E E T 3 j.
Acid. sulph. dil., B. Phar........... ... 3 ij
Soda Sulph oe os aecaveseuaws veesesece eee 3 je
Tinct. Card. co. svete ea I EE ij
AG Su dev eels te again tageeeuen laa "vad z viii
Misce Pao en
two hours.
This mixture, given French fashion, in potions, or por-
tions, well diluted with water, made a perfect solution and
was readily absorbed. It was my ‘“‘multicharge gun.”
It gave me the best results. Hot baths. Pilocarpine in
one case, aconite, etc., were in order, to produce free ac-
tion of the skin. If the cases were purely malarial, the
quinine and sulphate of soda met all the indications.
The sulphate of soda acts like a charm, free, bilious mo-
tions following. Every dose contained fifteen grains of
quinine and half an ounce of sulphate of soda. If after
two doses the temperature remained high, roo° and up-
ward, with the usual symptoms, yellow fever was the
verdict. Valuable time had been saved ; the bowels freely
acted upon, a most important indication. Later, I added
to this treatment the following: A phosphoric acid mix-
ture every hour or two, largely diluted with water; gave
it and it only, purposely to bring about an acid condition
of the blood. Ina few words, to make it wholly un-
inhabitable to the germs. I adopted this course only after
serious thought, and said to a medical friend, ‘“‘ My next
patient with yellow fever gets well or dies on phosphoric
acid.” I explained it to two friends, Dr. L. Girerd and
Dr. Arthur Gore, who saw my cases; also, to Dr. Brans-
ford, United States Navy, who crossed the Isthmus on his
way to Nicaragua. Previous to my adoption of this pure-
ly acid treatment, following the quinine and soda mixture,
my patients kept on dying in a way that was simply
appalling. Not that I lost more than my confrères. Our
helplessness dazed me. As stated, after mature deliber-
ation, I settled on phosphoric acid, well diluted, for life
or death. ‘Three cases so treated, all in succession, got
well, an absolutely unheard of thing there. I had friends
see them, knowing as I do what unbelief and professional
jealously will do. My reasoning was sound. The acid
did not destroy the oxygen-bearing function of the red
corpuscles, while the germs of the yellow fever did, and so
killed my patients. By rendering the blood acid these
germs could not live and reproduce. ‘They were destroyed
in situ and the blood ceased to be a culture-fluid. Any
student of medicine familiar with bacilli and their cultures,
knows full well that even faintly acid solutions are fatal
to the propagation of bacilli. Such was my reasoning
as far back as 1884. I have the notes on those cases,
taking full notes on all, as I had been taught to do while
a student at the Montreal General Hospital, 1868-72.
The blood is the habitat of the germs of yellow fever.
When my first case in the series of three demanded my
attention, alas ! I could not procure a reliable phosphoric
acid, when I had to fall back on a formula published on
P- 93, “ United States Dispensatory,” being that proposed
by Mr. James T. Shinn, American Journal of Pharmacy,
October, 1880, thus: “ Liguor Acidi Phosporict. A sim-
ilar preparation, under the name of Horsford’s Acid Phos-
phate, has a large use in this country. The formula is as
follows: Liguor Acidi Phospkorict (without iron); Cal-
cii phosphat., 384 grains; Magnesii phosphat., 256
grains ; Potassii phosphat., 192 grains ; Acidi phosphor-
ici (6o per cent.), 640 minims ; Aq., q. s. to make a pint.”
As stated, not being able to procure a reliable phosphoric
acid, I was forced to use Horsford’s Acid phosphate. It,
as I knew, was a standard preparation of uniform strength
and excellence. I strongly object to employing a patent
preparation, so to speak. Its contents or make-up was
known, and it was “ Hobson’s choice.” ‘The preparation
did all that I anticipated, and I give its formula as found
in the “ United States Dispensatory.” I knew what I
used. It is essentially a strong acid mixture.
To repeat, having given my quinine and sulphate of
soda mixture, thus securing free motions from the bowels,
the malarial element being eliminated by the noneffect
Sig. : Take a quarter at once and repeat in
32
THE MEDICAL RECORD,
[July 13, 1889
of the quinine ; I then treated for yellow fever, thus: To
bring about free action of the hot and burning skin was
absolutely necessary. As stated at first, I tried hot baths,
aconite, etc., and abandoned them, using a simpler and
more effective means, in a vapor-bath, named in Peru as
“ Dr. Wilson’s treatment,” being that of an English phy-
sician who used it with great success during an epidemic
there in 1854, and later. ‘The patient was placed on a
chair—one with a wooden seat—all clothing being re-
moved ; he was covered with blankets tucked in closely
under the chin. A spirit-lamp was lit and placed under
the chair, thus furnishing heat and vapor. To Dr. Wil-
son’s vapor-bath I added a foot-bath, all under the blan-
kets, the water as hot as the patient could bear it. Fi-
nally I grafted on some Jamaican treatment, giving a pint
of hot lemonade or orange-leaf tea. Under this triad, a
profuse perspiration followed, usually within ten minutes ;
it fairly ran off them. Assoonas it was freely established
they felt better. The scarlet hue of the face faded. The
hard pulse became softer. If the bath caused faintness,
that was guarded against by a shorter exposure. With
this I had no unpleasant symptoms, but with nitrate of
pilocarpine, profound pallor and faintness in a well-nour-
ished man caused me alarm. I tried it in but a single
case, and that was previous to my knowing of Wilson's
vapor-bath. The necessary exposure being made, ten to
fifteen or twenty minutes, the patient stood up, the chair
was slipped from below the blankets and he was lifted
into bed en masse to prevent any escape of heat or moist-
ure. More blankets were put over him. In some cases
the perspiring lasted one or two hours, to the marked re-
lief of the patient and the lessening of all the symptoms.
After a vanable time, the skin again became hot and dry,
when the same procedure was repeated, as often as neces-
sary. ‘Thus, two highly important indications were met at
the very outset. First, under the quinine and soda, free
motions from the bowels were secured ; remember the
marked constipation in these cases, often extending over
three or four days, while the man had been eating as
usual. Secondly, full and free action of the skin. Ac-
cording to my way of thinking and reasoning, the patient
was placed under the most favorable conditions for fight-
ing the disease. Generally large quantities of fecal mat-
ter were voided, and the pores were thoroughly opened.
Next, the rest of the treatment was in order. It was of
the simplest. A teaspoonful of the acid phosphate in a
half tumbler of water, every hour or two, day and night,
for the first twenty-four hours. It never caused nausea.
I continued it for two or three days, according to tem-
perature of patient and symptoms. The bowels continued
to act freely—bilious motions. Later they became very
dark under the acid. Previously, I had used sinapisms
and a lot of things recommended by the books, and those
supposed to be experienced in treating the disease. The
sinapisms were placed over the stomach to try and check
the distressing vomiting. At times they were beneficial ;
again, useless. Diet in these cases isa matter of very
small importance. They were too busy with the disease.
I fail to recall a single case where food of any kind was
asked for. ‘The highly irritable stomach must be remem-
bered. Iced milk and beef broth in very small quantities,
at frequent intervals, if the stomach tolerates them. Iced
lemonade and pure soda water. Small pieces of ice al-
lowed to dissolve in the mouth. I gave champagne a
fair trial, and abandoned it. I am satisfied that the purely
acid treatment is ample. The simpler the treatment the
better. The quinine and sulphate of soda mixture, vapor-
baths à /a Wilson, and the acid meet all requirements.
I abandoned the old time treatment. As I have already
informed you, I had three recoveries, one after the other,
all in infected premises where the previously attacked had
died. These recoveries were in the fall of 1884. Early
in the spring of 1885—March—l left for my annual hol-
iday, visiting Nicaragua, when I returned to the Isthmus,
to leave it, April 25th, for New York City.
Three swallows do not make a summer, nor do I claim
that three successive recoveries are everything; but as
nearly all attacked died, I do earnestly claim that three
successive cases getting well furnish food for thought.
Personally, I am satisfied that, by persistently acidulating
the life-currents, they ceased to be blood-heat culture-fiuids
for the germs of yellow fever. I say germs. The follow-
ing facts, I believe, will strengthen my claim that three
successive recoveries were absolutely unheard of at Pana-
ma. A few words regarding the dying from yellow fever
thereaway. I can recall twenty-seven admissions to the
yellow fever ward of the Canal Hospitals, Panama, with
but a single recovery. My brother, the late Dr. George
W. Nelson, then Resident Surgeon, furnished me with the
figures. Of forty-two cases sent to the Charity Hospital,
Panama, during the epidemic of 1880, when I had the
disease, not a single recovery. As a concluding statement,
I could amplify them to any extent—the Dingler expe-
dition. Mr. Dingler and Mrs. Dingler, accompanied by
Mr. and Miss Dingler, and a party of canal engineers—all
told, a party of thirty-three—arrived at Colon in October,
1883; Mr. Dingler being the new Director-General of the .
canal works. Within six weeks of landing Count de
Cuerno and Mr. Zimmerman were dead—specific yellow
fever. Within fifteen months of the landing of that party
of thirty-three, fourteen had had yellow fever, and but one
recovered; Mr. Dingler losing his wife, son, and daughter.
He was very patient and had been on the Isthmus pre-
viously. His regular life, no doubt, was the factor that
saved him. Contrast three successive recoveries with the
above—my cases were specific yellow fever.
As previously intimated, yellow fever spares none.
While it is quite true that total abstainers have been swept
away by it, it is equally true that, even in the severest
cases, they have recovered, where the moderate drinker
was lost from the start. Time and again, my own experi-
ence has conf:rmed this. The regular life, particularly
within the tropics, is its own reward. In “ Ziemssen’s
Encyclopædia,” vol. ii., in the article on yellow fever much
valuable information will be found on this very subject—
the value of total abstinence. “ Panama in 1855,” Harper
Bros., New York. ‘The Handbook of the Panama Rall-
way,” 1860, Dr. Otis, Harper Bros. Dr. L. Girerd’s
work on “Panama,” published in 1883, in French, in
Paris. All contain much information regarding that land of
pestilence and death, as well as “ Five Years in Panama,”
1889, Belford, Clarke & Co., New York.
In reference to the inestimable benefits of total absti-
nence within the tropics, it simply confirms the opinion of
a valued friend at Panama, the Consul-General of the
United States, who, when asked, “ How do you live in the
tropics?” wittily replied: “It all depends on the “iver.”
So it does. An alcoholic liver in yellow fever means
death.
The time allowed for the reading of this paper ne-
cessitates my leaving out much that I should like to dis-
cuss. I must ignore the interesting history of the disease
and hasten on.
A few words or points on the after-treatment. The
treatment during convalescence calls for constant watch-
fulness. It is here that malarial symptoms crop up in
the cases of those who have been at Panama a few months.
Dr. L. Girerd examined the blood of hundreds on arrival,
and found it normal, in no case showing the malarial ba-
cillus. After the first month he re-examined scores of
them ; the blood of all these showed it, simply confirming
the statements to be found in Dr. ‘Tomes’ work, “‘ Panama
in 1855,” statements amplified in Dr. L. Girerd’s work.
To return to the stage of convalescence. I have known
a beefsteak to cause death on the tenth day. During con-
valescence such patients are simply ravenous. Well do I
recall my own intense hunger. Slops are in order, fluid
food, given at short intervals, not to overload the stom-
ach. Its irritability lasts for weeks and weeks. Bathing,
a thorough washing of the patient’s body and hair daily,
in a weak carbolic bath, the thorough disinfection of the
patient’s effects and room.
July 13, 1889] THE
MEDICAL RECORD.
33
The majority of cases were fatal on or before the fifth
day, closing with black vomit, suppression of the urine, etc.
In such patients it was a fever of single “ access,” or parox-
ysm. Other cases passed through the “ period of calm”
and died in the third stage, or that of “secondary fever,”
from the sixth to the ninth day. Cases of a typhoid char-
acter were rare. I saw but one, being that of my friend
Dr. Arthur Gore, now in San Francisco, Cal.
The sequelz : Boils, pimples, parotid swellings, and in-
termittent fever. Jaundice—It was of a rich canary color.
It lasted a whole month. People were never curious
about it, or anxious to ask me questions—not any.
_ Now for a very brief reference to post-mortem appear-
ances. My small experience under this heading simply
confirms what an old and clear-headed American writer
has stated: “ Yellow fever has no pathology.” I refer to
Dr. Grenville Dowell, whose little brochure contains a
mine of information, or what the great French under-
taker, M. de Lesseps, calls “an arsenal of facts.”
The post-mortem findings are so variable in patients cut
off by the same symptoms that no reliance can be placed
upon them. I deem it a blood disease, pure and simple,
and if my view is accepted, absence of any marked path-
ological changes, save in the blood itself, must be ex-
pected.
The liver: It presented a variety of conditions. I have
found it fatty ; again, fatty on section, showing an im-
mense quantity of oil-globules ; again, perfectly normal
1n size and color. ‘The chamois-colored liver is supposed
to be the characteristic liver. I never saw but one, and
it was the only one found in nearly one hundred autopsies
made at the Canal Hospitals, Panama, by Dr. S. Didier,
a gentleman profoundly versed in yellow fever. He was
born in one of its habitats, the Island of Martinique,
French West Indies.
The kidneys: Nothing constant. I met them large and
small; again, perfectly normal to the eye.
The stomach: This organ presented signs of acute in-
flammation. Generally its coats were thickened ; it con-
tained more or less black vomit ; I saw nearly a pint in
one case; its inner surface showing innumerable pink
points or foct of congestion, and small deposits of blood.
Dr. Castellanos, a physician to the Charity Hospital, Pana-
ma, a Spaniard, and formerly a hospital surgeon in Cuba,
told me that it was the only constant condition found by
him, and he, while there in Cuba, had made nearly one
hundred and fifty autopsies.
The brain I never examined. Dr. L. Didier found
nothing worthy of remark in his large experience. Noth-
ing.
_The blood : I always found it in a perfectly fluid con-
dition. Remember the destruction of the corpuscles and
the great amount of albumen eliminated by the kidneys.
Its specific gravity, taken by me two hours after death, was
nearly normal. ‘To this fluid we must direct our whole
attention. To repeat, I deem it a blood disease, pure and
simple, and have held this view since 1884. Death in
these cases is due to a true necræmia. If this view, which
I believe is peculiar to myself, be proven, we have an ex-
planation of the majority of symptoms of yellow fever,
and, as already stated, it explains the absence of any
characteristic pathological changes, save in the blood itself.
The brain symptoms are due purely and simply to the
destruction of our oxygen carriers, the red corpuscles.
The great Virchow attributes loss of consciousness to
their failure to carry oxygen. By rendering the blood
uninhabitable to the germs that prey unon and destroy the
corpuscles, we triumph. Much remains to be explained
about yellow fever. Many honest and patient toilers are
at work on this great problem. I believe that with the
discovery of the specific germ by Dr. Domingo Freire, of
Rio de Janeiro, Brazil ; by Dr. L. Girerd, at Panama, and
its discovery by Dr. Carlos Findlay, in Havana ; to his
and the work of his friend, Dr. Delgado, of that city ; add
to this our knowledge of the truly wonderful strides made
by these gentlemen in their bacteriological studies and
inoculations ; to the above, by acidulating the blood, as I
have done, where it has invaded the system; with such
factors the future seems full of hope to me. May it
prove so. Having digressed I must get back to the
post-mortem findings.
The bladder: Generally a few drachms of highly albu-
minous urine were found. Remember the suppression.
Black vomit has a peculiar odor, and is slightly acid to
the taste. To clear up a vexed point in my mind, I col-
lected some in one of my cases and tasted of it. It re-
quired a little courage, but I was in earnest and working
for results. I may state, ‘zfer alía, that it will never com-
pete favorably with other beverages. The “vomit,” on
settling, deposits coffee-ground “particles,” the fluid
above being the color of weak black tea. Black vomit is
not bilious vomit. I tasted it to clear up this very point.
Black vomit, as a symptom, is of grave import. It indi-
cates advanced blood-changes, the beginning of the
necrzemia. While at Panama I sent friends specimens of
my late patients. My rooms were miniature graveyards.
Some “black vomit” sent to my old classmate, Dr.
William Osler, then Professor of Clinical Medicine in the
University of Pennsylvania, with other material, furnished
pabulum for a lecture on “ Vomited Matters.” To-day he
is Professor of Practice of Medicine in the Johns Hopkins
University, Baltimore, Md., and Physician-in-Chief to
the magnificent hospital of the same name.
To recapitulate: Now that Drs. Freire, Girerd, Find-
lay, and Delgado have found the same germ, Dr.
Domingo Freire being the first investigator and its dis-
coverer, to him the honor and credit aredue. He caused
others to work. Now that this has been accomplished, I
firmly believe a new era is at hand, and that soon this
constant reproach to our profession and much-vaunted
modern civilization, the sway of yellow fever, is about to
receive its coup de grdce. Inoculations will protect man
against this awful disease as vaccine does against small-
pox. Dr. L. Girerd proved his good faith in such a vac-
cine, if the term is permissible, by making attenuated
cultures of the microbes of specific yellow fever, and by
inoculating himself ; and without carrying it to the full
protective influence, he allowed himself to be bitten by
mosquitoes (Dr. Carlos Findlay’s discovery) that had been
feeding on a man in the yellow-fever ward of the Canal
Hospital, a case of specific yellow fever ; the fifth day the
mosquitoes were disturbed and allowed to bite him. The
result was a mild yellow fever. I translated his report,
and it was published in the Canada Medical Record, Mon-
treal, in the fall of 1886, together with an editorial.
With inoculations to protect and prevent, and the
purely acid treatment where the germs have invaded the
system ; with these and a strictly scientific quarantine 2 /a
Dr. Joseph Holt, our profession can save the lives of
hundreds of thousands in the future, who, but for such
measures, would die like rotten sheep. The acid, I be-
lieve, is a germicide in these cases. I like the term and
make no apology for using it. Intermittent fever, as
we well know, thanks to the crucial work of Leveran,
Girerd, and Osler, has its daci//us malaria ; quinine is its
germicide.
When these things are thoroughly understood and put
in practice, travel within the tropics will be divested of
its terrors. People ere visiting them for business or
pleasure will be inoculated, and with quarantines @ /a Dr.
Joseph Holt, the commerce of nations will be almost
free and untrammelled.
Here, gentlemer, I must say farewell. I have to thank
you for your kind attention and patience. In the near
future I trust that you will recall these statements made
in the presence of the members of the State Medical So-
ciety of Arkansas, on this the 28th of May, 1889.
Articles extensively quoted in preceding from author's
papers as under :
“« Yellow Fever Considered ; its Relation to the State of
California ;” Ninth Biennial Report of the State Board of
Health, 1886. Sacramento.
34
THE MEDICAL RECORD.
[July 13, 1889
“ Cuba in its Relation to the Southem United States ; its
Danger asa Disease-producing and Distributing Centre ;”
Tenth Biennial Report of the State Board of Health,
California, 1888. Sacramento.
“ The Present Tendencies to Epidemics ;” Tenth Bien-
nial Report of the State Board of Health, California,
1888. Sacramento.
“The Isthmus of Panama considered as a Disease-pro-
ducing and Distributing Centre ;” Tenth Biennial Report
of the State Board of Health, California, 1888. Sacra-
mento.
“ The Holt System of Maritime Sanitation, or an Ideal
Quarantine ;” Tenth Biennial Report of the State Board
of Health, California, 1888. Sacramento.
THE INHIBITORY ACTION OF ANTISEPTICS.'
By G. W. McCASKEY, A.M., M.D.,
PROFESSOR OF THE THEORY AND PRACTICE OF SIKDICINF, AND CLINICAL DISRASES
OF THE CHEST AND NERVOUS SYSTEM, IN THE FORT WAYNE COLLEGE OF MED-
ICINE, FORT WAYNE, IND.
THE views of the advanced workers and thinkers in the
field of bacteriology, in its relation to practical surgery, are
fairly well crystallized and harmonious so far as the basal
facts are concerned. It has appeared to me for some
time, however, that there was an unaccountable failure to
recognize the great practical importance of a well-known
fact, viz., the power of weak antiseptic solutions to tem-
porarily suspend the vital processes of micro-organisms.
Carbolic acid, for instance, in solution of one to twenty,
will kill the majority of germs in a few minutes’ time; on
the other hand, the same species which would be de-
stroyed by the above-named solution, if placed in a solu-
tion of one to three hundred, would have all their func-
tions suspended, but would retain their vitality for an
indefinite period. In a solution of one to three hundred
and fifty, however, they would flourish luxuriantly.”? In
other words, their physiological processes are suspended by
contact with a solution one-fifteenth as strong as that re-
quired to destroy them. A solution materially weaker
than this fails to exert any restraining influence.
The ‘disposition to ignore this important biological law
has been manifested in a variety of ways, but perhaps
most prominently by the unwarranted assumption that an-
tiseptics are useless, or worse than useless, in the treat-
ment of wounds unless applied in solutions strong enough
to kill the germs. I was particularly impressed with the
fallacy of this position by an editorial which appeared in
a leading metropolitan weekly a few months since. (See
“A Reaction against Antiseptics,” in THE MEDICAL
Recorp for November 17, 1888.) In this editorial Dr.
Saenger is quoted as follows: ‘ The disinfection of a liv-
ing tissue he considers to be impossible. Either the tis-
sue is free from germs, in which case there is no need of
an antimycotic, or it is infiltrated with pathogenic fungi,
in which case it is impossible to destroy the fungi without
at the same time seriously injuring the tissue.” These
views of Dr. Saenger, approvingly quoted by THE MEDICAL
RECORD, I believe to fairly represent the deliberate judg-
ment and “ working formulz” of a large and intelligent
contingent of the medical profession. ‘The position taken
is very plausible, and, indeed, so far as the specific state-
ments are concerned, is entirely unassailable. To use an-
tiseptics in the absence of micro-organisms would, of
course, be extremely irrational; while the direct applica-
tion of antimycotics strong enough to immediately kill the
germs would undoubtedly produce considerable injury to
the tissues. But this is only a part of the truth, and it
does not follow because of these facts that antiseptics are
useless as applications to wound surfaces. Such a con-
clusion ignores the inhibitory law above referred to. ‘To
kill a pathogenic organism is one thing; to inhibit or
1 Read before the Fort Wayne Academy of Medicine, May 13, 1889.
2 Cheyne’s Antiseptic Surgery, p. 262.
~~
suspend its growth and functional activity is quite an-
other.
What does the inhibition of bacterial action mean from
a clinical stand-point? This question is best answered
by stating what it means physiologically, which is, sus-
pension of all those secretory or excretory processes
which result in the production of ptomaines ; and also
complete arrest of the multiplication or numerical growth
of the micro-organisms. This fact is of the highest im-
portance. Robbed of their power to produce the chem-
ical poisons known as ptomaines, to which the morbid
processes of septic wounds are due, and especially when,
in addition to this, they are rendered powerless to increase
in numbers, the few septic organisms which primarily gain
access to a wound are as harmless as so many particles of
lifeless organic or inorganic matter. So long as they do
not functionate they can do no harm.
While the micro-organisms are thus rendered tempo-
rarily inert, another important fact is to be borne in mind.
The longer the living tissue-cell remains in contact with
micro-organisms in an inactive state, the lower becomes
their vitality, and the greater becomes the probability
that the internecine contest between the tissue-cell and
the organism, to which Virchow long ago called attention,
will result in a victory for the former. It might be
answered that whatever inhibits the micro-organism will
also lower the vitality of the tissue-cell. But this does
not logically follow, because, among other reasons, the
change in the life-state of the micro-organism is somatic,
while in the case of the tissue-cell it is molecular, viewing
the tissues as a mass. ‘There are dynamic forces back of
the tissue-cell, in the great mechanism of life of which it
forms a part, which reinforce and sustain it. ‘The micro-
organism has no such forces in reserve.
It seems clear to me that the sweeping assertion that an
antiseptic application to a septic wound is useless unless
strong enough to exert a distinctly germicidal effect, 1s
not only a scientific mistake but a dangerous fallacy,
leading to erroneous practice. If everything constituting
the paraphernalia and environment of an operation, down
to the skin through which the incision is to be made, 1s
absolutely aseptic the use of antiseptics would be absurd,
for they must be regarded as irritants, and, as compared
with sepsis, simply as the lesser of two evils. As has
been repeatedly said, the object, and the only object, of
antiseptics, is asepsis. To drench the virgin tissues wit
chemical irritants during the progress of an aseptic opera-
tion is not only unnecessary but positively injurious, and
entirely contrary to the teachings of antiseptic surgery mM
the light of its latest achievements. But when a wound
is known to be, or there is good reason for believing that
it is, infected, and especially if the infection is recent,
the case is quite different. ‘The use of antiseptics, as
strong as the tissues will tolerate without undue irritation,
is certainly dictated by the information which we now
possess. Who has not seen a post-partum septic fever
disappear after, and undoubtedly in consequence of, the
intra-uterine, or even intra-vaginal, injection of a one-half
per cent. solution of carbolic acid solution or its equiv-
alent? Who has not seen an offensive septic wound-dis-
charge, perhaps with constitutional symptoms, disappear
under a similar treatment? Yet we all know that such a
solution is not germicidal, but only inhibitive. It is not
strong enough to kill, and can only suspend physiological
activities.
The conditions which determine the success or failure
of weak antiseptic solutions in morbid conditions, such as
those just mentioned, are not always clear. It is probably
dependent in large measure upon the degree and depth of
tissue infiltration which exists at the time such treatment
is instituted. If, as often happens, the chemical products
are largely formed upon the surface, the combined irrigant
and inhibitive action removes the cause, and with it the
symptoms, as if by magic. But if, on the other hand, the
germs have permeated and made their habitat deeply in
the tissues, they are manifestly beyond the reach of surface
July 13, 1889]
THE MEDICAL RECORD.,
35
applications. Infiltration of the tissues forming the boun-
daries of a wound can scarcely occur without considerable
surface infection, where the greater part of the ptomaines
would be manufactured, to be absorbed from thence into
the blood and lymph spaces. Hence, even after tissue
infiltration has taken place, surface irrigation with anti-
septics in inhibitive doses would remove the poisons
already formed on the surface, as well as a very important
source of their continued formation.
There is an interesting medical aspect of this question
to which I will briefly refer. It is this: Can the general
infectious diseases be rationally treated, in the light of ex-
isting facts, by an attempt to convert the blood into a
solution of antiseptics strong enough to restrain or en-
tirely prevent the physiological activities of micro-organ-
isms contained in it, by means of the inhibitive action
above referred to? It must be conceded at once that
the killing of these germs, while in the blood, by a direct
germicidal action, is not within the range of possibility,
unless entirely new facts are discovered. Their lethal
dose is probably the same here as elsewhere. There is
not a single fact, so far as I know, which would justify us
in assuming a difference in this respect.
The possibility or impossibility of their inhibition in
the blood ought to be capable of a decision coming within
the range of highest probability, if not of certainty. Let
us glance for a moment at the principal factors which
must enter into the solution of the problem.
The blood vascular system of an average adult con-
tains, we will assume, twelve pounds avoirdupois. It
probably vanes within pretty wide limits, according to
state of health, character and quantity of diet, condition
of the various secretions, etc. But this is sufficiently ac-
curate to form the basis of a calculation.
As to the kind of antiseptic to be considered, it may be
remarked in passing that the mercurial salts, while con-
ceded to be the most potent germicides under proper
chemical conditions, are not entitled to the slightest
consideration in this connection, inasmuch as they are
now known to combine with any albuminous fluid, such
as the liquor sanguinis, forming an albuminate of mercury,
which is absolutely inert as an antiseptic. In view of
this fact, the administration of fractional, frequently re-
peated doses of mercuric chloride for an antiseptic
effect upon the blood is absurd.
Let us take carbolic acid as the basis of our calcula-
tion. We now know that it takes a solution, at least as
strong as one to three hundred, or one-third of one per
cent., to exert an inhibitive influence upon the common
forms of micro-organisms in laboratory experiments.
About the same proportion in the blood, it is fair to as-
sume, would be required to be effective.
Twelve pounds of blood represent eighty-four thousand
grains. ‘To make a one-third of one per cent. solution of
this quantity of fluid would require two hundred and eighty
grains of carbolic acid, or about half an ounce of the pure
crystallized acid. A dose of eight grains is considered by
Huseman to be dangerous. ‘The difference between eight
and two hundred and eighty is so enormous as to make
any comments unnecessary. It is certainly obvious that
no antiseptic can be introduced into the blood in sufficient
quantity to make the latter represent an antiseptic solution
strong enough to have the slightest restraining influence
upon the development of micro-organisms. Eight grains,
if evenly distributed through the mass of blood, would be
less than one-thirtieth of the amount required. A child
weighing twenty-five pounds, and having about two pounds
of blood, would require forty-six grains of carbolic acid
to make the necessary antiseptic solution of the blood.
There is not the slightest reason for believing that the
largest quantity which it is possible to introduce into the
blood would have any effect whatever upon the life
phenomena of any bacteria which it might contain.
To all these deductions from laboratory experiments
it may be objected that they are belied by clinical expe-
Tience at the bedside. But, so far as I know, the diseases
in which the administration of antiseptics has appeared to
have a germicidal, or, at least, a modifying effect upon
the germs which are the efficient causes of all infectious
disease, have been those in which (as in dysentery,
typhoid fever, etc.) the micro-organisms find their prin-
cipal habitat and base of operations in the alimentary
canal. The germs are thus probably brought into actual
contact with the antiseptic solutions before absorption,
when they might easily be sufficiently concentrated to
have at least an inhibitive influence, and, under certain
circumstances, possibly an actual germicidal effect. And
especially in reference to the mercurial salts, which are so
largely used in this way, they could exert their specific
effect without being rendered inert by a chemical com-
bination with albumen. But whatever the explanation
may be, it seems clear that we must look in some other
direction for it than that of blood disinfection from anti-
septics held by it in solution. The following conclusions
are Offered :
1. Solutions of antiseptics one-fifteenth as strong as
those required to kill a given germ (its lethal dose) will
render it functionally inactive, and consequently harmless,
in wounds during the continued action of the antiseptic
and for a variable time thereafter. ‘This should be called
its inhibitive dose.
2. In solutions materially weaker than one-fifteenth the
lethal dose bacteria will flourish, to all appearance, quite
as well as though no antiseptic were present.
3. The inhibitive doses of the various antiseptics should
be as accurately determined and as widely known as are
their lethal doses; and should be studied with special
reference to the different species of pathogenic and putre-
factive organisms.
4. If wounds were irrigated, either continuously or at
brief intervals, with inhibitive doses of antiseptics, surface
bacteria could not manufacture ptomaines, the chief or
only cause of morbid wound processes. Fresh infection
of the wound would also be impossible.
5. A sufficient quantity of antiseptics to render the
blood inhibitive in its effect)upon any organisms which It
might contain cannot at present be introduced into it. _
6. The beneficial effects following the administration
of antiseptics in dysentery, typhoid fever, and other dis-
eases of that type, are probably due to the direct action
upon the germs of the antiseptics before their absorption.
NOTES ON ENTERO-COLITIS IN INFANTS:
ITS CAUSES AND TREATMENT.’
By JOHN LORD BABCOCK, M.D.,
ASSISTANT TO THE CHAIR OF CHILDREN'S DISEASES, ST. LOUIS POLYCLINIC.
WHEN the genial sun of springtime opens the buds and
greens the lawns, there always appear two concurrent
phenumena in the medical journals. One of these is the
article by the doctor who knows a great deal about
cholera infantum, and the other is the advertisement of
the patented baby-food man who knows a great deal
more about it. Recognizing this fact, and in obedience
to the unalterable law of this recurrence, I beg to offer
the following notes, not as embodying a single idea that
is new, but merely for the purpose of placing before you
the general results of the study of a large amount of clini-
cal material bearing upon an important subject.
The green and fetid diaper, like “ the poor,” we have
with us always, and it is to this humble garment—which
a friend of mine asserts to be the modest rudiment from
which have been developed all of the beauties of the
modern bustle—that we must direct our attention.
Before proceeding with the discussion of my subject,
however, permit me a few words upon the closely allied,
but very hackneyed, question of infant feeding by artificial
means. In the clinic of the Post-graduate School of this
city all of the proprietary foods have been weighed in the
1 Read by title before the St. Louis Medical Society, May 18, 1889.
36
THE MEDICAL RECORD.
[July 13, 1889
balance of practical experience and have been found
wanting, although some of them have been found useful
in emergencies, and those of them that involve the use of
cow’s milk are, to that extent, good. Many of them, as
is well known, contain starchy substances, alleged to have
been “converted into the soluble form of dextrine” by
superheating. These foods, of course, do nourish chil-
dren, and in many cases do it well; but their success is
by no means universal, as we might be led to suppose by
the advertising matter so copiously furnished us. Those
consisting of “ dried milk solids and soluble starch” are
apt, in certain cases, to cause obstinate constipation,
which in time produces intestinal irritation, so that the
mother may be surprised to find her child, for this
reason, suffering from a sudden and severe diarrhcea.
‘They are by no means “ideal foods,” and then our pa-
tients, who are numbered largely among the less wealthy
classes, are not able to pay, and we ought not to ask
them to pay, the advertising bills of these food-makers,
which, I am told, form thirty per cent. of the cost of
manufacturing (?) the article; for these foods when
used exclusively are expensive. ‘They have, however, a
slight therapeutic value in checking a simple diarrhoea
after the bowels are freed from irritation. The pre-
digestion of milk with the animal ferments has been
found in our cases to be impracticable. As has been
well said, “the woman who can treat milk with the ani-
mal ferments does not have children.”
The disgusting flavor of an over-digested sample of
milk would make a well man ill, and one may imagine
the results in the case of a sick child. This seems to be
an instance of the cases in which the principle is sound,
but the results unattainable in practice. Of course, in
discussing this question, we must remember the inevitable
baby that “ate anything,” and was the healthiest baby in
the recollection of the oldest inhabitant. Such an infant
is almost always brought into the discussion of baby-feed-
ing ; but the survival of these remarkable youngsters on a
diet of pie and pickles proves nothing, of course, but the
well-known fact that a few children thrive on food upon
which most children could not subsist. After a prolonged
and careful study of this question from the stand-point of
practice, we have come to the conclusion that the milk-
_ and-cream food advocated by Dr. Arthur Meigs, of Phila-
delphia ; Dr. Joseph Winters, of New York, and others,
is, beyond any comparison, the best artificial food for in-
fants. Its composition for an infant of six months is as
follows: Milk, 3 parts; cream, 1 part; lime-water, 1
part ; boiled water, 2 parts; and sugar of milk, 1 part.
Solution of bicarbonate of soda, three grains to the ounce,
may be substituted for the lime-water in case the baby is
constipated. ‘This food meets the general indication of
resemblance to mother’s milk in specific gravity, richness
in fats, alkalinity, and sweetness.
The “hardness of the curd of cow’s milk” is largely a
bugbear that is kept before the profession by the public-
spirited advertisers of prepared foods, who make such
heroic efforts to defend our little patients from the poison-
ous curd of the milk of the malevolent cow. A stomach
that has any physiological activities left-can digest, with
certainty, small amounts of this food. When you have to
do with a depraved organ, modify the food by increasing
the proportion of cream and lime-water, and give it in
small, often-repeated doses. You are then not at the
mercy of compounds of an unknown nature, that have been
on druggists’ shelves for an unknown time, and contain an
unknown variety and number of micro-organisms or prod-
ucts of decomposition. You have the matter of feeding
in your own hands, and experience with this milk-and-
cream food will soon teach you to modify it to suit indi-
vidual cases.
Anyone can now sterilize and preserve milk by the
familiar and simple process of steaming. It is only neces-
sary to have a deep kettle with a perforated tin false bot-
tom, a t:ght-fitting cover, and a flat-iron to place on this
cover. Milk in cotton-plugged bottles, each containing
enough for one feeding only, can be steamed in such a
simple apparatus for twenty-five minutes, and will remain
sweet and good until used. As is the case with all foods,
this milk-and-cream preparation occasionally does not
agree with a child, but in our experience it has failed less
often than any other. In four such cases condensed milk,
which is often a very good temporary food—though I
think a bad one for prolonged use—did well. Three
others took very kindly to malted milk, and two others
seemed to have a selective affinity to the dried milk and
dextrine-food. Inasmuch as milk-sugar is rather expen-
sive, one-fourth the amount of cane-sugar may be substi-
tuted in cases of healthy children over six months of age.
But with all children younger than that, and with older
ones who are suffering from bowel or stomach disturb-
ances, the milk-sugar will be found decidedly preferable.
A word right here in regard to your milk supply. Milk
is the doctor’s sheet-anchor to windward in treating these
cases ; but you will find that among the poorer classes the
habit prevails of running into “the store for a nickel’s
worth o’ milk,” and the milk they get is a common cause
of intestinal disturbance among young children. I am
informed by the manager of one of the large milk com-
panies of the city, that they sell to these groceries their
“ separated ” milk, that is, milk that has been skimmed
three times, so that the uttermost morsel of cream has
been removed. This skimmed milk is watered by its
purchaser, and then brought up to a better color by the
addition of a little good milk. Then, after standing for an
indefinite time in close quarters with ham, bad butter, de-
caying potatoes, codfish, and numerous other odoriferous
specimens of the grocer’s stock, it is sold at five cents a
quart. A sample of this milk which I examined con-
tained about three-fourths per cent. cream, was acid in
reaction, bluish in color, had a disagreeable odor, and a
specific gravity of 1.026, so that it must have been wa-
tered as well as skimmed, as the removal of the cream of
course raises the specific gravity. This awful compound
is fed to babies quite largely in St. Louis, and no doubt
in other large cities also, and must take an important
place among the causes of gastric disturbances among
infants. Our safest plan is to order the milk we use from
one of the three or four large companies. The chances
of getting poor milk are thereby reduced to a minimum,
and if it is sterilized at once, no trouble will be expe-
rienced.
Our patients’ parents should at least be warned about
this corner-grocery milk. The small dairies that abound
in the outlying districts of the city are not to be trusted.
They all possess a large “ swill wagon,” although, of course, |
none of their owners will admit that they ever feed the
cows on brewery grains, better known as swill.
Considered from a clinical stand-point, infantile diar-
rhoeas may be divided into four classes: First, the simple
diarrhoea, that which is caused by intestinal irritation only ;
second, the inflammatory diarrhoea, due to entero-colitis,
or, more rarely, either enteritis or colitis alone ; third, the
colliquative diarrhoea of cholera infantum ; and fourth, the
symptomatic diarrhoea which occurs with varying degrees
of severity in almost all acute diseases, as well as in the
minor ailments of childhood. Simple diarrhcea is due to
the presence in tne intestine of irritation in the form of
fermenting or indigestible material. Its diagnosis and
treatment present no difficulty. ‘The catharsis is a con-
servative action on the part of nature, for the purpose of
expelling from the economy useless or dangerous material.
It is characterized by a discharge which differs from the
normal in fluidity and frequency, and contains some par-
tially digested matters, together with more or less flatus.
It is usually brought to a termination by a few doses of
“rhubarb and soda.” I cannot speak in too high praise
of this simple mixture of our grandfathers. The rhubarb,
as is well known, combines tonic and astringent as well as
laxative principles, the former asserting itself after the
latter has had its effect, and for this reason the rhubarb
is the remedy par excellence for this condition, in com-
July 13, 1889]
bination with the alkaline soda and a carmuinative, usually
cinnamon, or, perhaps better, a few drops of an alcoholic
solution of menthol. By gently stimulating the action of
the bowels it aids nature in relieving itself of the cause of
the trouble and does not leave the intestines in a relaxed
condition. The well-known tendency of neurotic chil-
dren, as well as of all very young infants, to suffer from
convulsions directly after the sudden checking of a
diarrhoea should always be borne in mind. It is unwise
as well as unnecessary to check this form of diarrhoea at
once. A dose of bismuth or paregoric would simply shut
up in the bowels a mass of fermenting material much bet-
ter out of them. In four of the cases which form the
basis of this paper a simple diarrhoea was changed into a
severe type of enteritis by “home treatment” consisting
of paregoric, or what amounts to the same thing, “ sooth-
tag syrup.: 7 |
The victim of entero-colitis presents a very different
picture. Here we have the infant suffering acutely from
abdominal pains, the belly is tumid and tender. The
child’s appetite is lost, it loses flesh and strength progres-
sively, and has from five to twenty movements of the
bowels a day. The fæcal matter may be from a pale
greenish to a grass-green color, or more or less blood-
stained. It usually has a very foul odor. In severe cases
which assume the dysenteric type and which are patho-
logically very similar to dysentery, the discharges consist
largely of a watery, bloody mucus. In this disease there
is always some rise of temperature, particularly in its ear-
lier stages. The progressive emaciation becomes very
marked when the disease assumes a chronic form. I am
convinced that the cause of very many of these cases is
the withholding of water from the thirsty infant. My at-
tention was first directed to this point several years ago by
Dr. Clarke, of Oswego, N. Y., and my experience with
sick children has confirmed his views. Of course decom-
posing as well as improper foods, together with foul air,
play an important part in its causation ; but the importance
of the deprivation of water as a cause has been too often
overlooked. When a child drinks milk or any fluid food
because it is thirsty, and not because it is hungry, it inevi-
tably drinks too much. Its digestive apparatus is flooded
with milk, which of course curdles rapidly, and the stomach
has more than it can attend to. ‘The result is simple and
prompt. ‘There is felt in that organ a greater or lesser
amount of sour fermenting stuff, which makes the baby
cross and feverish and thirsty. Its thirst is again quenched
—not with cool water—but with another bottle of milk,
which it takes eagerly enough, but which simply adds fuel
to the fire and makes a bad matter worse. The intestines
are soon filled with this fermenting mass, and the result is
a simple diarrhoea.
The milk is copiously supplied to the child, however,
and the simple diarrhoea soon runs into an entero-colitis,
and perhaps the child dies from exhaustion or in a con-
vulsion, while the parents, and possibly the doctor too, talk
about a mysterious visitation of cholera infantum —most
convenient and most misused of terms. I have made it
routine practice to tell mothers to give their children all
the water they want, and particularly in hot weather to
always give the baby a drink of water before feeding it.
Then the child will take milk to satisfy its hunger only, and
will not drink too much of it. Having already taxed
your patience with my remarks on feeding and the causes
of entero-colitis, which, however, here as in all children’s
diseases, are by far the more important matter, my re-
marks on treatment will be quite brief, and in this connec-
tion allow me to say that my experience has been strongly
confirmatory of the statements made by our colleague,
Dr. Hendrix, in his paper read before this Society in June
of last year, in which he spoke highly of the value of wa-
` ‘ter in the treatment of diarrhoea in infants. The child
that has a profuse diarrhoea absolutely needs water.
There is an actual lessening of the total amount of fluids
in the body caused by the serous flow from the bowel.
Water never makes a diarrhoea worse. On the contrary,
THE MEDICAL R®&CORD.
37
by flushing the kidneys and by furnishing fluid for the
general interstitial circulation it lessens the morbid pro-
cess by stimulating normal tissue-metamorphosis and thus
increases the general vitality of the patient. In regard to
each case it is necessary to find out first and chiefly about
the diet of the child in answer to the questions, * What ? ”
“ How often?” and “ How much?” Our one hundred
and eight cases of entero-colitis presented about this his-
tory: First, a harmful diet or deprivation of water, or
both, then a simple diarrhoea occurred, followed rapidly
by the inflammatory diarrhoea of the disease.
Their treatment may be divided into three parts: First,
the regulation of food and drink ; second, the disinfecting
treatment, including sometimes the high injection per rec-
tum of large amounts of stenlized water ; third, the opium
and astringent treatment.
The regulation of food consisted usually fn prescribing
small amounts of the muilk-and-cream @ood referred to
above, with plenty of water. Small doses of calomel at
short intervals for two days will often change the charac-
ter of a foul, green, watery discharge to a much more
normal color and consistence, and put your patients in a
condition in which astringents may be given. Rhubarb’
and all resin-bearing purgatives must be carefully avoided
when any inflammation exists. Dysenteric conditions are
best treated by frequent small doses of magnesium sul-
phate. ‘The rule of action in these cases, as in all the dis-
eases of children, must be to give the smallest dose that
will do the work, and the indication is to give the stomach
and bowels rest by removing from them the imitation
caused by the presence of fermenting matters and the
products of decomposition and inflammation. To accom-
plish this we must, as much as possible, disinfect the con-
tents of the alimentary canal, as well as remove them.
Thanks to some of the recent additions to our list of
drugs, it seems now to be possible to do this in many
cases. ‘To that end the diet as above is ordered, or, if
the child is vomiting severely, no food at all is allowed
for two days, and calomel, gr. 4 to +, (this for a child of
six months) given every hour until five doses are given,
and these doses repeated next day, using stimulants as in-
dicated. On the third day, if the green diarrhoea con-
tinues, salol, gr. 3 to gr. 5, may be given three times a day,
laudanum gt. 4 being added if severe pain exists. We have
employed this treatment in seventeen cases, nine of which
recovered rapidly, five were lost track of, and three did
not do well. If the seat of the trouble is in the large in-
testine, the action of the salol does not reach it, and in
these cases large enemata of sterilized, rather hot, water
were given. A large, soft-rubber catheter was used, and
it was gently inserted, injecting the fluid meanwhile, for
its whole length. In two of these cases the improvement
was very marked. ‘The third case, which had been poi-
soned with brandy by its mother, died the day after the
high injection was practised, although the enema relieved
it of its colicky pain and tenesmus. If this general line
of treatment is followed, you will be pleased to find, in
many quite severe cases, that after the small doses of
calomel have been taken for two days, if the directions as
to food and drink are followed, the entero-colitis has
about disappeared, under which conditions we have re-
maining a case of simple diarrhoea, which needs a few
doses of the rhubarb and soda, to each of which from
one-half to a drop of the tincture of nux vomica has been
added, to effect the cure.
Bismuth or chalk mixture is very useful when the
diarrhoea shows a tendency to become chronic, and should
both be used in large doses in order to produce positive
effects.
Just as some of our professional brethren make a prac-
tice of calling every severe case of tonsillitis, for obvious
reasons, diphtheria, so do many medical men call most
cases of entero-colitis in children cholera infantum, for
possibly the same reasons. Cholera infantum is a rare
disease ; true “inflammation of the bowels” is only too
commonly met with. Among two hundred and fifty cases
38
THE MEDICAL RECORD.
[July 13, 1889
of diarrhoea at the Post-graduate School, within a year,
excluding the “symptomatic” variety, we had only three
cases of cholera infantum, properly so called.
"This is not the time or place to speak of the differential
diagnosis. Suffice it to say that the clinical pictures of
the two diseases are as unlike as they well can be, and the
confusion of the names is gross carelessness, if it is not
something worse.
VILLOUS TUMOR OF THE RECTUM.
By GEORGE J. COOK, M.D.,
PR+SIDENT OF THE MISSISSIPPI VALLEY MEDICAL ASSOCIATION, CONSULTING
SURGEON FOR DISEASES OF THE RECTUM TO THE INDIANAPOLIS CITY HOSPITAL
ANDINDIANAPOLIS CITY DISPENSARY, ETC.
On December 28, 1887, Dr. Cline, of this city, called me
to see Mrs. S—#-, forty years of age, formerly robust and
healthy, the mother of several children, and still men-
struating. About five years previous she began to have, at
times, some pain in the rectum and sacral region, dull and
aching in character, and noticed occasionally a free dis-
charge of mucus. These symptoms of rectal disease
gradually increased until the pain became almost constant
during the daytime, when she was up attending to her
household duties, and the discharge of mucus was of daily
occurrence. During the previous six months she had
been losing flesh and strength rapidly, and now was con-
fined to her bed most of the time, on account of general
weakness and the distress in the rectum when in the up-
right position.
For two months past a tumor would present at the anus
while straining at stool, but never entirely prolapsed, and
occasionally some blood was lost. There was one natural
passage from the bowels daily ; but several times a day a
large quantity of thin mucus would pass, sometimes a half
pint or more at once. Her appetite was poor, could take
but little food, and her skin was pale and waxy in appear-
ance. Her history and appearance suggested some form
of malignant disease.
On digital examination I recognized a tumor resting in
the rectal pouch, well above the internal sphincter muscle.
It was different from anything I had ever before felt in
the rectum ; so slippery that it was with difficulty held
beneath the finger for examination, of a spongy consist-
ence, with no induration, and firmly attached to the pos-
terior rectal wall.
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Tumor Removed.
When the patient was placed under an anæsthetic and
the sphincters dilated, the tumor was easily drawn out-
side ; it was the size of a large hen’s egg, of a bright ar-
terial color, had no pedicle, but grew from the gut wall by
a broad base. A fold of mucous membrane was dragged
down to allow it to come outside the anus. There was
some thickening of the fibrous tissue at the base, and
from this sprang long villous processes, which composed
the bulk of the tumor. Each one of these increased in
size from the base toward the free extremity, giving the
ends a clubbed appearance.
The outline of the tumor was very distinct. There was
no surrounding zone of congested or inflamed membrane,
but the healthy tissue came up to the outer row of villi.
The contrast in color was marked ; the surrounding mem-
brane was pale, owing to the great debility of the patient,
and the tumor was of a bright arterial hue.
It was removed by passing a double ligature through
the fold of mucous membrane above it, tying, then cutting
off with the knife. The ligature came off after a few days,
and the patient made a rapid recovery, soon becoming
strong and more fleshy than ever before in her life.
I quote the following from the chapter on “ Villous
Tumors of the Rectum” in the latest edition of Alling-
ham on “ Diseases of the Rectum,” issued last year:
‘This is a rare but interesting disease. Mr. Quain in
his work gives the details of only two cases that had
fallen under his observation. I have seen eighteen ex-
amples of this growth; eleven in my own practice, three
in St. Mark’s Hospital, under the care of my late col-
league Mr. Gowlland, one in the practice of my colleague
Mr. Alfred Cooper, and three under Mr. Goodsall’s care ;
added to these I only find reported two by Mr. Symes,
one each by Messrs. Cripps, Gosselin, Van Buren, and
Bryant—twenty-four in all.”
It is indeed a rare surgical disease of which only twenty-
four examples can be found recorded in surgical litera-
ture, this case making the twenty-fifth.
Some of these tumors are described as having distinct
true pedicles ; others broad pedicles composed of a fold
of mucous membrane dragged down by the tumor; and
others again, like this one, attached to the rectal wall bya
broad base. ‘Those having a true pedicle seem to be
composed mostly of fibrous tissue, with the surface cov-
ered with villous processes, while those attached bya
broad base are formed almost entirely by the elongated
processes, thus differing in structure according to the
varying proportion of the different elements. Hence we
find the authors differing in their descriptions. One says
they have a soft, velvety, villous feel, and a want of the
solidity and firmness which is felt in large polypi; another
says they have the feel of a large warty polypus, with
cauliflower surface ; and still another says they have the
feel of a huge warty growth.
‘This tumor has been found only in adults, and the ma-
jority of the patients have been over fifty years of age.
The prominent symptom is the discharge from the rectum
of large quantities of thin mucus, increasing in amount
as the tumor increases in size. This mucus must come
from the enlarged villi, since, as in this case, the discharge
immediately stopped when the tumor was removed, and,
the surrounding mucous membrane was very pale and
could not in that condition have secreted an excess of
mucus. In many of the cases blood was lost in large
quantities. Quain calls this the “ peculiar bleeding tumor
of the rectum.” When any of the villi are broken, free
bleeding will certainly occur ; and when there is prolapse
of the tumor during stool, and it is grasped firmly by the
sphincter, such a result could scarcely be avoided, though
the villi are not easily broken down or torn. There is a
gradual loss of flesh and strength, and this without the
loss of blood. In the present case the loss of strength
and flesh began long before any blood passed away; so
the general prostration must be attributed largely to the
loss of mucus, which may amount to several pints daily.
‘The tumor in time will be forced down and prolapse at
stool, and when seen by the surgeon need not be mistaken
for any other form of growth in the rectum.
Most authors describe these tumors as innocent in
character, and seldom recurring after thorough removal ;
but Mr. Allingham states that they may recur as malignant
growths, he having seen three cases in which epithelioma
replaced the villous tumor.
18 West OH1o STREET.
A MEDICAL COLLEGE in Chicago has been sued in the
sum of $5,000 for refusing a ticket of attendance to a
lady medical student. The college claimed that she did
not apply early enough in the season.
July 13, 1889].
THE MEDICAL RECORD.
39
APPARATUS FOR STERILIZING MILK.’
By T. M. CHEESMAN, M.D.,
ASSISTANT IN BACTERIOLOGY, COLLEGE OF PHYSICIANS AND SURGEONS,
NEW YORK.
THE necessity for sterilizing infant food, more particular.
ly during the hot seasons, is my reason for drawing your
attention to a sterilizing apparatus, which is known as the
“ Arnold Steam Sterilizer.” It was introduced into the
laboratory of the Alumni Association of the College of
Physicians and Surgeons by Dr. Prudden, for sterilizing
culture media, and its recommendation comes from a thor-
ough test of its merits.
To Professor Soxhlet is due the credit of first sterilizing
milk for infant feeding, and to Dr. A. Caillé the credit of
introducing the practice to the profession in this country ;
but the apparatus here shown presents certain advantages
over that which is recommended by them.
‘Fhe cooker consists of (1) a flat shallow boiler, holding
but a small amount of water, and therefore requiring but
a minimum amount of heat to produce steam; (2) a
reservoir, which constantly feeds the boiler and causes
steam to be formed continuously; (3) the steam chest
or receiving vessel; and (4) a hood, enclosing a space
between itself and the receiver, which is constantly sup-
Hood.
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SMAN
A, Boiler. B, Reservoir. D, Steam Chest or Receiver.
plied with escaped steam, a device which causes a tem-
_ perature once reached to be maintained so long as the heat
is unchanged.
Sterilization is accomplished by bringing the object to
be sterilized to the temperature of live steam, and main-
taining it at that temperature for about forty-five minutes.
Boiling for the same length of time, in a vessel the sides
of which are exposed to the air, is not efficient, as the
temperature in different parts of the vessel is found to
vary considerably. ‘This is the main objection to Soxh-
let’s apparatus, the principle being that of a water-bath.
While in the cooker, we have a steam-bath, in which
variation of the temperature is prevented.
Numerous tests have shown that with a single Bunsen
burner, and ordinary gas pressure, the temperature of
100° C. is reached, in all parts of the receiving vessel, in
less than ten minutes. The time required to raise the
fluid to be sterilized to the same temperature is found to
be directly proportional to its bulk. So that less time is
required when the food is in divided quantities. When
the temperature of 100° C. is reached, sterilization has
commenced, and should be continued for the time speci-
fied, forty-five minutes, which time is necessary on account
of the great resistance of the spores.
As a sterilizer, the cooker presents these principal ad-
vantages: 1, its effectiveness in sterilizing ; 2, economy,
! Read before the Section on Pediatrics of the New York Academy
of Medicine, June, 1889.
both of time and fuel; and 3, great convenience, on ac-
count of its portability.
The recommendations to any who might use it are as
follows :
That the food be prepared as it is to be administered,
and that the quantity required for twelve or twenty-four
hours’ feeding be distributed in eight-ounce flasks or nurs-
ing bottles, providing one such bottle for each feeding,
so that no unnecessary exposure or transference shall be
had, In filling the bottles a funnel should always be used
to keep the necks clean, and the fluid should be a full
inch below the neck. ‘The bottles should be plugged
with cotton, extending well down into the neck, any 1m-
purities which this may contain, in the form of moulds
or bacteria, being destroyed by the same process which
sterilizes the food. ‘The bottles are now placed in the
cold receiving-vessel (to prevent breakage) and heat is
applied by means of gas, or a kerosene or coal stove. To
insure a complete sterilization, heat should be maintained
altogether for one and a quarter hour.
Food thus prepared can be kept at ordinary temperat-
ures for an indefinite period, doing away entirely with the
use of an ice-pail or refrigerator for keeping the milk
sweet. :
When the food is to be given the bottle is to be well
shaken to mix in the cream, the cotton plug is removed,
and the nipple applied to the bottle at once. In cases
where it may be necessary to administer food at a higher
temperature, the bottle is stood in warm water, as is cus-
tomary. In regard to the nipples, it is not practical to
sterilize them, as heat destroys the rubber, but they can
be thoroughly cleansed by the ordinary methods.
Clinical Mepartment.
TREATMENT OF DIABETES.
By JOSEPH S. CARREAU, M.D.,
NEW YORK.
DUJARDIN-BEAUMETZ, at a meeting of the Academie de
Médicine, March, 1888, praised the happy effects of anti-
pyrine in certain cases of diabetes, especially when the two
symptoms, polyuria and nervous irritation, predominated.
Henri Huchard, at the Société de Thérapeutique, Feb
ruary, 1888, said that he had employed antipyrine in a
case of symptomatic polyuria resulting from meningo-my-
elitis, with good effects. He gave from four to six
grammes daily, and the quantity of urine was brought
down from thirty-six litres to four. He also reported a
case of diabetes, where he noticed, in a few days, the su-
gar diminish from 735 to 271 grammes a day under the use
of antipyrine—two to six grammes daily. He also said
that the prolonged administration of antipyrine, in his own
experience, has never been followed by albuminuria.
M. Panas reported two cases to the Académie de Médi-
cine, April, 1889, where great relief followed the adminis-
tration of antipyrine. A man aged thirty-eight, passing
forty-nine grammes of sugar in twenty-four hours, by tak-
ing two to three grammes daily during six days, had all
traces of sugar in his urine removed. A woman, aged
seventy-three, by taking three grammes daily, for a few
days, also received similar benefit.
The following are some cases in which I employed
antipyrine.
Case I.—Mr. C——, aged sixty-two, diabetes of long
standing. From 1885 to 1888 had been under various
forms of treatment in different countries; the sugar had
been reduced in quantity, but had never entirely disap-
peared. In March, 1888, he began the treatment by
antipyrine, ten grains four times daily, with strict diet, to
be continued for three days. On the fourth day no im-
provement was found ; then ten grains were ordered six
times in twenty-four hours. At the end of these last three
40
days, the urine was decreased in quantity, the specific
gravity was lower, and the quantity of sugar was less. The
pulse being feeble and rapid, the antipyrine was decreased
to ten grains three times a day. At the end of six days
more the sugar had entirely disappeared, the quantity of
the urine had also diminished from nine quarts to two,
and all the other symptoms had also improved. The an-
tipyrine was discontinued, and the patient was placed
under tonic treatment and strict diet. Since then he has
had two more attacks, which were subdued by the same
treatment, the first lasting seventeen days, the second
only eleven. Since March, 1888, the patient’s health has
been better, he has gained flesh and strength, and has been
able to take some outdoor exercise.
Case II.—Mrs. A——, aged thirty-eight, a thin and
nervous woman, mother of three living children, having
had a miscarriage, which occurred ten years previously.
She complained of excessive thirst, and passed six quarts
of urine in twenty-four hours, specific gravity 1.032 with
traces of sugar. She hada chronic pelvic abscess, with
fistulous tracts opening into the vagina. She was placed
under strict diet, and took from forty to eighty grains of
antipyrine daily, during sixteen days, after which the
quantity of urine became normal, all traces of sugar
had disappeared, and the characteristic symptoms had
Improved. She was placed under diet and tonic treatment.
She has been able to work ever since, supporting her three
children by her labor.
Case III.—Mr. B , aged forty-eight, had sciatica
for ten years; has to urinate every half hour, passing in
twenty-four hours from eight to ten quarts of urine,
specific gravity 1.030, loaded with sugar. He was ordered
fifteen grains antipyrine four times daily for three days.
Slight improvement followed. On the fourth day the
same dose was ordered six times in twenty-four hours for
three days more. At the end of this period the pain had
stopped, the quantity of urine was bruught down to two
quarts, and no sugar was detected by ‘Trommer’s test. An-
tipyrine was discontinued ; iron and cod-liver oil with
strict diet was ordered. In January, 1889, he had an-
other attack of sciatica and glycosuria, which was subdued
in ten days by the above treatment.
MACERATED FŒTUS AS A COMPLICATION
OF LABOR.
By SARA E. POST, M.D.,
NEW YORK.
THE case was that of a primipara. The date of con-
ception was uncertain, but quickening occurred, I was
told, about October 10, 1888. About the middle of Jan-
uary the mother fell, so as to inflict a wound upon the
knee, of which the scar still remains. Pregnancy, how-
ever, appeared to progress normally until about the mid-
dle of February, when I was called in because the move-
ments of the child had apparently ceased. The mother
could not say how long previously such movements had
last been shown. I was unable to detect life, but found
nothing peculiar in the contour of the tumor. As the
mother remained well the condition was not interfered
with, and labor came on in March, at about the calculated
time. There had been some loss of fluid the night pre-
viously, but, it being the first child, the young mother
could not tell whether it had been more than the escape
of urine. The quantity at least was not large. At the
time I was summoned, labor was progressing. A mem-
branous bag presented, smooth, its contents plainly fluid.
The bag itself, however, had a peculiar feel of leathery
thickness unlike that of the amniotic sac. The cervix
dilated and this bag came down so as to distend the vagina.
Contractions then became feeble and labor was delayed
for a number of hours. My first suggestion was that I
was dealing with a condition of thickened membranes, as
no amniotic fluid whatever had been lost in my presence.
Upon this hypothesis I was considering the question of
THE MEDICAL RECORD.
[July 13, 1889
puncture, and had exposed the bag of fluids for the pur-
pose, when I found it muscular or “ fleshy” in appearance,
causing me to abandon this first view. It then seemed to
me more probable that the membranes had ruptured the
night previously, and that a monstrosity of some descrip-
tion had presented. Upon this supposition I asked for
counsel. On account of this request, or for some other
reason, labor recommenced, the mass descended, and
within it some loose cranial bones, so that its character
became soon apparent, and the labor was completed with-
out difficulty. When born, the foetus was found of about
eight months’ development, the skin macerated over the
whole body as well as the scalp. The brain was replaced
by a reddish liquid of the consistency of pea-soup, in
which the bones of the cranium floated. Even the base
of the skull was loosely articulated, and the whole head
had become the fleshy fluid-containing bag which, on ac-
count of the absence of hair and epidermis, I had failed
to recognize. There was no odor about the specimen,
and the abdominal and thoracic contents were not notice-
ably softened.
I cannot think that this is a very common complication
of labor, as I have mentioned it to several physicians with
large obstetric practice who had never met such a case.
I relate it particularly for the benefit of other young prac-
titioners, and simply to draw attention to the fact of pos-
sible misapprehension connected with it. Had I gone
on to rupture the supposed bag of waters the result would
not have been nice.
THE PREPARATION OF CATGUT.
By JOHN C. SCHAPPS, M.D.,
BROOKLYN, N. Y.
For the last four or five months I have been making use
of the following simple, and thus iar satisfactory, process in
preparing catgut. ‘The gut, in as long pieces as can be prc-
cured without knots, is placed, with sufficient ether to
cover it, in a wide-mouthed, glass-stoppered bottle. What
is known as a six-ounce, German XX, saltmouth is an
economical size, as the internal diameter just permits the
ordinary coil to lie flat. The stopper should, of course,
be a very perfect fit. The ether soon becomes discolored
and gives off a strong animal odor, and should be changed
every day or two until it remains colorless and has no 1m-
pure scent. The catgut in a few days is nearly white, and
has a peculiarly clean feel. ‘The fatty and other soluble
organic matter being removed, it is probably now per-
fectly aseptic. Certainly aqueous germicidal solutions
can easily penetrate it. It 1s, however, my custom to
wind each piece upon a glass spool, and keep it in a small
bottle containing an ethereal solution of mercuric bi-
chloride, one to one thousand. By means of a needle, the
end of the catgut is passed through the cork, which need
not be removed until the spool is empty. The tensile
strength of the catgut appears in no way affected by this
process, though it rapidly loses its stiffness in water.
As yet, with one exception, I have not had a drop of
pus in any wound (including those of knee-joint excision
and amputation of the breast) in which catgut thus pre-
pared was used. This exception was probably due to im-
perfect scraping of an old suppurating cavity. It is, how-
ever, to be stated that I have not experimented with the
thickest kinds of catgut ; but if ether will not permeate
them it will be hard to find anything that will. The fact
that the danger of catgut lies in the fatty matter, in which
the microbes are ambushed beyond the reach of watery
solutions, has led to the recent movement toward aban-
doning the use of this material altogether. These points
are well expressed in an article by Dr. George R. Fowler,
in the December number of the Annals of Surgery. But
if a more extended experience shows that in ether we have
a remedy, catgut is for many reasons to be preferred, as
suture or ligature, to silk or linen thread.
I have only recently learned that it has been the custom
July 13, 1889] THE
MEDICAL RECORD. 4I
at the Methodist Episcopal and St. Mary’s Hospitals, in
this city, to employ juniper oil as a sterilizing agent, and
then to use ether to wash out the excess of oil. But the
ether process appears to me to be more direct, simple, and
thorough.
486 BEDFORD AVENUE.
ee
Progress of Medical Science.
THE USE AND ABUSE OF MassaGE.—At a recent meet-
ing of the British Gynecological Society, Dr. Macnaugh-
ton Jones gave the Fellows his views on the r/e of mas-
sage in gynecological practice, and at the following meet-
ing a lively discussion took place which brought out many
points of interest and instruction. Although it was by no
means the intention of the author to run down a method
of treatment which he evidently holds in great esteem,
his paper contained certain observations on the subject of
the degenerate way in which massage is at present carried
out in the hands of the masseurs and masseuses (whose
name is legion), and these served as a text upon which
the opponents of massage preached a very stirring sermon.
Looked at from a disinterested point of view, massage is
a practice the value of which is certified by a hoary an-
tiquity, and is doubtless of service in a large class of
cases which are more or less obnoxious to other methods
of treatment. Nothing, however, that we know of the
practice can justify the extraordinary vogue which it at
present enjoys, and the high-flown expressions upon
which it is sought to build up a pseudo-scientific proced-
ure are little else than a cloak for one’s ignorance on the
subject. Leaving on one side, for the present, the precise
indications for massage and the method in which it should
be applied, the great and general ground of complaint is
that the method has fallen into unscrupulous and _ unskil-
ful hands, with detriment to the interests of the patients
and to the method itself, which is in serious danger of
falling into disrepute in consequence of the doubtful
way in which it is carried out at certain institutions and
by certain persons. The only indications for massage,
according to one of the speakers, is that the patient shall
have a thin body and a fat purse, and the whole treat-
ment is more or less a process of “ milking!” ‘The ap-
plication of massage to disease of the internal pelvic or-
gans, as exemplified in “ massage of the uterus,” came in
for severe strictures on all hands. As described by the
author of the paper, the performance would seem to bear
a singular resemblance to masturbation, and one can
understand and sympathize with the reluctance evinced
by many medical men to being parties to any such pro-
ceeding ; more especially as one is aware of the fact that
for purposes of treatment, the patient is confided to per-
sons of whose accomplishments and morality we have
little or no guarantee. It is possible, as urged by the
president, that good results may be obtained thereby, not-
withstanding that anatomical considerations would seem
to negative the idea of the possibility of any efficient
massage of that much-tried organ, but we are certainly
justified in asking that the treatment shall only be carried
out under the direct superintendence of a medical man,
so as to avoid any risk of improper practices. ‘The au-
thor of the paper seemed to be much disappointed at
having elicited a discussion so foreign to his intentions,
but there can be no doubt that it is high time the profes-
sion, as a body, took official cognizance of the harm that
is being done by indiscriminate employment of this par-
ticular method of treatment by persons whose only claim
to practise as such is based on a three months’ course of
lectures by this or that person, who has arrogated unto
himself the proud title of professor of the noble art of
massage. We are informed that the applications of
marauding masseurs and masseuses for employment has
come to be a ventable tribulation to men who are.
credited with being in a position to recommend patients.
The only way to put a check upon the degradation com-
plained of would be for the medical societies to discuss
the matter, and to bring the pressure of public and pro-
fessional opinion to bear upon the persons, many of
whom belong to the profession, whose conduct conduces
to the practices in question. Gynecologists are not more
interested than practitioners in other departments in tak-
ing the matter up, and, perhaps, now that the ice has
been broken, the subject may be considered worthy of
attention at the hands of the representatives of the pro-
fession who weekly meet and assemble together, as they
flatter themselves, for the advancement of medical science.
—The Hospital Gazette.
THE TREATMENT OF WHOOPING-COUGH.—Dr. R. Daniel
writes to the British Medical Fournal that in a recent
epidemic of whooping-cough he had an opportunity of
giving many drugs a trial, and of noting their efficacy.
Glycerine of carbolic acid was administered in a large
number of cases, but was by no means universally suc-
cessful in checking the disease. It was most beneficial
(1) in children under one year; (2) in uncomplicated
cases ; (3) where secretion was excessive. It sometimes
had a marvellous effect in controlling spasm, and its good
was intensified by carbolic vapor or a spray in the sick
room. The dose invariably given was 4 minim every
three hours to children under one year, that amount being
increased to 1$ minim for children of two years, and so
on in proportion. In the majority of cases treated he.
found the best results from a mixture of tincture of bella-
donna (in full doses), vin. ipecac., and glycerine, given
every two or three hours, according to intensity and fre-
quency of the paroxysms. With Dr. Collyns, he pre-
ferred to give a dose of potass. bromid. at bedtime, in-
stead of with the day mixture. A hot. bath, too, at night,
had often a most soothing effect, and formed a very
useful adjunct to medicinal treatment. ‘The employment
of compresses to the spine during the day also proved
beneficial. Diet, regular and nourishing, he found of
the greatest importance. Sickness is often exceedingly
troublesome, and in such cases a peptonized-muilk diet was
of ‘great value. Dr. R. Guaita, medical director of the
Children’s Hospital at Milan, confirms (British Medical
‘Fournal) the value which has been attributed to antipy-
rin as a remedy in whooping-cough. During an epidemic
at Milan, last summer, he used it in 22 cases, 12 of which
were of great severity, with the result that in every in-
stance the disease was completely cured in from four to
five weeks. No complication of any kind occurred. The
age of the patients varied from five months to nine years,
with the exception of one who was over twenty. In all
the cases the symptoms subsided or became more marked
according as antipyrin was given or withheld. Dr. Guaita
thinks that the good effect of the drug is due partly to its
inhibitory action on the nervous system, and partly to its
antiseptic properties ; he calls it the “sovereign remedy,
for the present at least, in whooping-cough.” He gives
twenty-five centigrammes of antipyrin in twenty-five
grammes of syrup of orange peel, with an equal quantity
of distilled water, in four doses in twenty-four hours, in-
creasing the dose of antipyrin to one or one and a half
gramme, according to the indications. If the cough
causes vomiting he finds a small quantity of hydrochlorate
of cocaine given with the antipyrin most useful.
IMPROVED METHOD OF AMPUTATION OF THE PENIS.—
The most unpleasant symptom following amputation of
the penis is the funnel-like retraction of the urethra, which
causes the patient endless discomfort. Dr. Assaky over-
comes this by dissecting the pars spongiosa of the urethra
from the penis, for about an inch beyond the superficial
incision. ‘Then the corpora cavernosa of the penis are
cut through from below, leaving about half an inch of the
urethra protruding beyond. ‘The tunica albuginea and
the skin are then brought over the stump of the pars ca-
vernosa and stitched around the protruding urethra. ‘This
will retract to some extent, leaving a very natural looking
meatus.—Centralblatt für Chirurgie.
42
ee a ee ee -
THE MEDICAL RECORD:
A Weekly Journal of Medicine and Surgery.
*
GEORGE F. SHRADY, A.M., M.D., EDITOR.
PUBLISHED BY
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
New York, July 13, 1889.
THE NORMAL POSTURE IN LABOR.
THE observations and records of travellers, ethnologists,
and physicians show that women of various races, during
labor, assume very different postures. ‘The precise post-
ure seems to be determined partly by instinct, but largely,
in many cases, by custom. Instinct, among civilized races,
does not seem to be a very certain guide, if one may
trust the reports of Schiitz and Von Baren. These physi-
clans took a young, healthy woman, pregnant for the
first time, quite ignorant of the process of labor, and
totally uninstructed as to what she should do during
its continuance. Such a woman was placed entirely
alone in a room containing chairs, stools, sofas, cushions,
beds, etc., with every opportunity to use any, all, or
none of them, as she might desire, and to assume any
position or positions she might wish. .On being watched,
it was observed that she behaved, in each of the ex-
periments, exactly as a man or any other person would
do when suffering from a severe attack of colic. Find-
ing no relief in one position, she would get into an-
other, and so on; continually changing her posture, simply
following the instinct of seeking relief from pain. Of
50 such experiments recorded by Schütz, “ 32 (over half)
occupied abnormal positions ; 14 standing, 16 crouching
or squatting, 2 kneeling.” Of 100 other such cases, cited
by Dr. Cohen v. Baeren, of Posen, 50 “occurred in un-
usual positions: 30 stending, 18 crouching or squatting,
and 2 kneeling” (“ Transactions American Gynecologi-
cal Society,” 1880, p. 176). In one such experiment by
Naegele, “the girl took all possible positions, and was
finally delivered tossing about on the bed.”
Some years ago Dr. Engelmann, as the result of his
studies as to the normal posture in labor, concluded that:
I. In the ordinary labor case, which is a purely mechani-
cal process, the patient should be given greater liberty
and should be permitted to follow the dictates of her
instinct in regard to her movements, more freely than is
now customary.
2. In the earlier stages of labor the parturient must be
guided in her actions and in the position assumed by her
own comfort and by the dictates of her instinct.
3. The recumbent position retards labor and is inimical
to easy, safe, and rapid delivery.
4. In ordinary labor cases the expulsion of the child
should be expected in an inclined position: kneeling,
squatting, or recumbent, in bed, on the chair, or lap, as is
done by the great majority of uncivilized people.
THE MEDICAL RECORD.
[July 13, 1889
5. Of these positions, the semi-recumbent is the most.
serviceable, and should be adopted as the obstetric posi-
tion in all ordinary labor cases; it is preferable to the
kneeling or squatting.
Many years ago American physicians were taught to de-
liver the woman while lying on the left side ; but fora
long time this practice has been given up, and the rule
generally is now to allow the labor to occur with the
woman lying on the back.
Recently there has been considerable said again in favor
of the left-side posture. Dr. A. F. A. King, of Washing-
ton, has discussed the subject exhaustively in the 4 mert-
can Fournal of Obstetrics, No. 4, 1889.
Dr. King is convinced that there is no one posture
which is best, and that a change in position to meet va-
rious indications is the most important element. He
cites the case of a woman who, in obedience to her phy-
sician, and contrary to her own expressed, instinctive wish,
was kept in bed during labor for sixty hours ; at the end
of this prolonged dole of agony, no progress being appar-
ent, her request was acceded to; she was allowed to sit
up, and immediate delivery followed. It may be added
that this woman was sixty years of age, and had previously
given birth to seventeen children! In three other cases,
when it was thought necessary to apply forceps, a similar
change of posture sécured rapid delivery without difficulty,
and without instrumental aid.
, The exact changes and final position of the woman
should be determined by the obstetrician after a careful
examination of the case. He concludes :
1. There is no one posture that can be normal for the
parturient woman.
2. The continued maintenance of one posture wastes
and exhausts the forces of labor, interferes with the nor-
mal mechanism, and adds to the duration and intensity of
the woman’s suffering.
3. Exactly opposite results are produced by proper
changes of posture.
4. The indications for change are: Instinctive desire
for it; arrest of the mechanism of labor; emotional dis-
content, peevishness, and despair.
5. The normal mechanism of labor being at present
imperfectly understood, and the influence of different
postures upon this mechanism, during the several stages
of the several “ positions ” of the several ‘ presentations á
being unknown, the selection of given postures for given
conditions cannot be defined without further study.
We must be permitted to conclude that some of these
conclusions, if true, reflect little credit upon the modern
obstetric art. If ‘the normal mechanism of labor is still
imperfectly understood,” it argues extraordinary dulness on
the part of physicians who have been delivering babies
since medical science began. Furthermore, as over ninety
per cent. of labors are normal and take place in almost
precisely the same way, it seems as though obstetricians
should be able to tell the woman what would, with the
greatest probability, be the proper position for her to
adopt. Professor King, it seems, would leave the un-
happy parturient uncertain whether she should squat like
a Kaffir, hang from a rope like an Apache, kneel like a
Mexican, hang to a pole like a Blackfoot squaw, stand
like the Ceramites and ladies of the Nile, lie on the
stomach like the Creeks, on the side like the English, or
July 13, 1889]
THE MEDICAL RECORD. 43
on the back like ihe American. It seems but fair that
modern obstetrics should give parturient ladies less pos-
tural latitude than is implied in Dr. King’s conclusions,
which, we take it, are held to apply to the second stage of
labor.
“ HALF-FILLED HOSPITALS.”
Some correspondence has recently taken place in one of
the leading daily papers relative to hospital management.
It began with an editorial with the caption of this article,
and was followed by a letter from the general agent of
the Hospital Saturday and Sunday Association. The
charge made in the editorial was, in general, that there are
in Brooklyn and New York many empty hospital-beds,
while the sick poor are suffering from lack of hospital-
care ; that the managers of these institutions do not admit
these proper objects of their charity, because either of
their inability to pay or the disagreeable nature of their
illness. The charge is still further particularized in being
applied to the hospitals directly under the charge of the
different religious denominations.
We cannot but believe that the writer is misinformed
as to the true facts in the case. He may, as many do,
make the mistake of not recognizing the distinction be-
tween a hospital for acute diseases and a home for con-
valescents, or for chronic maladies. Application is often
made fur the admission to hospital of a chronic case
which has worn out a family at home, and disappointment
is felt that the patient is refused admittance. Such re-
fusal is justly based upon two reasons. In the first place,
it is the obvious duty of any charitable agency to labor in
that field where it can do the most good. The filling of
the Leds with such cases, generally susceptible of but
slight improvement, prevents the reception of cases of
acute illness or severe accident where a little timely aid
may save a life. In the second place, a hospital is not,
for therapeutic reasons, the place for such chronic cases
to be treated. They need cheerful surroundings, and the
avoidance of all depressing scenes. In a hospital these
conditions cannot obtain, particularly in the larger ones,
with an ambulance service where maimed and bleeding
cases are being brought in at all hours of the day and
night, and where deaths are constantly occurring.
It is greatly to the credit of our so-called denomina-
tional hospitals that religious belief is not made a test of
entrance. You will find Jews in St. Francis Hospital,
Catholics in St. Luke’s, and Protestants at Mount Sinai,
and, as far as we have observed, all are treated equally
well. l
The story related in the daily journal above alluded to
is an exceptional case. It is, briefly, that a woman recently
confined applied to an institution in Boston. She was
refused admission because “ they didn’t take that class of
cases,” and finally was found dead on the docks with the
corpse of the baby under her ragged shawl. This is, of
course, a most deplorable case, but a wholesale indictment
should not be based on it. It must be admitted that in
this instance “some one had blundered.” We venture to
say that that thing would not have happened at any of
our institutions in connection with the ambulance service.
It'is evident that an institution founded for the carrying
on of certain lines of medical and surgical work cannot
alter its scope at every application for admission. But
what could be done, and what, we are happy to believe, is
done here in New York, is to take charge of every ap-
plicant who comes in a condition of acute physical suffer-
ing. If the case is a proper one, itis kept. If this can-
not, for any reason, be done, it is transferred to some city
institution where it can be properly cared for. It is not
told merely to “ move on.”
Relative to the charge that “there are a few well-en-
dowed and amply maintained institutions that expend a
large share of their revenues -in keeping up appearances
and are not doing the work which their open-handed
patrons have placed it within their power to do,” we
can say nothing in the absence of more definite partic-
ulars. We can believe this possible, but do not think it
probable. Anyone who knows much about our local
institutions knows that the great annual problem is to
make buckle and strap meet over the necessary expendi-
tures, let alone keeping up useless appearances. The low
current rates of interest have greatly lessened the sus-
taining power of endowment funds. To anticipate a
remedy for the alleged state of affairs, we would recom-
mend, as we have so often done, that medical men should
be admitted to the hospital managing boards. We believe
that material resources could be greatly conserved thereby,
by a wiser and more discriminating expenditure.
THE DEFICIENCIES OF OUR VITAL STATISTICS.
THE report of a special committee, composed of Drs. J.
G. ‘I'ruax, J. R. MacGregor, and Alfred L. Carroll, to the
New York County Medical Association, discloses a fact
which has long been known with regard to the deficiencies
in our system of obtaining vital statistics, viz., that the
birth-returns are very deficient.
The State law puts upon the parents or custodians of
children the duty of reporting births, except only in five
specified cities, of which New York and Brooklyn are two.
In these cities the responsibility is put upon the physicians
and the few registered midwives. The result is that, where
no physician is called in at a birth, and no responsible
midwife, the chances are that the birth will not be regis-
tered.
As a remedy, the committee recommend that the law
be made uniform for all the cities, and that the responsi-
bility of notification be placed on parents or custodians.
We should welcome any change which takes away an
unwarranted responsibility imposed upon physicians ; but
it is not easy to see how the change would increase the
accuracy of the returns.
THE NOTIFICATION OF PHTHISIS PULMONALIS AS A
CONTAGIOUS DISEASE.
Tue Health Department of this city is studying with much
care the problem of the prevention of phthisis through
destruction of its infecting agent, the bacillus. It is, in
particular, directing its efforts to the more crowded por-
tions of the city, where the danger of infection is greatest.
The exact mode of attack upon the bacillus has not, we
believe, been fully decided upon, although some prelim
inary steps have been taken. ‘The most serious question
which has arisen, we take it, is as to the advisability of
classing tuberculosis with the contagious diseases that are
now reported to the Health Department, and requiring
44
—--
that it be similarly reported. The advantages of this step
would be that it would educate both physician and public
to the view that phthisis js infectious, and would impress
upon both the fact of the necessity of using disinfection in
connection with its treatment.
On the other hand, it might needlessly alarm the public.
and perhaps add, unnecessarily, to the discomfort and suf-
fering of the patients. We doubt very much, also, if the
medical profession would co-operate heartily in notifica-
tion, except as regards hospital and dispensary patients.
Despite some disadvantages, however, we believe that
a trial at least of the notification plan might be made.
In promulgating and practically enforcing the view that
pulmonary phthisis is a contagious disease, however, most
careful and explicit statements should be made as to what
is meant by this contagiousness. It should be shown that
the disease is not contagious in the popular sense at all,
i.e., communicated by contact, or the breath, but only by
the medium of the sputum ; also, that unlike syphilis and
other infectious diseases, it cannot be communicated un-
der any ordinary conditions, except to those who are pre-
disposed by various constitutional and depressing agencies
to its development.
Hews of the Week.
Sır MORELL MACKENZIE.—A most elaborate banquet
was given Sir Morell Mackenzie last week. Lord Ran-
dolph Churchill presided and many distinguished men
were present.
A BANQUET TO DR. TRAILL GREEN was tendered at
Easton, on June 2oth, by the County Medical Society.
A large number of Easton physicians were present, as well
as several gentlemen from Philadelphia. Dr. Green was
born in 1813, and has practised medicine since 1836—
fifty-three years.
ACCIDENT FROM THE ELECTRIC CURRENT.—A man liv-
ing in St. Paul, Minn., accidentally received a severe shock
of electricity which knocked him senseless for forty-eight
hours. He has recovered, and says that the sensation on
receiving the current was not painful.
SUICIDE OF A Puysic1an.—Dr. Waters, an aged physi-
cian of this city, recently committed suicide because, it
is said, he was unable to get sufficient practice to support
himself.
THE DEATH OF Dr. C. B. RADCLIFFE, of London, re-
cently took place, in the sixty-seventh year of his age.
Dr. Radcliffe was an original and voluminous contributor
to physiological and pathological subjects.
LacToseE aS A Diuretic. — Professor Germain Sée
asserts that lactose is a powerful diuretic and is the active
diuretic principle in milk. It acts with certainty in
cardiac dropsies and is the diuretic in such conditions.
It does not relieve the cardiac dyspncea, for which potas-
sium iodide is needed. One hundred grammes a day
may be given. A propos of this, we may cite a paragraph
in the Boston Medical and Surgical Fournal to the effect
that milk-producers in New York State think they see a
small measure of promised relief from the present depres-
sion of prices due to over-supply, in the development of
the sugar-of-milk (saccharum lactis) manufacturing indus-
THE MEDICAL RECORD.
[July 13, 1889
a a MM — m —
try. Formerly consumers of the article in this country
have depended entirely upon. importations from Switzer-
land and Bavaria, and it is only lately, and in view of the
increasing demand, that an attempt has been made to sup-
ply the market with a home-made product.
Dr. STEPHEN WICKES, of Orange, N. J., died on
July 8th, aged seventy-six. Dr. Wickes was a man of fine
education and unusual literary attainments. He edited
the “ Transactions of the Medical Society of New Jersey”
from 1860 until 1882; also the old transactions of the
Society from 1766 till 1858. He published “ Topography
of Orange,” “Water Cure in Orange,” “ Memoirs of
Thomas W. Blatchford, M.D.,” of Troy; a memorial
volume of the First Presbyterian Church, with which he
was so long connected ; “ Living and Dying, their Physics
and Psychics,” “ History of Medicine in New Jersey,”
“ Sepulture : Its History, Methods, and Requisites,” and
“ History of the Newark Mountains.”
A REMARKABLE EPIDEMIC OF PNEUMONIA.—In the
Maritime Medical News for May there is an account of
an epidemic of pneumonia in Prince Edward Island.
During the months of February and March no less than
five hundred and torty-six cases occurred in the practice
of twenty-six practitioners, and at the date of the report
the disease was still very prevalent. As there are over
fifty practitioners in the island, it is computed that the
total number of cases is fully upward of one thousand.
As the population of the island does not exceed one
hundred and fifty thousand, the number attacked is rela-
tively very great. It appears that in the majority of cases
the pneumonia was attended by acute bronchial catarrh.
The catarrhal complications, which in some cases also in-
volved the larynx and middle ear, were more frequent in
children and the aged. In the five hundred and forty-six
cases reported there were only forty deaths, a decidedly
low mortality.
MEDICAL AND SuRGICAL WorRK AT ROOSEVELT Hos-
PITAL.—The annual report for 1888 contains some inter-
esting medical and surgical statistics and is a great im-
provement on the average hospital reports. We learn
that there were 56 cases of typhoid fever treated in the
hospital, with seventeen and one-half per cent. of deaths ;
also 56 cases of lobar pneumonia, with 24 deaths, or
forty-three per cent. We note the record of 5 laparoto-
mies, 4 exploratory, with 4 deaths—not a very brilliant
showing. ‘There were 3 operations for typhlitis, with 2
deaths. On the other hand, there are 27 operations re-
corded for laparotomy for diseases of the reproductive
organs, besides 4 vaginal hysterectomies, with but 4 deaths.
PROFESSOR T. G. RicHARDSON has resigned from the
faculty of Tulane University on account of ill-health. He
has had an exceptionally long term of service—thirty-one
years—fourteen years in the chair of anatomy and seven-
teen in that of surgery. In Germany, Professor Richard.
son would be given a jubilee. |
Dr. R. J. Hatt has resigned the Professorship of Anat-
omy in the College of Physicians and Surgeons on account
of ill-health. This leaves two of our colleges without
professors of anatomy.
A GERMAN ANTHROPOLOGICAL CONGRESS will be held
in Vienna, August 5th to roth.
July 13, 1889]
THE MEDICAL RECORD. 45
NORTH CAROLINA INSANE ASYLUM.—The daily papers
contain reports of the trial of Dr. Gnssam, for many
years superintendent of the North Carolina Insane
Asylum, on charges of cruelty and immorality. We trust
that Dr. Grissam, who has long sustained an excellent rep-
utation, will acquit himself of the painful accusations
made against him.
A REcENT Decision of the Surrogate has been made
to the effect that, as a matter of law, the indulgence in the
opium-habit, even though to excess, cannot be considered
sufficient to establish want of testamentary capacity.
THE STUDENTS OF THE AMBULANCE Corps of the New
Orleans Charity Hospital have made their appearance in
uniform. The outfit consists of a navy-blue suit, square-
cut sack-coat with brass buttons, and a white cap.
THEY WANT CLINICAL FACcILITIES.—At a meeting of the
students of the Medical School of Maine, held in Bruns-
wick, June 24th, the following resolutions were formally
adopted by the students :
Whereas, We, the students of the Medical School of
Maine, unanimously believe that the benefits of the school
are marred by the lack of clinical advantages, and for this
reason many of the students are accustomed to leave the
school at the end of the first or second year to finish their
course in schools possessing greater clinical facilities ; and
Whereas, The city of Portland presents by far the best
advantages of any locality in the State, both clinical and
in other respects; -°
Resolved, That we unanimously second the resolutions
relative to the removal of the Maine Medical School
adopted by the Maine Medical Association at their last
session.
The students at Ann Arbor might read these resolutions
with profit.
Ir may LEAD TO AN INTESTINE WaR.—The daily
papers announce that the latest trust that is forming in
the West is the Castor-oil Trust. It appears that manu-
facturers are ready to take the final step and organize a
trust combination with a capital stock of $250,000 to
$500,000. The Castor-oil ‘Crust will be an immensely
profitable one. ‘The price of the seed has been about
$1.50 a bushel for years, while the price of the oil has
been over 15 cents and as high as 16 cents, and not lower
than 12 centsa pound. On the basis of 15 cents the
crushers have a profit of 4 cents a pound, with a yield of
sixteen pounds toa bushel of seed. ‘There are but seven
regular mills in the country. The medical profession has
had a trust in castor-oil for many years, in doses of from
one to four drachms.
‘PREVENTING CONSUMPTION.—The New York City
Board of Health has issued the following rules to be ob-
served for the prevention of the spread of consumption :
Pulmonary tuberculosis (consumption) is directly com-
municated from one person to another. ‘The germ of the
disease exists in the expectoration of persons afflicted with
it. The following extract from the report of the pathol-
ogists of the Health Department explains the means by
which the disease may be transmitted: ‘ Tuberculosis is
commonly produced in the lungs (which are the organs
most frequently affected) by breathing air in which living
germs are suspended as dust. The material which is
coughed up, sometimes in large quantities, by persons
suffering from consumption contains these germs often in
enormous numbers This material when ex-
pectorated frequently lodges in places where it dries, as
on the street, floors, carpets, handkerchiefs, etc. After
drying in one way or another, it is very apt to become
pulverized and float in the air as dust.” By observing the
following rules the danger of catching the disease will be
reduced to a minimum: 1, Do not permit persons sus-
pected to have consumption to spit on the floor or on
cloths unless the latter be immediately burned. The
spittle of persons suspected to have consumption should be
caught in earthen or glass dishes containing the following
solution : Corrosive sublimate, 1 part ; water, 1,000 parts.
2. Do not sleep in a room occupied by a person sus-
pected of having consumption. The living-rooms of a
consumptive patient should have as little furniture as
practicable. Hangings should be especially avoided.
The use of carpets, rugs, etc., ought always to be
avoided. 3. Do not fail to was. thoroughly the eating
utensils of a person suspected of having consumption as
soon after eating as possible, using boiling water for the
purpose. 4. Do not mingle the unwashed clothing of
consumptive patients with similar clothing of other per-
sons. 5. Do not fail to catch the bowel-discharges of
consumptive patients, with diarrhoea, in a vessel cor-
taining corrosive sublimate, 1 part; water, 1,000 parts.
6. Do not fail to consult the family physician regarding
the social relations of persons suffering from suspected
consumption. 7. Do not permit mothers suspected of
having consumption to nurse their offspring. 8. House-
hold pets (animals or birds) are quite susceptible to tuber-
culosis ; therefore, do not expose them to persons afflicted
with consumption ; also do not keep, but destroy at once,
all household pets suspected of having consumption,
otherwise they may give it to human beings. 9. Do not
fail to thoroughly cleanse the floors, walls, and ceilings
of the living- and sleeping-rooms of persons suffering from
consumption at least once in two weeks. Ten thousand
copies of the report were ordered to be printed for distribu -
tion.
A REsoLuTION has been adopted by the Board of
Health, directing the Register of Vital Statistics to make
a daily report of all deaths which occur in tenement-
houses from tubercular meningitis and pulmonary and in-
testinal tuberculosis, whsch are to be sent to Dr. Cyrus
Edson for investigation.
A SEPTIC SUPPURATION has recently been produced by
Dr. Kaufmann, working in Schmiedeberg’s laboratory,
through the subcutaneous injection of a sterilized solution
of digitotoxin in absolute alcohol with ten per cent. of
carbolic acid.
A HEALTHFUL CosTuME.—According to the Business
Woman's Journal, the present style of the Directoire
suit is probably the most hygienic dress that has ever been
worn by woman. ‘The absence of full drapery and the
plain skirts prevent it from encumbering the limbs, and
relieve it from the unnecessary weight which has been so
serious an objection to the old styles.
THE PLuMBeR.—The Sanitary News is at pains to
deny that there is no good plumber but a dead one; it
offers arguments of considerable weight in support of its
view.
46
Society Beports,
American Medical Association.
FORTIETH ANNUAL MEETING,
Held at Newport, R. 1., Fune 25, 26, 27, 28, 1889.
(Continued from page 26.)
ON PRACTICE OF MEDICINE, MATERIA
MEDICA, AND PHYSIOLOGY.
SECTION
THIRD Day, THURSDAY, JUNE 27TH.
Dr. Vicror C. VAUGHAN, of Ann Arbor, Mich., read a
paper entitled
THE ETIOLOGY AND PATHOLOGY OF TYPHOID FEVER.
The germ is found practically in every case of typhoid
fever. Indeed, it is so invariably found that one is often
suspicious, for this germ of Eberth has been reported
found in almost all the organs, including the brain, lungs,
and the blood. It has been found, by numerous writers,
in drinking-water. Pure cultures of it may be found in all
our laboratories: Goffky was the first to inoculate animals
with these cultures, the inoculation being made into the
blood or the peritoneal cavity. Many of these died of
tuberculosis. In successful inoculations, the animals died
in from a few hours to four to six days. Many of the
glands were enlarged, the micro-organism was found in
the liver, spleen, and blood, but not at the point of inocu-
lation. This was supposed to be true typhoid. Some
found that the effect on the animal was in direct pro-
portion to the amount injected, and other organisms pro-
duced the same result, showing that death occurred from
intoxication, and that it was not specific. Thus it was
shown that death was not caused by the Eberth germ.
Eberth’s germ, found in the body, has been isolated and
cultivated outside of the body, does not grow in the body,
and soon dies. Experiments on man might produce dif-
ferent results. The chemical products produced by this
germ must be considered also. Typhoid fever is prob-
ably due to a mixed infection, as experiments made with
impure cultures help to show. Feeding on typhoid stools
produces symptoms and signs much like typhoid fever.
Rabbits fed with dnnking-water known to cause typhoid
fever, gave many symptoms of typhoid fever, and death
resulted in from two to eight weeks. Vaughan found in
drinking-water known to cause typhoid fever, at Iowa
City, germs exactly like Eberth’s germ in morphology and
behavior. Dogs inoculated with this water showed, after
several weeks, evident signs of typhoid fever, as shown in
the autopsy. One of these dogs died, and the others be-
came emaciated, and they showed rise of temperature.
Soon after, the second dog died, and showed same signs
as in the first dog. Vaughan had lately turned his atten-
tion to studying the ptomaines in the typhoid stools of
patients. The stools were received in sterilized vessels
directly from the patients, and were studied with all pos-
sible caution. He had obtained certain crystals, a solu-
tion of which, injected into the abdomen of a dog, elevated
the temperature, caused purging and straining. All these
symptoms give a hope that these ptomaines are the ones
always present in typhoid. When the cultures were kept
at 40° C. (104° F.) the ptomaines were then most abun-
dant. It is not feasible yet to give a name to this sub-
stance.
Dr. WELCH, of Baltimore, said that
HE MUST PROTEST AGAINST ACCEPTING ONE CONDITION
which Dr. Vaughan formulated, viz., that before we ad-
mit that a given micro-organism is the cause of a disease
we must isolate from cultures of this organism chemical
products which are capable, by inoculation or feeding, of
producing the symptoms of this disease. It is certainly
an important addition to our knowledge of a disease to
THE MEDICAL RECORD.
[July 13, 1889
———
become acquainted with such chemical products, but this
is wot essential to a belief in the causative agency of a
specific micro-organism. If Dr. Vaughan’s condition be
accepted as an essential link in the chain of proof, then
we have not sufficient evidence that many recognized in-
fectious organisms, such as the spirillum of relapsing fever,
the bacillus of leprosy, or even the tubercle bacillus, are
the causes of their respective diseases. From our present
knowledge we are justified in believing that a micro-
organism which is invariably associated with a disease,
which is always found in the lesions of the disease, and in
situations which explain the lesions and symptoms, and
which is never found except in association with the dis-
ease, must be regarded as the cause of the disease. Where,
in addition to this, we are able, by experiments on animals,
to reproduce the disease by inoculation or ingestion of
pure cultures, this additional proof is most welcome, but
in many infectious diseases we cannot furnish this last
method of proof, either because we have not been able
to isolate and cultivate the suspected organism, as 1s the
case with relapsing fever, or because animals available
for experiments are not susceptible to the disease, as
seems to be true of typhoid fever and cholera. For this
reason we may agree with Koch, that it is not absolutely
necessary that we reproduce the disease experimentally in
animais by inoculation before we admit that a given or-
ganism, found invariably associated with the disease under
the conditions stated, is the specific cause of the disease.
The evidence Dr. Welch believed to be conclusive that
the typhoid bacillus is the specific cause of typhoid fever.
Dr. Vaughan’s emphasis of the necessity of demonstrat-
ing the chemical products of pathogenic micro-organisms _
before we accept. their etiological significance he per-
haps bases upon the assumption that infectious organisms
produce their disastrous effects solely by their chemical
products ; but this assumption is unwarrantable. In fact,
there is reason to believe that, while some pathogenic
micro-organisms act by their chemical products, others do
not so act.
As Dr. Vaughan himself is doubtful as to the interpre-
tation of his experiment: on dogs, Dr. Welch was not in-
clined to attribute to them, without further experiments,
any bearing upon the etiology of typhoid fever.
Dr. Vaughan is to be congratulated, said Dr. Welch,
upon the isolation from typhoid stools of a definite crys-
talline substance with such interesting properties, but, as
Dr. Vaughan himself has stated, it will be necessary to
make control chemical observations with diarrhoeal or
other stools not derived from typhoid patients before the
relation of this substance to typhoid fever becomes clear.
Dr. James Tyson, of Philadelphia, thought the organ-
ism should’ be found in the diseased animal, should pro-
‘duce the disease in a second animal, and it should be
found in the second animal. This seemed to be proof
enough that the organism is found irrespective of the dis-
ease and location of the lesions.
Dr. T. C. Witson, of Philadelphia, inferred from Dr.
Vaughan’s remarks that he was using this knowledge of the
presence of ptomaines as a beginning simply, and was
working out from this point. ‘The clinician and the bac-
teriologist have not done all; there are waste places, and
here the chemist, and especially the bacteriological chem-
ist, could help us and had helped, and we should welcome
the help they offered.
Dr. W. J. Scorr, of Cleveland, did not think we
should expect to find the organism in the second animal
poisoned by the ptomaines of the first. How could we
expect to get bacilli from ptomaines ?
Dr. VAUGHAN, in conclusion, said that in a recent talk
with Koch, the latter said he did not think the Eberth
bacillus was the cause of typhoid fever, and he gave
Koch’s four rules, and when these rules had been com-
plied with there could be no doubt of that disease. Dr.
Welch asked us to give up every rule except the first.
He did not mean to say that every disease produced its
deleterious effects by its ptomaines, but it had been
eases Asiatic cholera is the best example.
Dr. J. C. Witson, of Philadelphia, then read a paper
entitled
PROPHYLAXIS QF TUBERCULOSIS.
He began by saying that pulmonary consumption was
hereditary, contagious, and preventable. So many dis-
eases whose history is familiar to us pass from parent to
child, some appearing early, some later, but all showing a
clear hereditary history. ‘Tuberculous diseases do not
correspond to the acute infectious diseases whose history
we know. ‘Tuberculosis in general seems to pass not
through the blood, but by local contagion from parent to
offspring. We should not, and do not, speak of a tuber-
cular diathesis any more than we speak of a typhoid
or of a variolous diathesis. ‘Tuberculosis may be caused
by the flesh of animals. The careless manner in which
the sputum is deposited in handkerchiefs, open cups, etc.,
-tends to spread the disease. Animals which feed on tu-
berculous flesh contract the disease. Cornet found the
bacilli in the scrapings of walls, etc., of rooms, hospitals,
etc. He concluded that the dried bacilli were drawn
into the lungs and thus caused the disease. Milk from
cows with tuberculous teats may give the disease to in-
fants Flick, of Philadelphia, showed that tuberculosis
spread by neighborhood, contact, etc. ‘The mortality is
high in prisons, cloisters, etc., and the disease attacks by
preference those who attend the consumptive. Monkeys,
when confined in menageries, die by tuberculosis. As
tuberculosis is not hereditary in the strict sense of the
term, prevention is not so hopeless. ‘The avenues of in-
fection are by the respiratory and digestive tracts. Rigid
inspection of food—animals’ milk, diseased and impure
—vould do much good. The nature of the disease
should be communicated to the patient and his friends as
early as possible. l
Dr. C. G. STOCKTON, of Buffalo, did not altogether be-
lieve in a tubercular diathesis.
Dr. SoLLY, of Colorado, in his practice saw all varieties
of the disease, and thought it was hard to say what amount
of lesion was sufficient to cause the disease.
Dr. HERRICK, of Cleveland, was very sceptical on this
subject. The tests of microscopy and therapeutics are
wanting to support this theory.
Dr. S. SoLis-CoHEN, of Philadelphia, thought it was
natural to be sceptical. It was almost like a repetition of
ancient belief in certain old theories. It was not always
certain which was first, the disease or the organism. We
must draw the line between phthisis and tuberculosis.
Dr. CuTTER, of New York, believed that consumption
was curable, and we should not take away hope from the
patient.
Dr. WHITNEY, of Pawtucket, thought that the germ
theory had worked more harm than good.
Dr. J. C. WILSON, in conclusion, said the development
of a single case proved nothing. ‘The fact that some
points still remain unsolved should not make us exclude
what is known.
Dr. M. R. Crane, of Rutland, Vt., then read a paper
entitled
TOXIC AGENTS IN THE BLOOD AS A CAUSE OF DISEASES
OF THE NERVOUS SYSTEM,
in which was reviewed our knowledge of ptomaines, and
leucomaines, and the diseases produced by these toxic
agents, such as neuritis, neuralgia, diseases of the spine,
cerebral disorders, tubercular meningitis, convulsions, neur-
asthenia, etc.
Dr. W. L. ScHENcK, of Kansas City, then read a paper
entitled
SOME THOUGHTS ON THE ETIOLOGY, PATHOLOGY, AND
THERAPEUTICS OF PHTHISIS PULMONALIS,
the substance of which was a plea for the use of fat, the
absence of which in the diet seemed to increase the mor-
THE MEDICAL RECORD.
47
tality in a people, as evidenced in the inhabitants of the
warmest and coldest climates.
Dr. SOLOMON SOLIS-COHEN, of Philadelphia, read a
paper on
FOOD IN THE TREATMENT OF PULMONARY CONSUMPTION.
‘Though the paper was in its scope therapeutic, yet as
therapeusis must be founded on sound pathology, it was
necessary, the author said, to state that the morbid phys-
iology of the disease, and not its bacteriology, is consid-
ered the fundamental indication. In deference to pre-
vailing views, tuberculosis may for the present be granted
to be the history of the growth, life, and activity of a
bacillus. But for rational treatment we must revert to
the views of Niemeyer, who said that the danger of
phthisis is tuberculosis; or to those of Rush, who de-
clared that tubercle and other anatomical lesions were
“the effect, not the cause, of pulmonary consumption ;”
and recognize the disease we have to combat not in epi-
phenomena of possible microbic origin, but in the con-
sumption, the aberration of nutrition, which precedes the
entrance of the microbe. Consumption is a disease of
nutrition whose exact mechanism is as yet unknown,
though the results of prolonged observation justify us in
considering heredity, unhygienic surroundings, and, in
general, those influences called “depressing,” as among
its remote or proximate causes; the pulmonary form being
further dependent upon errors in respiration, whether of
the substances respired or of the performance of the act.
Thus we dismiss as futile microbicidal treatment, and
recognize ptomaines of bacillary origin only as giving rise
to intercurrent symptoms which may call for antidotal or
symptomatic treatment. Fixing attention upon the mal-
uutrition, which is not a mere “predisposition” to suc-
cumb to a bacillus, but the essence of the whole morbid
process, we combat it by direct measures, hygienic and
‘medicinal, the latter secondary, the former all-important.
Chief among hygienic measures is food. Food consists
not alone of meat and drink, but also of air. Full res-
piratory diet is necessary to the utilization of alimentary
diet. As in diabetes, so in phthisis, there is imperfect
metabolism of carbohydrates. Experience shows a nitro-
genous dietary to be best. Debove has shown that con-
sumptives can assimilate a quantity of food far in excess
of the needs of the healthy organism. ‘This excessive
quantity should be supplied; though resort to the stomach-
tube, as in Debove’s experiments, can be reserved for
special cases.
Meat, principally beef, with milk, fish, eggs, leguminous
vegetables and greens, should form the bulk of the dietary ;
with the addition of fat, in large quantities, in the form of
cream, butter, oil-dressing for salads, or, if necessary, cod-
liver oil or oleaginous inunctions. Alcohol is a food in
consumption. It should be combined with malt, milk,
glycerine, or cod-liver oil. Not more than three, at most
four, hours, except during sleep, should be allowed to
elapse without taking food. Milk punch on going to bed,
and a glass of wine or spirits with liquid peptonoids in
case of waking during the night, are strongly urged. Hot
water before meals, lavage if necessary, to prepare the
alimentary tract for the digestion and absorption of in-
creased food, and the free drinking of water to wash out
waste products, are essential to success. Predigested
foods may be employed with great benefit, especially pep-
tonized milk and beef peptonoids. In case gavage is re-
sorted to, they should be used almost exclusively. Gavage
is best preceded by lavage with an alkaline solution and
chloroform water. Proper alimentary diet being secured
through over-feeding, and the digestive tract and its ad-
nexa being kept in good condition, proper respiratory diet
must be supplied. Open-air life, exercise on horseback,
or bicycle, voluntary respiratory gymnastics, may suffice
when the patient is still strong enough. In the majority
of cases, there must be some artificial aid. ‘The inhala-
tion of compressed air, with or without expiration into
rarefied air, is the best means. Apparatus should be sim-
48
THE MEDICAL RECORD,
[July 13, 1889
In reply to the Chairman, Dr. F. B. Shattuck, Dr. Watson
re a Ss SS
ple and cheap, so that the patient can use it at home.
The principles laid down by Waldenburg are the correct
ones. Cohen’s apparatus consists of a bellows and a
small gasometer modelled upon Waldenburg’s. Its ad-
vantages are cheapness, simplicity, and small size, fitting
it for home use. After patients are sufficiently advanced
toward recovery, the pneumatic resistance valves of the
author, a still more convenient and very cheap pocket-
apparatus (costing about five dollars) may be used. It
may be used in the first instance with strong patients.
It is also useful as a prophylactic measure with ill-devel-
oped children. It gives-the effects of breathing against
pressure, #.¢., into compressed air, or out of rarefied air.
The effects of pneumatic measures are to increase the
volume of respired air, open up unused air-cells, facilitate
expulsion of pathological products, increase gaseous ex-
change, facilitate absorption of oxygen by the hemoglo-
bin, while at the same time the volume of blood and the
activity of circulation in the lungs is increased, bringing
more corpuscles into contact with the increased volume
of oxygen. Penetration of blood into the tissues, tissue
respiration, and production of lymph are also increased.
Thus local and general nutrition are powerfully stimu-
lated, and an improved respiratory habit and increased
respiratory and circulatory power are gained. The pro-
ducts of digestion are properly oxidized and utilized, im-
mature tissue is destroyed and expelled. The promotion
of sleep is one of the most marked effects.
The physician thus, by altering his patients’ environ-
ment in the manner described, puts them into a con-
dition where natural powers complete the cure, and
bacilli need not be feared. Illustrative cases were cited,
and the conclusion reached that the proper treatment of
consumption is not microbicide, but nutrition.
Dr. T. A. CUTTER then read a paper entitled
TROPHOPATHY IN THE FATTY AND FIBROID DEGENERA-
TIONS,
which dealt with the treatment of certain cases of serious
kidney trouble.
SECTION ON PRACTICE.
FourtTH Day, FRIDAY, JUNE 28TH.
Dr. J. G. T RUAX, of New York, read a paper on
ULCERATIVE ENDOCARDITIS,
in which he reported six cases, drawing attention to
certain points. The symptoms were not pathognomonic,
the heart-sounds were often found normal on ausculta-
tion, the temperature never rose above 104° F. ; the infec-
tion is undoubtedly due to some germ.
Dr. Mary E. BALDWIN, of Newport, read a paper en-
titled
STOMACH REST AND CLEANLINESS,
in which was related a case treated by proper diet,
stomach washing, stomach rest by enemata, change of
scene and air, and the results were successful. ‘The
constipation which was so obstinate has been entirely re-
moved, and the bowels were regular. ‘The abuse of the
stomach during infancy and childhood is undoubtedly an
important causative factor in such cases.
Dr. W. S. Watson, of Matteawan, N. Y., then read a
paper on
ADDISON’S DISEASE,
with exhibition of a specimen. After enumerating the
symptoms and history of the ordinary type of this disease,
the writer spoke of the experiments made in incision of
the supra-renal capsules. These glands contain a large
number of vessels and nerves, indeed, larger in proportion
to their size than any other gland in the body. Ina case
terminating fatally he had found at the autopsy heart,
lungs, normal; the supra-capsules normal in size, but
much changed and inflamed on microscopic examination.
said there was no increased pigment on the mucous mem-
brane of the mouth.
SECTION ON OBSTETRICS AND DISEASES OF WOMEN.
THIRD Day, THURSDAY, JUNE 27TH.
Dr. Wittiam H. TAYLOR, of Cincinnati, related a case
in which
PREGNANCY OCCURRED AS A COMPLICATION OF OVARIAN
TUMOR.
He was called to see a woman who expected to be de-
livered in January. She was not delivered in that month.
In February she met with an accident, being thrown from
her iage, and he was allowed an examination. He
told her that she was not pregnant, but that she had a
tumor, and recommended treatment for it. She insisted
she was pregnant, and would permit no treatment.
Eighteen months after he was first called to deliver her
she passed a blighted ovum. He was criticised very much
by the patient and her frends, but he told them that he
laughs best who laughs last, for he had re-examined her
and found the tumor still distinctly present. The woman
went on growing, and, being very short in stature, she be-
came greater in circumference than height. She finally
died. ‘The doctor was sure that the pregnancy occurred
after he was called to attend her.
Dr. A. Van Der VEER, of Albany, N. Y., was of the
opinion that the complication of ovarian tumor with
pregnancy would grow less and less common as our ability
to diagnose improved, but with fibroid tumors it would
not be so. Nothing so lowers us in the confidence of our
patients and their friends as the operating on a pregnant
uterus. He called attention to the fact that Peaslee had
a case of tetanus after ovariotomy which he thought due
to the use of a clamp, and he always argued against the
use of a clamp thereafter.
Dr. KimBeEL, of Lowell, Mass., reported four cases of
tetanus following ovariotomy which occurred in his
practice. His experience with tetanus following ovariot-
omy had been extremely unfortunate. A peculiarity of
his case was that the tetanus had not come on till the
twelfth day in one case. ‘The patient grew worse and
died. He has had three cases since, two of which died.
The fourth case recovered. He did not know that any
treatment had any particular power over this disease, but
thought more reliance could be placed on opium than any-
thing else.
Dr. Kirsy, of Pennsylvania, had removed an ovarian
tumor weighing thirty seven pounds from a woman who
was pregnant, and the pregnancy went on to term and a
healthy child was born.
Dr. THEOPHILUS Parvin, of Philadelphia, read a paper
entitled
CASUISTRY IN OBSTETRICS.
Zoroaster, long before Cicero, gave us the maxim which
contained the teachings of Cicero, “ In doubt as to whether
an action is right or is wrong, abstain.” ‘The order of Jesuits
has given especial attention to this subject. Zoroaster’s
rule is excellent, but will not always do in obstetrics, be-
cause we cannot in all cases abstain; we must do some-
thing. Casuistry sometimes perverts, as in the case of the
wife who excused her adultery by saying that she gave her
body to her lover, but not her lips, with which she had
made her vows of fidelity.
THE TREATMENT OF ECTOPIC PREGNANCY
in its earlier stages is one of the pressing questions of the
hour. ‘The progress of science brings up new questions
in casuistry in obstetrics. The ophthalmologist finds
albuminuric retinitis in the pregnant woman, and tells her
physician that the conti.uation of her pregnancy is at the
peril of her vision, and possibly of her life. The speaker
thought that woman when pregnant should be treated as
July 13, 1889]
THE MEDICAL RECORD. 49
well as other animals in a similar condition. Continence
for months or years is possible, and not injurious. Not-
withstanding the many influences brought to bear on the
physician to prevent conception, he takes great respons-
ibility who attempts to thwart nature’s law. Information
of this sort, if given even to those who may seem to re-
quire it, will soon become general, and a strong defence
to female virtue will be taken away.
CRANIOTOMY
he considered one of the most painful, serious, and dif-
ficult questions in casuistry in obstetrics. He reported
several cases in which the operation had been performed,
and the child had to be killed after delivery, or partial de-
livery. Those who advise craniotomy on the living foetus
cannot decide on the measurements of the conjugate
which demand it. The field of craniotomy is being
steadily restricted, but that it will entirely disappear, ex-
cept for hydrocephalus, few are sanguine enough to be-
heve. Amputation of the pregnant uterus is destined to
occupy a more prominent position than it has yet done.
Itis yet to be decided whether hysterectomy or hyster-
otomy will save the larger number of patients.
Dr. Wa. H. PARRISH, of Philadelphia, then read a
paper on
PELVIC ABSCESS IN THE FEMALE.
He divided this into three subdivisions, areolar, intra-
tubal, and ovarian. Chronic pelvic cellulitis occurs only
as a sequel to pelvic abscess. We usually have the history
of gonorrhcea in the husband, dyspareunia in the woman.
He had never met with an areolar abscess dependent
upon extension of gonorrhceal inflammation from the
vagina or uterus directly through the walls of these organs
into the pelvic areolar tissue. Chronic cellulitis, unless
becoming such by complication, is a gynecological myth,
and has an existence only as an ignis fatuus in the brains
of former members of the profession. Abdominal surge
has demonstrated in numerous instances that chronic cel-
lulitis has no independent existence. That intra-tubal
abscess occurs with very much greater frequency than
areolar abscess must appear to every one familiar with
abdominal surgery. The successful treatment of pelvic
abscess often demands an exercise of the most deliberate
judgment and the highest operative skill. The speaker
urged the necessity of operating early in every variety of
curable pelvic abscess. ‘The besetting sin of the family
practitioner and the timid and doubting operator is to
wait. In this delay the dangers become cumulative and
the surgeon is asked to operate when the case has become
hopeless. If the patient dies the practitioner is discour-
aged, and in his next case he waits longer still in the hope
that pus may not form, or that it may escape spontan-
eously. He thinks that in some of his cases suppuration
has taken place, resolution followed, and so justifies his
delay. Early surgical interference with the knife should
be the rule in all varieties of pelvic cellulitis.
Dr. A. Reeves Jackson, of Chicago, read a paper on
INJURIES OF THE BLADDER DURING LAPAROTOMY.
Details more or less complete were given of sixty-seven
cases which had been collected by the author from various
sources. Some of them had been already published, but
the greater number were obtained through personal cor-
respondence with the operators in whose practice the
accidents happened, and were made known for the first
time
Considering the conditions under which bladder injuries
may happen during laparotomy, it is not necessarily dis-
creditable to any surgeon to meet with them, for they may
not be due to any carelessness or lack of skill on his part.
In many of the cases cited no possible degree of diligence
could have averted the accident. Adhesions of the peri-
toneal surface of the elongated bladder to that of the an-
terior abdominal wall frequently cannot be known in ad-
vance, and their existence is only demonstrable after the
viscus has been opened. The use of the catheter as a
diagnostic means is not always available, because the
compression of the bladder against the pubis may prevent `
the introduction of the instrument beyond that point.
Certainly, however, this attempt should always be made
in any case of suspected difficulty, and would seem to be
even a proper and unobjectionable routine method. An-
other useful precaution is to avoid prolonging the abdom-
inal incision far down toward the pubic bone, until the
opening into the peritoneum has permitted the relations
of the bladder to be ascertained.
The mortality of the cases in which the bladder has
been wounded is large, namely, about thirty per cent., but
this is due to the complicated and serious character of the
cases in which the accident has occurred, the consequently
increased length of the operation, and the greater danger
from shock, rather than to the mere vesical injury. The
latter, indeed, does not seem of itself to be very import-
ant as influencing the recovery of the patient. But, not-
withstanding this fact, a urinary fistula adds greatly to
her discomfort, and, occurring under such circumstances,
must be productive of chagrin and annoyance to the sur-
eon.
: Inasmuch as the bladder is recognizable with more diffi-
culty when empty than when full, it would be better, in
cases presenting doubtful features, to commence the op-
eration with the viscus wholly or partly distended. When
its position has become known, after the completion of the
abdominal incision it may be emptied by an assistant.
TREATMENT OF INJURIES OF THE BLADDER DURING
LAPAROTOMY.
When it is known at the time of operation that the
bladder has been cut or tom, the opening should be at
once closed with a continuous suture of catgut or fine
silk, applied so as to invert the edges of the wound and
bring together the serous surfaces. A permanent catheter
ought to be used during the first two days. After the ex-
piration of that time, its constant use is usually unneces-
sary; and, if the wound is small—less than an inch in
length—the instrument may be subsequently dispensed
with. If, however, the wound is large—exceeding two or
three inches—the bladder ought to be artificially emptied
during three or four days additional. In all cases the
catheter should be used so long as the urine contains
blood.
In the cases in which urine appears through the abdom-
inal wound subsequently to the operation, at a time and
under circumstances which may make it dangerous or in-
expedient to reach the seat of the vesical injury, the cath-
eter ought to be used either continuously, or at short inter-
vals, for the purpose of lessening the amount of urine which
escapes through the fistula, and thus aiding in the closure
of the latter. If, however, the fistulous opening shows no
disposition to close after two or three months, the edges
should be freshened to the depth of half an inch or more,
and stitched together.
In exceptional instances it may be expedient to affix
the wounded edges of the bladder within those of the
abdominal incision, in the manner detailed by Thomas
and others ; but as this plan must interfere to some extent
with the subsequent contractility of the bladder, it is
not to be commended as a usual practice. The sutur-
ing and “dropping” of the vesical wound is the better
method.
Dr. A. B. CARPENTER, of Cleveland, read a paper en-
titled
ALEXANDER’S OPERATION, WITH A NEW METHOD FOR SE-
CURING THE ROUND LIGAMENTS.
The speaker confined himself principally to a few re-
marks regarding the fastening of the round ligaments. As
a radical cure for this most distressing condition he be-
lieved the Alexander operation had no equal, because
of the simplicity of the work and the comparative, indeed
almost absolute, freedom from mortality. Deaths have
been recorded as resulting directly from the operation,
EO
THE MEDICAL RECORD.
[July 13, 1889
yet this occurred in the early time before the detail was
well understood.
The greatest objection raised in the past against this
method has been the difficulty in finding the round liga-
ments. This, however, applied chiefly to the operations
for retroversion and retroflection where the ligaments
were small and very fragile, breaking while being drawn
out, and causing the operation to be abandoned as incom-
plete, and the surgeon to bear the blame of his work be-
ing a failure. . . .
In cases of complete prolapsus it is entirely different,
the ligaments have become thickened and greatly enlarged,
the difficulty in finding them in most cases is entirely re-
moved ; the many years of constant dragging upon the
ligaments usually resulting in an hypertrophied condition,
so that, instead of being small and fragile, we find them of
much greater proportions ; so that, by first replacing the
uterus and then having it held well up by a sound in its
cavity, the ligaments can be carefully drawn out with little
or no danger of their breaking.
In 1885, the speaker had the pleasure of listening to a
paper by Dr. Alexander himself, read before the British
Gynecological Society, wherein the method of shortening
the round ligaments was described, and he was particu-
larly impressed with what seemed to him to be the inse-
curity of the fastenings.
If we consider, he said, the structures involved, the
dense unyielding fibres of the pillars of the external ab
dominal ring, at the same time the round, smooth char-
acter of the ligaments, composed as they are of dense
fibrous tissues, thus affording a limited opportunity for the
formation of strong adhesions in the wound, it seemed to
him that a reasonable explanation could be found why
many of the cases that have been operated upon have re-
ported themselves in after months as not improved, the
anchorage being so slight and frail that the uterus, by con-
tinually dragging, tears the ligaments loose and gradually
settles down to its old position.
The author’s method is the following: The uterus be-
ing replaced and held high up by an assistant, the incisions
are made and ligaments on either side drawn out until the
uterus is found to be well up and forward, a needle armed |
with a silver wire No. 26 is then passed through the ex-
ternal pillar of the ring, through the round ligament, then
through the internal ring ; this is then twisted down firmly,
cut off, and the ends bent over and crushed down, that
they may cause no irritation. The slack of the ligaments
is then cut off, leaving just sufficient to fill the bottom of
the wound. ‘The ligaments are then split to within a
short distance of the silver wire and turned partly outward
from each other, and stitched with fine gut to the lateral
walls of the wound, the latter being then closed, a small
drainage-tube inserted, and the whole covered by an anti-
septic dressing. The silver wire is left to become perma-
aed encysted, and thus hold the ligaments firmly in
place.
A high posterior plastic operation should then be made
on the vagina, and upon the removal of the sutures from
the latter operation, a Hodge, or perhaps what is better,
an Albert Smith pessary with a high bar, should be intro-
duced and worn for not less than six months.
This method of fastening the round ligaments was, in
the author’s opinion, superior to any with which he was
acquainted, as it afforded a firm anchorage and prevented
the uterus from dragging upon the ligaments, thus draw-
ing them gradually out, and defeating entirely the object
of the operation.
Dr. A. CORDES, of Geneva, Switzerland, exhibited
A NEW TWO-WAYS CATHETER FOR UTERINE INJECTION.
He had a new catheter made in Paris, consisting of one
tube sliding into another so as to permit of thorough
cleansing and scrubbing in every corner where microbes
might penetrate. This did not act well, for it could not
be made watertight without making it too hard to work.
In his new catheter he uses Bozeman’s form of the sig-
moid flexure. He hoped to have it made of hard rubber,
which does not corrode in bichloride or any other liquid.
He then described and criticised the instruments of Dolé-
ris, and Pajot, Roderier, and Olivier. Cordes’ instru-
ment has no rigid tube, no screw, no blind end, or cul-de-
sac, no angle, no corners where the microbe could hide,
and no eyelets. Being open on the distal end it throws
the fluid into the fundus uteri, from whence it comes down
and returns by the exit channel. ‘The idea of two grooves
came to him on looking at the horse-shoe catheter of
Budin.
Dr. AuGcustus P. CLARK, of Cambridge, Mass., read
a paper on
CHRONIC CYSTITIS IN THE FEMALE.
Few diseases prove to gynecologists so vexatious or in-
tractable as chronic cystitis. ‘The lesion, or morbid causes
giving rise to cystitis are numerous, whether it be the acute
or chronic form. Each case merits separate consideration.
The arrangement of the muscular coat of the bladder is
such as to give it a wonderful immunity against ordinary
accidents and conditions which occur in the viscus itself.
This fact should make us remember that symptoms pres-
ent in a case of cystitis are often but an expression of
the organ that there has occurred a lesion or a morbid
process at a distance from the part seemingly affected.
Anal and rectal inflammation are not uncommon causes
of cystitis. Resort to dilatation of the urethra will be
followed by the best results in cases where tenesmus is an
important symptom, and in which the parts around have
been contracted and hypertrophied. Faradism with one
pole near the uterus and the other over the bladder gives
speedy relief. Corrosive sublimate, 1 to 2,000, will often
prove of benefit when no marked organic changes have.
occurred, the train of symptoms due to suppuration, fer-
mentation, and the uncleanliness generally. No general
rule of application can be laid down in all cases. Some
will yield readily, others will defy all recognized methods
of treatment, and cari be cured or corrected only after
the most ingenious and skilful operation.
Dr. A. S. GORDON, of Portland, Me., reported
A SUCCESSFUL OPERATION FOR EXTRA-UTERINE PREG-
NANCY.
He had on a former occasion reported to this Section
his first case, which he supposed to be the second success-
ful case in America, but which he now knew to be the
third. ‘The case ran as follows: February, 1888, Mrs.
B—— missed her menses. She was twenty five years of
age, married eight years, and had never been pregnant
nor used means to prevent pregnancy. March, April, and
May were missed. June 1st, she was taken with a severe
agonizing pain in the abdomen, but finally got relief. Op-
eration was made and a fcetus at three and a half months
was taken out. He believed that just as soon as a diag-
nosis of extra uterine pregnancy was made, we should
open the abdomen and remove the foetus.
THE USE OF GALVANISM IS SIMPLY MALPRACTICE,
he said. If we can make a diagnosis, and he thought as
a rule we could, we should operate. He did not believe
that we could make a diagnosis in ninety-five per cent. of
the cases, as had been claimed, but we could in a great
many.
The paper was discussed by Drs. Taylor, of Cincinnati ;
Currier, of New York; Cushing, of Boston; Hoffman,
Price, and Baldy, of Philadelphia. The strong statements
of Dr. Gordon concerning electricity were considerably
modified by the discussion.
Several other papers were read by title, and the session
then adjourned.
A COoLoRADO Pitysician recently held the body of a
Kansas man, who died, for the payment of his bill, amount-
ing to $3,600. Report does not state whether it was
effectual in securing the money.
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, June 6, 1889.
ALFRED L. Loomis, M.D., PRESIDENT, IN THE CHAIR.
Dr. Prince A. Morrow related
PERSONAL OBSERVATIONS OF LEPROSY IN MEXICO AND THE
SANDWICH ISLANDS,
and gave magic-lantern illustrations of typical cases. Lep-
rosy, he said, possessed only a historical interest to the
majority of persons ; it was by them classed in the same
category as pestilences and plagues, which formerly devas-
tated countries but which now were extinct. Unfortunate-
ly, however, it was not to be so regarded ; it was a living,
an actual reality. In area it embraced fully one-third the
surface of the globe. By reference to a map which he
exhibited, it would be seen to extend from the tropics to
th: Arctic regions ; it embraced every variety of soil and
climate ; it affected most diverse peoples.
Thus climate, soil, and race could not be regarded, as
had been done by some, as efficient factors in etiology.
It would be impossible to estimate the exact number of
lepers on the face of the earth, but India alone was sup-
posed to have fully one hundred and fifty thousand, China
and Japan contained large numbers, and there were many
in Egypt and other portions of Africa, South America, and
elsewhere. There were from five to ten thousand in Brazil.
Whenever leprosy appeared in a country in which it
had not been known before, it could be traced to a human
agent. It never originated spontaneously. ‘There was
good authority for the assertion that the disease was in-
troduced into Central America by the Portuguese, into
Mexico by the Spaniards, and into Canada by the French.
In the United States it could be traced to at least three
or four distinct sources, according to the locality. In
California it was introduced by the Chinese, in the North-
west by the Scandinavians, etc. Ye called attention to
the fact that a centre not yet mentioned was Salt Lake
City, where it had been brought by Mormon converts
from the Sandwich Islands.
His own observations began the past winter about New
Orleans. It had become well known that Dr. Blanc had
alone seen forty-two cases in that city. He had learned
during his visit that cases were scattered here and there
at different places about New Orleans. He sawa
number in Mexico, and in San Francisco he found six
or eight in the pest-house, three of them being Chinese
and one a negro. ‘The Sandwich Islands afforded perhaps
the bést opportunity for studying the disease of any place
in the world. ‘There were many cases on the Islands, and
they were segregated. In other countries certain elements
of confusion surrounded the origin and general study of the
disease which were absent here. It was easier to arrive at
the truth with regard to the influence of heredity, race, etc.,
in the Sandwich Islands, where the disease had been intro-
duced within half a century. There were nearly eleven hun.
dred cases in the settlement at Molokai when Dr. Morrow
was there.
Most of our positive knowledge of leprosy has been de-
veloped by modern methods, and might be formulated as
follows: It was a parasitic disease; the leper bacillus
presented certain analogies with the bacillus of tuberculo-
sis. Like the latter, it was endowed with remarkable vital
tenacity, and, like all specific microbes, it showed an affinity
for certain tissues rather than for others. It was found
in the nodular infiltrations upon the skin and mucous
membranes ; it was abundant in the lymphatic spaces; it
was present in the liver, spleen, testicles; very abundant
in the connective tissue and peripheral nerves ; it was
absent from the blood, from the urine, and, as far as
known, from the physiological secretions. It was present
in abundance in the vaccine pustule of leprous patients.
It never originated spontaneously ; it did not attach to
the soil, water, air, or food; it could always be traced
to man. It was known, further, that leprosy had a some-
THE MEDICAL RECORD. 51
what prolonged, diowah indere period of incuba-
tion, varving perhaps from three to five years, but in some
cases it seemed to have been prolonged to seven, ten, or
even fifteen years. The prodromal symptoms were often
very indefinite ; when well developed, however, the disease
had a characteristic symptomatology. It was slow and
irregular in course, and progressed almost invariably to a
fatal issue.
Belief in the contagiousness of leprosy had been almost
universal until recent times. After the Royal College of
Physicians of London formulated the dogma, in 1867,
that leprosy was not contagious, this view gained very con-
siderable ground. Jm the United States, however, the
leading dermatologists had never accepted the heresy
of non-contagion. The history of its development and
course in the Sandwich Islands afforded most conclusive
evidence of its being contagious. Upon no other possible
ground could its diffusion among the native population be
explained. At the present time it was supposed from five
to ten per cent. of the Sandwich Islanders were lepers.
He had had opportunity to examine a great many of the
patients there, and his experience had been like that of
others, that in almost every instance a history of exposure
could be obtained, either in sexual relations or conditions
of prolonged intimate contact. One way in which the
spread of the disease could be accounted for was the fact
that relatives were permitted to care for the diseased in
leper settlements. A large proportion of such helpers
also became diseased, the percentage amounting in 1880,
according to the report of the President of the Board of
Health, to about one-third (twenty-three out of sixty-six
helpers had contracted the disease, and eleven others were
suspected). Many of the lepers came from countries
where leprosy was not known, and where the question of
heredity could not be entertained.
With regard to the mode of infection, our knowledge
was imperfect. ‘The probabilities were that in the large
majority of cases infection took place through sexual in-
tercourse. But it was alsu probable the disease could be
inoculated through abrasions upon the skin and mucous
membrane, and by the bite of insects. Another mode of
infection was through impure vaccine, and in this manner
it seemed probable a number of cases arose in the Sand-
wich Islands. One patient who came under Dr. Morrow's
observation claimed to have acquired the disease through
the bite of a leper, and another through sticking himself
with a pin, which he did in a spirit of bravado, in imita-
tion of this act by a leper who had used the same pin.
Dr. Morrow mentioned the case of the criminal who
was permitted to choose between the death penalty and
inoculation with the virus of leprosy and imprisonment
for life. He chose the latter, was inoculated in 1884,
and for some time his case was regarded as negative ; but
recently he had shown what Dr. Morrow regarded as un-
mistakable symptoms of leprosy, including the presence
of the bacillus in his tissues at the point of inoculation.
This was the first instance on record in which intentional
inoculation had succeeded.
Belief in the heredity of leprosy has been almost ut.i-
versal, yet from his own observations he had found little
evidence to support it. He thought, however, that a
predisposition to the disease might be transmitted to off-
spting, as was true of tuberculosis ; but he did not believe
the actual germs of the disease were ever transmitted.
Children never showed evidence of leprosy before the
third or fourth year, usually not before the fourteenth
year, while the great majority of cases occurred between
the thirtieth and fiftieth years of age. Thus it would be
seen that there was a certain analogy between this disease
and late hereditary syphilis. Only a small proportion of
the children in the Sandwich Islands, born of leprous
parents developed the disease, unless exposed to prolonged
contact with those thus affected.
The speaker said he was well aware that there were
cases which seemed to show that leprosy was a non-con-
tagious disease. For instance, he threw on the screen the
52 . THE MEDICAL RECORD.
many years, and who had one daughter, aged twenty-five,
who was a leper, yet he had himself remained in excellent
health. There was a woman on the Islands who had had
three husbands, each one of whom had become lepers, yet
she remained apparently free from the disease. Was it
not possible that she had had the disease without external
manifestations, and had given it to her three husbands
successively ? It would appear that in leprosy, as in
other contagious diseases, the system had to be in a re-
ceptive condition before it could be acquired on expos-
ure. In some instances persons had remained free from
the disease during an exposure of twelve or fifteen years,
then contracted it and died. ‘The author then read from
his published description of the symptomatology, and
showed, in the course of his illustrations, typical examples
of the anzsthetic, tubercular, and mixed forms, and closed
his remarks by asking the question whether there was dan-
ger of the spread of leprosy in the United States; or did
the disease, under our hygienic and civilized conditions,
lose its potentiality for mischief ?
ae C. W. ALLEN opened the discussion on the sub-
ject o
THE DANGER OF THE SPREAD OF LEPROSY IN THE UNITED
STATES.
_ His convictions on the subject, he said, were very de-
cided. Two years ago, before the County Medical
Society, he had expressed the view that lepers should not
be admitted to this country, and that those already here
Should be segregated. At that time he had estimated the
number of cases here at one hundred and fifty, which was
considered by some to be an overestimate. He now be-
lieved, however, that there were many more. When we
further considered the large numbers at Key West, Cuba,
and elsewhere, likely to gain access to our mainland at
any time, we could not shut our eyes to the danger.
With regard to the influence of civilization being against
the spread of the disease, it should be remembered that
there were many cases in England only a century ago,
when the conditions were essentially what they were now
in this country. ‘There were so many there then that a
leper-house had to be established for their reception.
With regard to evidence of the disease not being con-
tagious, it was altogether negative, and a single fact of a
positive nature was sufficient to overturn it.
Dr. L. D. BuLkLey regarded the question as one of the
most important ever brought before the Academy. He
thought no one who had listened to the remarks of Dr.
Morrow, and read the literature of the subject, could fail
to be convinced that wherever leprosy had been in-
troduced and allowed full freedom it had spread ; and no
one could deny that where those affected were properly
cared for and segregated that the disease had disappeared.
Dr. Morrow having asked the question whether the leprosy
was in danger of spreading throughout this country, he
would say that until the past six or eight months his fears
had not been greatly excited, but he had been somewhat
surprised to learn of the number of cases recently re-
corded in New Orleans and elsewhere, and he thought it
well that the question should be agitated, that boards of
health in different places should learn the number of pa-
tients in their vicinity and report them. While leprosy
seemed to be conveyed by contact from one person to
another, yet he saw no reason why the bacillus should not
be capable of living in the water or soil.
Dr. G. H. Fox took a more hopeful view of the subject
than that expressed by the other members. The cases of
leprosy in this country, he said, were nearly all imported
ones. They were few, in spite of the fact that there was
no law prohibiting their immigration, and none compelling
their segregation. Only one patient, as far as he was in-
formed, had been cured. He was willing to grant that
the disease was contagious under certain circumstances,
but that there was much danger he did not believe.
There was no more danger than that dogs would go mad
[July 13, 1889
and spread hydrophobia in a neighborhood ; yet in this
case the people generally did not hesitate to take the risk
and keep dogs, even though they were useless. In fact,
he thought that the danger of the spread of leprosy in the
United States had no rational basis. He had not yet
learned of its spreading throughout a civilized community.
It might be different among the Sandwich Islanders, who
lived in large numbers under the same roof, ate with their
fingers out of the same dish, etc. ; but the white people,
even on the Sandwich Islands, were remarkably free from
leprosy.
He thought, however, that lepers should be kept out of
this country by a strict enforcement of the quarantine
laws, not because of danger of spread of the disease, but
because, like paupers, they were likely to become a bur-
den to the community.
Dr. H. G. PIFFaRD said the questions raised to-night
were the same as he had asked ten years before, and the
ground taken by the majority of speakers was the same as
that which he had then taken. At that time the Academy
appointed a committee to investigate the existence of
leprosy in the United States, and it was able to learn of
only forty or fifty. It was probable there were more then,
but he believed there were now five times as many as ten
years ago.
He advocated a strict enforcement of quarantine
against all incoming lepers by the general Government, the
establishment of a hospital by the same power for the re-
ception of those who would voluntarily enter it, and
forced segregation by State authority against others if
thought desirable.
Dr. F. R. Sturcis thought the question of legislative
interference depended altogether upon that of the con-
tagiousness of leprosy. He did not doubt this, although
there were some links lacking in the chain of proof. He
thought the earlier stage was more contagious than the
later. It could be admitted that there were bacilli in both
syphilis and leprosy, but it was still a question whether
they were the true cause of either disease. As to less
danger of spread of the disease in this country than in
the Sandwich Islands because our people were more
cleanly, he would only suggest to Dr. Fox to go into
some of the tenement-houses of New York and observe
there the degree of cleanliness existing among a large
part of our population ; he thought it was proper for this
. Society to call attention of the authorities to the fact that
leprosy was contagious, and that quarantine should be en-
forced against leprous immigrants. :
Dr. R. W. TAYLOR said the speaker of the evening
had clearly shown the possible danger of leprosy bé&com-
ing endemic in this country, yet during the past fifteen
years he had seen almost constantly one to three lepers
sleeping in the crowded wards af the hospitals on Black-
well’s Island, and in no instance had the disease been
conveyed to others. While it was desirable to call at-
tention to the existence of cases in the country, yet
he believed there was no immediate danger of an en-
demic.
Dr. Morrow, in closing the discussion, called atten-
tion to the improved condition of the people of the Sand-
wich Islands over that of some twenty years ago, and said
the spread of leprosy there could not be attributed to
dirty habits. They washed themselves very often, perhaps
half a dozen times a day. He thought the tendency of
the disease to spread more rapidly in some communities
in which it had gained a foothold, than in others, might
be accounted for by the fact, as he believed, that the an-
æsthetic form was not contagious, and it was this form
which predominated in some places, while the tubercular
form was in the ascendency in others. He doubted also
whether leprosy was contagious during the later stage.
In reply to Dr. Fox, he said all would probably be in
favor of enforcing strict segregation and quarantine
against such contagious diseases as syphilis, tuberculosis,
etc., if there were altogether but a few hundred cases,
and by doing so the disease could be entirely extin-
July 13, 1889]
THE MEDICAL RECORD.
53
guished. That, he believed, was what could be done in
the case of leprosy.
NATIONAL BOARD OF YELLOW-FEVER EXPERTS, ETC.
The committee appointed to report on this question,
consisting of Drs. Hadden, Jacobi,.and Armstrong, re-
ported that the proposed resolutions were in conflict with
the Constitution of the United States, and that the pres-
ent quarantine laws, if enforced, were sufficient.
Dr. Jonn C. PETERS called attention to the report of
the State Board of Health on the nuisances existing in
the region of the Croton water-shed, and, on motion, a
committee, consisting of Drs. Jacobi, Peters, and Baruch,
was appointed to petition the Mayor and Aqueduct Com-
missioners to have the nuisances abated.
THE PRESIDENT announced that at the next meeting the
architect would report on the plan of the proposed new
building, after which a collation would be served, and he
invited as many as could possibly do so to be present.
Stated Meeting, June 20, 1889.
ALFRED L. Loomis, M.D., PRESIDENT, IN THE CHAIR.
NUISANCES ON THE CROTON WATER-SHED.
The committee appointed at the last meeting, consist-
ing of Drs. J. C. Peters, A. Jacobi, and S. Baruch, re-
ported through its chairman, Dr. Peters, that it had thus
far traced the sole responsibility of abating the nuisances
to the Commissioner of Public Works, Mr. Gilroy.
On motion, the report of progress was accepted, and the
committee continued.
Dr. A. Jacost then read
NOTES ON THE BAKING OF BACILLI,
being a denunciation of Weigert’s advertising scheme, and
a review of his own experience with the inhalation of hot
air in the treatment of phthisis. Weigert, supposed to be
an American physician, now of Germany, claimed to have
discovered a method of curing phthisis by the inhalation
of hot air, and he had made free use of Dr. Jacobi’s name
in advertising his apparatus for carrying out this treat-
ment. ‘The treatment was not original with Weigert, nor
had Dr. Jacobi, as had been asserted, bought, endorsed,
or recommended the apparatus in question. Moreover,
as appeared further along, he had little confidence in the
method. To Halter belonged the honor of suggesting the
treatment of phthisis by the inhalation of hot air with the
view of killing the bacilli in the lungs. The idea arose
from observing the immunity from phthisis of workmen in
a lime-kiln where they were exposed to a high degree of
heat, 122° to 158° F., so high that it would destroy the
tubercle bacilli provided it continued at that degree until
it had reached the lungs. The air inhaled by workmen
in a lime-kiln was dry and rarefied. A moist atmosphere
of a like temperature would be more destructive of the
bacilli, but was less endurable by the phthisical patient.
Dr. Jacobi said, that having been requested to admit
Weigert’s apparatus into his wards at Bellevue Hospital,
he did experiment with it some time ago, and for a while
the results made a favorable impression on the physicians
in attendance, for the patients, or a part of them, seemed
to improve under the treatment. More careful observa-
tion, however, showed that the improvement was doubt-
less due to rest in the hospital, in an atmosphere much
purer than that in which the patients had lived in their
tenement homes. The instrument itself was not as good
as that which one of ordinary ingenuity could improvise ;
the atmosphere on its way to the lungs from the flame was
found to have fallen from above 300° F. to about the
temperature of the body when it had reached the mouth.
Of course if it were above the temperature of the blood
it would become further cooled on its passage toward the
lungs. Some of the hot air might get into the alveoli,
but very little. In order to obtain benefit from such
treatment it would be necessary not only that the air in-
haled be of a high temperature, but that the patient be
in a room in which the thermometer registered at least
105.5’ F. In other words, it would be necessary to pro-
duce a sort of artificial fever, and it was evident that such
treatment must prove injurious to any other than patients
in the very first stage of phthisis. He added that two of
his patients suffered from cough and vomiting during the
treatment with hot air, and were distinctly better when it
was discontinued.
Mr. R. H. RoBERTSON, architect, then presented
PLANS FOR THE NEW ACADEMY BUILDING,
about to be erected in Forty-third Street, west of Fifth
Avenue. The building will present a front of seventy-five
feet, a depth of one hundred feet, will be four stories and
a basement, be constructed of a dark-red sandstone and
rock-faced brick. The first floor will be two-step rize
from the sidewalk, be divided into coat, reception, smoke,
and dining-rooms, and the large hall. The latter can be
still further enlarged by raising the door which will sepa-
rate it from the dining-room. eginning on the. next
floor, three elevations will be devoted to the reference
library, three reading-rooms, and one stack library with a
capacity for 230,000 volumes. On the third floor will be
four large section-rooms, also specimen and apparatus
room. ‘There will be a room for photography on the
fourth floor, also for the librarian, and for articles which
pertain to banquets. The basement will be divided into
boiler, unpacking, storage, closet, and janitor’s rooms.
Dr. WALTER MENDELSON read some resolutions, with a
preamble, practically consisting in a remonstrance against
the appointment of persons to the position of President
of the Board of Health who are ignorant of sanitary mat-
ters. His motion to refer the matter to the council was
carried.
MEDICAL SOCIETY OF THE COUNTY
NEW YORK.
Stated Meeting, May 27, 1889.
ALEXANDER S. HUNTER, M.D., PRESIDENT, IN THE CHAIR.
Dr. ABRAHAM JACOBI read a paper entitled
RHEUMATISM IN INFANCY AND CHILDHOOD,
in the first part of which he mentioned the limited bibli-
ography. It began with inaugural theses by two pupils
of Roger, 1864 and 1866, followed by a paper by Roger
himself in 1867. In 1875 Dr. Jacobi wrote on the subject
in the first volume of E. C. Seguin’s “ American Clinical
Lectures.” Its study had been renewed to a certain ex-
tent the past five years. It was Dr. Jacobi’s object to
consider principally the therapeutics of acute rheumatism.
Acute rheumatism, he said, was a frequent disease of
both infancy and childhood, but only few recognized it to
be so. ‘The number of cases of valvular disease of the
heart, mainly of the mght side, in children under five
years of age ought to be suggestive to doubters of the
frequency of rheumatism before that period. Nor was
the number of rheumatic cases limited to those having
cardiac disease; there were many cases which ran their
full course without terminating in disease of the heart.
The heart should be watched in every doubtful subject,
for endocarditis was sometimes the first sign of the acute
rheumatism of children, even in apparently mild cases.
Pericarditis was not very rare. When chorea minor
showed itself, the heart and the joints should be examined,
for there were instances in which this disease occurred not
at the end, but at the beginning, of acute rheumatism.
In adding a few words on diagnosis, he said fever was
a common symptom in small children, every physical dis-
turbance raising their temperature. In acute rheumatism
it was often but slightly elevated. Sometimes it rose at
irregular intervals, in some instances being highest about
noon. ‘The swelling of the joint was apt to be very trifling,
and to be overlooked. Pain, either spontaneous or on
pressure, was often much less than was seen after fatigue,
OF
54
syphilitic disease, etc. ‘The diagnosis was apt to be made
more difficult by the affection limiting itself to but one
joint temporarily, or throughout the attack. ‘Then the
disease often occurred in the knee or hip, joints much
subject to traumatic and tubercular troubles. The diag-
nosis also failed to be made in many cases because of its
being denominated growing pains, a term which should
have been dropped long since. What had been called
growing pains was of various origin and nature. It might
be a neurosis of the joint, an epiphysitis, but in a large
majority of cases it was rheumatism.
The treatment of acute articular rheumatism had been
quite unsatisfactory down to modern times. A few indica-
tions were furnished by the actual or alleged causes of
the disease. By some it had been regarded as endemic.
It was sure that certain localities had been known to har-
bor a great many cases at the same time. Thus, change of
home, if practicable, ought to be made, provided the case
was one of a number in the same neighborhood. Con-
tagion had been supposed to spread the malady, but the
number of observations of the kind had been very limited
indeed.
Rheumatism was apt to make its appearance after some
infectious disease, as diphtheria, scarlet fever, dysentery,
and erysipelas. Hence care devoted to those sick with
these diseases would prove a powerful preventive of rheu-
matic fever. =
The blood had been found changed, the alkalinity being
less pronounced ; but this change, or the actual presence
of acid in the blood, had also been either proved or as-
sumed to exist in cachectic conditions of numerous kinds.
In them, as in acute rheumatism, lactic acid had been
found in undue proportion, yet when introduced into the
circulation it never produced articular rheumatism. ‘The
diminution of the alkalies in the blood justified the ad-
ministration of an alkaline salt throughout the course of
rheumatism, particularly of potassium.
= Sudden changes of temperature were certainly among
the causes; exposure to wind and moisture would bring
on an attack. This was particularly so in those with an
inherited predisposition. Such inheritance was not at all
infrequent. ‘The treatment of such cases must be mainly
preventive. The tendency to be easily influenced by
sudden changes of temperature could be modified or re-
moved by the use of cold water. Warm clothing and
bedding were indicated. Nothing could be more in-
jurious than exposure of the surface to wind and rain.
The swollen and painful joints must be protected against
pressure of blankets. The ice-bag or cold wet cloth to
the affected joint was sometimes of benefit. The wet
bandage or pack, applied around the joint should be
changed every hour or half-hour. Anzmic children pre-
ferred hot applications, perhaps dry ones. ‘To relieve
pain he could not advise subcutaneous injections of car-
bolic acid, as had been done by some. In very severe
cases he had been compelled to administer a few drops of
a solution of morphine hypodermically. As a rule, an
anodyne application around the joint (such as chloroform,
morphine), covered by oiled silk, or the use of a mild
galvanic current, would give relief.
Distention of the synovial membrane during retarded
convalescence was troublesome, and might be treated by
compression with bandages or collodion applications, by
gentle massage and the galvanic current. Iodine was use-
ful, also the internal administration of iodide of potassium
or sodium, or both, five to twenty grains daily. Officinal
ointment acted through the gentle kneading necessitated
-by its use, but absorption did not take place. Iodide of
potassium in glycerine would act better, but was inferior
to lanolin ointment. Dissolve iodide of potassium in
equal parts of water, and some fat and a larger quantity
of lanolin, and apply to the joint. Best of all was to
brush copiously iodoform collodion over the affected
joint, and allow to dry. Very old cases, with chronic
effusion into the joint, required aspirating and washing
out.
THE MEDICAL RECORD.
[July 13, 1889
Endocarditis demanded absolute rest, every exertion
proving injurious. Hence, occasional doses of opium or
bromides would have a good effect. ‘The ice-bag, or, if
too heavy, the ice-cloth to the cardiac region would act
well. But not every murmur meant endocarditis. Both
chorea and endocarditis could be mitigated or prevented
by early attention.
The temperature was rarely high, but there were cases
in which it went up to 104° or 107° F., and it was in
them that delirium and other nervous symptoms made
their appearance. Antipyretics were then required. ‘The
cold pack was the readiest and most effective. It was
particularly indicated in cases complicated with endo-
carditis. It was also in these cases that such antipyretics
as antipyrin, antifebrin, and phenacetin were indicated.
A single large dose of antipyrin for the night—say ten to
twenty five grains—sometimes succeeded better than many
smaller doses.
As a rule, salicylate of sodium hastened disappearance
of pain and swelling, but it ought not to be tried longer
than from three to five days. Sulphate of quinine was
sometimes indicated. Alkaline salts or mineral waters
were called for, as Vichy, bicarbonate of sodium, or one
of the nitrates. Vegetable acids had been warmly recom-
mended by some. Iodide of potassium and sodium had
been justly highly commended, particularly where there
was a tendency to chronicity. Remedies which had been
administered for a specific effect in the rheumatism of
children were not to be relied upon.
Gonorrhceal rheumatism was not sufficiently rare in
children. When present it was usually in the knee,
ankle, or shoulder. ‘The effusion was likely to be puru-
lent and excessive in amount. ‘The treatment was more
local than in ordinary rheumatism. Puncture might be
made to ascertain the nature of the effusion. If there
were pus, it might be removed, the cavity washed, and
thoroughly disinfected. Then establish rest and apply
gentle, steady pressure by bandage, with or without mer-
curial plaster or iodoform collodion beneath. Salicylate
of sodium, or iodide of potassiùm and sodium, must be
continued a long time.
After an attack of acute rheumatism smal] nodes or
neoplasms, consisting of young connective tissue with nu-
merous cells, might remain a few days or several months,
but called for no special therapeutics. In that form of
rheumatism in which there was a tendency to hemorrhage
into the parts, cardiac stimulants were indicated early.
Salicylate of sodium should not be administered, since ıt
had a tendency somewhat to increase the hemorrhage.
Chronic articular rheumatism was rare in childhood.
The treatment was about the same as in the adult. Sali-
cylate of sodium was indicated only in acute exacerba-
tions. ‘The so-called hydropathic treatment, cold or hot
baths, would prove beneficial. Local applications of
tincture of iodine, iodoform collodion, etc., were called
for. Much benefit was derived from alkaline waters.
Dr. Jacobi recommended lithia water.
Muscular rheumatism could be diagnosticated occasion-
ally in very young children; from six to twelve years of
age it was not very rare. The symptoms did not differ
much from those observed in the adult. The neck and
back of the shoulders were most affected. The best pre-
ventive was the habitual use of cold water. ‘The inter-
rupted current was beneficial, as were also certain other
remedial agents in individual cases.
Dr. WiLt1aM H. THomson opened the discussion. He
said his attention had been very early called to the etiology
of rheumatism by the fact that while it was commonly
attributed to cold and moisture, yet he had observed it to
be quite prevalent among the inhabitants of the hot and
dry desert of Syria. Gout, on the contrary, was to be
found nowhere in Mohammedan .countries. It was seen
only in countries where alcohol in some form was used.
On inquiring what there could be in common between the
climate of Syria, for instance, and that of the north of
Scotland which would account for the prevalence of
July 13, 1889] THE
rheumatism in both of those places, he had arrived at the
conclusion that the disease nust be due to chilling of the
skin when moist. In Arabia the heat during the day was
intense, the inhabitants lay on the sand with inadequate
cover during the night, the surface of the body, bathed
during the day in perspiration, rapidly cooled, and rheu-
matism resulted. To show how great was the change from
the temperature of the day to that of the mght, his father
had told him that he had never suffered so much from the
cold as one night at the foot of Mount Sinai, when the
thermometer during the day had registered 140° F.
Regarding the diagnosis of articular rheumatism, it was
difficult to make, for all affections of the joints were apt
to interfere with the functions in the same way. Diseases
quite distinct in origin were often called rheumatism. An
important point in differential diagnosis between rheuma-
tism and gout was found in the pulse, it being soft and
compressible in rheumatism, the contrary in gout. In
scarlatinal rheumatism, however, there was an incomrres-
sible pulse, and with it there was often an enormous de-
posit of uric acid in the unne, sometimes pus, the affec-
tion approaching pyæmia. He was inclined to believe in
an unknown function of the skin, which, when disturbed,
led to a secondary product in the system which caused
rheumatism.
He said Dr. Jacobi had alluded to the possibility of a con-
nection between acute articular rheumatism and quinsy.
He had himself seen some patients in whom an attack
of quinsy was pretty sure to be followed within ten days
by acute rheumatism. He had been able in nearly all
cases to trace a connection between the rheumatic attack
and chilling of the moist skin. That being so, he had a
great fondness for the continued use of the warm bath in
this affection. It acted as an anesthetic, and rendered
the urine alkaline. The skin should always be kept en-
veloped in flannel in rheumatic subjects. As a prophy-
lactic he had for years prescribed oily inunctions, particu-
larly on the back of the neck and shoulders. He also
placed a great deal of reliance on cod-liver oil in chronic
rheumatism. He fully shared the views expressed by Dr.
Jacobi regarding carditis in the rheumatism of children,
and warning against the likelihood of its occurrence even
in mild cases. Particular care should be taken of chil-
dren who showed any choreic symptoms. ‘The growing
pains referred to by the author led him to take precaution-
ary measures, particularly in the administration of cod-
liver oil, inunction of the skin, and the use of flannel
underclothes.
A most violent rheumatic inflammation might be present
in a joint and disappear within a short time, and leave no
signs whatever of its former presence, a fact which was
peculiar to this disease alone, yet in the heart permanent
lesions were likely to result. He could partly account
for this fact by the continued and rapid movement of the
heart, it being much more rapid even than during health,
and more rapid in the rheumatism of children than in that
of the adult, while in the joints there was usually complete
voluntary or involuntary rest or immobility. Because of
the marked rapidity of the heart’s action in the rheu-
matism of children, he gave aconite in full doses. Digi-
talis would not do so well as aconite in these cases. At
the same time the blood should be rendered alkaline.
The chest should be protected from cold air, and he
would not allow the precordial surface to be exposed
under any circumstances.
Dr. J. Lewis SMITH said that during a practice of thirty
years, or more, he had seen a large number of cases of
rheumatism in children in private practice, but not having
kept a record of them he would base his remarks upon
the cases seen the past fifteen years at the Outdoor De-
partment of Bellevue Hospital. He had diagnosticated
seventy-elght cases in persons under fifteen years of age.
In many of them, however, the diagnosis was based on
the history and the presence of a heart-lesion. No case
was under one year of age, few under two. He believed
that rheumatism before the second year seldom showed
eee ven
MEDICAL RECORD.
55
— + ee ———— P TRAEN = sane ay —
much walling bes which it could be diagnosticated. He
had seen tumefaction in tetany in babes six or eight months
of age, which might be mistaken for rheumatism. In the
vast majority of cases the rheumatism was in the lower
extremities. The local manifestations were likely to be
much less pronounced than in the adult. In some of the
cases the parents had spoken of it as growing pains. The
laity should be taught that there was no such thing as
growing pains. Of his seventy-eight cases, forty-nine had
distinct cardiac murmurs, and in many it was the cardiac
disease that had led him to inquire for a history of rheuma-
tism. In one child, aged twelve, an embolus of the brachial
artery had led to lividity and coldness of the right hand.
The parents said it had previously been troubled in the
same way in the right leg. Most of the patients were
seven to eight years of age, the vast majority between
three and seven. . It was very difficult to diagnosticate
pericarditis if there were an aortic or mitral bruit to cover
the sound. Enlargement of the heart was often present
when the disease had lasted a year or more. ‘The pulse
was often Irro or even 150. As bearing on the relation
between chorea and rheumatism, he said that during the
same period (fifteen years) he had seen chorea minor in
sixty-seven cases, in only eighteen of which was he able
to assign rheumatism as a cause. There were certain rea-
sons why the profession should yet hesitate to accept the
m:cr bic origin of rheumatism.
The important practical point was to make an early di-
agnosis and prevent heart disease. He had been in the
habit of administering salicylate of sodium or salicylic
acid in some form, and believed by thus cutting off an
attack cardiac disease might often be avoided. He ap-
plied it to the parts also.
Dr. H. D. CHarpin thought that while it had come to
begenerally recognized that rheumatism was not an un-
common disease in children, yet it was very difficult to
diagnosticate. There was no pathognomonic symptom.
One had to judge rather by what might be called the
composite of the disease ; by the presence of pain, which
was likely to exist in the fascia as well as the joints, by
endocarditis, by the profound hydrzmia which he thought
was generally present, and by chorea. ‘The pains were
likely to first attract attention, yet a child often had
pains in the legs due to over-exercise and not to rheu-
matism. Unlike in rheumatism, however, they were not
so likely to have pain on rising in the morning as after
retiring.
He quite agreed with what had been said as to the need
of rest in endocarditis. ‘The mistake was made in allow-
ing the child to go about too soon. He had found ton-
sillitis in connection with rheumatism too frequently to
be accounted for as a mere coincidence. He had diag-
nosticated rheumatism in one child of eleven months. It
began in the elbow, went to the knee, then to the neck.
In treatment he sought to stop intestinal fermentation and
promote action of the skin. He gave hot alkaline baths,
had flannel worn next the skin, regulated the diet, gave
cod-liver oil, in many cases iron, and thus sought to pre-
vent recurrence of the attacks.
Dr. Aucust SEIBERT had counted his cases at the dis-
pensary in 1888, and at that time had found rheumatism
in thirteen children under one year of age. He had seen the
disease occur in children first, then in the mother and fa-
ther. He had for years been disposed to look upon rheuma-
tism as an infectious disease. It occurred where sanitation
was poorest ; wherever there was filth and dirt there also
was inflammatory rheumatism. ‘The same was true of
other infectious diseases. ‘The best remedy was salicylate
of sodium ; its action must be in doing away with the
germs of the disease. He administered it in children by
the rectum, thus avoiding stomach and cerebral symp-
toms.
Dr. Jonn C. PETERS thought the rheumatism occurring
under the conditions referred to by Dr. Seibert might be
accounted for by cold and damp, and want of sufficient
underclothing. He was disposed to account for it in that
way rather than by infection. He placed great reliance
on alkaline baths.
Dr. AuGusT CAILLt thought the evidence favored the
view that rheumatism was surely an infectious disease.
Ever since he had so regarded it, he had considered in
what way it had entered the system. Those who had
spoken to-night had mentioned its frequent connection
with sore-throat, and he was disposed to believe that that
was one of the channels through which it entered the
system.
Rest was essential in treatment, yet it was very difficult
to obtain in children. The indication in the use of drugs
was to neutralize the poison in the blood. Alkalies in-
creased the alkalinity of the blood and were beneficial ;
antiseptic chemicals were good. To prevent heart com-
plication he gave a cardiac sedative, and also applied an
ice-bag over the præcordium. He was very sanguine that
within a reasonable length of time the chemists would
find even a more efficient antiseptic remedy than those
now used with which to counteract the poison of rheu-
matism.
NUISANCES ON THE CROTON-WATER SHED.
Dr. JOHN C. PETERS presented the report of the State
Board of Health on the Croton water-shed, showing the
necessity for abating the rapidly increasing nuisances in
the region whence the city obtained its water supply, and,
on motion, resolutions were adopted appointing Dr. Pe-
ters, the President, and the Secretary of the Society a
committee to wait un the Mayor and Aqueduct Commis-
sioners, and urgently request them to enforce the law in
this respect.
Gee St ee PS a Se nee ENOO EE, a ae Rae eos Si
Correspondence.
ELECTROLYSIS AND THE RADICAL CURE OF
STRICTURE—WHY THE CHALLENGE HAS
NOT BEEN ACCEPTED.
To tHe Epitror or THe Mepicat Racorp.
SiR : So many inquiries have been received by us in re-
gard to the progress of the tnal of electrolysis in the radi-
cal cure of urethral stricture, that we feel called upon to
present a statement of how the matter stands, especially
as there is an erroneous impression prevalent that our
challenge was accepted.
We have had three meetings with Dr. Newman, who,
after much amiable discussion, declines our challenge on
the following grounds :
1st. That he is unable to obtain fair play in New York.
2d. ‘That he objects to the use of dispensary patients.
3d. That he objects to either party interested furnish-
ing the patients.
He offers, however, a counter-proposition, viz., that the
trial take place in Philadelphia. That the patients be
furnished by some disinterested party in that city, and
that the committee consist of one member from New
York, one from Philadelphia, and one from Baltimore.
In regard to the Doctor’s inability to obtain fair play
in this our city of New York, we must leave that for the
profession to judge, stating, however, that the names of
the gentlemen who had consented to act on the com-
mittee, if so requested, comprised those of Drs. Weir,
McBurney, Bangs, and Abbe.
In regard to the second objection, we were unable to pro-
vide ten private patients who were willing to become the sub-
jects of the experiments ; nor (third) have we been able to
discover any disinterested party who is willing to do so.
The Doctor’s proposition we must decline, not only on
account of the imputation on the profession such accept-
ance would imply, but also on account of the practical
impossibility of making the constant trips to and fro
which such trial would necessitate.
While regretting the outcome of this endeavor to prove
or disprove the efficacy of electrolysis in the cure of
56 THE MEDICAL RECORD.
[July 13, 1889
urethral stricture, we cannot but feel that, to those of a
logical turn of mind, at least, our effort has not been
wholly fruitless. ' Respectfully yours,
GEORGE E. BREWER,
WiLuiaM K. Oris.
VANDERBILT CLINIC, GENITO-URINARY DEPARTMENT, June 20, 1889.
Army and Bavy Bews.
Official List of Changes in the Stations and Duties of Cfi-
cers serving in the Medical Department, United States
Army, from June 16 to June 22, 1889.
Forwoop, WILLIAM H., Major and Surgeon. By di-
rection of the Secretary of War, the extension of leave of
absence on surgeon’s certificate of disability, granted in S.
O. No. 118, May 22, 1889, from this office, is further ex-
tended four months on surgeon’s certificate of disability.
Par. 14, S. O. 142, A. G. O., Washington, June 20, 1889.
FISHER, WALTER W. R., Captain and Assistant Surgeon.
The leave of absence for one month granted by S. O. 30,
C. S., Department of California, and extended fifteen days
by par. 3, S. O. 37, c. s., from these headquarters, is fur-
ther extended fifteen days. Par. 1,S. O. 4, Headquarters
Division of the Pacific, San Francisco, Cal., June 12,
1889.
Harris, Henry S. T., First Lieutenant and Assistant
Surgeon. By direction of the Acting Secretary of War,
leave of absence for two months is granted. Par. 13, S.
O. 140, A. G. O., June 18, 1889.
Ten Eyck, BENJAMIN L., First Lieutenant and Assist-
ant Surgeon (recently appointed). By direction of the
Acting Secretary of War, ordered to Fort Leavenworth,
Kan. Par. 2, 5. O. 138, A. G. O., June 15, 1889.
GARDINER, JOHN DE B. W., Captain and Assistant Sur-
geon. By direction of the Acting Secretary of War, re-
lieved from duty at Fort Leavenworth, Kan., and ordered
to Fort Reno, Ind. Ter. Par. 2, S. O. 138, A. G. O.,
June 15, 18809.
Wates, P. G., First Lieutenant and Assistant Surgeon.
By direction of the Acting Secretary of War, par. 3, S. O.
132, June 8, 1889, A. G. O., 1s so amended as to direct
to report at Fort Huachuca, Ariz., for duty in place of
Presidio of San Francisco, Cal. Par. 2, S. O. 138, A. G.
O., June 15, 1889.
WYETH, M. C., Captain and Assistant Surgeon. By di-
rection of the Acting Secretary of War, relieved from
duty at Fort Huachuca, Ariz., and ordered to Fort
McDowell, Ariz. Par. 2, S. O. 138, A: G. O., June 15,
1889.
Woop, LEONARD, First Lieutenant and Assistant Sur-
geon. By direction of the Acting Secretary of War, re-
lieved from duty at Fort McDowell, Ariz., and ordered to
post of San Francisco, Cal. Par. 2, S. O. 138, A. G. O.,
June 15, 1889.
Official List of Changes in the Medical Corps of the United
States Navy for the week ending June 22, 1889.
BEARDSLEY, GROVE S., Medical Inspector. Granted a
year’s leave of absence, with permission to leave the United
States.
FEREBEE, N. M., Surgeon. Detached from special
duty at Naval Academy, and wait orders.
ROTHGAUGER, GEORGE, Assistant Surgeon.
to the Naval Hospital at Mare Island, Cal.
SIEGFRIED, C. A., Surgeon. Detached from the United
States Ship Quinnebaug, and wait orders.
Curtis, L. W., Passed Assistant Surgeon. Detached
from the United States Ship Quinnebaug, and wait orders.
SMITH, GEORGE T., Assistant Surgeon. Ordered to the
Army and Navy Hospital, Hot Springs, Ark.
Ordered
The Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 36, No. 3
New YORK,
Original Articles,
RESUME OF THE EXPERIENCE OF SEVEN-
TEEN YEARS IN THE OPERATION OF DI-
LATING URETHROTOMY.’
By FESSENDEN N, OTIS, M.D.,
CLINICAL PROFESSOR OF GENITO-URINARY DISEASES IN THE COLLEGR OF THYSI-
CIANS AND SURGEONS, NEW YORK , CONSULTING SURGEON TO CHARITY HOSPI-
TAL, ST. ELIZABETH’S HOSPITAL, THE MANHATTAN EYE AND SAR HOSPITAL,
RTC.,
THE operation of dilating urethrotomy, for the removal
of urethral stricture, as devised and practised by myself,
has now been before the medical profession for nearly
seventeen years; the first dilating urethrotome, with a
brief report of six cases upon which it had been used,
having been presented at a meeting of the New York
Medical Journal Association, November 24, 1871.
Previous to that time internal urethrotomy, as a rule,
was performed only as a last resort, in cases when gradual
dilatation was for some grave reason deemed impracti-
cable, or when only very temporary relief had been ob-
tained by that method.
In the performance of internal urethrotomy, at that
time, there were no fixed principles established for the
guidance of the surgeon, as to the extent of the incisions.
‘The standard urethral calibre accepted by all authori-
ties was then 21 mm. circumference (French scale), or
No. ọ of the English scale, beyond which sizes no neces-
sity for interference, on account of symptoms, was re- '
cognized. ‘The individuality of the urethra had not been
discovered, and urethral instruments for the most extreme
dilatation, as for the over-distention of stricture, did not
exceed 30 mm. in circumference ; while 21 mm. was con-
sidered sufficiently large for use in all ordinary practice.
The permanent cure of stricture by dilatation, by divul-
sion, or by division was not effected nor expected, and
even the possibility of a radical cure, by any method, was
denied by all accepted authorities. Under this condition
of things, dilating urethrotomy was proposed. It was
based upon the acceptance, first, of an individual calibre
for every urethra ; second, upon the alleged necessity (in
order to secure the best results) for complete division of
all presenting stricture up to the normal urethral calibre ;
this point to be ascertained by actual measurement in
each case.
This was at first determined with difficulty, and only
approximately, by means of accurately graded metallic
bulbous sounds. Subsequently, however, with increased
ease and precision, through the urethrometer which was
presented by me to the profession in 1874. Through the
use of this instrument, after a time it became apparent
that a proportionate relation existed between the size of
the flaccid penis and the normal urethra in any given case,
and this fact was subsequently found of much value in
estimating the normal urethral calibre, in cases where no
instruments for actual measurement were attainable.
Through the use of the urethrometer, also, the external
urethral onfice, which had early proved a serious obstacle
in ascertaining or estimating the normal urethral calibre
(especially as it had been previously accepted as a guide
to that calibre), was found to be of varying size (indepen-
' Read before the Association of Genito-Urinary Surgeons, Wash-
ington, September, 1888. ‘
ULY 20, 1889
Whole No. 976
dently of the urethra associated with it), except in its per-
fect development, when it was then found to correspond
completely in size with that of the canal behind it. Fur-
ther observations soon made it evident that contractions
of the orifice were capable of producing troubles similar
to those caused by stricture farther down the urethra.
‘The importance of recognizing the various degrees of
contractions between the previously accepted standard
(ie 21 F. org E.) and the normal
calibre, as ascertained by actual meas-
urement, was made more evident as
the study of stricture troubles under
these new conditions was proceeded
with. It was found, notably, that
gleet, which had from time immemo-
rial been considered the opprobrium of §$
medicine and surgery, was, in certainly
a large proportion of instances, de-
pendent on the presence of urethral
strictures usually of large calibre, not
readily detected in ordinary examina-
tions. ‘The urethrometer, which was
the outcome of a necessity for definite
measurements (in order to use the
dilating urethrotome with accuracy),
thus broadened its own field to an ex-
tent little expected when its use was
initiated. Through the division of
strictures, often but slightly diminish-
ing the normal urethral calibre (pre-
viously recognized as frequent in cases
of gleet), it was found that in some
cases the gleet disappeared without
other treatment, and thus its depend-
ence upon the stricture for its continu-
ance was finally demonstrated. It was
also found that the method of opera-
tion upon a stricture made tense and
thinned by dilatation required a much
less extensive incision for its complete
division than when flaccid, and that in
thus dividing it there was a marked
immunity from serious hemorrhage,
from urethral fever, from abscess,
pyzmia, etc., which had been consider-
ed sources of danger in internal ure-
throtomy when complete division of
the stricture was contemplated.
In the experimental experience of
the first years (1871, 1872, and 1873)
w.th the dilating urethrotome, the grave
responsibility of so radical a departure
from previous methods was not under-
estimated. ‘The attention of eminent
surgeons was invited to the procedure,
and their presence secured at many of
the operations.
Frequent reports of progress were
thrometer.
strate in public and in private, at home
and abroad, the method of operating, and from time to
time to present for examination cases upon which the op-
eration had been performed.
The new instruments, which at first were of necessity
more or less crude in design, as well as in manufacture,
58
were studiously modified and simplified, until, by 1874, it
may be said that they were brought to a condition of sat-
isfactory efficiency, and the operation of dilating urethrot-
omy—already having received much attention, and some
practical acceptance, from surgeons in our .own country,
as well as in various parts of Europe—was now fairly
launched into the field of genito-urinary surgery. The
approval and the adoption of the operation necessarily
implied abandonment of the old views of urethral propor-
tions, and an acceptance of the individuality of the ure-
thra with a normal calibre of from 30 to 40 mm. in cir-
cumference, and an average of about 32 mm.
After the experience of another year, with the opera-
tion and its results (a report of one hundred tabulated
cases, comprising division of 258 strictures, having been
presented by me at a meeting of the New York State
Medical Society in March, 1875), it was thought not too
soon to make a distinct statement of the claims of dilating
urethrotomy for precedence over the usual methods of
internal urethrotomy for the treatment of urethral strict-
ure ; as well as those by divulsion, and (in the greatest
majority of cases) over the plans of gradual dilatation.
For all strictures anterior to the bulbo-membranous junc-
tion I insisted, first, upon a necessity for acquiring knowl-
edge of the normal urethral calibre before any operative
measures were instituted, and of the exact locality and
size of every stricture in a presenting urethra ; second, that
there should be an accurate adaptation of surgical pro-
cedures to the individual strictures, with intent to remove
them through complete sundering at some one point.
Claiming this to result (when the division has been com-
pletely effected), first, in the complete removal by absorp-
tion of strictures so divided ; second, greatly diminished
total risks of operative measures, as compared with at-
tempts at more or less complete removal of strictures by
any other method.
In my first report of one hundred tabulated cases, com-
prising two hundred and fifty-eight strictures operated on,
it was shown that no deaths or grave accidents had oc-
curred, and that in thirty-one re-examined, two over three
years, and three over one
year after operation, freedom
from every trace of stricture
was demonstrated. From
this fact the possibility of a
radical cure of stricture was
then asserted. Since that
time, March, 1875, the claims
which were then squarely and
earnestly made in favor of
dilating urethrotomy have found full corroboration and
steadily increasing favor, so that here to-day there is no
necessity of citing specific evidence of its general accept-
ance by the surgeons of America as a valuable surgical
procedure. From what has come to my own personal
knowledge, I am led to believe that many hundred op-
€rations upon strictures, by dilating urethrotomy, are per-
formed in public hospitals, and also in private practice, in
America, every year, and that the favor extended to it is
steadily increasing ; but, perhaps from the fact that it is no
longer a novelty, and that there is but little credit to be
gained from statistics which offer no new subjects for con-
templation or discussion, the reports of these operations or
their results do not find their way into the medical jour-
nals. It is because of this and also from the fact that,
within the past year, already sixty complete cases of
instruments for the scientific diagnosis of stricture, and
for the performance of dilating urethrotomy by my
method, have been ordered for use at the military posts
of the U. S. Army alone; and further, that prominent sur-
gical instrument makers have claimed increasing sales of
my instruments to the profession at large; chiefly on
these accounts, I have concluded that perhaps some of
the results of a studious experience of my own in the use
of these instruments might not be unacceptable. Espe-
cially has this seemed desirable for those whose previous
poon Ehei etyan
Urethrometer with Springs.
THE MEDICAL RECORD.
[July 20, 1889
opportunities have not been favorable for observation and
comparison of results by different instruments, or of va-
rious modifications in the details of operations and after-
treatment, and also who have not had opportunities of test-
ing results after a long period from the date of operation.
In pursuance of this design, I also beg leave, first, to
speak of some of the changes and improvements which
have been made in instruments for diagnosis of stricture
and operations by dilating urethrotomy up to the present
time. After much experimentation the urethrometer,
which was made originally (1874) with jointed metallic
bars, was superseded in great measure, in 1875, by one
made with steel springs, which latter had the advantage of
giving a better shaped bulb, and could be made 5 or 6
mm. in size less than the former. It proved a very effi-
cient instrument and, when well made, seemed to fulfil all
the necessary requirements ; but the difficulty of having it
well made, especially as to the strength and
temper of the springs, and its liability to rust
and breakage, proved a source of much an-
noyance, besides involving much care and ex-
pense to keep itin good working order. A
little more than a year ago, especially urged
-by the necessity of having a more enduring
instrument for use in the military and naval
service, I succeeded, through a competitive
contest between the prominent instrument-
makers of New York, in having a perfectly
satisfactory instrument made, without springs
and with a compass of from 18 to 45. This,
when well made, lasts for many years, without
the necessity for repair.
Next, in regard to the dilating urethrotome.
Since its first presentation to the profession
in 1872 this instrument, through continued
efforts for increased simplicity in construction
and increased directness and accuracy in ap-
plication, has necessarily undergone many
modifications. One of these was fully twelve
inches long, and curved, with an especial design
to securing its more easy adaptation for the
division of strictures at or beyond the bulbo-
membranous junction. It was soon found,
however, that while introduction into the
curved portion of the urethra was facilitated,
the dilatation by it, thus curved, was unequal,
and could not be correctly indicated on the
dial, thus rendering it unreliable. And what
was a still stronger reason for condemning it,
a further experience with dilating urethrotomy
proved that division of stricture, by any form
of urethrotome, beyond the bulb was unsafe
and, in my opinion, distinctly not within the
| legitimate province of dilating urethrotomy.
Original Form I have repeatedly condemned this long,
of Urethrometer. curved, dilating urethrotome, in public and
in private, to surgeons, students, and instrument-makers,
for the last ten years; but in spite of my efforts they con-
tinue to be called for, and consequently to be made and
sold ; for which reason I take this especial opportunity
again to condemn utterly this form of dilating urethrotome.
The one, and the only, dilating urethrotome I use and
recommend for all operations of dilating urethrotomy is
the short, straight instrument which I now exhibit, 8}
inches in length, circumference of shaft 16 mm., and ca-
pable of being expanded to 45, with a blade running 2 to
24 mm. above the groove. I desire here to advise against
the use of this delicate instrument as a divulsor, unless
much more heavily made. When, in dilating strictures
during operation, any undue strain is felt, it should be at
once relieved by passing the blade through the stricture,
then continuing the dilatation, and if necessary cutting
again in a similar way until a dilatation of two or three
millimetres may be made without marked resistance, a
fact which, as a rule, indicates the complete sundering
of the stricture. In cases where there is some uncer-
July 20, 1889] |
tainty as to the exact point of binding during the opera-
tion, the use of the bulbous sound will define it, saving
unnecessarily long incisions. In regard to the locality of
the incision, I do not hesitate to reiterate my former opine
ion in the strongest terms, that it should be always and
only superiorly, ¢.¢., on the roof of the urethra, and as
nearly as possible exactly in the median line. A more
generous vascular distribution in the peri-urethral tissue;
will account for the fact that hemorrhage is more liable
to be severe when the incisions are
made inferiorly, and is a sufficient
reason why inferior incision should
be avoided.
Again, when the tissues are sub-
jected to the tension necessary to
secure the complete sundering of
more than usually deep or resilient
strictures, when the knife is drawn
through them, the incision may ex-
tend even through the fibrous sheath
of the corpus spongiosum, and make
an infiltration of urine into the ad-
jacent cellular tissue possible. A
number of cases of this, always
grave, accident have occurred
within my personal knowledge—
one within the past year. ‘This
case I saw in consultation, on ac-
count of unusual hemorrhage,
which continued after the opera-
tion; much swelling followed,
which it was thought might be from
blood - extravasation. Two inci-
sions were said to have been made
with the dilating urethrotome, one
on either side of the urethra, for
the division of several strictures.
‘The urine was first drawn by cath-
eter, but during the night follow-
ing the operation it was passed
voluntarily. Increase in the size
of the penis was immediately no-
ticed, and when I saw the case it
was about two inches or more in
diameter, and considerably distort-
ed. Escape of urine into the cel-
lular tissue had evidently taken
place.
Immediate free incisions through
the integument and superficial
fascia, and release of the impris-
oned urine, saved extensive slough-
ing, but when I saw the patient,
several weeks after, he had a un-
nary fistula on the side of his penis,
while several prominent points of | \
stricture still remained in the |,-
urethra. f
In dividing the strictures supe-
riorly, and in the median line, the :
knife, if penetrating to a point be- .-6 1.—Cut of the Authors
yond the sheath of the corpus Improved Urethrometer. =
spongiosum, comes in contact with Urethrometer, condemned as
the fibrous tissue joining it to the unsafe_and otherwise unfit for
corpora cavernosa, which barner ` l
affords the greatest security against accidents from in-
cision in the median line, but to which deep incisions in
all other directions are always liable.
I believe that one important reason why the operation
of dilating urethrotomy, in my hands, has been so uni-
formly successful, and so uniformly free from untoward re-
sults, lies in the fact that I always divide the stricture on
the superior surface of the urethra, and as nearly as pos-
sible in the median line. Up to the present time, as I
have stated, dilating urethrotomy has,'in my hands, proved
an eminently safe operation.
THE MEDICAL RECORD.
59
At the meeting of the International Medical Congress,
held in London in 1881, I reported six hundred and sixty-
four operations of my own without a death, or permanent
disability of any sort. My operations since that date will
swell that number to more than one thousand, and not
only have I never yet hada death resulting, when the dilating
urethrotome alone was used, that is, when it was not pre-
ceded by the use of the urethrotome of M. Maisonneuve,
or its equivalent, but I have never yet seen an abscess,
nor an escape of urine into the tissues, nor an attack of
pyæmia, follow the operation. I believe another promi-
nent reason for the safety from accidents which has at-
tended my operations will be found in the scrupulous
care of instruments, securing absolute cleanliness and
asepsis as far as possible, and in the use of all available
antiseptic precautions, for patients and instruments, both
before and after operation ; washing the parts externally
with a solution of the bichloride of mercury 1 to 1,000,
and using injections of boric acid internally, two or three
times a day, until healing is complete ; using the catheter
for emptying the bladder, for the first few days after op-
eration, whenever it is well borne, chiefly as a preventive
of urethral fever ; but in certain cases, where the urethra
is very sensitive and intolerant of its use, allowing the
patient to pass his own urine from the outset. J am a
believer in the power of quinine and morphine to pre-
vent urethral fever, in many cases, when contact of urine
with freshly made urethral wounds cannot be avoided,
and am accustomed, in such cases especially, to administer
a suppository composed of ten grains of quinine with one-
quarter grain of morphine, immediately after operation.
And now, in regard to the accidents of hemorrhage.
When incisions are made beyond three inches, I take the
precaution of having the perineal crutch’ in position immedi-
ately after operation, so that, should hemorrhage occur
subsequently, the patient can readily bear down upon it,
and thus be promptly secured from any leakage back into
the bladder. Effective pressure may be made at any
desired point anterior, and thus always prevent any con-
siderable loss of blood in any case. In cases where hem-
orrhage is not completely controlled by temporary pressure,
I have found nothing better than the introduction of my
hard rubber endoscopic tube, formerly recommended ; any
necessary counter-pressure being made by bandage. This
may remain, if necessary, for two or three days, removing
the tube only for cleansing ; urination being readily effected
or catheter passed, through it, on removal of the obtura-
tor. Cases requiring these unusual measures have not
occurred, in my experience, in more than one-half of one
per cent. of cases operated on. As a rule, to which there
are very few exceptions, but slight inflammatory action
follows even the most extensive incisions of dilating
urethrotomy, although there is, as a rule, a pre-existing
more or less acute urethritis in every case operated on;
on the contrary, this is usually lessened, and the sensitive-
ness diminished. ‘There is, however, in some instances
where there is much sexual irritability, increased ten-
dency to erection, more or less plastic exudation in the
immediate vicinity, resulting in more or less troublesome
chordee. ‘The exudation causing this, as in gonorrheea,
usually passes off in a few days, unless the irritation is kept
up and increased by some extraneous influence, such as a
previously existing acrid discharge, sexual excitement, or
too frequent or rude introduction of sounds. In such
cases adhesions between the mobile layers of the peri-
urethral fascia may occur, which, unless accidentally
broken up by strong erections, may remain for weeks and
even, in some cases for many months ; sometimes a source
of great annoyance, but finally passing off completely with-
out any special treatment. In a former account of such
cases,’ I recommended a diagonal incision across the supe-
rior wall of the urethra, at the most salient point of in-
curvation ; an operation which, at my hands, met with
1 See Otis on Stricture of the Urethra, its Radical Cure, p. 283.
2 Otis on Stricture, pp. 290-291. Putnam’s Sons, New York.
60
success in several instances. Subsequently, however, I
adopted the plan of a mercurial inunction at the point of
adhesion, which gave slow but finally satisfactory results.
Within the past year, however, I have combined this with
systematic, gentle massage, on a short sound, for ten or
fifteen minutes daily; always falling short of producing
tenderness. The results of this plan have
already proved its capacity to remove the
most pronounced troubles of this sort within
a few weeks. Extension of the penis upon
the sound, to as nearly as possible its full
length, every day or two after the operation,
has seemed to me serviceable in preventing
such adhesions.
One point in connection with the opera-
tion of dilating urethrotomy which has
been the source of much discussion and of
some animadversion may, perhaps, be briefly
considered to advantage at this time. This
is in regard to divisions either of congenital
or acquired contractions of the meatus
urinarius externus. The experience and
the study given to this matter, since my early
discussion and advocacy of this procedure
in 1875, have only confirmed the views then
presented. ‘lhe necessity of repeated pas-
sage of sounds of the full normal calibre of
the urethra, subsequent to the complete di-
vision of stricture, in order to secure a per-
manent cure, renders enlargement of the
orifice to that extent essential. This can
rarely be done without unwarrantable vio-
lence, except by incision. Contractions at
the meatus, congenital or acquired, have
been also proven to initiate and prolong
gleety discharges, and to be asource of vari-
ous more or less important reflex difficulty
throughout the genito-urinary tract, and
not infrequently involving some of the spinal
centres. Anything short of a complete
division of the contracted orifice, up to the
full normal urethral calibre, is usually in-
sufficient to give the desired relief in such
cases, and, if skilfully and judiciously per-
formed, the operation is, in my belief, absolutely free
from all reasonable objection, with results productive of
more prompt, complete, and lasting benefit to the patient,
and more satisfaction to the surgeon, than any operation
of like gravity in the entire range of surgery.
The charge that has been made against it, that it di-
minishes the sexual power, I believe my experience with
the operation justifies me in asserting, is wholly ground-
less; the fact being, on the contrary, that, in cases of
sexual weakness, strictured meatus I have not infrequently
found to be a prominent factor in inducing it, and the
judicious division of the contraction one of the most po-
tent measures in its relief or cure. That occasional irreg-
ularity of the stream has resulted from unskilful division
is true, and that the apparent force of the stream has been
diminished, in rare cases, is also quite true. ‘There is
no excuse for the former with a fairly skilful surgeon, and
in the latter case, when it is remembered that the propel-
ling force is in the bladder, and not in the urethra, it will
be seen that such division could only affect the stream
slightly, and then only when the propelling power of the
bladder was, by a previously existing atony, reduced to
the minimum. I have reported a case where the urethral
orifice was divided, for the relief of grave reflex troubles,
to 40, in a urethra of normal calibre 34, giving complete
relief to those troubles, which resisted repeated lesser in-
cisions, and where subsequently the patient (now an emi-
nent medical man) became the father of several children ;
and with the meatus of this enormous size, he is able to
propel his urine in an unbroken steady stream fully three
feet. In this connection I would suggest that the dilating
urethrotome should, in my opinion, never be used for the
@. LILMANN- CO, Me Ve
Author’s Endos
copic Tube,
THE MEDICAL RECORD.
[July 20, 1889
division of contractions within half an inch of_ the orifice,
and that incisions for that purpose should be made with a
straight blunt-pointed bistoury, and always on the inferior
aspect or floor of the urethra, except where the meatus is
placed so low that it is impossible to get sufficient room
for the passage of the proper sized sound without incising
the superior also. ‘This for the reason, chiefly, that inci-
sions superiorly in the glans recontract quickly, or, if they
do not, absorption of the tissue of the glans may occur
in the line of the incision, if at all extensive, which may
result possibly in a distinct cleft; in one such case that
came under my observation, some years since, giving the
appearance of a bifid glans. ‘The enlargement of the ori-
fice should never be made by a sudden, quick stroke of
the knife, as it is sometimes the custom of surgeons to do,
but under cocaine or ether, very deliberately, and by re-
peated careful incisions, always downward and exactly in
the median line, until by repeated trial with the bulbous
sound the precise size required is attained. Should the
freenum be in the way, if broad and flat, the incision may
be carried through its centre as far as its base ; if narrow,
it should be snipped away to the same extent. When the
meatus is situated too low to allow sufficient room, the sur-
geon must content himself with an inferior incision that
shall not encroach upon the true floor of the canal, and
will have to use the urethrometer, or its equivalent, in-
stead of the sound, for keeping the sundered ends of the
strictures trom uniting until healing of the incision is com-
plete. And now I wish to speak, lastly, of my experience
and belief in regard to the permanence of results in dilat-
ing urethrotomy ; that is, as to the validity
of the claims which have been made for the
radical cure of stricture of the urethra by
this method of treatment. It is not unu-
sual for surgeons to infer that cases treated
by various methods, and apparently cured,
are really so when they do not return to
them for treatment. ‘This proof, however,
will not suffice where the radical cure of
stricture is claimed.
A re-examination, with the bulbous sound,
of the full size of the predetermined nor-
mal urethral calibre, after many years, will
alone give the necessary proof upon which
such a claim can be sustained. The ac-
knowledged failure of all methods, except
that of dilating urethrotomy, to wholly and
permanently remove the stricture-tissue is
accepted by those without an ample expe.
rience in this, as a sufficient evidence that
radical cure of stricture is impossible by any
method. Even Sir Henry ‘Thompson says,’
the more freely he divides stricture the more
permanent are the results ; that he has never
had trouble from cutting stricture too freely,
while he has often had occasion to regret
having cut too little; and that he has fre-
quently seen cases where relief has continued
for years after internal urethrotomy. Yet
he says, “ I question very much if I have
ever seen a case which has been complete-
ly cured by any treatment whatever.” Un-
der such a weight of testimony adverse to
the probability of the radical cure of strict-
ure, proof of facts claiming this for dilat-
ing urethrotomy must be full and conclusive.
Preliminary to the production of such proof, it may not per-
haps be out of place to call attention to the important fact
that by no other method than dilating urethrotomy is com-
plete sundering of the stricture at some one point insisted
on ; that upon the accomplishment of this, whether by means.
of the dilating urethrotome or by any other instrument,
or by repeated operations, possibility of a radical cure
Author’s Bulbous
Bougies.
l Some Important Points Connected with the Surgery of the Uri-
nary Organs.” Student's Edition, 1884.
July 20, 1889]
solely depends; that occasional failure to secure against
the return of stricture, after the operation of dilating
urethrotomy, does not disprove this position, but simply
indicates a miscalculation on the part of the surgeon as
to the depth and extent of the incision required, result-
ing in a failure to completely sunder the stricture. ‘The
only exceptions I have met have been very rare, and ap-
parently due to the extension of the stricture-tissue be-
yond the reach of any incisions which could be safely
made. The first really confident claims for the capacity
of dilating urethrotomy to bring about the complete and
permanent cure of stricture were made in 1875, and were
based upon the results of thirty-six re-examinations with
the bulbous sound of the full size of the normal urethra,
at periods varying from six months to three years after
the operation, during which interval no use of sounds had
been resorted to. In 31 of these cases, or about eighty
per cent., complete freedom from the former strictured con-
dition was demonstrated, by the unobstructed passage, to
and fro throughout the entire urethra anterior to the
bulbo-membranous junction, of a metallic bulbous sound
of the full normal size of the urethra, as determined at the
time of operation. In a second series, consisting of 136
tabulated cases, presented in 1878, 82 re-examinations
were reported ; out of which 67 were found entirely free
from stricture. In 3 of these cases six years and six
months had intervened between the date of operation and
the re-examination; in 2 cases, over five years; in 3
cases, over four years; in 10 cases, over three years; in 7
cases, over two years ; in 20 cases, Over One year; in Io
cases, Over six months.
Besides these, 2 cases were reported in the second edi-
tion of my work on “ Stricture of the Urethra,” operated
on in 1872 and in 1880 re-examined, and then, over eight
years from date of operation, found to be free from strict-
ure. In the first case, five strictures were originally pres-
ent, the smallest of a calibre of 22 French. In the second,
there were also five bands of stricture operated on, the
smallest, 16 French. In addition to these cases was one
operated on in March, 1875, for four strictures, defined
by a bulb of 24 mm. in circumference, in a urethra of
normal calibre, 36 French. ‘This case was re-examined
in May, 1880, and found completely free from all strict-
ure by the easy passage of a No. 36 bulbous sound—five
years from the date of operation, and no sound, bougie, or
other instrument of any sort introduced during the inter-
val. Again, in 1881, 2 cases presenting a long interval
between operation and re-examination were met; the
first seven years, the second eight years. In the first,
strictures, four in number, were divided from 27 to 36
French. In the second, there were six strictures, ranging
from 24 to 30, which were divided to 38.
Another case, operated on in May, 1871, re-examined
in 1883, the longest interval then on record, showed com-
plete cure of stricture by dilating urethrotomy, over twelve
years after the date of operation. During the past sum-
mer I have had extracted from my case-books, and care-
fully tabulated, a third series of 420 cases, in which the
normal calibre of the urethra, the size, number, and
locality of the strictures are recorded, with the results of
re-examination in 62 cases.
Recontractions were found to have taken place in 7
cases of strictures situated posterior to one inch, while at
or near the meatus recontractions had occurred in 11
cases. I have recently had an opportunity of re-examin-
ing the case first operated on by dilating urethrotomy, and
for the complete division of whose strictures the dilating
urethrotome was originally designed. Extensive stricture
was present, which had failed to be permanently relieved
by several years of treatment by gradual dilatation. Di-
vulsion with the instruments of both Holt and Vollemier
had been practised to the fullest capacity of those instru-
ments, and recontractions, from that point to 24 of the
French scale, had taken place, associated, as the chief
source of annoyance, with a persistent gleet. By means
of the dilating urethrotome the strictures were all divided
THE MEDICAL RECORD. 61
up to 32 French. Subsequent re-examinations, on several
occasions, at intervals of three or four years, were made
with the bulbous sound No. 32, without at any time de-
tecting a trace of former stricture, and the gleet disap-
peared within a few weeks after the operation. No
instrument of any sort was introduced for dilatation or
any other purpose, except by myself at the intervals just
mentioned, for the purpose of examination alone. On
the last occasion, May, 1888, Mr. A (whose case is
fully described in my book on “Stricture of the Male
Urethra”), came to me for consultation concerning a diffi-
culty quite independent of stricture, but was induced to
permit me to again examine his urethra. I at first intro-
duced, as on previous occasions, a 32 bulbous sound, and
was struck with the complete freedom from any holding
at any point. I then introduced the urethrometer,
turning it up to 34, two millimetres above the previously
estimated normal calibre, and found that traction enabled
me to draw it out at this size, thus demonstrating in the
most perfect manner the complete absence of the former
strictures and the radical cure of the case, as shown by
entire absence of every trace of stricture fifteen years and
ten months from the date of operation.
THE RELATION OF DUSTY OCCUPATIONS
TO PULMONARY PHTHISIS.*
By WILLIAM BUCKINGHAM CANFIELD, A.M., M.D.,
CHIEF OF THEA CLINIC FOR CHEST DISEASES, UNIVERSITY OF MARYLAND.
THE connection between dusty occupations and pulmo-
nary consumption is a subject by no means new, but it is
of especial interest to those who have much to do with
diseases of the lungs. ‘The pulmonary diseases caused by
the different kinds of dust have received a variety of
names, according to the character of the dust inhaled, but
collectively they are all covered by the name “ pneumo-
nokoniosis.” ‘The pathology of these conditions was not
clearly understood. They were spoken of as “ miner’s
phthisis,” “ grinder’s phthisis,” even when their tubercu-
lous nature could not be proven. Even after Koch’s dis-
covery of the tubercle bacillus, and the gradually im-
proved classification of the other classes of lung diseases,
there seemed to be some doubt whether these dust dis-
eases were tubercular or not.
Most writers agree that the inhalation of non-tubercu-
lar dust can only produce non-tubercular disease of the
lungs. Naturally the different kinds of dust, such as
sand, coal, soot, slate, etc., when inhaled in large quanti-
ties, as by persons enclosed in a thickly laden, crowded at-
mosphere (unventilated mines, etc.), gradually overcome
the action of the ciliated epithelium and penetrate to the
alveoli of the lungs, whence they find their way, by their
sharp edges, through the wounded epithelium, through the
pseudo-stomata in the alveolar wall, or between the cells
through the Xvttsubstanz (Osler). ‘Those that are not
carried off, rendered homeless or devoured by the greedy
phagocytes, remain in their subepithelial bed and cause
an irritation, a determination of blood, inflammation, and
resulting hypertrophy of the connective tissue of the lungs.
There results then a fibroid condition of the lungs, a fi-
broic phthisis or chronic interstitial pneumonia.
This condition seems to be produced by all kinds of
dust indifferently when inhaled in condensed quantities.
Fagge ° says that this condition is only tubercular when
tuberculous matter enters; that the common occurrence
of phthisis among miners is due to the crowded and un-
ventilated condition of the mines and to the great heat
which the miners must endure. C. J. B. Williams’
thinks that the fibroid element seems to oppose a direct
barrier to the growth and multiplication of the bacillus
1 | Read before the Medical and Chirurgical Faculty ulty of Maryland,
at its Ninety-first Annual Session, April 24, 1889.
2 Fagge : Principles and Practice of Medicine. Philadelphia, Blaki-
ston, 1886, p. 997 ff.
s Williams: Pulmonary Consumption. Philadelphia,
1887, pp. 13 and 23.
Blakiston
62 | THE MEDICAL RECORD.
tuberculosis, and in large tracts of lung-tissue which have
been converted into this material, often not a bacillus can
be detected. Moxon" says that when they are found it
is because fibrosis has supervened on a tuberculous con-
dition of the lungs. Watson Cheyne,’ Percy Kidd,’ Sir
Andrew Clark,‘ and others have also failed to find them.
According to Orth,® consumption is one of the rarest
complications of miner’s lung, and Kunze,’ often examin-
ing the lungs of those engaged in a variety of dusty occu-
pations, concludes that if tuberculosis is present it is
almost an accident, or was present before the’ patient be-
gan this occupation. The most recent literature on
this subject may be found in the “ Milroy Lectures on Oc-
cupations and ‘Trades in Relation to Public Health,” by
John T. Arlidge, M.D. and B.A., London.
Although a fact founded on one case, perhaps im-
perfectly reported, may be of little value, I have thought
it worth while to relate the following case :
CasE.—J. M———, Welshman, aged fifty-six, was ad-
mitted to hospital about February 1, 1888, with the fol-
lowing history, imperfect on account of his want of
familiarity with the English language: As a boy he had
been well and had been in health up to two years before,
in Wales, where he took a “cold,” which, growing worse,
entirely unfitted him for his work, which was that of a
miner. On inquiring more particularly as to his occupa-
tion, he said that he had been employed for about fifteen
years in the slate-mines of Wales, and that his particular
work was to split the slate. He said that there was
always slate-dust flying about in the air, but not in such
quantities as in coal-mines. Upon questioning him
further, he said that the slate-miners were frequently
affected with a cough and profuse gray or blackish ex-
pectoration, and that they usually died from this cough at
about fifty. He said their manner of coughing was very
hard, and there was much wheezing and shortness of
breath. Inspection showed a spare man, with large chest-
cavity, but not barrel-shaped. On percussion, which was
carried out with great difficulty, a possibly increased dul-
ness was found over the right apex in front, and at the
base behind. The left lung was slightly hyper-resonant
from increased work. ‘The vocal fremitus was not
markedly different on the two sides. Auscultation gave
coarse and fine mucous and dry sonorous and sibilant
riles, with expiration and inspiration over the whole chest,
the expiration being much prolonged, as in ordinary
pulmonary emphysema. Cough and shortness of breath
were the troublesome symptoms, as were shown in his
anxious expression and in his entire inability to lie in the
horizontal position. His expectoration had been dark
and also grayish-black, but recently it was white or color-
less, as it was when I saw him. In order to promote
expectoration I put him on the following mixture :
B. Ol. terebinthin ...... EIEEE EIEN 3 iij.
Mucilag. acac....eesssno.o e teens q.s.
Aq. cinnamomi,.............0..-. = ss.
MAG TE 56s ih Sse, Barrons’ s q s. ad & yj.
S. : A tablespoonful well diluted three times a day.
But as it produced nausea I changed to the following :
B. Ammon. muriat ............. 000085
Mist. glycyrrhiz, comp.............
M. et adde:
Potass, iodid ....... onenen 5, iij.
S. : A dessertspoonful well diluted three times a day.
This seemed to remove the mucus, but the dyspnæa still
continued, and the råles, though dryer, were just as audible
as before. Dr. Fraser's article on “ Dyspnæœa in Bron-
chitis” ” having just appeared, it suggested itself to me
to use the nitrite of sodium, which resulted in alleviating
es ee eee
1 Williams: Loc. cit.
2 Practitioner, April, 1883.
3 Medico-Chirurgical Transactions, vol. Ixviii.
4 Clinical Transactions, vol. i.
6 Lehrbuch der spec. path. Anatomie. Berlin, 1887, s. 549.
* Beitrag zur Lehre der Staubsinhalations Krankheiten. Kiel, 1887.
7 American Journal of the Medical Sciences, October, 1887. `
[July 20, 1889
much of the dyspnoea. During the whole time the
sputum was examined for bits of slate-dust or pigment-
laden cells, but they did not seem to be present. His
diet was regulated, and his bowels kept open. ‘The urine
was tested before the turpentine mixture was given, and
albumen was found, but later it disappeared.
A few weeks after he entered hospital the sputum was
examined for tubercle bacilli, not because I expected to
find them but because I had made it a habit to examine
the sputum in every chronic case for them. They were
found in abundance. Specimens of sputum were exam-
ined with care at short intervals, and the bacilli were al-
ways found in large numbers. This surprised me, as I
had not thought the affection tuberculous, and had given
a favorable prognosis. His family history was good. Now,
however, I feared a bad prognosis. Notwithstanding this,
he continued to improve under tonics, and returned later
to Wales. I have heard from him within the last month,
and he says he is entirely well. As I have examined the
sputa for bacilli many times, I feel certain that I made no
error here, and yet it seems to me rather peculiar in this
case.
Dr. G. Hunter Mackenzie’ says that the number of
tubercle bacilli found in the sputa of any case does not
seem to bear any reference to the severity of the case, and
that a case may go on for years with an enormous num-
ber of bacilli found at every examination.
I think the points of interest in this case are :
1. The patient had no previous history of, or predispo-
sition to, pulmonary tuberculosis.
2. He contracted a disease with which tuberculosis is
supposed to be very rarely present.
3. He had tubercle bacilli in abundance in his sputa.
4. He reports himself entirely well.
1010 NORTH CHARLES STREET, BALTIMORE, Mop,
e
SULPHONAL: ITS DOSAGE AND EFFECTS.
By A. G. BROWNING, M.D.,
MAYSVILLE, KY.
WITH the first introduction of this hypnotic I made some
haste to procure it, having at the time an exceptional
case which did not just respond to chloral, paraldchyde,
the bromides, or others of its class. Since, have used it
rather perseveringly, and, frankly, more to account for its
erratic action—to ascertain, if possible, its fitting place,
than from any real satisfaction with its behavior in any -
given case. I beg to cite:
Case I.—Aged forty; plethoric; a don vivant and par-
oxysmal spreer; plagued with insomnia and on the verge of
delirium ; no hypnotic would quite suit. Accepting posi-
tive assurances that sulphonal was absolutely harmless, I
yet made my first dose only ten grains, repeating this
every hour until forty grains were given. Net result
within twenty-four hours—a fidgety, wakeful night, worse
than before, with giddiness, nausea, and general wretched-
ness all the following day; “cuss words” for drug and
doctor—a failure.
The following evening, at eight o’clock, gave aggregate
of previous doses—forty grains—in one portion. For
four hours he carried it off lightly, as if only so much
flour ; but at twelve he talked wildly, had tremors, finally
becomihg so ugly as to compel some restraint. Now
gave fifteen grains sulphonal. Uproar continued till five
next morning, when he dropped to sleep.
Called at ro a.M.—Still sleeping profoundly—just how
much so, did not care to test by disturbing him ; wanted
him to sleep.
Recalled at 3 P.M. Friends much alarmed. Pa-
tient could be aroused, but somewhat incoherent, and
promptly lapsed into stupor ; cyanosed, and some stertor ;
with help, came slowly around, but was confused,
dizzy, and generally uncomfortable for two or three
days—all the time sleepy and dull.
- eee,
— ee o
1 Edinburgh Medical Journal, January, 1829.
July 20, 1889]
At the time I knew nothing of the postponed action of
sulphonal—nothing of its action in any way; but coming
early or late, it was unsatisfactory. I agreed with patient
when saying he would take no more.
Case 1I.—Young man, aged eighteen; feeble develop-
ment, and anemic always ; troublesome insomnia ; couldn’t
tolerate taste and odor of paraldehyde ; afraid of chloral ;
bromides did not suit. Gave twenty grains sulphonal and,
two hours later, twenty grains more; no effects, early or
remote. Got forty grains early next evening ; after four
hours there was excitement, which by twelve midnight
bordered upon delirium, with delusions, and what I regard-
ed as peculiar, harassing and tormenting priapism. No
sleep worthy the name during night or on following day,
but instead, a condition of lethargy, with frontal head-
ache, vertigo, muscular inco-ordination, mental depression.
Patient described the situation as, ‘ Beastly! infernal !
Half-dead for sleep—all the time half-asleep, but never
quite!” Wasn’t himself for five or six days.
Case III.—Gentleman, aged forty-two ; fairly healthy,
but strung on wire ; wanted the earth, and that in a day ;
did brain-work over midnight oil ; broke down; got insom-
nia and all that comes of it; was neurasthenic. To prop
his flagging energies he took some whiskey daily, and more
beer ; was an habitual but “‘ genteel” drinker before suspect-
ing it, or being suspected. The more he drank the less ke
ate, till, his starved nerves taking on a neuralgia, he was
something of a wreck. I aimed to tonify him by the
usual means—some physic, more food, less drink. In
view of alcoholic factor, and to avoid other habit, put him
on bromides and cannabis, which did very well. But he
clamored for more, and I gave him sulphonal, thirty
grains first night; negative results. Following night he
got forty grains; in two hours, fifteen grains more. The
night was passed in a prolonged wail for sleep—faithfully
wooed, but never won! The ensuing day he was too de-
pressed and confused for attention to affairs; his gait
was staggering as if drunk; he had nausea, vertigo, and
frontal headache.
Two weeks later, under protest, he took fifteen grains,
repeated in an hour; the next night the same. It gave
refreshing sleep, and he was charmed. ‘The third venture
was followed by the original trouble, intensified, and he
would have no more of it.
Case IV.—Colored girl, aged seventeen; uncertain
quantity, mentally and physically; had, from history,
rung all the changes of hysteroidal trouble, from insomnia
to delinum and mania, and back again. Had been a cir-
culating medium from doctor to doctress—vicarious of
the whole troublesome genus, coming my way in due
course, or in obedience to the “fitness of things.” In-
somnia to the front, with lurking movements which looked
to me choreic. Was generously asked to do what man
had not yet done—make her sleep! The ground was
pre-empted: she had taken every created thing save sul-
phonal. I directed twenty grains, and repeat in an hour.
No one could tell me what she did; she did ot sleep !
Next evening, in a moment of humane weakness, I gave
forty grains ; in two hours, fifteen more. Visited her next
morning ; again, she hadn’t slept, but was writhing, twist-
ing, and grimacing with chorea, after most approved fash-
on.
Odds were against me in an impending riot, the wrath-
centre being in my vicinity ; discretion seemed all there
was of valor, and I retreated in good order, under a vigor-
ous charge of having given this girl “fits!” Maybe I
did ; was coming to think sulphonal could do anything,
save putting a patient quietly to sleep. Later there was
a reaction in sentiment, and I had satisfaction of seeing
this patient get well while I was giving her bromides and
arsenic. A pleasing coincidence, under the bellicose cir-
cumstances.
The four cases here cited will be seen to cover the dif-
fering conditions of plethora, anzemia, neurasthenia, and
hysteria, pure and simple. The primary object in all was
to induce sleep. Failing in this, the question presents, in
THE MEDICAL RECORD.
63
how far did opposing conditions affect results? Or, favor-
ing conditions ascertained, how estimate the dose in an
individual case? I cannot answer this; the action of sul-
phonal has been, with me, so erratic as to leave no base
for logical deduction; much like Hercules with his club,
striking in the dark. ‘This is not the total of my experience
in its use, but zs the average of results obtained. I find
it uncertain in action in same individual, in same or dif-
fering doses, with no recognized condition clearly indi-
cating or contra-indicating its use, as yet.
It would not be fair to say I have never gotten good re-
sults from sulphonal ; it is only true that I have been most
times disappointed. ‘Together with its delayed action, and
too frequent unpleasant secondary effects, I do not find it
comparable, as a hypnotic, to chloral or paraldehyde ; have
had less experience with amylene hydrate. Possibly, when
the place for sulphonal is found, sulphonal will be found
to fill the place.
CHRONIC LYMPHATIC GEDEMA OF THE UP-
PER LIP, COINCIDENT WITH INTRANASAL
PRESSURE.
By JONATHAN WRIGHT, M.D.,
NEW YORK.
In THe Mepicat Recorp of September 8, 1888, I called
attention to a train of symptoms caused by the firm press-
ure of the middle turbinated bones against the septum.
A few weeks previous to this an article by Dr. Roe, of
Rochester, dealt with the same subject. As far as I know,
Dr. Harrison Allen, of Philadelphia, was the first to dis-
cuss the subject, and his paper in the Zhe American Four-
nal of the Medical Sciences for 1880 was overlooked by me
until my attention was drawn to it. In these and other
articles various symptoms—neuralgic, reflex, and obstruc-
tive—are mentioned. Since the appearance of my contri-
bution I have seen a very curious, and, I presume, a very
rare sequence of the pathological condition referred to.
The case, I think, deserves recording.
Lizzie C , aged fifteen, was referred to me at the
Demilt Dispensary, by Dr. G. T. Elliot, for a large dif-
fused swelling of the upper lip and left cheek. ‘The pa-
tient was otherwise perfectly healthy, and her previous
and family histories were good. When seven years of age
she fell and cut the upper lip, which remained swollen for
three months, when it subsided. Four years ago, when
she was eleven years old, the lip began to swell again, and
a month later she noticed some nasal obstruction, at times,
on both sides. She was also troubled a good deal with
toothache. In two or three months the hip had reached
the dimensions which it presented on her application to
the dispensary, having never abated nor increased during
the four years. She had derived no benefit froin the use
of ointments. There had never been any pain or ten-
derness to pressure.
On examination it was evident that the upper lip was
two or three times its normal size. It projected far out
over the under lip, producing a marked deformity. The
skin was smooth, somewhat tense, and had a natural color,
except that on handling it easily became red. ‘There was
no pitting on pressure, nor was the blood-circulation
apparently interfered with. The enlargement extended
markedly to the left cheek, but very little to the right.
An intranasal examination showed that the left nasal fossa
was enlarged, and the septum deviated considerably to the
right. The mucous membrane was atrophied in many
places. The middle turbinated bone on the left side was
displaced upward and inward against the septum, and
along its free border there was a muco-purulent discharge.
As the crown of the first molar tooth was decayed and
gave evidence of defect at the root, I surmised that the
trouble might be an empyema of the maxillary sinus.
This afterward proved to be incorrect. She was given an
alkaline nose-wash to use three or four times daily. At
the end of a week she came back with some diminution
64
-——— a ao a
of the lip swelling, and the nasal cavity presented a better
opportunity for observation. ‘There was no more muco-
purulent discharge. Far back and high up, the middle
turbinated bone was seen impinging on the septum at
about the junction of the middle with the posterior third,
both ends of the bone being free. As it at first seemed a
simple hypertrophy of the soft parts, the patient was di-
rected to continue the alkaline douching. At the end of
another week there was still further diminution of the lip
and cheek swelling, and the hypertrophy of the mucous
membrane had decreased somewhat, but it was evident
that 1t would-be necessary to remove the remaining por-
tion by surgical interference. ‘This was accordingly done
with a nasal snare, and the fragment, as large as, and about
the shape of the pulp of the middle finger, proved to be a
hyperplasia of the mucous membrane. ‘The douching was
continued, and at the end of another week the lip and
cheek had reached almost their natural outlines. At the
seat of the former operation there was, however, a bony
excrescence, the soft parts only having been removed.
Judging that when this became recovered with mucous
membrane the intranasal pressure would be renewed, the
bony growth was removed by means of the snare and for-
ceps. A microscopic examination showed hyperplasia of
bone combined with rarefying osteitis.
‘This may serve as an illustration of how the bony cysts
are formed which we occasionally observe in the turbi-
nated bones, and which are described by Zuckerkand.
The hyperplasia of bone having advanced to considerable
dimensions, a rarefying osteitis begins in the centre, and
we soon have a cavity with rigid bony walls.
Six weeks or a month after the operation, when some
thickening of the lip still remained, but luckily after the
intranasal wound had healed, the patient was attacked
with facial erysipelas, which spread all over the face and
into the scalp, having begun in the region of the molar
prominences. When this had subsided, which it did
without intranasal treatment, it was seen that the lip was
smaller than before. It is now five months since the
operation, and, generally, the size of the lip is not notice-
able, but occasionally is seen to be much larger than
usual, though it never reaches its former proportions.
The swelling of the left cheek has not recurred. The
middle turbinated bone on the left side is free throughout
its whole length, very little deformity having resulted from
the cicatrization following the operation. ‘The mucous
membrane. has a healthier look, and the nasal secretion is
much less than formerly.
When we come to consider the nature and the cause of
the long-standing labial hypertrophy in this case, we are
confronted by the meagreness of the literature on the
subject. For want of a better name I have called it
chronic lymphatic oedema. Although it is probably of an
entirely different nature, its essentially local character re-
sembles somewhat the cases of circumscribed cedema de-
scribed first by Dinkelaker* and Quincke,’ and later by
Jamieson,’ Graham,‘ Matas,’ Osler,’ Smith,’ and others.
Their cases were acute, resembling urticaria somewhat.
In most of the descriptions the doughy feeling of the skin
and its transparent, watery look are spoken of. Their
cases liad a neurotic element, and the swellings occurred
more often in the extremities, and were usually not con-
fined to one region of the body.
More nearly resembling it were the cases reported by
Major ° at the last meeting of the American Laryngolog-
ical Association. I regret that I have as yet seen only
an incomplete report of Dr. Major’s paper. They were
erythematous and erysipelatous in character, and extended
over comparatively short periods. ‘They seemed to de-
1 Dinkelaker : Ueber acutes Oedem. Inaug. Dis. Kiel, 1882.
2 Quincke: Monatshette für prakt. Dermatologie, No. 5, 1882.
3 Jamieson: Edinburgh Med. Journal, June, 1883.
4 Graham : Canadian Practitioner, 1885.
š New Orleans Medical Journal, October, 1887.
6 Osler: American Journal of the Med. Sciences, April, 1888.
7Smith: Medical News, March 23, 1889,
^ Major: Medical News, June 8, 1889.
THE MEDICAL RECORD.
[July 20, 1889
pend on intranasal pressure, and treatment directed to
the nose relieved them. Other gentlemen present nar-
rated similar cases. ‘To one of these categories belongs a
case of which I have preserved short rotes. —
A boy, aged fourteen years, employed at the time in
Roosevelt Hospital, said that his father had died of
erysipelas or gangrene. He himself had always been per-
fectly healthy until about eighteen months ago. At that
time his nose began to swell occasionally, beginning at the
tip and extending as far back as the bridge. This would
last for two or three days and then disappear. His nose
was often obstructed, but he thought that this had no re-
lation with the external swelling. He was never troubled
in summer, but in the winter it would occur every week
or ten days. ‘There never was any pain or constitutional
disturbances with it. He has never had erysipelas nor
rheumatism, although a médical man once pronounced
the nasal affection erysipelas. Ouintments always gave
him relief (?). There was no itching. The nose looked
red and hot, and there was considerable lachrymal con-
gestion. ‘The upper lip was slightly swollen. There was
some hypertrophy of the mucous membrane, covering the
turbinated bones, but no intranasal pressure ; the rhinitis,
being slight, had produced no extensive structural change.
Intranasal treatment seemed to have little or no effect
on the external condition, which lasted but a short time.
This patient had later an attack of true erysipelas, from
which he recovered, but since then I have lost track of
him.
Dr. H. Lavrand’ has reported a case of frequently
` recurring facial erysipelas, in a case of ‘Tornwaldt’s dis-
ease, which was cured by treatment directed to the poust-
nasal affection. I have seen a case of general dermatitis
of the nose associated with nasal polypi and hypertrophic
rhinitis, and also several cases of acne in the nasal and
malar regions which were cured or greatly benefited by
intranasal treatment.
lt seems to me evident that in many of these cases the
lymphatics must be the channel of communication be-
tween the external and the internal affections.
In the case of Lizzie C , I see no other explanation.
There was no neurotic element in the case, and erysipelas
only occurred after the relief of the intranasal pressure.
The anastomoses of the lymph-channels seem so com-
plete that it is difficult to understand how pressure at any
one point, or even over a larger area, could cause engorge-
ment at a distant point. ‘The little that is known about
the nasal lymphatics does not help us very much. Simon,’
in 1859, found that they formed a wonderfully close
net-work of vessels, more abundant in the region of the
cribrous plate of the ethmoid. They all communicate
with those of the external wall, and form a very close net- -
work there in three places, viz. :
1. At the top of the superior turbinated bone.
2. Upon the external surface of the middle turbinated
bone.
3. In the space anterior to this.
He, as well as Axel Key and Retzius, traced com-
munications with the lymphatics of the subdural and
arachnoid spaces. Communicating with the lymphatics of
the face they enter glands in the neighborhood of the angle
of the jaw—the deep carotid and cervical. Internally they
terminate in trunks which pass close to the openings of the
Eustachian tubes to join glands on the lateral wall of
the pharynx (Quain, Gray, M. McKenzie). Clinically we
have an illustration of the absorbing power of the lym-
phatics in the rapidly fatal course of nasal diphtheria.
While it will be noted that the pressure in the case re-
ported was in the neighborhood of the lymphatic nidus
spoken of by Simon, the abundant collateral supply would
seem amply sufficient to prevent any local congestion out-
side of the nose, and yet the onset, course, and subsidence
of the external swelling corresponded so closely with the
1 Lavrand: Journ. des Sciences médicales de Lille, April 27, 1888,
Ref. : La Revue de Laryngologie, etc., May 1, 1889.
2Simon: Schmidt's Jahrbacher, Band cvii., p. 161.
July 20, 1889]
THE MEDICAL RECORD.
65
history of the intranasal pressure that it seems more than
probable the latter was the prime factor. In nearly all
the cases referred to there seemed to be some more or less
definite connection with erysipelas.
Clinical Department.
A CASE OF CYSTIC GOITRE.
By GEORGE T. WELCH, M D.,
KEYPORT, N. J.
GOITRE is looked upon without much fear in the United
States, so far as any tendency toward mortality is asso-
ciated with it, and special operations are seldom required
for its relief ; but an occasional fatal termination awakens
a vivid interest in the mind of the practitioner in all the
known methods of combating and eradicating the dis-
ease. Excision of the thyroid gland is a proceeding so
formidable that few surgeons have had the courage to
undertake it, and in view of the probable advance of goitre
from a benign to a malignant growth, the physician should
prescribe, and insist upon the patient’s carrying out, all the
known alterative means at his command while the tumor
is yet small and tractable.
After remaining stationary for a quarter of a century a
goitre will at times suddenly take on a savage energy of
_growth, and the victim, long lulled into security, will awake
to find his passive enemy now become as relentless as
any Thug in India. Such a case recently came under my
notice in the person of Mrs. C. W , aged sixty-three,
. who consulted me in October, 1888, in regard to labored
respiration, cough, and attacks of extreme nervous ex-
_haustion. Her description of the symptoms attending
these attacks was so similar to those of reflex asthma that
I was inclined to call it by that name until I could dis-
cover the exciting cause. The patient was apprehensive
that a goitre which she had might be the origin of the at-
tacks, but as it had remained stationary in size since its
development, more than a quarter of a century before,
during her first pregnancy, I could not feel sure that this
was the case. The tumor did not feel sufficiently fibrous
and fixed to give the impression that it was of a malig-
nant character, or that it was grasping the windpipe and
producing stenosis. An examination with the laryngo-
scope was, however, unsatisfactory, and left me in doubt.
A measurement of the circumference of the throat over
the goitre was taken, and the patient was placed on a
tonic and nervine treatment, with inunctions of compound
iodine ointment over the surface of the tumor. She
showed signs of improvement for a short time, but the
next attack of dyspnoea was still more pronounced and
alarming.
Thereafter the voice was either whispering, or hoarse
and croaking in character, and evidently the pneumogas-
tric nerve was encroached upon. Measurements taken
from time to time showed increasing size of the goitre,
the attacks of dyspnoea became more frequent, and at
times death seemed imminent. On two occasions large
amounts of atropine, y'5 gr. used hypodermically, alone
rescued the patient, who appeared moribund at the time
of the injections, but who slowly revived as the blood
came flaming to the surface.
Of all external applications I was convinced the use of
the ointment of the red iodide of mercury was most satis-
factory. After several days’ inunction with this, I discov.
ered an obscure sense of compressibility, and with the
hope of finding that a cystic goitre had been developed, I
thrust a hypodermic needle -straight into the tumor and
drew out a few drops of dark-colored liquid which con-
firmed this view.
I determined now to operate on the goitre after the
method of Mackenzie, and had made a small trocar and
cannula with a collar to which tapes could be tied.
Kindly assisted by Dr. Cook, of Holmdel, I thrust the
-trocar from below upward into the mass, after incising
the skin, and withdrawing it, left the cannula in position,
tying the tapes firmly at the back of the neck. About
two ounces of grumous fluid escaped and the tumor col-
lapsed somewhat, although the outer wall was quite thick.
Two drachms of the solution of perchloride of iron
were now thrown into the sac with a syringe, and the can-
nula was plugged up. After three days the stopper was
removed, and the contents of the sac allowed to escape.
I now found that the tumor remained enlarged upon each
side, and conjecturing that it was multilocular, I intro-
duced a blunt probe and broke down the walls, causing
a further flow of dark fluid, when the injection of the iron
solution was again used. At different times thereafter
this had to be repeated, the sac filling up with liquid to
its original size, but finally a complete cure was effected.
The patient remained weak for a time, but gradually
improved in strength and spirits, and finally went to her
home, twelve miles distant, early in January. There had.
remained some cough, of a spasmodic character, and ex-
amination of the throat with a laryngoscope now showed
stenosis of the larynx, and led me to suspect further dan-
gerous complications, which the sequel unhappily demon-
strated; for, after four weeks of comparative comfort,
the dyspnoea again took on a dangerous character, hectic
supervened, the heart showed signs of failure, while, the
cough and strangling efforts at expectoration became
frightful to behold. All drugs were perfectly powerless
to control the paroxysms, except chloroform and nitrite
of amyl. Inhalations of cocaine, steam, etc., were tried
. in vain, while dressings of hot water or poultices were
frantically torn away by the patient. Occasionally the
_happiest effect would be produced for a few hours by
hypodermics of atropia, but the dryness of the mucous
membrane of the throat which supervened would increase
the suffocation.
The singular sound in breathing, together with the char-
acter of the product expectorated ; the inflammatory swell-
ing, recognized by the fitful glimpses to be had with the
laryngoscope; the pain, cough, dyspnoea, dysphonia, and
dysphagia concurred in pointing to necrosis of the carti-
lages of the larynx, and the prognosis was entirely hope-
less. On the night of February 18th, after informing
the family and husband that the end was in all probability
near, and that nothing further could be done except tra-
cheotomy, which might add to the days of suffering but
could not cure the disease, I made an effort, after spray-
ing the throat with cocaine solution, to lance what ap-
peared to be an abscess in the larynx, but the most heroic
efforts of the patient could not control the spasmodic
cough long enough for me to succeed. I then tried to
reach the part with a slender sponge probang dipped in a
solution of chromic acid, and was rewarded by finding the
patient breathed easier, ‘and I retired about 11 P.M. with
the intention of performing tracheotomy next day, should
it seem called for; but shortly after midnight on February
19, 1889, the patient died peacefully in her sleep.
It is possible that early efforts at a cure of this goitre
might have been entirely successful, but the physician
whom this lady consulted eighteen years before recom.
mended a do-nothing policy, and assured his patient that
nothing would ever come of the goitre.
SOME SUGGESTIONS IN REGARD TO TREAT-
ING GONORRHGA.
By E. P, RICE, M.D.,
CHICAGO, ILL.
A GREAT variety of methods for treating gonorrhoea can
be found in the very many text-books at our command,
yet the average practitioner has not, as a rule, any very
definite plan, not having given the subject generally any
special attention. Among the thousands of readers of
THE MeEvicaL RecorD we will find undoubtedly an al-
most numberless variety of formulas in use ; and, in view
66
of these facts, permit me to make a few statements in re-
gard to the treatment of this very common disease, which
“may be the means of inducing others to try this plan. My
-attention was called to it, some three years ago, by a few
remarks from a practitioner in Wisconsin, which appeared
in THe Record. I thought favorably of the plan, and
will give the modus operandi as I use it.
First, taking for granted that gonorrhoea is due to the
action of a specific microbe, the gonococcus, we must
treat it on the antiseptic plan, hence the following line of
treatment. The patient should be placed in the recum-
bent position, and after lubricating an ordinary softtrubber
catheter with five per cent. carbolized oil, introduce it as
far as the prostatic portion of the urethra. In acute cases
it may be necessary to inject a little five per cent. solution
of muriate of cocaine, if pain is produced. Now insert
into the free end of the catheter an ordinary glass syringe,
having a nozzle ‘with an opening sufficiently large to
allow the liquid to pass through easily, which will be about
the consistence of an ordinary emulsion, and should be
made as follows:
GI CONN e ereer sean too sou SS i
Mix, and rub well together, and shake well before using.
Pour about two drachms of this mixture into the sy-
tinge, having previously withdrawn the plunger. Now,
gently insert the plunger, and force the liquid into the
catheter, which is held in place with the thumb and fore-
finger of the left hand—the forefinger of the right hand
should be used to force in the plunger. After all the
liquid has passed out, gently withdraw the catheter, strip-
ping it at the same time in order to force all the liquid
into the urethra. Let the patient remain in the recum-
bent position for ten minutes longer, the whole operation
lasting generally about fifteen or twenty minutes. This
treatment should be repeated every day, for the first two
or three days, and then on each alternate day. Asa rule,
in acute attacks, five or six treatments will suffice. In
long-standing cases the same treatment should be used,
alternating with some mild astringent injection, as Lloyd’s
hydrastes, used in the same way. The sound should al-
ways be used in subacute and chronic cases, at intervals
of about three days. It is also advisable to give internally,
in all cases, a saline laxative, and in the old cases I gener-
ally give, in addition, capsules of bal. copaibii, Ml vj.; ol.
cubebe, Tl iv., t.i.d., either before or after meals.
The fact of antisepsis should never be lost sight of, as
so many are apt to do. It is a well-known fact that boric
or boracic acid is a mild and unirntating antiseptic which,
when combined with glycerine as a vehicle, also an anti-
septic, renders it a very safe agent to use for this purpose.
One important point is also gained in this plan. We
always have the patient practically under control, and can
watch the progress made, not being dependent upon the
say-so of the patient. I have used this method of treat-
ment in quite a number of cases, with the very best results,
and can unhesitatinyly recommend it to the profession.
. PNEUMONIA TREATED WITH PEROXIDE OF
r HYDROGEN.
By J. L. GREENE, M.D.,
RED CLIFF, COI..
ABOUT a year ago, after some study of the action of
peroxide of hydrogen, it occurred to me that it might be
well employed in treating the “ high line,” or congestive,
and the croupous, or acute lobar pneumonias which pre-
vail and are often very fatal in the Rocky Mountain
region. Out of twenty-three cases treated by me since
that time there have been twenty-two recoveries and one
‘death. The death was in the case of a puny infant, eleven
weeks old, and so far gone when first seen that any treat-
ment whatever could avail but little. These cases com-
prise some with double pneumonia, some persons of robust
habit, some with constitutions impaired by long intemper-
THE MEDICAL RECORD.
[July 20, 1889
ate use of alcoholic liquors, and several children ranging
in age from three months to three years.
The main treatment has been the internal use of peroxide
of hydrogen, though I have used any rational measures
that were indicated to meet complications, or unusual
conditions arising in any case. I have had but little use
for either opiates or antipyretics.
The dosage mentioned in the rather scanty literature on
the subject, as applicable to other classes of cases—tea-
spoonful three times a day—is far too light for pneumonia.
In the high line, or congestive form, common enough at
high altitudes, the patient would exhaust the effect of the
first dose and die from apnoea before the second would be
due. I have often given one-fourth to one-half a tea-
spoonful, well diluted with water, once in five to ten
minutes for an hour or more, with good results. In acute
lobar pneumonia I usually give half a teaspoonful, diluted,
every hour, with benefit, even when no emergent condi-
tions exist, and I continue it till after the crisis occurs.
I am not aware that any one else has made a systematic
use of peroxide of hydrogen in such cases, and I have
had to feel my way in establishing 1 dosage adapted to
my cases, which are possibly considerably influenced by
peculiar conditions of climate and altitude.
Under this treatment the crisis appears to be a time of
comparatively small importance, and a case taken early in
the stage of engorgement can usually be aborted and the
infiltration cleared from the lung.
I do not apprehend that these few cases will go far to-
ward establishing anything; but if the method of treat-
ment I have used, and outlined here, proves valuable in
other hands I shall be satisfied.
SEVERE SYMPTOMS RESULTING FROM AN
APPARENTLY TRIVIAL INJURY.
Dr. J. J. Boone, of Mount Victory, O., reports the fol-
lowing case: “ Elihu J had sustained an injury by
running a small splinter of wood into the thumb, about
half an inch from the end, on the flexor surface. On the
following day, as it was giving him some pain, his medi-
cal attendant proposed to cut it out for him, which was
agreed to by the patient, and he worked hard for about
one hour to extract the splinter, though I do not know
whether he got it out then or not. ‘The case was placed
in my hands from the fact that the patient’s medical at-
tendant had gone out of town, not to be back for a few
days. On February 3d, the first time I had seen him
during his sickness, and two weeks after the accident. his
temperature was 1034° F., pulse 125, and he was so weak
that he could not stand up, and could sit up only with
great exertion, and was suffering great pain, with a tightly
swollen forearm, hand, and fingers. Pus was discharging
from the wound in the thumb. I dissected off the epi-
dermis of the thumb, as under it was a layer of thick,
greenish pus; then with an ordinary Davidson syringe,
stretching a piece of one-eighth inch rubber tubing
about eight inches long over the nozzle, I proceeded to
wash out the abscess cavity in the thumb witha 1 to 2,000
bichloride-of-mercury solution, when I discovered a
greenish-black spot, the size of a silver five-cent piece,
between the distal ends of the metacarpal bones of the
little and ring finger, on the extensor surface. I picked
it up with a pair of forceps and cut it out without pain to
patient ; then, on use of syringe, I was enabled to inject the
solution of mercuric chloride into the tissues of the thumb
and have it come out where I had removed the piece of
dead skin, carrying with it a large quantity of pus. The
next morning I discovered another abscess between the
distal ends of the metacarpal bones of the index and
middle finger, on the extensor surface, which I opened,
using the same solution as before. The solution was
ejected from both new openings. In the evening I exam-
ined the arm carefully, and found evidence of an abscess
midway between the wrist and elbow. Cutting in about
July 20, 1889]
half an inch with a curved pointed bistoury, I was enabled
to evacuate about four ounces of greenish-yellow pus;
again washing out through the thumb, the solution came
out through all three openings, carrying with it a large
quantity of pus. Under the treatment of frequent cleans-
ing with a solution of mercuric chloride about three times
a day, in five days the swelling had almost gone, and the
patient made a good recovery, although there is some
stiffness in the fingers vet.”
Progress of Medical Science.
CONFLUENT SMALL-POX TREATED SUCCESSFULLY WITH
SALICYLIC AcID.—In March, 1881, the Bulletin de Théra-
peutigue published an article in regard to the use of sali-
cylate of soda in the treatment of variola. In the same
journal of May 15, 1889, Dr. Baudon reports a case in
which he made use of the same treatment (modified to
suit the case) which he had formerly, in 1881, used so
successfully. The patient, a woman, aged twenty-five,
was supposed to have been vaccinated in early infancy, but
no scar could be found. She had assisted at the burial
of her two brothers, who died of variola, and after return-
ing home she suffered from the prodromata of this disease.
On April 4th the eruption appeared, and it quickly be-
came confluent. The face became red, enormously swol-
len, and covered with pustules, which were everywhere
confluent. Over the surface of the body, although more
discrete, they were still large and numerous. He adopted
the following treatment : ‘Three times a day the face, limbs,
and chest were to be covered with a pomade of one part
of salicylic acid to twenty-five parts of vaseline. A pow-
der of talc, one part ; salicylicacid, twenty-five parts, to be
then dusted upon the parts. Four grains of quinine to
be given three times a day. Borated gargles for the throat.
Milk was given as needed. ‘The discharges were covered
with quick-lime and buried. The soiled clothing was put
into boiling water. The other occupants of the lodging-
house were vaccinated and sent away. The body of the
patient exhaled xo odor at all, and, notwithstanding the
severity of the eruption, the patient was almost free from
suffering. On the 7th, delirium, of some hours’ duration,
setin. The swelling gradually subsided, and on the 12th
he scraped carefully away the coating which had until then
covered the parts, and found the skin smooth, without the
least trace of cicatrix, supple, elastic, a little more red
than normal, but entirely free from scabs. Recovery was
complete, without any accompanying accidents, without
those repulsive exhalations which make small-pox patients
so disgusting and such dangerous sources of infection.
This case is related by Dr. Baudon in a simple way, with
the hope that it will prove useful. He believes that the
treatment is rational, and that those who try it will find it
a great comfort, if only in preventing the foul odors of the
diseased body.
NEPHRITIS AS A SEQUEL OF WHOOPING-COUGH.—Dr.
Mircoli, of Monterubbiano, has lately called attention to
the eccurrence of nephritis as a sequela of whooping-
cough. In 1887, among ten children who suffered from
the disease, the attack was followed in two by nephritis,
which proved fatal in one of them. The necropsy left
no doubt as to the existence of nephritis. In 1888, among
thirty-five cases of whooping-cough, Dr. Mircoli met with
nephritis in four ; two of these died, and in one of them
a post-mortem examination was made. ‘The kidneys were
seen with the microscope to show severe parenchymatous
nephritis. No cultivation experiments could be made to
determine whether the disease was parasitic or not. ‘Ihe
microscope showed no trace of micro-organisms.—Brit-
ish Medical Journal.
SPLENIC MuRMURS.—In a recent paper, Professor Bou-
chard drew attention to the existence of a bruit over the
region of the spleen in cases of enlargement of this organ
THE MEDICAL RECORD.
67
—a bruit not attributable to pressure upon vessels or to
conduction from the heart, but apparently generated in
the splenic artery or in the spleen itself. During the past
three years he has constantly practised auscultation of the
spleen, and on five occasions has detected such a bruit.
Three times the splenic enlargement was due to cirrhosis
-of the liver; in one case the spleen was hypertrophied, as
in leukzemia, but the blood was not altered; and in the
other the swollen spleen was associated with a large liver
in an obese subject. In several cases—notably in mala-
rial spleen and in one marked case of leukæmia—no bruit
was to'be detected. He entered into details of his first
case—one of cirrhosis of the liver—in which the spleen
was very large, measuring seventeen by eleven centimetres
(about 6.3 by 3.9 inches), and was hard and smooth. Over
its whole area there was audible a soft, prolonged bruit,
synchronous with the pulse, but the bruit could not be
traced beyond the splenic region. It was still audible
when the patient was made to lie on the left side, to pre-
vent the organ exercising any pressure upon the abdomi-
nal vessels. The bruit was audible whenever the patient
was examined during the three years the patient was under
observation. The case was otherwise interesting as an
example of “ cured cirrhosis,” upon which the chief dis-
cussion took place. There had been considerable ascites,
which required paracentesis on three occasions ; but Pro-
fessor Bouchard attributed the arrest of the disease to the
prolonged administration of calomel in small doses. The
patient also had an attack of uræmia, which was success-
fully treated by naphthol, on the theory of intestinal anti-
sepsis being needed to limit the operation of auto-intoxi-
cation in the production of the uremia.— 7he Lancet.
THE Ways AND WANDERINGS OF THE CONTAGION
oF SYPHILIS.— Lang believes that at the time of the infec-
tion with syphilis a cell infiltration takes place which forms
a wall of isolation between the diseased centre and the
sound parts in the neighborhood. A part of the syphilitic
poison is thus rendered harmless, while the rest gains ac-
cess into the system either by means of the lymph-cells
into the lymphatics, or directly into the blood-vessels. If
by the former way, the syphilitic infection will take place
gradually ; if by the latter, at once. Another way of in-
fection is by what he calls regionary infection, by which
is meant that the poison is carried into the regions in the
neighborhood of the original focus through the interstices
of the tissues, and there gives occasion to the forma-
tion of papules. The frequent infection of the rectum in
women is, in most cases, due to the regionary infection
from the primarily infected genitals. Another manner of
the spreading of syphilis is the “ post-initial infection,”
in which, on a region distant from the initial lesion, an-
other initial manifestation appears, as on the lip from a
genital chancre. An initial lesion with intact epithelium
can only spread by way of the lymph-channels and tissue-
spaces, while an ulcerated initial lesion permits all possi-
ble ways of infection. A part of the syphilitic contagion
will be destroyed in the blood, a part got rid of by the
excretory organs, and the rest can give rise to irritative
processes, while some may remain for years quiescent,
then to give rise to gummatous formations. During these
years the poison must have undergone important modifi-
cations, as it is not infectious in the gummatous stage.
The poison sometimes remains fixed in a certain organ
without impairing the functions of the organ.— Zhe New
York Medical Journal.
°
-—-
PHYSICIANS IN THE CrviL SERVICE.—The Government
offices at Washington are fairly overflooded with retired
M.D.’s, most of whom are working for a mere song,
whose melody, however, is more voluminous than the
clink of the scattering dollars that were wont to jingle into
their coffers while -they were still practising physicians,
The young doctor assuredly traverses a hard road, but
there are prizes to be won by him who pegs it out to tha
end.— Philadelphia Record.
68
THE MEDICAL RECORD.
[July 20, 1889
THE MEDICAL RECORD:
t
. SHRADY, A.M., M.D., EDITOR.
PUBLISHED BY
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
New York, July 20, 1889.
A PHYSICIAN’S STUDY OF POVERTY AND
ITS CAUSES.
No class of men come into such close and constant rela-
tions with the poor as physicians. It might be expected
that they should be able to contribute something of value
to the subject of poverty, and its social causes. This, in
fact, physicians have done. In the June number of Zhe
Forum, Dr. H. D. Chapin has contributed an interesting
and suggestive article on the subject. We doubt not that
students of sociology will find in it more of immediate
practical value than in learned treatises on single-tax or
co-operative commonwealths. Our world-betterers have
two duties before them, one to remove immediate distress
and its causes as far as possible, the other to encourage
the adoption of some social system which shall eliminate
as far as possible poverty and misery. The prophets of
new dispensations have their uses, but we confess to a
greater liking for those who are content to help their
fellow-man as much as they can now, without waiting for
society to be reorganized on some new basis.
In the article referred to, Dr. Chapin states that, while
one of the gravest problems to-day confronting society is
found in the wide extension of great poverty, very few,
unfortunately, of the panaceas offered to remedy this state
of affairs are based upon a correct appreciation and knowl-
edge of the operation of natural law. A careful study of
this subject is desirable, inasmuch as poverty tends to be
especially dangerous to social order under democratic in-
stitutions. With more freedom come greater wants, anda
greater sensitiveness to social disadvantages. The pres-
ence and growth of extreme poverty and a sharp struggle
for subsistence, particularly in our large cities, force them-
selves upon the attention of physicians who serve in the hos-
pitals and dispensaries erected for the poor. After some
years of such service, the author has come to the conclu-
sion that physiology can afford the best preliminary solu-
tion of some of the problems of sociology. That there is
some defect in our method of dealing with the poor is
shown by the fact that, in spite of the large sums annually
donated for such purposes and the good thereby accom-
plished, the real problem of grinding poverty does not
seem to have been touched. Asa resultof a little more
than five years’ work, the Charity Organization Society of
New York reports 101,916 families who have sought or
received relief, which is equivalent to 407,664 persons
living in actual or simulated dependence. An investiga-
tion of this vast army of unfortunates will, in very many
cases, show a combination of ignorance, inefficiency, and
shiftlessness which are largely the results of physical and
mental ill-health. This being the case, public opinion
must be directed more and more toward the means of
increasing and preserving physical, mental, and moral
health and vigor among the poor and unfortunate. Much
disability comes from an utter ignorance of the simplest
hygienic laws. This is, perhaps, most notably seen in re-
gard to food. Granting the lack of means to purchase a
variety of food, that form of nourishment should be
selected which will yield the most energy, and which can
be easily digested. This is precisely what is not done.
The most glaring instance of this is seen in the diet of the
very young, at a time when growth is extremely active.
Such errors cannot be excused on the ground of extreme
poverty, as the cost of proper nutriment—milk in some
form—is less than that of the food so often substituted.
The resultant rickets, with its softening of the bones and
various developmental changes, may seriously handicap
future healthy growth.
At his children’s clinic, Dr. Chapin found, out of ore
hundred cases presented for treatment, forty-three showed
marked evidences of this taint, in addition to the illness °
for which medical aid was sought. All efforts to relieve
the very poor must start and end in the family, which con.
stitutes the fundamental unit and basis of society and the
State. No institution can take the place of the family.
The domicile must hence assume great importance, not
only as regards the efficiency, but also the morals, of its
occupants. ‘The problem of housing the poor is not so
easy of solution as it looks. Reduced to a simple form,
it would seem as if the destruction of bad tenements and
the construction of good ones would settle the question.
Unfortunately, a change of domicile will not necessarily
change the nature of the inhabitants. In order to have a
clearer conception of the condition of the very poor in
tenement-houses, and the mutually acting relations of the
people and their environment, it is necessary to go back
and study their previous condition before coming to this
country, as most of them are foreigners or of foreign de-
scent. In the Irish census of 1841, touching the social
condition of the people, the astonishing discovery is made
that about seventy-seven per cent. of the people lived in
cabins without floors, chimneys, or windows. These data
are specially pertinent, as in the decade following 1847,
944,798 Irish immigrants landed in New York. Many of
the Italian and other immigrants now swarming into New
York find in the poor tenements better quarters than they
are accustomed to. From this aspect it would seem. as if
the tenement-house system of our large cities were an up-
ward step in evolution so far as many foreigners are con-
cerned, quite as much as an accidental and unfortunate re-
sult of crowding on a restricted area. ‘The plan advised by
Dr. Chapin is to educate the poor—to elevate them in their
own sphere, before trying to take them into a higher one
that they cannot fill. Such education can only be accom-
plished by visiting the poor, and can be better done by
women than by men. If intelligent help is to be extended,
it must follow an investigation of the circumstances and
character of those needing it. Something more than
money must be taken to the poor and helpless. We must
bring to them knowledge, foresight, a better judgment, a
July 20, 1889]
THE MEDICAL RECORD.
69
stronger will, and to a certain extent must exercise these
qualities for them, until they begin to give evidence in
some degree of possessing them. The only kind of help
that does good and not harm is that which leads to self-
help. ‘This relief will be slow, as it involves undoing
habits of life formed by years of unfortunate environment.
Dr. Chapin maintains that the physician, who has so much
to do with the sick and ailing, can often have an insight
into social problems that is denied to political economists.
THE ELIXIR OF YOUTH.
Ir is curious, in this age of scepticism and of scientific
reasoning, to read in our Paris letter of the discovery of
the elixir of youth, and to learn that the one who claims
to have found this longed-for potion is no less a person
than the president of the Biological Society of Paris.
Yet, at a recent meeting of this society, M. Brown-Séquard
gravely asserted that he had extracted a liquid from the
testes of animals, which, when injected into other animals
or man, rejuvenated them and removed the infirmities of
age.
The first experiments were made upon dogs. An old
dog, who had long since abandoned the company of the
fair sex, was subjected to a series of these injections, with
the result that no puppy just gaining consciousness of the
powers of ripe doghood was more ready to test those
powers than was this quondam decrepit specimen of
caninity. Encouraged by such promising results of his
experiment, M. Brown-Séquard determined to try the
effects of the injections in his own person. The results
surpassed his most sanguine expectations. Things that
he had been unable to do, or to do but feebly, for many
years past, he was now able to execute to his entire satis-
faction. He was formerly constipated, by reason of a
paretic condition of the large intestine, but now his bowels
were as those of “a romping boy.” Formerly urination
was feeble and the stream of water was propelled with
but little force, owing to vesical weakness, but now Gar-
gantua himself would envy the vigor of his performance
of this act. Formerly he was obliged to rest from all
intellectual effort after dinner, but now his thoughts flowed
as freely after dinner as before breakfast. He could now
stand on his feet for three hours at a time without feeling
the least fatigue. There were other functions also, of
which he did not care to speak more particularly, which
had been re-established in all their pristine vigor. In
short, he felt himself to be at least thirty years younger,
and all this as a result of fifteen injections of testicular
juice—at the rate, therefore, of two years for each injection.
It is fortunate that the experiment was not continued
further, for fifteen or twenty more injections, at the same
ratio of rejuvenation, might have worked a startling change
in the venerable scientist.
The improvement was not merely a temporary one, due
possibly to a slight stimulation by the injections, as two
weeks had passed at the time of his report, and he had
lost none of his thirty years during that period.
Brilliant and epoch-making as this discovery is, we can-
not but regard it as incomplete, for the male sex alone
can profit by it. A sad condition would result were all
the old men rejuvenated, while their aged companions
through life were still weighed down by the heavy hand of
time. Indeed, Dr. Brown-Séquard himself, with his in-
creased mental acuity, was not slow to note the one-
sidedness of his discovery. He suggested that the injec-
tion of ovarian juice might render the same service to the
aged of the other sex, and he called for volunteers among
the female doctors of advanced years to submit them-
selves to the experiment. Let us hope that the response
to his call will be prompt, and that many of the old ladies
of the profession in Paris will be willing to become young
again for the sake of the science which they love so well.
DEATH BY ELECTRICITY.
As our readers know, we have not been very ardent ad-
vocates of the law providing for the execution of criminals
by electricity. It has seemed to us that, apart from the
question of obtaining currents that would kill cito et ju-
cunde, the methods proposed involved cumbersome para-
phernalia, and might disfigure and convulse the victim.
The attempts of the counsel for the condemned man
Kemmler, however, to show that electricity is not a suit-
able agent for capital punishment have brought out
exhibitions of electrical non-expertness almost sufficient
to cause a revulsion of feeling toward the new law.
There can be no doubt whatever that electricity can kill,
and kill certainly and uniformly, nor is there any doubt
that apparatus can be so adjusted as to kill a man, with as
much certainty at least as there is in any human affairs.
The question is really and solely one of zsthetics. The -
lethal current may possibly burn or scald; it may con-
vulse, producing unpleasant contortions; and the ma-
chinery for its application, with all its tables, straps, ad-
justment of wet electrodes, etc., is more complicated than
hanging.
THE REGULATION OF eo MEDICAL EDUCA-
ALL interested in the progress of medical education and
the elevation of the status of American medical students
will learn with pleasure that the New York State Legis-
lature recently enacted a law requiring of medical students
a certain standard of preliminary education.
The law reads as follows :
“ SECTION 1. Before the Regents of the University of
the State of New York, or the trustees of any medical
school or college, within this State, shall confer the degree
of doctor of medicine on any person who has not received
a baccalaureate degree in course from a college or univer-
sity duly authorized to confer the same, they shall require
him to file with the secretary or recording officer of their
university or college a certificate showing that, prior to
entering upon the prescribed three years’ study of med-
icine, he passed an examination conducted under the
authority and in accordance with the rules of the Regents
of the University of the State of New York, in arithmetic,
grammar, geography, orthography, American history, Eng-
lish composition, and the elements of natural philosophy,
and such certificate shall be signed by the secretary of the
regents and countersigned by the principal or commis-
sioner conducting said examination.
‘SECTION 2. This act shall not apply to persons who
have already entered upon the prescribed three years’
study of medicine, nor shall it alter the time of study or
the courses of medical instruction required to be pursued
in the medical colleges of this State by existing statutes.
JO
penao A
“SECTION 3. This act shall take effect immediately.”
This law, which, it must be confessed, is somewhat
paternal in its scope, places the students of medicine on
the same footing with the students of law, who, before
they enter its study, must also pass a regents’ examina-
tion.
It should be distinctly understood that the law does not
apply to students who have already matriculated ; but all
persons hereafter intending to get medical degrees in the
medical colleges of this State must pass a preliminary ex-
amination. The Chancellor states that medical students
may enter the examinations already held three times every
year at each of the three hundred and eight academies and
high schools of the State under visitation of the regents ;
and, in addition to this, provision will be made for special
free examinations for medical students, as is now done for
law students. |
The Chancellor sends to the faculties of the different
schools the following queries :
“x1. ‘To what extent, if any, should the grade of the ex-
aminations be lowered from the standard at present used
in our academies ?
“2. Would you favor a law compelling graduates from
medical colleges outside of this State to comply with the
above provisions as to preliminary education before prac-
tising in this State ?
“3. At what times and places and how many examina-
tions a year would you recommend ?
“4. How would you regard an amendment to the law
allowing the regents’ examination to be taken during the
first of the prescribed three years’ study of medicine, in-
stead of ‘prior to entering’ on such study ?”
We venture to say that the professioh of the State, as
well as the faculties, will be decidedly averse to lowering
the requirements. ‘They should eventually be made much
more stringent.
It certainly would be unfair to graduates of our State
institutions to compel them to have special qualifications,
when graduates from just over the border do not have to
possess them. Unless some provision is made the medi-
cal students will slip off to some neighboring State col-
lege, get their degree, and return. We trust that there
may be found some practicable way of amending the law
in this direction. As to the fourth question, it will be
quite imperative that the preliminary examination be al-
lowed, if necessary, after probative matriculation. It
would be difficult to accommodate the many students
from outside the State otherwise. F urthermore, some
provision ought to be made by which certificates of exam-
inations from high schools and academies outside the State
may be made equivalent to regents’ examinations.
REGULATION OF VETERINARY PRACTICE.
WE are glad to learn that the Legislature of Pennsylvania
has enacted a law regulating the practice of veterinary
medicine and surgery. ‘The law provides, “ That every
person who shall assume, or use, or cause to be used,
any title pertaining to the practice of veterinary medicine
or surgery, or any of the branches of veterinary medicine
or surgery, shall ‘be a graduate of a legally chartered vet-
erinary college or university, having the power or au-
thority to confer the degree of veterinary surgeon or
analogous title, except as provided for in section two ;
THE MEDICAL RECORD.
[July 20, 1889
and such practitioner shall be required to register in the
book kept for that purpose in the office of the county
clerk of the county in which he resides.”
It is stated in the Yournal of Comparative Medicine
and™Surgery that the Legislatures of New Jersey and Cal-
ifornia have bills of similar purpose before them. There
is much in comparative pathology and in the hygiene of
the domestic animals that is closely related to the practice
of human medicine, and the advancement of veterinary
science will be a help to medical science as a whole.
We trust that the regulation of veterinary practice may
be undertaken by all the States.
Hews of the Weck.
BROWN-SEQUARD’S NEW REJUVENATOR. — Brown-
Séquard’s statements regarding the stimulating power
of testicular juice, which were received with much in-
credulity, have been in a measure confirmed through
further experiments by M. Variot, who made a communi-
cation to the Société de Biologie on June 29th. The pa-
tients chosen were debilitated men, aged fifty-four, fifty-
six, and sixty-eight years respectively, and they were not
informed of the nature of the treatment adopted. In all
three cases the injections were followed by general nervous
excitement, increased muscular power, and stimulation and
regulation of digestion.
Brown-Séquard is not the first to lay stress on the
potency of juices artificially extracted from the genera-
tive organs. Horace, says Zhe Medical Press, in one
of his odes, beseeches the witch Canidia to reveal to
him the secret of the draught which she prepared at
night by crushing in a mortar pieces of flesh torn from the
most fiery horses of Rome, and the patricians, says the
Latin poet, used this mysterious liquid with great confi-
dence. Consequently M. Séquard is but an humble suc-
cessor of Canidia! It would not be at all surprising if the
testicles contained some stimulating leucomaine. We know
that the salivary glands can generate a poison, and Dr.
Wooldridge found an active principle in the thymus gland
which caused a rapid clotting of the blood when injected
into the veins. ‘The toxic agents in the urine secreted at
night are said to be stimulating and anti-hypnotic. There
is not much known about the leucomaines, and possibly
Brown-Séquard has hit upon one of them. That his dis-
covery, if it is one, is more than the discovery of some stim-
ulating product of tissue change, we do not believe. But
it will no doubt give a great impulse to the consumption
of lamb fries.
THE NAPHTHA Hasit.—The Medical Standard calls
attention to the growth of the “ naphtha habit ” among
the female employees of rubber factories. The inhalation
of naphtha fumes produces a peculiarly agreeable inebri-
ation. Naphtha is used to clean rubbers, and is kept in
large boilers to the valve of which the female employees
obtain access and breathe the fumes. ‘The habit was in-
troduced from Germany, and is chiefly found in the New
England States.
McGııL Universiry.—Dr. George Ross has been ap-
pointed Professor of the Practice of Medicine, and Dr.
Richard Z. McDonnell Professor of Clinical Medicine, in
the Medical Faculty of the University.
July 20, 1889].
THE MEDICAL RECORD. 71
en a
SELLING CIGARETTES TO CHILDREN.—A conviction,
under the new law in New York State prohibiting the sell-
ing of cigarettes to children under sixteen years of age,
has been obtained. The offender was compelled to pay
a fine of fifty dollars.— Medical News.
THE ORGANIZATION OF THE ‘TENTH INTERNATIONAL
MEDICAL CONGRESS, which is to be held at Berlin, August
4 to 9, 1890, is under way. At the call of Professors
Virchow, Bergmann, and Waldeyer, a large number of
representative men will meet at Heidelberg to begin the
arrangements.
FADSES FOR PARISIAN STUDENTS.—The Parisian stu-
dents have recently decided to wear certain marks of dis-
tnction, to denote the courses which they are pursuing.
Medical students will wear, on a boutonnière of red and
black, a little violet band with a skull made of some white
metal. Army medical students will wear, on a garnet
boutonnière, the symbol of health—the rod of Esculapius
in gold. Students of pharmacy will be distinguished by
the emblem of Pharmacy, a silver shaft encircled by a
gold serpent, worn on a green boutonniére.— Wew York
Medical Journal.
THE HOSPITAL oF Jouns Hopkins University.—Dr.
Henry M. Hurd, of Pontiac, Mich., has been appointed
superintendent of the hospital. He is at present the
superintendent of the State Asylum for the Insane, at
Pontiac.
THE Mississippi VALLEY MEDICAL ASSOCIATION will
meet at Evansville, Ind., September 24, 25,and 26, 1889.
Going To CHuRcH.—This is what a Dakota doctor
advises about it: “ I went to church and Sunday-school,
and if any of you young M.D.’s do not attend Sunday-
school, you should begin, as it will help you to a good
class of patients, besides its grave duty as a gentleman and
a man of education. I have a class of young misses, and
am sure they help me to as many patients as any of my
friends ; besides, you had better be at church than hang-
ing around the streets or saloons.”
DEATH oF Dr. J. Lewis SMITH, JR.—We regret to learn
of the recent sudden death of Dr. J. Lewis Smith, Jr., of
this city, a very promising young physician.
A HOSPITAL FOR ANN ARBOR.—The city of Ann Arbor,
Mich., has voted to issue bonds for $25,000 for the erec-
tion of a hospital, for which the legislature appropriated
$50,000.
THE Law REGULATING THE PRACTICE OF MEDICINE
IN MAINE has been declared invalid through a techni-
cality.
Dr. Harris H. BEECHER, late Assistant Surgeon of
the One Hundred and Fourteenth ‘New York Volunteers,
_ and a well-known writer and speaker of the Shenango Val-
ley, died at Norwich, N. Y., on July 15th, aged sixty-nine
years.
DEATH OF Joe Focarty.—Almost every physician in
this city, and hundreds living elsewhere, knew of Joe Fo-
garty who, for nearly twenty years, was assistant keeper of
the Morgue, and who died somewhat suddenly last week.
Fogarty had a talent for the peculiar and repulsive kind
of work in which he was engaged ; and he pursued it with-
out becoming brutalized, or losing the natural kindliness of
his disposition.
VERMONT UNIVERSITY MEDICAL COLLEGE.—The annual
commencement of the medical department of the Univer-
sity of Vermont occurred, July 15th. ‘There were sixty
graduates. ‘The annual address was delived by ex-Minis-
ter E. J. Phelps, who spoke on “The True Standard of
Success in Life.”
Dr. AUSTIN WHITE ‘THOMPSON, for some time Assist-
ant Superintendent of the Northampton (Mass.) Asylum
for the Insane, and for fifteen years proprietor of the
Shady Lawn Retreat, died last week of consumption. He
was born at Pelham, May 22, 1834. He was graduated
at Harvard in 1854 with salutatory honors. After special
study at various hospitals, he was appointed Assistant
Superintendent of the Northampton Hospital by Dr. Earle.
He was forced to retire on account of poor health at the
end of two years. In 1874 he started the Shady Lawn
Retreat. Dr. ‘Thompson was a man of literary tastes and
a poetical tum of mind. He was also a skilful surgeon.
CONTINENCE AND SyPHILIS.— The Lancet, comment-
ing editorially upon our remarks regarding continence as
a preventive of syphilis, adds: “ Though Dr. Gowers’
testimony to the importance of chastity as a means of
health is the last great note sounded to Englishmen, it
does not stand alone in medical literature. ‘There is an-
other voice which may be recalled here which will sound
for generations yet, as characteristic in its ethical strength
as in its medical and scientific authority. Sir James
Paget, in his clinical lectures, speaking of patients that
expect us to prescribe fornication, says: ‘I would just as
soon prescribe theft or lying, or anything else that God
has forbidden. | If men will practise fornication or un-
cleanness, it must be of ‘their own choice and on their
sole responsibility. Chastity does no harm to
mind or body ; its discipline is excellent ; marriage can be
waited for; and among the many nervous and hypochon-
driacal patients who have talked to me about fornication,
I have never heard one say he was better or happier after
it; several have said they were worse ; and many, having
failed, have been made much worse.’”
HEART-FAILURE AS A CAUSE OF DEATH.—“ It would
be an excellent idea,” says the Manchester Union, “if
physicians of the present day would invent some other
reason for about all of the deaths which occur nowadays
than the cheap fraud, ‘heart-failure.’ This might not
be of serious moment were it not for the fact that hun-
dreds of people are being nearly frightened to death by
the constant use of the cause for sudden deaths, and
many people who are sick, and necessarily have some
heart symptoms, are kept in constant terror by reading or
hearing in other ways of death after death by heart-failure.
There are probably no more deaths from heart-failure in
these times than heretofore, but a new cause for death
has been coined, and the nervous and timid are being
severely injured by it.” We would Suggest that hereafter
physicians use the term “ cardiac asthenia,” which has a
learned sound and means just the same. ‘The immediate
cause of death in many diseases being, in fact, “ heart-fail-
ure,” we do not see how otherwi@ the “nervous and
timid ” can be protected.
Dr. A. E. M. Ponp, the inventor of Pond’s sphygmo
graph, died at Rutland, Vt., recently.
72 THE MEDICAL RECORD.
Society Reports,
ONTARIO MEDICAL ASSOCIATION.
Ninth Annual Meeting, held at Toronto, Canada, Fune
15 and 16, 1889.
(Reported by our Canadian Correspondent.)
Dr. W. H. HENDERSON, OF KINGSTON, PRESIDENT, IN
THE CHAIR.
MEETING opened with an attendance of two hundred
and seventeen members. |
After the report of Committee on Arrangements had
been presented, Dr. W. J. Gisson, of Belleville, read the
history of a case of
SYMMETRICAL GANGRENE,
which he was inclined to consider an example of Ray-
naud’s disease. ‘The gangrene was limited to the toes,
the patient (a male, aged forty-one) eventually losing all
the toes of the right foot and the second and third toes
of the left foot. The constitutional symptoms were less
severe than the local. The onset of the disease was sud-
den, commencing with pain and a feeling of numbness in
both arms and legs; a condition of ischemia was then
observed in the feet; this was followed by cyanosis, ery-
_ thema, and gangrene, limited to the parts above mentioned.
Dr. Gibson concluded his paper by giving a short sketch
of the supposed pathology of Raynaud’s disease, and also
a brief account of its clinical history.
Dr. J. CAMPBELL read a paper giving reports of cases
in practice, one of which was an interesting case of
LOBULAR PNEUMONIA IN A PRIMIPARA AT CONFINEMENT.
This case was marked by a high temperature and complete
suppression of lacteal secretion, and ended in recovery of
the patient.
i R. W. Bruce SMITH, of Seaforth, read a paper en-
title
REFLEX NERYOUS PHENOMENA, DUE TO PREPUTIAL CON-
TRACTIONS.
He briefly related a few cases, coming under his own ob-
servation, of nervous irritability in children, arising as a
result of narrow prepuce, accompanied by preputial adhe-
sions.
Case I.—A male child, aged five months. Parents
complained that the child cries almost constantly without
any apparent cause, is very fretful, and has marked evi-
dence of nervous prostration, trembling of eyelids, con-
vulsive moveménts of the limbs, etc. On examination
Dr. Smith found a pinhole orifice, with extensive adhe-
sions, between the prepuce and glans. He broke down
the adhesions, and forcibly dilated the prepuce, so that it
could be drawn back over the corona glandis; the parts
were then thoroughly cleansed. As a result of this small
operation the patient was relieved of all nervous symp-
toms.
Case II.—A male child, aged eight months. This child
was very fretful, especially during micturition. These
symptoms of fretfulness and dysuria had existed for three
months. Dr. Smith treated this case by means of gradual
dilatation, until the prepucé could easily be retracted over
the corona. The result was entirely satisfactory, there
being no return of the symptoms.
Case III.—A male child, who at eighteen months
showed no inclination to walk. About this time had sev-
eral convulsions ; at the age of three years could scarcely
stand ; legs were very weak, but not wasted. On general
tonic treatment made no improvement. On examination
an elongated prepud®was found bound down to the glans.
When the adhesions were broken down and the prepuce
dilated, the latter could be easily retracted. ‘The parts
were then thoroughly cleansed and the smegma, as in each
of the other cases, was removed. In about a fortnight
[July 20, 1889
there was marked evidence of improvement, and from this
the child progressed rapidly, so that at the end of four
months he was able to run about with the other children.
In concluding his interesting paper Dr. Smith alluded
to Mr. Edmund Owen’s teaching, that a small preputial or
urethral orifice and adherent prepuce were, perhaps, the
commonest causes of hernia in children. He also briefly
referred to Mr. Bryant’s statistics bearing on the same
point, and urged attention to a subject upon which text-
books say so little. He believed that in some cases with
marked nervous symptoms in male children we may find
a causative relation to those symptoms in an abnormal
condition of the penis, and that by directing our attention
to the relief of that condition we may convert a feeble,
puny, wakeful, and irritable boy into a healthful and happy
child.
Dr. Newman, of New York, made a few remarks,
highly approving of Dr. Smith’s treatment and method of
operating, deprecating circumcision in those cases where
dilatation is quite sufficient. Drs. McGuire, of Guelph,
Murray, of Thorndale, and others continued the discus-
sion.
AFTERNOON SESSION.
‘THE PRESIDENT cordially welcomed the fraternal dele-
gates present from American Medical Associations, and
invited the following visitors to the platform: Dr. Alex.
J. C. Skene, of Brooklyn ; Drs. Roswell Park and Tre-
maine, of Buffalo; Dr. Newman, of New York; Dr. Fos-
ter, of Portland, Me., and others.
Dr. W. H. HENDERSON, of Kingston, then delivered
the
PRESIDENT’S ADDRESS.
He first expressed his gratitude for, and appreciation of,
the high honor paid to him, as one of the younger mem-
bers of the Canadian medical profession, in being elected
to the office of president of this most prosperous associ-
ation. Appropriate “in memoriam” reference was then
made to the late Dr. R. P. Howard, of McGill College,
and others who had been called away during the year.
Referring to the present condition of the medical pro-
fession in the Province, the President uttered some apt
and interesting remarks concerning the wide and rapid
diffusion of knowledge at the present time. He thought
that “at no time in the history of our country has the
medical profession of Ontario been in a more favorable
state than at the present time.” Congratulatory and com-
plimentary remarks regarding the high standard of pro-
fessional education in the Province, and the increase of
hospital accommodation were indulged in, and reference
was made to the enterprise shown by Canadian students
in acquiring hospital experience of the most valuable
kind in Europe and the United States. The President
then directed his remarks to a review of the medical
legislation at present existing, and expressed regret
that the Ontario Medical Council, an institution which
has done much to elevate the standard of medical edu-
cation in the past, should persist in enforcing the rule
excluding men who possess British diplomas from prac-
tising in this Province. He did not consider it just that
an M.D. from London University, or a Fellow or Mem-
ber of the Colleges of Physicians or Surgeons should, on
coming out to this country, be required to undergo a fur-
ther test of his ability, at a very considerable expense, be-
fore he shall be allowed to practise in Ontario. He also
believed that the fact of a British diploma exempting a
man from passing the Ontario Medical Council had, in the
past, been an incentive to Canadian students to visit the
hospitals and compete in the examination halls of Great
Britain. This was particularly of value to those who felt
they could not afford to pay the high fees charged for
both examinations. He expressed the hope that our med-
ical legislators would see their way clear to remove this
obstacle to the medical student, and which might ulti-
July 20, 1889]
mately, by discouraging post-graduate study abroad, impair
the future usefulness of the profession. ‘To those who
would place obstacles in the pathway of our students, and
who, though perhaps unintentionally, prevent them from
pursuing their post-graduate studies abroad, he would, he
said, answer in the words of Medea to the Corinthians,
viz. :
There are who distant from their native soil,
Still for their own and country’s glory toil ;
While some, fast rooted to their parent-spot,
In life are useless and in death forgot.
He alluded then with expressions of regret to the ac-
tion of certain medical men who, notwithstanding the un-
excelled system of medical education in this Province,
carry on their practice with unblushing quackery. The
factthat they had regularly obtained registration at the
Medical Council was set up as a defence, but permission
should be given by Parliament to the Medical Council to
cancel the diploma of any person acting in an irregular
manner. ‘Then this question could be speedily disposed
of by the council, and, while the public would be better
protected, our profession would be freed from the few of
whom we are ashamed, and from whom we would be
gladly separated. Dr. Henderson then eloquently made
reference to the importance of making more provision for
post graduate study and pathological research. He urged
the claims of the profession for government aid in found-
ing and establishing a great ‘‘ Provincial Medical Ex-
change,” where every practitioner of medicine in the
Province might bring the results of his labors, and where
facilities for pathological study might be afforded to stim-
ulate research and original investigation among all mem-
bers of the medical profession. While not advocating
the expenditure of public money for medical education in
the ordinary routine of college work, he hoped that in the
near future our provincial authorities, regarding as they
do education as the corner-stone of our civilization, will
decide to encourage the post-graduate study of medicine
by liberally providing for our higher educational needs in
that respect. The investment would, he considered, bea
profitable one from every stand-point.
The address, which was a most able and eloquent pres-
entation of the present needs of scientific medicine in
Ontario, concluded with a graphic reference to the
achievements which might yet be made in the interests
of the profession in Canada, and earnestly urged co-
Operation in maintaining untarnished the high reputation
already attained, and by patient, diligent advancement
adding fresh lustre to the honors achieved in the past.
DISCUSSION ON SURGERY.
Dr. W. T. Arxins, of Toronto, opened the discussion
on surgery with the subject, :
THE GENERAL MANAGEMENT OF THE PATIENT AND SICK-
ROOM IN SURGICAL CASES.
He first dealt with the question of pure air in the sick-
room, and maintained that sufficient attention was not
paid to what some might consider the minor details in the
arrangement of the sick-room. He instanced the large
mortality in Canada every year from phthisis as evidence
of the fact that too little attention was paid to the proper
ventilation of our homes and schools, and, above all, to
the sleeping apartments. Why was it regarded of such
Importance to guard carefully the proper disposal of
feces, while at the same time little was done to warn
people of breathing over and over again the same air?
If, then, ventilation was of so much importance to those
in health, how much more detrimental would it be
to neglect looking after the purity of the air-supply to
those who have undergone the shock of some operation,
or might be debilitated by some exhausting discharges.
He urged the importance of every surgeon taking the pre-
caution to see that there was a means of escape for foul
air near the roof or ceiling of every room where a patient
was confined. A practical lesson was given in the filter-
ing of air. ‘The placing in the window of the sick-room
THE MEDICAL RECORD. 73
of two sheets of mosquito-netting, with a thin layer of
cotton-batting between these, was recommended by Dr.
Aikins. He related several examples where attention to
these details had proved advantageous.
Dr. RutTan, of Napanee, continued the discussion, and
said he had used the window netting with great satisfac-
tion. His plan was to place between the layers of the
netting antiseptic cotton or oakum, to which some reli-
able antiseptic agent had been added. His method in
private practice was to have: the room for the operation
carefully cleaned with a bichloride solution the day
before, and to have the antiseptic filter in the window
several hours before the operation was commenced.
Dr. BRITTON, of Toronto, considered it was very im-
portant to see that the patient had none but the most
cheerful surroundings. He thought there had been too
great a tendency, of late years, to restrict the diet of in-
valids, and believed that the mortality in lying-in cases
was increased thereby. He briefly showed the advantages
gained by having small wards in hospitals, and of the
cottage system, in order to secure what was of the greatest
importance, viz., a regular supply of fresh air to the con-
valescing patient. |
Dr. SKENE, of Brooklyn, N. Y., thought foul air was
even worse for a patient than foul water. We must, he
said, all breathe air, but he did not thmk, from the ap-
pearance of the robust Canadians he had before him, that
many of them drank only water. In abdominal surgery
he was particular to have the air of the operating-room
as pure as possible. He was careful to limit the number
of spectators in the operating-room, for he had noticed
that while some surgeons made elaborate preparations in
regard to the room, bedding, instruments, etc., they were
not careful in keeping the air free from being contami-
nated by the exhalations of numerous spectators. He
favored the method of filtering the air as advocated by
Dr. Aikins, and instanced several institutions where he
had seen the same used with satisfaction.
Dr. WILLIAM OLDRIGHT, of Toronto, considered that
it was important to have the temperature of the room
always suitable and uniform, and, while the air must be
kept as pure as possible, its temperature should be care-
fully looked after.
Dr. RoswE i Park, of Buffalo, N. Y., then read, by
Invitation, a paper on
THE RADICAL CURE OF HERNIA.
He first briefly reviewed the many operations which had
been devised with the hope of a permanent cure, and then
minutely described his method of operating, which, he said,
could not be regarded as either new or original, but was
rather a combination of several well-known plans. After
shaving the parts and thoroughly washing them antisepti-
cally, he made an incision over the external ring. The
sac will usually be found without much search, but is
sometimes blended with the cord in such a way as to be
very confusing to the operator. When the sac is isolated.
after splitting up the canal if necessary, it is opened. If
omentum is found it is ligated and removed, the pedicle
being dropped. The sac is then ligated with catgut close
to the external ring, and divided close to the ligature. If
the hernia be a congenital one, it is similarly ligated close
to the testicle, so as to leave a tunica vaginalis. A similar
procedure is adopted in femoral hernia. The pillars of
the ring are then drawn close by silver wire, which is
twisted, cut short, and the ends turned over upon them-
selves. The integumentary wound is closed with catgut,
generally without drainage. If asepsis be perfect, union
should be obtained in forty-eight hours. In femoral
hernia he generally adopted Ball’s plan of twisting the
pedicle of the sac. He does not often wire the femoral
ring, but leaves it to fill by granulation. In umbilical
hernia, usually found in women with lax and flabby abdom-
inal walls, he favored extirpation of the sac and hinging
the margins of the ring together in two or three tiers. ‘The
truss he did not consider should be worn after the opera-
74 THE MEDICAL RECORD.
tion, as its pressure had a tendency to cause absorption
of the granulation-tissue. He had operated in cases of
acute strangulation twenty times, in patients ranging from
six to seventy-eight years. Of these, four died, and one
had a relapse. He had fifty two cases of deliberate op-
eration for radical cure, and all recovered without any
sign of disturbance. Of these, fifteen were in females ;
six of these being umbilical and two femoral. He did
not hesitate to operate on both sides simultaneously, and
had in some cases relied solely upon cocaine as the anzs-
thetic. :
Dr. MCFARLANE, of Toronto, had operated three times
with good results, from Wood’s operation with silver wire,
and after two years there had been no relapse. He had
also had two successful cases in which he operated ac-
cording to Czerny’s method. His experience, however,
taught him, if a suitable truss, properly adjusted, will keep
the bowel reduced, it is preferable to any operation.
The Association then divided into Sections.
SURGICAL SECTION.
THE PRESIDENT nominated Dr. Howitt, of Guelph,
Chairman of this Section.
Dr. MITCHELL, of Enniskillen, presented a paper on
EARLY OPERATION IN CASES OF OBSCURE ABDOMINAL
DISEASE,
in which he made reference to the frequency with which
the general practitioner, in country practice, meets with
urgent cases in which an abdominal section is called for.
He related two cases, where after some delay, owing to
the refusal of the patient’s friends to consent to an opera-
tion, he had opened the abdomen, in both cases to relieve
obstructions, caused in the one case by hernia, and in the
other by a large abscess pressing upon the sigmoid flexure.
In the case of hernia the patient rallied, passed flatus on
the following, and fæces on the fourth, day. She, how-
ever, died on the fifth day. In the second case, after
evacuating the abscess the bowels moved and the patient
improved for some days after the operation, but ultimately
died from exhaustion. Dr. Mitchell considered that both
of these cases might have been saved if an early operation
could have been done.
Dr. Mann, of Buffalo, thought that not only should
we operate earlier, but that more cases should be operated
upon. He related a brief history of a case of pyo-salpinx
of six years’ standing, and also another of abscess of
the ovary, as evidence in support of early operative
procedure. There was difficulty in diagnosing pyo-salpinx,
owing to the fact that there was often little or no
rise of temperature, and sometimes nothing else, to
direct suspicion to the presence of pus. The only guide
to diagnosis in such cases seemed to be the previous
history of repeated attacks of so-called pelvic cellulitis.
He related a case of laparotomy, performed successfully
for general septic peritonitis following labor, in which one
pint of pus was evacuated and the patient had made a
good recovery.
Dr. W. OLpDRIGHT, of ‘Toronto, spoke of a case he
recently had of hzemato-salpinx, in which he had operated
with a good result. There had been in this case a history
of chills, high temperature, and sweating, and a diagnosis
of pelvic abscess had been given.
Dr. Groves, of Fergus, was in favor of evacuating
pelvic abscess in the female through the vagina. It was
certainly the shortest way to reach the pus, and afforded
the best facilities for drainage.
The discusston on ophthalmology was introduced by
Dr. Moore, of Brockville, who had chosen for a subject
GLAUCOMA,
one of the most important, he said, and dangerous dis-
eases of the eye, which came frequently under the observa-
tion of the general practitioner ; and it was of the utmost
importance that an early and correct diagnosis should be
[July 20, 1889
made. Dr. Moore said he was convinced that the study
of diseases of the eye, and especially clinical teaching of
the subject, should have a more prominent place in the
curriculum of medical colleges, for the general practitioner
should be able to recognize and treat successfully all the
ordinary diseases of the eye. Glaucoma was a disease so
insidious in its course that it might destroy sight before
the patient was aware of its presence. ‘The points in
diagnosis to be relied upon were : (1) Increased tension
of the eyeball; (2) limitation of the field of vision, espe-
cially on the nasal side ; (3) the hypermetropia ; and (4)
the anzesthesia of the cornea. We generally find acute
inflammatory glaucoma preceded by a premonitory stage,
the signs of which were often mistaken for neuralgia or
stomach derangement. The nature of secondary and
hemorrhagic glaucoma was referred to, and the treatment
was then discussed. The operation of iridectomy was
frequently resorted to, but gave the best results in acute
and subacute cases. He thought sclerotomy was better
in cases of simple glaucoma, as it does not disfigure the
eye to so great an extent. Eserine is a valuable drug for
lessening the tension, but atropia was certainly contraindi-
cated. Attention must be paid to the general health, and
particularly to digestion, which was often seriously at
fault in these cases.
Dr. BuRNHAM, of Toronto, thought that primary glau-
coma was of more interest to the general practitioner, as
the secondary affection soon drives the patient to the
specialist on account of the severe pain. Primary glau-
coma should be considered as either acute or chronic.
In the former the severe headache was such as to often
divert attention from the eye, so that the patient might
become quite blind before he is aware that there is any-
thing the matter with the eye. Then, if not attended to
early, it may become necessary to remove the eye. ‘There
was a difficulty also in recognizing the chronic form of
the disease on account of its resemblance to cataract, in
there being dimness of vision without pain, so that the
patient might be told to wait for the development of the
cataract, and in that way total loss of sight result.
Dr. PALMER, of Toronto, thought indectomy was to
be preferred to sclerotomy in most cases of glaucoma.
Dr. R. A. REEvE, of ‘Toronto, said he considered sec-
ondary glaucoma of more importance to the general prac-
titioner than the primary form of the disease, owing to the
rarity of the latter. The development of glaucoma in,
children, following ulceration of the cornea, should be
looked for. He considered that eserine, on account of its
usefulness to relieve tension, was the sheet-anchor in
treatment.
MEDICAL SECTION.
Dr. W. B. GEIKIE, of Toronto, acted as Chairman.
Dr. McKinnon, of Guelph, presented a paper on
VENESECTION IN PUERPERAL ECLAMPSIA.
His experience warranted him in warning young practi--
tioners against placing confidence in bromide of potas-
sium, chloral hydrate, or even hypodermic injections of
morphia, in cases of puerperal eclampsia. The use of the
lancet was no new treatment, but rather a return to old
practice, for time had brought forth nothing he considered
equal to it in those cases. He thought death usually re-
sulted from pressure on the brain from serous effusion,
hemorrhage, or cedematous infiltration, and to combat
such there was nothing of such value as free venesection.
He did not wish, he said, to be understood as recommend-
ing venesection aS a measure to arrest the convulsion,
but by diminishing the tension on the cerebral vessels to
disarm the convulsion of its fatal power. When called to
acase of puerperal convulsions he always adopted the
following as a guide to his procedure :
1. Bleed the patient if convulsion be severe or followed
by coma. `
July 20, 1889]
2. Control the convulsion with chloroform.
3. If the patient be at full time, take steps to terminate
labor as quickly as possible.
4. Administer an active purgative—Epsom or Rochelle
5. If the convulsions recur, give a large hypodermatic
of morphia.
This interesting paper closed by giving an account of
seven cases of puerperal eclampsia in which he had fol-
lowed the above course of treatment with success in each
case.
Dr. RICHARDSON, of Toronto, looked upon venesection
as the sheet-anchor in the treatment of puerperal eclamp-
sia, for it not only prevents extravasation, but is the very
best method for reducing the total quantity of poison in
the system.
Dr. Howes, of Chatham, would, besides employing
venesection, use diaphoretics freely, and in markedly an-
æmic subjects would hesitate before bleeding.
Dr. A. H. WRIGHT, of Toronto, contributed an ex-
cellent paper on
THE PREVENTION OF PUERPERAL SEPTICAMIA.
He said he considered no apology was necessary for bring-
ing such an ordinary subject before the meeting, for he
maintained this matter should be continually discussed
until sepsis became practically unknown in the lying-in
room. It is anything but creditable to the medical pro-
fession that puerperal septicemia is more common in
private practice than in well-conducted hospitals? We
are not to judge its effects simply from its death-rate, but
must also take into account the amount of misery and
suffering resulting from the milder forms of septicemia.
Can we prevent this septicemia? Dr. Wright answered
this question in the affirmative. How can it be done?
By thorough and perfect cleanliness on the part of our-
selves, and the essentials for such are hot water, soap, a
nail-brush, and a penknife; on the part of our patients,
proper clearing of bleeding surfaces and dressings which
will keep them clean, and along with these good venti-
lation, thorough drainage, and perfect plumbing. Dr.
Wright cautionea the profession against pinning their
faith to any special antiseptic, thinking that, by simply
using this, dirty hands and dirty instruments could be
employed with impunity ; at the same time he believed
that modern antiseptic remedies furnish invaluable assist-
ance in efforts toward asepticism. Dr. Wright then gave
the following short account of the methods practised in
the Burnside Lying-in Hospital, Toronto. On admission,
the patient is bathed and dressed entirely in clothing be-
longing to the hospital. When labor comes on she is
clothed in a clean night-dress and drawers. ‘The presenta-
tion is made out by abdominal palpation. Vaginal ex-
aminations are made in the first stage, occasionally, but-
as seldom as possible. Each one who touches the pa-
tient first washes his hands thoroughly, using soap, nail-
brush, and penknife, and then rinses them out in a solu-
tion of lichloride of mercury, t to 1,000. ‘This process
must be repeated before each examination. When the
presenting part is pressing on the perineum the vulva is
protected by a towel which has been soaked in the bi-
chloride solution. After the delivery of the child no
inal examinations are made ; the placenta is expressed
by the Dublin method. ‘The assistant keeps the uterus
contracted with gentle rubbing with the finger-tips. The
soiled clothes are then removed, the nurse washing the
vulva with a bichloride solution. No vaginal or intra-
uterine douche is used either before or after delivery.
The antiseptic pad is then applied. Dr. Wright then
illustrated the making of this pad, which consists of ab-
surbent cotton, enclosed in butter-cloth; before the dry
pad is placed in position a layer of absorbent cotton
wrung out of a bichloride solution is placed over the
vulva, the pad lying on this. Septiczemia had been ex.
ceedingly rare in the Burnside during | the last few years,
the temperature rarely reaching 100° F.; the patients
THE MEDICAL RECORD.
75
ood
generally go out in two weeks after labor. Dr. Wright
objected to vaginal and intra-uterine douches, “ because
they are unpleasant for the patients, because they interfere
with the physiological rest which the torn and bruised
parts should have, because septic matter or air may be
introduced and brought in contact with rents in the cer-
vix, vagina, or vulva, and finally because they are unneces-
sary.” He also laid great stress on the danger of intro-
ducing the fingers into the vagina after labor ; it is entirely
uncalled for in the great majority of cases, the placenta
being easily expressed by external manipulations ; it is at
this stage that septic matter is most readily taken up by
the open vessels and the abraded surfaces. He believed
that puerperal septiczmia is more frequently caused by
absorption of septic matter by the torn fourchette or peri-
neum than from any other source, therefore the practi-
tioner should be careful to avoid this ‘by the use of the
antiseptic pads, and cleansing the vulva with the bichloride
solution when the pads are changed.
Dr. TEMPLE, of Toronto, agreed with the reader of the
paper that there would be very few cases of puerperal
septicemia if the accoucheur took all necessary precau-
tions. He also objected to the routine use of douches.
In his own practice he never used an antiseptic pad, but
simply a perfectly clean diaper. He believed that most
septiczemic cases were due to absorption of septic matter
by rents in the passages.
Dr. W. Gunn, of Clinton, then read a paper on
A CASE OF SCLERODERMA,
and exhibited the patient. He first gave a brief outline
of the history, nature, and peculianties of this rare form
of skin disease, and then explained the history of the case
presented. The patient, a male aged forty, upon whom
the disease was well marked, was examined with much in-
terest by members of the Section.
EVENING SESSION.
THE PRESIDENT first introduced DR. ALEXANDER J. C.
SKENE, of Brooklyn, N. Y., who was present by invita-
tion, and read a paper on
INTRALIGAMENTOUS OVARIAN CYSTOMA.
This term, said Dr. Skene, embraces only those cysts
which are developed from the ovary and situated com-
pletely within the folds of the broad ligament, being thus
neither pedunculated nor provided with a sessile attach-
ment, but surrounded by a capsule formed from both folds
of the broad ligament. ‘Two theories have been advanced
to explain the origin and unusual position of these cysts.
The first assumes that the ovary itself is placed between
the folds of the broad ligament from developmental error.
The second theory is that the cystoma burrows during its
growth into the ligament. In order that this may come
about it is necessary that the ovary, bya special formation,
be closely attached to the ligament or fixed there by in-
flammatory adhesions. The latter view is supported by
some observations in the author’s cases. They are gener-
ally monocysts, a fact accounted for by Bland Sutton by
their development from the deeper structures of the ovary
—the parodphoron. The position of the cysts with ref-
erence to the other organs is also of interest, because in
different portions it would cause different displacements.
Their anatomical relations were of the utmost impor-
tance in regard to their surgical treatment. As a point in
diagnosis they are generally accompanied by more dis-
tressing pains in the pelvis, and more disturbance of the
functions of the bladder and rectum, than are ovarian or
parovarian cystomata. Physical examination shows that
the cyst is fixed at its most dependent part, the fixation
being at one side or extending from side to side, accord-
ing as the tumor occupies one or both ligaments. Fluc-
tuation is noticeable in the pelvic portion of the tumor.
Dr. Skene then gave in detail the points of diagnosis from
fibrocysts, etc. For treatment enucleation ranks first, as it
76 THE MEDICAL RECORD.
is applicable to more cases than any other method. The
operation was fully desctibed and drainage of the pouch
advocated. The peritoneal surfaces of the edges of the
pouch are brought together by a continuous catgut suture,
and brought up and fastened to the peritoneal edge of the
abdominal wound, if possible. Another method was to
remove the cyst and capsule together by hgating the liga-
ments below the cyst by means of the repeated continuous
ligature. Another was by a combination of these two
methods. Unfortunately there are some cystomata of
this variety which cannot be removed by any method
known at the present time. ‘These should be treated by
drainage above, uniting the cyst to the abdominal wall,
after removing as much of the cyst as possible. The
drainage must be long continued and the recovery of the
patient is generally tedious.
Dr. Mann, of Buffalo, and others took part in the dis-
cussion that followed.
The President then introduced to the Association the
Hon. Georce W. Ross, Minister of Education for the
Province of Ontario, who made a few remarks welcoming
the members of the profession to the city, and congratu-
lating them on the interest shown by the large attendance
in the welfare of the Association.
The discussion in medicine on the subject,
THE PROGNOSTIC SIGNIFICANCE OF MODERATE CARDIAC
HYPERTROPHY AND DILATATION,
was then opened by Dr. Charles Sheard, of Toronto, and
continued by Dr. McPhedran, of Toronto, and Dr. Bruce
Smith, of Seaforth. i
The Association then went into executive session, and
considered certain amendments to the Code of Ethics.
SECOND Day, THURSDAY, JUNE 16TH.
The meeting of the Association was resumed. After the
transaction of routine business the meeting was again di-
vided into Sections.
SURGICAL SECTION.
Dr. E: E. Kinc, of Toronto, presented aepaper on
THE USE OF THE CYSTOSCOPE IN DIAGNOSING OBSCURE
BLADDER DISEASE.
This was followed by an interesting discussion, and the
following papers: Dr. N. A. Powell, of ‘Toronto, on
“ Demonstration of the Use of an Improved Form of Re-
laxation Suture ;” Dr. J. E. White, of Toronto, on “ Re-
cent Modes of Treating Fractures above the Wnist-joint ; ”
Dr. Newman, of New York, on “Electrolysis in Surgery
and Gynecology ;” Dr. Howitt, of Guelph, on “ Miscel-
laneous Laparotomies ;” Dr. Groves, of Fergus, on “A
Case of Vaginal Hysterectomy, with Abdominal Ovari-
otomy ;” Dr. Walker, of Toronto, on “Some Practical
Points in Gynecology and Abdominal Surgery ;” Dr.
N. McPhatter, of Cleveland, O., on “ Cholecystotomy.”
These papers were each followed by interesting discus-
sions.
MEDICAL SECTION.
Papers were presented as follows: Dr. Price Brown, of
Toronto, on “ ‘The Treatment of Phthisis Pulmonalis ;”
Dr. Smith, of Orangeville, on “ Pathological Relations of
Spleen and Bone Medulla ;” Dr. Sweetnam, of Toronto,
on “The Probable Future of Electricity in Gynecology ;”
Dr. Anglin, of Kingston, on “ Cases of Typhoid Fever
with Perforation of the Bowel;” Dr. McPhedran, of
Toronto, on “ Abortive Forms of Typhoid ;” Dr. Ryer-
son, of Toronto, on “Some Forms of Headache ;” Dr.
Dickson, of ‘Toronto, on “ A Plea for Electricity in Med-
icine ;” Dr. McKinnon, of Alvinston, on “ Alcoholic
Stimulants as Regards Quality.”
[July 20, 1889
GENERAL SESSION.
Dr. ALLAN Barnes, of Toronto, opened an interesting
discussion on obstetrics with the subject
LACERATION OF THE PERINEUM.
Drs. Barreck, of Toronto, Fenwick, of Kingston, A. H.
Wright, of ‘Toronto, and Howitt, of Guelph, followed in
the discussion.
The evening session opened with the discussion in
therapeutics, opened by Dr. ‘Thorburn, of Toronto, on
THE USES AND ABUSES OF ANTIPYRETICS,
in which Drs. J. L. Davison and Wishart, of Toronto,
took part.
After the reception and discussion of the reports of the
various committees had taken place, the report of the
Nominating Committee was presented, and by its unani-
mous adoption the following officers were elected :
President—Dr. J. Algernon Temple, ‘Toronto; Vice-
Presidents—ist, Dr. Lundy, Preston; 2d, Dr. Shaw,
Hamilton ; 3d, Dr. Fenwick, Kingston ; 4th, Dr. Hanley,
Waubaushene ; General Secretary—Dr. D. J. Gibb
Wishart, Toronto ; Assistant Secretary—Dr. W. P. Casen,
‘Toronto ; Zreasurer—Dr. E. J. Barreck, Toronto.
The report of the Treasurer showed an income for the
year of $625. The newly elected president, Dr. Temple,
of Toronto, was then conducted to the chair, and the
Ninth Annual Meeting was brought to a close.
KENTUCKY STATE MEDICAL SOCIETY.
Thirty-fourth Annual Session, held at Richmond, Ky.,
May 8, 9 and 10, 1889.
Dr. L. S. MCMURTRY, OF DANVILLE, PRESIDENT, IN THE
CHAIR.
THE attendance was good, and the meeting from the first
promised to be an unusually good one. Reports of the
Secretary, Treasurer, Committee on Arrangements, and
other committees were briefly made. Ex-Governor James
B. McCreary was present and made a speech, in which he
extolled the medical profession very highly. He had
served with them in the pursuits of peace and of war, in
the legislative halls of the State and nation, had yielded
his place in the gubernatorial chair to a doctor, and one
of this profession, from his own city of Richmond, now
occupied the office of Chief Justice of the United States.
On motion, it was voted to appoint a Committee pf Ref-
erence in each county of the State to see to the
ENFORCEMENT OF THE NEW MEDICAL LAW,
by proceeding against all violators, and to use the money
in the treasury of the Society for the prosecution of these
offenders.
On motion, the national formulary was indorsed. A
committee, consisting of Drs. J. G. Carpenter, of Stanford,
Steele Bailey, of Stanford, and H. Hunt, of Lexington,
was appointed to attend the meeting of the Pharmaceu-
tical Association at Crab Orchard, May 15th.
A motion to hold the vote for officers with closed
doors and by ballot, instead of committee, was voted down.
OFFICERS ELECTED.
President—John A. Ouchterlony, Louisville ; 1s? Vice-
President—William Jennings, Richmond; 2d Vice-Presi-
dent—R. L. Willis, Lexington; Permanent Secretary—
Steele Bailey, Stanford ; Assistant Secretary—John Young
Brown, Lexington ; Zreasurer—J. B. Kinnard, Lancaster.
Henderson was chosen as the next place of meeting, and
J. S. Letcher as Chairman of the Committee of Arrange-
ments.
On the first evening of the session an elegant hop was
given at the rooms of the Madison Club, and a banquet
was served at the Garnett House on the evening of the
second day. ‘The master of ceremonies was Dr. Jennings,
July 20, 1889]
THE MEDICAL RECORD. 77
of Richmond. ‘Toasts were responded to as follows:
“Our Guests,” ex-Governor McCreary, of Richmond ;
“ Medical Education,” Dr. Dudley S. D. Reynolds, of
Louisville ; “The Young Doctor,” Dr. J. M. Mathews,
Louisville ; “‘‘The American Doctor,” Dr. W. H. Wathen,
Louisville ; “ The Kentucky Doctor,” Dr. L. S. McMurtry,
Danville; “ The Absent Ladies,” Dr. O. D. ‘Todd, of
Eminence. ‘The banquet was a success.
Greetings were sent the Michigan and Kansas State
Medical Societies, then in session.
The attendance was very general from all parts of the
State. Several prominent gentlemen at Louisville were
not there, having been detained by the Louisville races.
Dr. Ap MorRGAN VANCE made an interesting discourse
on the subject of
THE ART OF ASEPSIS.
He showed the paraphernalia of the art and a very con-
venient case to carry when making calls or going into the
country.
The report on
MEDICAL ETHICS
was made by Dr. Dup_ey S. REYNOLDS, of Louisville. He
had looked into the requirements of this and other medical
societies and found them quite exacting. Ethics are not
law. ‘The ethical penalty is censure, expulsion, ostracism.
Ethics have no control over a man’s property or personal
nghts. He thought the Code of Ethics excellent, and that
the Secretary should place in the hands of every member
of the Society a copy, and send it into the counties where
there was no society.
Dr. LARRABEE, of Louisville, had never heard that hydra-
headed monster, medical ethics, made so pleasant as by
Dr. Reynolds. He considered ethics the conduct of
gentlemen. If a man is a gentleman he will need no
ethics. If not a gentleman, ethics will not make him one.
The report on
OPHTHALMOLOGY
was made by Dr. S. G. DaBNeEy, of Louisville. The ad-
vance during the past year, though nothing brilliant, had
been steady. Cocaine has fairly held its own. ‘The
cataract operation with indectomy was carefully discussed,
also antiseptics in eye practice.
ACUTE TRAUMATIC TETANUS
was the subject of a paper by Dr. R. C. McCuorp, of
Lebanon. He related some cases, and gave the results of
treatment. He considered bromide of potash the best
of all known remedies.
Dr. F. H. CLARKE, of Lexington, had had half a dozen
cases in his practice, and all proved fatal. He believed
all cases traumatic.
Dr. AP MorGaNn VANCE, of Louisville, had seen a good
many cases of traumatic tetanus, but never saw but one
get well, which case he reported.
Dr. J. G. CARPENTER, of Stanford, favored nourishing
his patients. He kept them drunk on whiskey, so as to re-
lax the spasms. One ounce of bromide of potassium in
twenty-four hours had cured many cases.
Dr. J. G. Brooks, of Paducah, reported a case of trau-
matic tetanus which occurred in his practice while in the
Hawaiian Islands. ‘The subject was a Chinaman, who
was nearly dying, and it was a case demanding kill-or-cure
treatment, as the man was suffering terribly and begging
to be killed. He gave him five grains of morphia, hypo-
dermically. The next morning he was awakened by a
crowd of Chinamen, who announced to him that the man
wasmuch improved. ‘Two years later he was still all nght.
Dr. J. A. LARRABEE, of Louisville, said that he had
had nine cases, four successful, and all children. He thor-
oughly believed that any case would yield to bromide of
potassium, provided the remedy was given in sufficient
dose. To the educated physician dosage is simply a
botheration. He knows the physiological action and
a for results. The pathology of the disease is un-
own.
Dr. Dubey S. REYNOLDS, of Louisville, was surprised
to hear that any one thought the pathology of traumatic
tetanus unknown. It was settled at the Second French
Congress of Surgery, which met in Paris in 1886, by Pro-
fessor Cornil, who presented the streptococcus as the
cause, and his demonstration was so perfect that the Con-
gress coincided totally with his belief. This great dis-
covery should not be passed over lightly.
Dr. J. M. MATTHEWS, of Louisville, thought the pa-
thology of traumatic tetanus still very unsettled. He be-
lieved there was more tobe learned by the report of
cases. In one case he had given bromide of potassium,
in sixty-grain doses, every second hour, for seven days,
and continued the dose at greater intervals. At the end
_of three weeks the patient was able to go home.
THE MANAGEMENT OF WOUNDS
was the subject of a paper by Dr. C. C. SKINNER, of
Louisville. He favored irrigation.
Dr. T. Hunt Stuckey, of Louisville, thought that in
some cases, circumcision for instance, irrigation favored
cedema. He thought the dry dressing better in this case.
THE REPORT ON OTOLOGY
was made by Dr. J. M. Ray, of Louisville. He thought
that medical men were now giving more time and atten-
tion to ear diseases. Many still treat the ear without
giving the nose and throat especial study. The death of
prominent men from diseases of these parts has called at-
tention to these troubles.
Dr. J. G. CARPENTER, of Stanford, thought the more
aseptic and antiseptic we were the sooner will these
troubles heal.
Dr. Jonn Younc Brown, of Henderson, renorted a
case of
OPERATION FOR IMPERMEABLE STRICTURE.
Dr. J. M. FOSTER, of Richmond, thought that the time
was near when external urethrotomy would be a more
common operation.
Dr. A. W. JOHNSTONE said, Coxe’s operation, though
difficult, was not so much so as most men thought. He
had made it three times, and all patients were living. A
little courage was necessary. He was in favor of the use
of the aspirator and trocar in some cases. °
Dr. W. L. Ropman, of Louisville, favored the use of
the aspirator
‘“‘ Ovarian Prolapse ” was the subject of a paper by Dr.
E. S. McKee, of Cincinnati.
A CASE OF TUBAL PREGNANCY WHICH ADVANCED TO TERM
WITHOUT RUPTURE
was the subject of a report by Dr. A. Dixon, of Hender-
son. The case was one of exceptional difficulties of diag-
nosis. There was an enlargement which he thought
an ovarian cystoma. He determined to make an ex-
ploratory laparotomy, and, to his surprise, opened up a
sac which contained a macerated fœtus at full term. ‘The
post-mortem showed a case of tubal pregnancy, with no
trace of anvrupture. ‘The case was a very rare one, and
some deny the possibility of such occurring.
A case of “ Tubal Pregnancy” was also reported by
Dr. Charles M. Mann, of Nicholasville. His case re-
sulted fatally, and a post-mortem was held.
A CASE OF EXTRA-UTERINE PREGNANCY
was reported by Dr. J. B. Evans, of Riley’s Station. He
was of the opinion that the ovule can become impreg-
nated before it reaches the Fallopian tube, and then get
into the abdomen. He believes the Fallopian tube can
be contracted till it will admit of the passage of the
spermatozoids, but not of the ovule. He reported a case
of extra-uterine pregnancy in which a patient suffered
long with peritonitis, and passed foetal bones and other
structures per rectum.
Dr. W. H. WaTHEN thought the case of Dr. Dixon
unique, and could not see how it could possibly occur
78 THE MEDICAL RECORD.
that an extra-uterine pregnancy could be carried in the
tube for this length of time. The tube walls are so thin
and weak that by the twelfth week the tube ruptures, and
the foetus escapes into the abdominal cavity. He was
sorry that Dr. Dixon did not make a thorough examina-
tion of the lining of the sac. He agreed with Tait that
there was no possibility of an extra-uterine pregnancy un-
less 1t occurred in the tube, with possibly a chance for an
ovarian pregnancy. It is utterly ridiculous to talk of an
abdominal pregnancy occurring primarily. It has never
occurred, and it never will occur. Extra-uterine preg-
nancy is tubal primarily. We have the electrical treat-
ment and the operative treatment. He does not believe it
possible to absolutely diagnose extra-uterine pregnancy
before the twelfth week. “It is mere guess-work before
this time. He reported cases where physicians had fallen
into error in diagnosing extra-uterine pregnancy when it
was intra-uterine. He argued against the treatment by
electricity, and said the only treatment was, when rupture
occurs, operate at once and treat the case antiseptically.
If it does not rupture, then laparotomy is the treatment.
Dr. J. G. CeciL could not understand how it was pos-
sible for Dr. Dixon’s case to go on ashe thinks it did. He
thought a very fine dissection and microscopical examina-
tion would be necessary to substantiate the diagnosis.
He could not agree with Drs. Wathen and Tait that there
can be no primary cause of abdominal pregnancy. Un-
doubted cases areon record, and Tait is aware of them but
fails to refer to them in his book. He thought the only
thing which could be done was to perform abdominal
section. The subject was further discussed by Drs. J. M.
Foster, of Richmond, and E. S. McKee, of Cincinnati.
THE REPORT ON THE PROGRESS IN OBSTETRICS
was made by Dr. J. G. Ceci, of Louisville. He dis-
cussed in an able manner antiseptics in obstetrics, the
delivery of the aftercoming head, in which he would
hasten the delivery of the head with the forceps, even at
the expense of the perineum and cervix. He discussed
the third stage of labor, and the methods of Crédé and
Ahlfield. He mentioned Berry Hart’s theory, and recom-
mended a compromise between Crédé and Ahlfield. He
waits till the placenta separates, then, if there is any delay,
uses Crédé’s method. He discussed Czesarean section
vs. Ovaniotomy, and quoted from Busey’s paper that the
former was proper in all cases where the child was living.
He favored abdominal section over electricity in extra-
uterine pregnancy.
THE REPORT ON GYNECOLOGY
was made by Dr. W. H. WaTHEN, of Louisville. He con-
fined his remarks to pelvic hematocele. He referred to
the generally accepted definition of hematocele, viz., blood-
tumor in the pelvis encapsuled within or without the peri-
toneal cavity. He said that all pelvic heematoceles were
extra-peritoneal, and thus it is not possible for hemorrhage
into the peritoneal cavity to become rapidly encysted so
as to form a fixed tumor in the pelvic or the abdominal
cavity ; that the blood is mixed with lymph and coagu-
lates so slowly that it is not confined in any one place in
the cavity, but changes its position upon the movements
of the body, obeying the laws of gravitation; that the
blood could not be confined by a layer of effused lymph
immediately above it; and that, if the hemorrhage into
the cavity is at all considerable, death would probably
result before it could be confined by adhesions of the
superimposed intestines. Intra-peritoneal hemorrhage is
nearly always fatal. Mr. ‘Tait has seen nearly one hun-
dred cases, and they all died except two, upon whom he
did abdominal section. He referred to the fact that the
blood never becomes encysted in intra-peritoneal hemor-
rhage from defective ligation in laparotomy for removal of
the tubes, ovaries, etc. He gave as causes of encapsulated
hzmatocele sudden metrostaxes of normal menstruation
or of pseudo-menstruation following abdominal or pelvic
operations and rupture of a tubal pregnancy. He said
[July 20, 1889
that intra-peritoneal hemorrhage is really always caused
by primary or secondary rupture of ectopic gestation.
‘The tumor may extend out of the pelvis, and even as
high up as the umbilicus, in extra-peritoneal hzmatocele.
The peritoneum is a tough and elastic membrane, not
readily ruptured, yet so easily separated from its attach-
ments that hemorrhage in the loose pelvic connective-
tissue may dissect up the tissue under the peritoneum be-
tween the broad ligaments, between the rectum and vagina,
from around the rectum, from the sides of the pelvis, and
from the anterior abdominal wall. In hemorrhage into
the cavity of the peritoneum no well-defined tumor or
fixation of the uterus can be felt in a bimanual examina-
tion; while in pelvic hematocele the symptoms are nearly
pathognomonic.
He gave the symptoms and diagnosis of hzmotocele,
and advised against surgical interference, unless the sac.
ruptures into the peritoneum or suppuration is imminent.
If the fluctuation can be detected from below, he recom-
mended making an opening giving free drainage in the
vaginal vault, and if fluctuation is well marked above the
pelvis, or ruptures occur into the peritoneum, an ab-
dominal section should be done.
LARYNGEAL SYPHILIS
was the subject of a paper read by Dr. A. B. ‘THRASHER,
of Cincinnati. He said little difficulty would be experi-
enced in the majority of cases, but occasionally the most
skilful diagnosticians would be puzzled. The diseases
most likely to be confounded with syphilis of the larynx
are tubercle, cancer, and lupus.
In tubercle, and especially cancer, there 1s more pain
than in syphilis. In cancer the pain is lancinating and
radiates to the ear, and may be felt at any time. ‘The voice
is more changed in cancer and tuberculous disease. The
classical pathognomonic syphilitic voice is usually more
easily recognized when the acute observer has detected
syphilis previously. Cough is much more pronounced in
phthisis than in either the other conditions. Deglutition
is more impeded in tuberculous or cancerous ulceration.
The syphilitic ulcer develops rapidly in a few days, the
cancerous requires weeks, and the tuberculous months.
Syphilis attacks, preferably, the upper surface of the epi-
glottis, tubercle the under surface, cancer the ventricular
band. In syphilis there is a solitary serpiginous ulcer
with sharp edges, surrounded by an areola of hyperzemia ;
in tubercle there are numerous small, shallow ulcers, or
these have run together forming a large ulcer with ragged,
“nibbled ” edges; the cancerous ulcer appears on the
summit of an angry tumor, and is surrounded by highly
inflamed tissue. In tubercle there is, as a rule, anemia
of pharyngeal and laryngeal mucosa, while hyperzemia is
the rule in the other affections. Enlargement of cervical
glands, anterior and posterior, is an indication of syphilis,
and is either absent or not so marked in the other affec-
tions. Lupus of larynx might be mistaken-for syphilis,
yet the disease is so rare as not to fall within the observa-
tion of most laryngologists. When the only manifestation
of lupus is in the larynx the administration of anti-syph-
ilitic remedies might be required to insure the diagnosis.
THE REPORT ON SURGERY `
was made by Dr. W. L. Ropman, of Louisville. The
doctor in looking over the work in this department dur-
ing the past year found himself surrounded by an embar-
rassment of riches. Senn’s hydrogen-gas test he considered
conspicuously the most brilliant, as it is perhaps the most
useful. Gas finds its way out of the wound if there. be
perforation, and burns with a bluish flame. The twelve
propositions of Senn were given. Senn’s discovery has
greatly increased the interest in penetrating wounds of
the abdomen, and in the results we find much to cheer
us. Suprapubic lithotomy has gained much in favor dur-
ing the past year. Epicystotomy has every advantage
for tumors and foreign bodies. ‘The new cystoscope of
Neitz and Leiter has rendered the diagnosis of tumors of
the bladder comparatively easy. In cystitis of the female
July 20, 1889] THE
More Madden, of Dublin, has recommended the dilatation
of the urethra, then curette the proliferating mucous mem-
brane and apply carbolic acid over its entire surface. In
iliac abscess it seems that early operation promises the
most. Dermoid cyst of the neck has been recently oper-
ated upon by Keetley, of London, by cutting away a por-
tion of the cyst-wall suturing it to the neck, and stuffing it
with gauze after cleansing it thoroughly. This has re-
sulted well in his hands, and is certainly quicker and safer.
Whitehead’s method of operating for piles has here
and there gained an earnest advocate, but will hardly
supersede the ligature. Piles with prolapsus can perhaps
be operated upon by Whitehead’s method with the best
advantage. Alexanders operation has fallen into disuse.
It can only do good in cases of retroversion with fixation.
Dr. Dudley, of New York, has recently described a new
operation for rupture of the perineum. In the treatment
of carbuncles Edmund Owen, of London, uses erasion.
He cuts away all slough and undermined skin, scrapes
thoroughly with a Volkmann’s spoon, and dresses it anti-
septically. In this way a painful and septic mass is con-
verted into a painless and aseptic one. Excision of car-
buncles is advocated by Gerster and others. The doctor
considered it probably the best means of treating them.
Cooles, of Dublin, has shown that changing from the
honzontal to the sitting posture in injuries to patients
with fracture of the bones of the lower extremities is
very injurious. A new treatment of aneurisms has been
suggested by Macewen. It consists of the introduction
of needles into the sac till they reach the endothelial
lining of the opposite .wall. The oscillation of the
needle scratches the endothelium and causes prolifer-
ation of the leucocytes, which are said to form a firm,
fibrous mass. Pneumonotomy is gaining laurels for pul-
monary abscess, fifty per cent. of the cases being success-
ful. Pneumonectomy has met with such success in the
lower animals that it is recommended in man. One lobe
or a lung may be excised. It is thought that the mini-
mal respiratory area compatible with life and health
amounts to two pulmonary lobes. ‘The past year has
witnessed many sharp discussions as to the comparative
merits of ether and chloroform. ‘The latter has not suf-
fered by the comparison. It is not desirable that one
should supplant the other, as we need them both. One is
good in some cases and inferior in others.
RECENT ADVANCES IN THE DIAGNOSIS AND TREATMENT
OF TUBERCULOSIS
was the subject of a paper by Dr. F. C. Witson, of Louis-
ville. He referred to the frequency and distribution of
the disease and the various methods of treating it, and the
numerous instruments and apparatus for the same. He
discussed Weigert’s method of treating tuberculosis by
breathing air at a temperature of 400 or 500 degrees Fah-
tenheit. He considered the ability of the patient to do
this without harm to the tissues a marvel, but it was never-
theless true. He had not yet tried it, but he meant to do
so. He favored the disinfection of every particle of the
sputa, and great care to avoid infection of nurse or hus-
band or wife.
Dr. J. N. McCormac, of Bowling Green, insisted cn the
disinfection or destruction of the sputa. For some time
the Kentucky State Board of Health, of which he is sec-
retary, has been distributing both to the laity and physi-
clans, literature to the effect that tuberculous patients
should be isolated and the sputa destroyed or disinfected.
It is preferable to have the patient expectorate on paper
and then burn the paper.
Dr. J. A. LARRABEE, of Louisville, thought if the con-
tagion was so great as described we should have more
cases, especially of physicians who are treating laryngeal
phthisis. At Brompton Hospital there are 4,000 persons
treated annually, and no one of the physicians or nurses
has contracted the disease. Mouth-breathing he thought
one of the great causes of tuberculosis, that is, the shallow
breathing which follows mouth-breathing.
MEDICAL RECORD.
79
THE TRANSMISSIBILITY OF TUBERCULOSIS
from the lower animals to man was the subject discussed
by Dr. J. A. OucHTERLONY, of Louisville, in a paper of
considerable length and learning. This question was in-
timately connected with the subject of the infectiousness
of the disease. ‘The power of the bacillus to resist anti-
septics is astonishing. Corrosive sublimate does not de-
stroy the bacillus, even at the strength of 1: 500. The
theory of inheritance has been thoroughly shaken by the
discovery of the bacillus. Tuberculosis is rarely if ever
congenital, but acquired. Ifthe former theory were true,
the prospects of the removal would be remote indeed. If
the latter be true, the prospects for the eradication of the
disease are bright. We have clinical proof also that the
disease is not congenital. The object of the paper was
to show that tuberculosis could be transmitted from the
lower animals to man. ‘There can be no security from
tuberculosis so long as tuberculous meat and milk are used.
The disease is contagious, infectious, and not congenital.
It is transmissible, especially through the alimentary canal
and respiratory tract. Rabbits kept near tuberculous pa-
tients contract the disease in twenty-seven days. Rabbits
suspended in cages so as to breathe the air exhaled by tuber-
culous cattle contract tuberculosis. ‘The lungs are the
primary seat of the infection. It may be contracted
through the integument, mucous membrane, abraded epi-
dermis, wounded and abraded surfaces. ‘Tuberculosis in
dumb animals is identical with tuberculosis in man.
Transmissibility to other species is very frequent. ‘The
medical profession should inform the public of the condi-
tion of affairs and insist on the control of the meat and
milk.
Speeches warmly commending the ideas presented in
this paper were made by Drs. Reynolds, McCormac, and
Carpenter ; and on motion a committee, consisting of Drs.
J. N. McCormac, Bowling Green; Dudley S. Reynolds,
Louisville ; John A. Ouchterlony, Louisville ; and Wm.
Bailey, Louisville, was appointed to bring this subject be-
fore the public.
THE IMPORTANCE OF RECTAL EXAMINATIONS TO LIFE IN-
SURANCE COMPANIES
was a subject dealt with by Dr. JosePpH M. MATTHEWS, of
Louisville. He considered it of great interest to life-in-
surance companies, and to those insured in them, that the
examination be as thorough as possible. Most companies
understand this, and have a long list of questions and ex-
aminations through which the applicant must go before he
is admitted. No company, to his knowledge, requires a
rectal examination. Many rectal diseases are incurable,
and often fatal. The only thing the insurance companies
do is to, in some instances, ask the question, Have you had
piles or fistulz. Piles and fistule are generally not very
serious to life, and some other rectal diseases are. ‘The
doctor reported a number of cases which had come under
his observation where insurance companies had lost money
after a short period of insurance by neglecting the pre-
caution of having a rectal examination made. The re-
sponsibility of the medical examiner for life insurance is
a very grave one, and is too often overlooked. ‘There are
diseases affecting this portion of the body which are wholly
unrecognizable save by a careful examination and the ex-
ploration of the rectum. ‘There are diseases self-limited,
incurable, and always fatal. The interim between their
incipiency and full development is so vaguely marked, and
the insidiousness so obscure, that nothing less than a full
exploration will reveal their nature. If in this interim
the patient were to apply for a life insurance policy he
_would probably be received into the company.
Dr. F. C. Witson, of Louisville, thought it a delicate
matter to ask this examination. It was with great reluc-
tance that examination of the urine was introduced, but
now no first class company fails to ask it, and it has saved
them much money. He favored a middle ground. Ques-
tion the patient, and if anything was found indicating
trouble of this nature then make the examination.
$0
THE PROGRESS MADE IN THE ENFORCEMENT OF THE
NEW MEDICAL PRACTICE ACT
was the subject of a paper read by Dr. J. N. McCormac,
Secretary of the State Board of Health. This has proven
one of the most popular general laws ever passed in the
State. Registration in most of the counties had been
complete. Large numbers of charlatans, being unable to
comply with the verv reasonable and conservative pro-
visions of the statute, had been compelled to leave the
State, and scores of irregulars from all parts of the Union
had been refused permission to practise in Kentucky.
As was to be expected, the principal difficulty in its en-
forcement will occur in Louisville. ‘The physicians of
that city are making an organized effort to secure its strict
enforcement, and there can be little doubt as to the final
result. After the first of January he would publish an
official medical directory of the State, giving the name,
age, place of birth, address, and place and date of gradua-
tion of each physician in the State.
At the conclusion of the report the Society appropriated
all the surplus in the treasury to be used, if the necessity
occurs, to assist the physicians of any county where the
law might be resisted, in enforcing its provisions.
“Syphilitic Ulceration of the Upper Air-passages ” was
the subject handled in an excellent manner by Dr. M. F.
Coomes, of Louisville.
“ Report on the Progress of Medicine” was made by
Dr. J. W. Gilbert, of Lawrenceburg.
“ Laparotomy for Penetrating Shot-wound of the Abdo-
men,” by Dr. David Barrow, of Lexington.
“The Report on Vital Statistics” was made by Dr. T.
B. Greenley, of West Point.
Correspondence.
OUR LONDON LETTER.
(From our Special Correspondent.)
ABDOMINAL PALPATION OF THE PLACENTA —OPERATIVE IN-
TERFERENCE FOR SUPPURATION IN THE NEIGHBORHOOD
OF THE CÆCUM—THE CROONIAN LECTURES AT THE
COLLEGE OF PHYSICIANS—THE RELATIONSHIP BETWEEN
CHEMICAL STRUCTURE AND PHYSIOLOGICAL ACTION—
SHORTHAND FOR MEDICAL STUDENTS—DEATH OF DR.
WOOLDRIDGE—DR. QUAIN, F.R.S.
Lonpon, June 18, 1889.
AN interesting subject was discussed at the last meeting of
the Obstetrical Society, viz., the possibility of determining
the position of the placenta by means of abdominal palpa-
tion, and especially in cases of placenta previa. A paper
on the subject was read by Dr. Herbert Spencer, Assist-
ant Obstetric Physician to University College Hospital.
‘Two cases were described in which the author had been
able to determine the site of the placenta by abdominal
palpation, when it was situated in the upper segment of
the uterus, and seven cases of placenta previa were then
described, in which the author had been able by abdominal
palpation to diagnose the presence of the placenta in, or
its absence from, the front wall of the lower segment of
the uterus before a vaginal examination was undertaken,
the diagnosis being verified afterward by vaginal and intra-
uterine examination. All the seven cases were those of
multiparz, with head presentations, and the observations
were made before the membranes were ruptured, without
anzesthesia, and in the absence of pains. In three of the
cases the exact site of the placenta on the front wall of
the lower segment was ascertained by this method, and in
two of these the placenta was felt at a time when it was
impossible to feel it by the vagina. In the other four
cases the placenta was diagnosed by abdominal palpation
to be absent from the front wall. Dr. Spencer recom-
mended that the examination should be made with the
patient lying on her back, the bladder having previously
THE MEDICAL RECORD.
— ——— ee a e o a m a e e m ——=— mA a
[July 20, 1889
been emptied ; that it should be gentle, made in the ab-
sence of pains, and prolonged over several minutes, or, if
necessary, repeated. The following conclusions had been
arrived at by the author : In an ordinary vertex presenta-
tion (placenta in the upper segment), the occiput, fore-
head (at a higher level), and side of the head could,
under favorable circumstances, be distinctly felt in the
lower segment of the uterus by means of abdominal palpa-
tion. In a case of placenta previa in which the head
presented, the head was not felt where the placenta was
situated, but was distinctly felt where the placenta was
absent. When in front, the placenta was felt as an
elastic mass of the consistence of a wetted bath-sponge,
which kept the examining fingers off the head. Its edge
might be felt, and had the shape of the segment of a
circle. Within the circle all was obscure to the touch;
outside the circle the head or other part of the child was
plainly felt. Impulses to the head were not clearly felt
through the placenta ; impulses to the head through the
placenta were distinctly felt at the spot from which the
placenta was absent. The same applied to combined
vaginal and abdominal examination.
A somewhat wandering discussion followed the reading
of Dr. Spencer’s paper. Dr. Braxton Hicks remarked
that in one case of placenta przvia he had diagnosed the
position some weeks before it was confirmed during de-
livery. Dr. Barnes said it had been observed that when
the placenta was seated in the upper zones, and in front
of the uterus, the uterine wall was thickened, and raised
at the area of placental attachment, forming a hillock,
which rose above the level of the smooth surface of the
uterus. This was also confirmed by auscultation. Dr.
Mathews Duncan said he had never succeeded with
placental palpation. Placenta przvia was not the best
condition to study it; far more favorable were the con-
ditions of advanced healthy pregnancy in a multipara
with a relaxed uterus and a thin abdominal wall. Dr.
Champneys remarked that the value of Dr. Spencer’s
paper lay in the subsequent verification of the diagnosis
made by palpation, though the cases were few. He be-
lieved auscultation was no guide whatever to the situation
of the placenta. Dr. Herman observed that such
placenta as those described by Dr. Spencer were the ex-
ception, and, as Müller had demonstrated, were generally
thinner than usual and expanded.
At the last meeting of the Medical and Chirurgical Society
an interesting communication was made by Sir Dyce Duck-
worth and Mr. John Langton. A boy was admitted into
hospital with symptoms indicative of acute suppuration in
the neighborhood of the cecum. An operation was per-
formed and the appendix vermiformis (which was gangre
nous and also contained a fecal concretion) was removed.
Some days later, in consequence of symptoms pointing to
a fresh suppurative peritonitis on the left side, a median
laparotomy was performed, and a collection of several
ounces of pus was found in a large cavity bounded by ag-
glutinated intestines. ‘The abscess cavity extended deeply
into the pelvic cavity. ‘The patient made a complete,
though tardy, recovery. ‘The authors urged the impor-
tance of early operation when suppuration in the neighbor-
hood of the cæcum was suspected, and the more so in
cases of young adults as the cause was often the presence
of some foreign substance in the appendix. They also
spoke of the value of making the incision in the nght
linea semilunaris, as being more directly situated over the
seat of the lesion than one made in the middle line.
The Croonian Lectures at the College of Physicians
are now in course of delivery, Dr. Lauder Brunton being
the lecturer for the present year, and the subject chosen
by him being “ The Relation between Chemical Structure
and Physiological Action.” In his first lecture he em-
ployed two homely similes to illustrate how either a re-
arrangement of, or a trifling alteration in, the chemical con-
stituents of an organic compound might greatly change its
nature. A closed pocket-knife was, he said, a harmless
plaything ; by opening one of the blades it was converted
July 20, 1889]
into a dangerous weapon. ‘The composition of the knife
was exactly the same as before, but the relation of the parts
to one another had been altered. Soin chemistry, an alter-
ation in the relation of the parts converted the compara-
tively harmless nitrile into the deadly isonitrile or carbyla-
mine. By means of graphic formulz we could represent
diagrammatically the relative position of the atoms in a com-
pound. Comparing ordinary formulz with words, the lect-
urer remarked that, as with a comparatively small number
of letters of the alphabet we were able to form a great num-
ber of words and to represent a great number of ideas, so,
with a small number of elements we could form many com-
pounds. Slight alterations in the composition of words,
the introduction or abstraction of a single letter, would
often completely change their meaning, and slight altera-
tions in chemical substances would change their proper-
ties. By altering the arrangement of the letters we con-
verted “room” into “moor,” and thus got a very different
idea. By making a slight addition to “ moor” we got
“ Moorish,” a word which, instead of conveying a sense of
bleakness and coldness, brought before the mind ideas of
oriental grandeur, sunshine, and activity. Similarly, in
studying the physiological action uf various chemical sub-
stances, we found that while usually certain alterations
or additions only modified the action of the radical to a
slight extent, yet now and again we met with cases where
slight modifications produced an altogether unexpected
effect. Thus sodium acetate had a very slight physiolog.
cal action, but when one atom of hydrogen in the acetic-| prolific nature of these animals.
acid was replaced by bromine the result was mono-bromo-
acetate of soda, which had a most remarkable action upon
the muscles of the frog, rendering them rigid. Another
example was phenol and aniline, both of which were mark-
edly poisonous, but ortho-amido-phenol was innocuous.
The value of shorthand to medical students was recently
brought before the General Medical Council by Sir Dyce
Duckworth, who, however, was not the best advocate that
could have been chosen, seeing that he is not himself a
stenographer. With a view to ventilating the subject
more fully, however, a committee has been formed, con-
sisting of Sir Dyce Duckworth, Mr. Howard Marsh, Dr.
Gowers, and Dr. Coupland. Some, at least, of these gen-
tlemen are experienced shorthand writers. It is proposed
to hold voluntary examinations among medical students
and to offer prizes for proficiency.
I regret to record the very sudden illness and death of
Dr. Wooldridge, Assistant Physician to Guy’s Hospital,
at the early age of thirty-one. Dr. Wooldridge was a
Doctor, both of Science and of Medicine, of the Univer-
sity of London, and was favorably known as a rising phy-
siologist.
Dr. Richard Quain, F.R.S., the projector and editor of
“Quain’s Dictionary of Medicine,” has been appointed
Physician Extraordinary to the Queen.
OUR PARIS LETTER.
(From our Special Correspondent.)
GOOD NEWS FOR THE OLD FELLOWS—HOW TO MAKE THE
OLD YOUNG AGAIN—REJUVENATION FROM HYPODER-
MATIC INJECTION OF TRITURATED TESTICLES-—A NEW
THEORY REGARDING MASTURBATION—LAVAGE OF THE
PERITONEUM—THE ANTISEPTIC PROPERTIES OF THE
HYDROCHLORATE OF PHENYLHYDRAZINE.
Paris, June 28, 1889.
PROFESSOR BROWN-SEQUARD has lately made a most
extraordinary communication to the Société de Biologie
of Paris, and to the Academy of Sciences, to the effect
that he had obtained marvellous results by the injection
into the subcutaneous cellular tissue of a liquid produced
by the trituration of the testicles of young animals. M.
Brown-Séquard declared that during the last ten years his
general vigor had notably diminished, even more so than
he had reason to expect, although he is in his seventy-third
year. He was obliged to sit down after half an hour’s
THE MEDICAL RECORD.
81
work in a standing position in his laboratory, which he
always left completely exhausted after having worked for
two, three, or four hours in a sitting posture. To the
great astonishment of all his assistants, he was able
to work for nearly four hours, without feeling the neces-
sity to rest himself, after the second injection that he had
practised on himself ; the bladder and the large intestine
had also notably gained in strength. With the dynamom-
eter he ascertained an incontestable augmentation of the
strength of the limbs. Although he is now submitted to
greater causes of fatigue than formerly, in the laboratory,
he is no longer obliged, as was his wont, during the last
ten years, to lie down, after meais which he took rather
hastily in returning from his work of experimentation.
Moreover, he affirmed that his intellectual work has be-
come more easy, and that he has regained in this respect
all that he had lost for several years. In other respects,
also, he experienced a rejuvenescence of all his forces,
physical and psychic, forces which had not been lost, but
diminished, owing to advancing age. In short, he found
himself possessed of the same vigor as he had enjoyed
thirty years before. ‘This communication has caused some
sensation in the medical and lay press, and it has been
pertinently asked by some writers in the latter why Pro-
fessor Brown-Séquard gave the preference to the testicles
‘of the guinea-pig to those of other animals for the com-
position he employed for the subcutaneous injections, and
one of them suggested that it was perhaps owing to the
At a subsequent meet-
ing of the Society, Dr. Brown-Séquard endeavored to prove
that the activity of the spermatic and physical and psy-
chical vigor are connected, and in cases of senile impo-
tence he.recommends masturbation, to be practised once
or twice a week, but in an incomplete manner ; that is to
say, it should not be allowed to be followed by ejacula-
tion, although sufficient to produce some venereal spasm.
Dr. Brown-Séquard had recently occasion to recommend
this extraordinary practice to two gentlemen, one a solic-
itor and the other a notary, aged respectively fifty-eight
and sixty-five years, who complained of premature loss of
their venereal powers. ‘Their genital organs were in a
good state, and under the influence of this practice they
partially recuperated their physical and intellectual forces.
This result he could only attribute to the resorption by the
organism of the products of secretion of the spermatic
gland, but how long it will last, time alone will tell. This
communication, made by such an eminent physiologist,
was too much even for French modesty, and the lay press
in particular was most severe in its criticisms against the
author, condemning the remedy prescribed by him as
being unphysiological and immoral. One writer suggested
that Dr. Brown-Séquard ought to be reminded that senile
atrophy, at the decline of life, invades all the organs, being
a fatal consequence of the degeneration of the tissues of
the heart; and that it is not by inoculation, even with
the manufactured liquid extracted from the testicles of
the guinea pig, or any other animal, that one could hope
to remedy this alteration.
Professor Trélat lately submitted to the Academy of
Medicine the experimental researches of Dr. Delbet,
Prosector, on “lavage,” or washing out of the peri-
toneum. Dr. Delbet at first endeavored to determine
the extent of the peritoneum which is bathed by the liquid
in the lavage, then made an estimate of the quantity of
liquid which remains in the peritoneum. Under the in-
fluence of the lavage neither the respiration nor the cir-
culation appeared to be affected. Dr. Delbet then ascer-
tained that the absorbing power of the peritoneum was
considerable, liquids were absorbed with great facility
and rapidity in the first twenty or thirty minutes. The
liquid injected passes into the circulation, then, when the
blood is super-hydrated, this power is arrested. There is
then a moment which may be taken advantage of to pass
without danger toxic substances into the peritoneal cavity.
This view is absolutely confirmed by the following experi-
ment: ‘The author injected into the peritoneal cavity of a
82 THE MEDICAL RECORD.
[July 20, 1889
dog a solution of the sulphate of strychnine, the animal
was soon seized with convulsions and died in about five
minutes. In another dog he repeated the same experi-
ment after having previously injected a saline solution
composed of seven per cent. of the chloride of sodium;
the animal did not present any symptoms whatever of in-
toxication. This is owing to the fact that the serous mem-
brane, having absorbed the first liquid, could not absorb
the second. ‘The knowledge of this property of the peri-
toneum is important, and leads to the conclusion that it
will be possible, in surgical practice, to wash this mem-
brane with antiseptic substances, a practice that surgeons
had not dared to attempt till now.
Dr. Janet relates in the Courrier Médical a very grave
and very curious case of hysteria. At the age of twenty
years, a young girl who had already presented several
manifestations of hysteria, was affected with absolute
dysphagia. Nourished by a tube, she soon fell off in
flesh, as she rejected the aliments ingested. Dr. Janet
then treated her by hypnotism, and during the periods of
sleep he was enabled to make her eat, but while she was
awake the dysphagia returned. ‘The doctor then adopted
the plan of leaving her nearly all the time under the in-
fluence of the hypnotic sleep. There was created in this
girl a sort of double existence, waking and hypnotic sleep.
This latter existence appeared to get the better of her
and to substitute itself for the first personality. Since the
month of January last, this girl is under the influence of
hypnosis and feels quite well, following her occupations
as usual, and not suffering from dysphagia.
Dr. Marpmann draws attention to the antiseptic pro-
perties of the hydrochlorate of phenylhydrazine ; added
to milk in the proportion of 1 per 1,000, it preserves this
liquid several days. It may not be applied to the pre-
servation of alimentary substances, on account of its dis-
agreeable savor and its toxic properties, when it is em-
ployed in any quantity. ‘This antiseptic may replace the
bichloride of mercury in medical practice. It does not
precipitate milk, pus, albumen, gum, solutions of sugar,
and consequently it presents an advantage over corrosive
sublimate, which precipitates albuminous solutions.
CAN NASO-PHARYNGEAL CATARRH BE
CURED?
To THe Epitor or THe MEoIcAL Recorp.
sir: “B. R.” in THE MEDICAL Record of May 25th,
seems inclined to look on my question as displaying a
lack of appreciation of the many factors entering into the
causation and aggravation of naso-pharyngeal catarrh. I
will acknowledge the truth of his statements, but I think
the question admits of a more definite reply than the one
he gives, and if I interpret the ownership of the initials
aright, I think *‘ B. R.” himself can, from his own experi-
ence, give such a reply.
That every organ in the body has a greater or less in-
fluence on every other requires no medical knowledge to
assert. The amount and character of such influence in
the individual case does require this knowledge.
The exciting cause of catarrh being a common cold (of
course the predisposing cause, local or constitutional, is
presupposed), the continuing cause may be a local mal-
formation, chronic bronchial or pulmonic irritation, dis-
ease of the sexual organs, deficient activity of the ex-
cretory organs, feeble circulation with consequent cold
extremities, any continuing irritation of the mucous tract
below the pharynx, unhygienic habits gr surroundings,
which may be many and various, and, finally, the by no
means unimportant neurotic diathesis, which was the one
touched on in the case as stated in my first letter.
The continuing causes just enumerated are a few of the
more important (prominent, at least), though not at all
the only ones, considering, as was stated above, the im-
mediate corporeal and the scarcely less near physical and
spiritual (in the broad sense) environment.
Now, supposing all the more prominent complications
mentioned, save the last one—the nervous didthesis—to be
absent in a given case, what then would be the treatment ?
That there are not other factors, in even such selected
cases, aggravating the disease under discussion, it would be
folly to say ; but that the principal reason for the chronicity
of the trouble in some patients is the nervous diathesis
present, must, I think, be admitted.
Persons of such a type going to the more elevated dis-
tricts, and breathing the rarer, and, consequently, dryer
and more stimulating air, will find that any disease of the
respiratory organs from which they may be suffering will
be aggravated.
My own belief, of course, shared in common with
others, is that, in this type, the only course which promises
any amount of relief approaching to a cure lies in a
change of climate. A mild, equable climate in a region
near the sea, and near the sea-level, is the one to be
sought.
By such means the constantly high-strung nervous sys-
tem is placed in the least irritating surroundings, every
part of the system drops more nearly to a healthy normal
activity, and a little of nature’s great healer, rest, is ob-
tained by the mucous membrane of the nose and throat
along with the other organs.
But this is not medical treatment in the common ac-
ceptation, and not one patient in twenty is able to seek
the climate suitable to his condition.
What, then, is the best thing to do if the patient must
remain in the unfavorable climate? The question asked
of these specialists of much experience is not What would
you do with this class of catarrhs? but What do you do
with them ?
As a matter of course, treatment is not restricted to
local applications, but to be scientific must attack at any
point presenting appearances of vulnerability. We will
also predicate that it is the individual whom we are to
treat, and that the disease is not to be attacked in exactly
the same way we would attack an enemy trying to scale the
walls of a fort. Without further explanations I will say
that if any one is kind enough to reply to this, I hope that
he will not devote any time to dissecting my article, but
will charitably forego that easy pleasure and give his pen
entirely to the question asked. I would refer such a one
to my letter in THE MepicaL Record of May 18th for a
more explicit statement of the exact variety of naso-
pharyngeal catarrh about which inquiry is made.
G. P. Heap, M. D.
THE INTERNAL USE OF CHLOROFORM.
To THE EDITOR or THe MapicaL, RECORD.
Sir: Your editorial ‘“ On the Internal Use of Chloroform,”
in the No. for the 8th ult., and the many articles that
have lately appeared in the medical journals on that sub-
ject, all advocating the use of the remedy in small and
largely diluted doses, prompt me to call attention to an
article “On the Use of Chloroform as an Internal
Remedy,” by A. P. Merrill, M.D., of Memphis, in Zhe
American Fournal of the Medical Sciences, October, 1865.
Dr. Merrill advises its administration in large (teaspoon-
ful and even greater) doses and undiluted, in many cases
of disease, especially “in every kind of convulsive move-
ment,” and in the “ chill stage of all fever, in its most
fatal and epidemic form.” Let me quote a few passages
from this paper: “ Objection is sometimes made to the
introduction of unmixed chloroform into the stomach, on
account of its highly excitant quality. But expenence
proves it to be much less stimulating to the mucous mem-
brane than to the skin, and in no case have I observed
anything more than very temporary effects upon the
mouth and throat, which soon subside. ‘The vehicles we
are advised to employ in its administration can only hold
the remedy in temporary suspension, and in most of the
cases requiring large doses it is quite impossible for the
patient to swallow them. Sometimes a single drop falling
July 20, 1889]
into the folds of the neck will cause vesication, while a
fluidrachm passing into the stomach gives only a slight
inconvenience by its stimulation of the mouth and throat.
As in the administration of other remedies, the dose of
chloroform must be varied according to the nature of
the case, and more than with most other remedies may be
the range of quantities given. I have administered it in
doses of a single drop to two fluidrachms, and have
sometimes repeated it at short intervals; and L have
reason to believe that the cases of infantile convulsions
in which I have given from one-half to a full drachm,
might have been relieved in the inception of the disease
by fifteen or twenty drops. But when convulsions have
continued for an hour or more, the smaller doses will
have no perceptible effect. Indeed, relief in such cases
is obtained only by such quantity as will produce sleep.
The sleep continues from one to four hours, and 1s some-
times followed by great restlessness and jactitation for
an hour oF more, when the patient is at ease again and
sleep returns.” Dr. Merrill gives particulars of fourteen
cases in which a teaspoonful of undiluted chloruform
was successfully administered, and in some of them the
same dose was repeated in half anhour. The ages reported
in these cases vary from a child of a year and a half to
“an elderly lady, very fat and plethoric.” Of these four-
teen cases, five had convulsions, three had chills, two
were poisoning by strychnine, and one each of asthma,
sunstroke, epilepsy, and fit of cramp-colic. I will relate
Case VI. as a “specimen brick:” “ A child, aged about two
years, was taken with a convulsion while nding in a little
hand-carriage, supposed effect of a chill, although the child
had not had chills previously. When I arrived her mother
and others thought the fit had continued two hours. She
had been several times in a hot bath. Sinapisms had been
extensively applied, and a physician was administering chlo-
roform by inhalation without effect. ‘The pulse was hardly
perceptible, the eyes open and bloodshot, pupils dilated,
skin of a purple color, jaws clinched, fingers and toes tightly
drawn inward, and the whole frame severly convulsed. I
administered a teaspoonful of chloroform by the mouth, the
physician present admonishing me of the probable violence
to the mucous membrane and of her inability to swallow,
and a few minutes afterward as much more was given by
enema. Very soon she was quite relieved of all spasmodic
action, and in a sound sleep. A dose of calomel at night,
and quinine for several successive mornings, completed
the cure.” Since the publication of Dr. Merrill’s article I
have often prescribed chloroform in similar doses, and never
with any unpleasant result, but have uniformly found it very
serviceable in proper cases. For the distressing pain of
congestive dysmenorrhcea I consider it a specific. . It will
give prompt relief from the awful agony of bilious colic,
and in epileptic and infantile convulsions, it “ acts like a
charm.” A teaspoonful of undiluted chloroform, followed
by no drink of any kind, is a hot dose ; but the pungent
effect is but momentary. Finally; I would urge the
readers of ‘THE RECORD to give it a fair trial, confident
that they will find it of vast service.
T. C. Wallace, M.D.
CAMBRIDGE, N. Y., June 12, 1889.
ELECTROLYSIS IN STRICTURE OF THE URETHRA.—Dr.
J. A. Fort, of Paris, France, writes: “In ‘THE MEDICAL
Recorp for April 13th I read, on page 418, an account
of my operation on stricture of the urethra by electrolysis.
It is stated in that article that one of my colleagues, Dr.
Lavaux, recorded the frequency of relapses after this op-
eration. In that statement there is a serious mistake
which it is impossible for me to allow to pass without
protest. This gentleman, Doctor of Medicine only for
the last five months, never saw a single relapse after any
of my operations, the relapses of which he speaks followed
operations performed in a different manner and by other
surgeons. I operate after a new method and possess
notes of 550 cases, and I have not yet recorded a single
certain relapse.” 7
THE MEDICAL RECORD. 83
Army and Havy Mews.
Official List of Changes in the Stations and Duttes of Cfi-
cers serving in the Medical Department, United States
Army, from June 30 to July 13, 1889.
‘Ten Eyck, BENJAMIN L,. First Lieutenant and Assist-
ant Surgeon (recently appointed). By direction of the
Acting Secretary of War, will proceed from New York
City to Fort Leavenworth, Kan., and report for duty to
the commanding officer of that post. Par. 2, S. O. 138,
A. G. O., Washington, D. C., June 15, 1889.
Corson, J. K., Major and Surgeon. Granted leave of
absence for one month, with permission to apply for an
extension of one month. Par. 2, S. O. 65, Headquarters
Department of the Columbia. The above leave of absence
extended one month. Par. 1, S. O. 45, Division of the
Pacific, June 24, 1889.
Horr, JOHN Van R., Captain and Assistant Surgeon,
is relieved from duty at Fort Reno, Ind. Ter., and or-
dered to Fort Riley, Kan. Par. 6, S. O. 145, A. G. O.,
Washington, D. C., June 24, 1889.
BACHE, Daras, Major and Surgeon, is relieved from
duty at Fort Riley, Kan., and ordered to report to com-
manding general, Department of the Platte, for duty as
medical director of that department. Par. 6, S. O. 145,
A. G. O., Washington, D. C., June 24, 1889.
Woonprurr, Ezra, Major and Surgeon. By direction
of the Secretary of War is relieved from temporary duty
at Fort Monroe, Va., and will report in person to the
commanding officer at Fort Hamilton, N. Y., for duty at _
that station. Par. 5, S. O. 146, A. G. O., June 25, 1889.
FISHER, WALTER W. R., Captain and Assistant Sur-
geon. By direction of the Secretary of War, the extension
of leave of absence granted in S. O. 41, June 12, 1889,
Division of the Pacific, is still further extended fifteen
days. Par. 8, S. O. 146, A. G. O., Washington, June 25,
1889.
Cuapin, A. R., Captain and Assistant Surgeon. Leave
of absence for twenty-five days, to commence on or about
July 2, 1889, is granted. Par. 6, S. O. 145, Division of
the Atlantic, June 27, 1889. À
Grsson, R. J., Captain and Assistant Surgeon. Reports
arrival, July 2, 1889, at Camp Lewis, Fisher’s Island, N. Y.,
in compliance with Par. 5, S. O. 133, Division of the At-
lantic, which designated him as M. O. for the encamp-
ment (rifle practice) at Fisher’s Island, N. Y.
CHERBONNIER, ANDREW V., Captain and Medical
Storekeeper. By direction of the Secretary of War, will,
in addition to his present duties, take charge of the office
and perform the duties of Acting Assistant Medical Pur-
veyor in St. Louis, Mo., during the absence of Captain
George T. Beall, Medical Storekeeper. Par. 2, S. O. 151,
A. G. O., July 2, 1889.
Gorcas, H. C., Captain and Assistant Surgeon. Leave
of absence for one month is granted, to take effect on the
arrival of a medical officer to relieve him. Par. 2, S O.
84, Headquarters Department of the Missouri, July 3,
1889.
BEALL, GEORGE T., Captain and Medical Storekeeper.
By direction of the Secretary of War, leave of absence for
two months is granted. Par. 8, S. O. 148, A. G. O.,
June 27, 1889.
McParLin, ‘THomMas A., Colonel and Surgeon. By
direction of the Acting Secretary of War his retirement
from active service, this date, by operation of law, under
the provisions of the Act of Congress approved June 30,
1882, is announced. Colonel McParlin will repair to his
home. Par. 2, S. O. 157, A. G. O., July 10, 1889.
84
THE MEDICAL RECORD.
[July 2 20, eno:
Suri ANDREW LK, Colonel and ORAN pranited
Surgeon, with rank of Colonel, to rank from July 10, 1889.
Vice McParlin, retired.
Town Francis L., Lieutenant-Colonel and Surgeon.
Promoted Surgeon, with rank of Lieutenant-Colonel, to
rank from July 10, 1889. Vice A. K. Smith, promoted.
PERLEY, H. O., Captain and Assistant Surgeon. on
dered to accompany troops from Fort Wayne, Mich.,
Gognac Lake, Mich., to encamp there with the Michigan
State troops, from August 8, to 13, 1889. Par. 1, S. O.
154, Headquarters Division ‘of the Atlantic, July 9, 1889.
Granted fourteen days’ leave of absence, to commence
about July 14, 1889. Par. 2, S. O. 154, Headquarters
Division of the Atlantic, July 9, 1889.
Official List of Changes in the Medical Corps of the United
States Navy for the week ending July 13, 1889.
WHITE, S. STUART, Assistant Surgeon. Detached from
the Trenton, July 7, 1889. Ordered to the Naval Hos-
pital, Brooklyn, N. Y.
White, C. H., Medical Inspector.
the Trenton, and wait orders.
Detached from
NORFLEET, ERNEST, Passed Assistant Surgeon. De-
tached from the Trenton, and to the Monocacy. `
Ames, H. E., Passed Assistant Surgeon. Detached
from the Monocacy, proceed home, and wait orders.
Harrison, G. E. H., Surgeon. Detached from the
Constellation, and to the Naval Academy.
Lownpes, C. H. T., Assistant Surgeon. Detached
from the Constellation, and to the Naval Academy.
a e m ne a ai
Dedicat Stems.
CONTAGIOUS DISEASES—WEEKLY STATEMENT. — Re-
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending July 13, 1889:
| Cases. | Deaths
Ty pus (Ever ernennen AAEE nee en | o o
Typhoid [EVEL oasa esas eke sadasne cathe RN E | 18 4
Scarlet EVET oie even sieges ttle deta saree aO¥s 47 10
Cerebro-spinal meningists...........0..ccceeeeeee 2 3
Measles cisions ita tans i ped ene e ea tote nueas | 49 4
Diphthéria sisis cereos iaee oreo a as eee subse se 84 28
SSMAMAPOXN sive eshte oar ana E E asetitier Wiss o o
Yellow fever........secoesososossoesesssnresossoe o ?} o
o | o
Cholera poin ene risa Sexwscava hesmuacor wires tegen |
THE NORTHERN Kansas MEDICAL Society held its
fifth annual session at Seneca on thagth inst. Dr. A. G.
Edwards, of Marysville, read a paper on “ Fractures and
their Complications, of the Femur, Tibia, and Fibula.”
Dr. H. P. Porter, of Oneida, spoke on “ The Disabilities
of Old Soldiers.” Dr. Grant Cullimore, of Atkinson, ad-
vocated, from successful experience, the use of the lead-
coil pipe in cases of mastoiditis, through which iced water
was caused to flow. In this connection the case of the
Hon. Roscoe Conklin was instanced as a favorable one
for successful treatment by this method. Dr. W. F.
Richardson, of Havensville, reported a case of “ Deafness
following Measles.” Specialists of Topeka and St. Joseph
had treated this case without improvement. . A gun was
accidentally discharged in proximity to the child, when
she exclaimed, “ I can hear! I can hear!” The case
was one in which there was thought to be collapse of the
membrane, with slight adhesions, or possibly a closure,
from like cause, of the Eustachian tube. Dr. M. M.
Wachter, of Baileyville, eit a paper on “ Cholera In-
fantum.” Dr. E. W. Bliss, of Hiawatha, reported a case
of “ Retention of Urine.” The catheter had been used,
but without relief. Paracentesis in the supra-pubic region
effected the desired result. The cannula of a small trocar
was left in the puncture for three days, when urine was
voided through the natural channel, and complete recovery
rapidly followed. He also spoke of a case of hernia now
under treatment. Some three weeks ago he cut over a
strangulated hernia, and found the bulk of the tumor
omental ; but a knuckle of the bowel was also found which
was so tightly constricted that the abdominal ring had to
be incised to effect reduction. The protruding omentum
was ligated, cut off, and the stump left in the sutured
wound, which yet remained unclosed. At ro P.M. the
proceedings became informal. ‘The subject of advertising,
such as giving cases to the public press, was freely dis-
cussed and forcibly condemned. Consultations with “ ir-
regulars” was also debated, and as severely ‘censured.
Resolutions on the death of Dr. C. J. Logie, of Hiawatha,
were adopted, and the Society adjourned, to meet again at
Seneca, on the 14th of November next. Dr. William
Strayer, Secretary of the Society, in sending us a report of
the meeting, writes: ‘“‘ Our membership extends from St.
Joseph, Mo., to Fairbury, Neb. Some of the most prom-
inent physicians of Northern Kansas are active members.
We have been termed the ‘ rowdy West,’ and it is likely
the shoe fits when we wish to carry a political convention ;
but we believe that our medical societies, and especially
the Northern Kansas, are conducted with as much dignity
and decorum, and possibly as much erudition evinced, as
some Eastern societies. Our Eastern brethren are better
known to us than we are to them, and one reason for this
is, that they are, or have been, more ambitious or enter-
prising than we in having their society proceedings pub-
lished in journals that we both take.”
THE REMOVAL OF Hair By ELECTROLYsIS.—Dr. Rich-
ard B. Faulkner, of Allegheny, Pa., writes: ‘ Now that
the use of electrolysis has become so common in the
removal of facial blemishes, it seems prudent to advise
the exercise of very great care in its application. The
face is always a very important part. Should a surgeon
accidentally mar its beauty, its financial value, as ex-
pressed in a suit for malpractice, cannot be estimated.
To do no harm should be our first consideration; and
the more important this matter becomes, as the more
fastidious and aristocratic the bearer of the face happens
to be. In the removal of hair, too much electric power,
and needles of too large a size, will sometimes occasion
minute cicatricial fibroid nodules, distinctly to be felt as
little lumps ; and I have no doubt will be plainly seen as
age advances as elevations upon the lips of those from
whom mustaches have been removed. Again, more elec-
tric power than just enough to remove the hair intended
to be removed, will, in proportion, stimulate the growth
of other hair in adjacent follicles. Care is always re-
quired that the positive current be not used, lest you bore
a permanent hole in some fine lady’s cheek. In the elec-
trolytic removal of hair, moles, wine-marks, warts, etc.,
the mildest power that is capable of doing the work is the
safest. The tension current is the electrolytic current.
And it would be well if all wnters would speak of the
various cells used, as compared to the standard cell of
Daniell. I use the excellent diamond carbon cell.
Each cell equals 1.75 Daniell cells. Two to four dia-
mond carbon cells are sufficient to remove hair; two to
eight, moles; six to ten, wine-marks. Silver needles are
the best conductors, and give the least pain. Cocaine
solutions dry upon and crust the surface, and are inappro-
priate for dermal anzesthesia.”
HEALTHY NEw York GIRLS.—Said a gentleman from
a small country town in Massachusetts to me recently :
“Talk about delicate New York women! Why, I see
more healthy women on Fifth Avenue in two hours than
I see in Massachusetts in a year.”— The Epoch.
The Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 3° No. 4
Original Artictes,
CONSIDERATIONS CONCERNING SOME EX-
TERNAL SOURCES OF INFECTION IN THEIR
BEARING ON PREVENTIVE MEDICINE.’
By WILLIAM H. WELCH, M.D.,
PROFESSOR OF PATHOLOGY IN JOHNS HOPKINS UNIVERSITY, BALTIMORE, MD,
No department of medicine has been cultivated in recent
ears with such zeal and with such fruitful results as that
relating to the causes of infectious diseases. ‘The most
important of these results for preventive medicine and for
the welfare of mankind is the knowledge that a large pro-
portion of the causes of sickness and death are remov-
able.
It is evident that efforts to preserve health will be most
intelligently and effectually applied when they are based
upon an accurate and full knowledge of the agencies
which cause disease. Public and private hygiene, how-
ever, cannot, and, fortunately, has not waited for the full
hght of that day whose dawn has only begun to appear,
when we shall have a clear insight into the causation of
preventable diseases. Cleanliness and comfort demand
that means shall be taken to render pure the ground on
which we live, the air which we breathe, and the water
and food with which we are supplied, and we must meet
these needs without waiting to learn just what relation
infectious agents bear to the earth, air, water, and food.
It is a fortunate circumstance that modern sanitation
has been controlled so largely by the belief in the depend-
ence of endemic and epidemic diseases upo organic im-
purities in the soil and in the water. Incomplete and
even erroneous in many respects as are the views which
have prevailed concerning the origin and spread of epi-
demic diseases by the decomposition of organic sub-
stances, the sanitary measures which have been directed
toward the removal of filth have achieved great conquests
in limiting the development and extension of many infec-
tious diseases. The benefits which one commonwealth
of this country has derived from the intelligent employ-
ment of public sanitary measures were clearly and forci-
bly presented before this Association, last year, by Dr.
Walcott, in his admirable address on “State Medicine.”
While nothing should be said, .or need be said, to lessen
the importance of cleanliness for public health, it is im-
portant to bear in mind that hygienic cleanliness and
esthetic cleanliness are not identical. In water which
meets the most severe chemical tests of purity typhoid
bacilli have been found. On the other hand, the air in
the Berlin sewers, which certainly does not meet the most
modest demands of esthetic cleanliness, has been found
to be nearly or quite free from bacteria.
It needs only to be stated to be generally admitted that
the scientific basis of preventive medicine must be the
accurate knowledge of the causative agents of prevent-
able diseases, a knowledge which can be derived only from
a careful study of all of the properties of these agents,
the modes of their reception and of their elimination by
the body, the circumstances which favor and those which
retard or prevent their development and spread, their be-
havior in the various substances which surround us, or
which we take into our bodies, and the sources of infec-
— +
iÁddress i in State Medicine, delivered before the Amencan Medical
Association, in Newport, on Friday, June 28, 1889.
NEw Vouk Jory 27, 1889
--—— M ——. - oe aps e Aa A i a ——
Whole No. 977
tion, not only those which laboratory experiments show
to be possible, but those which are actually operative.
So long as we were unacquainted with the living organ-
isms causing infection, the means at our disposal for `
studying the etiology of infectious diseases were limited
to the observation of all of the circumstances which we
could determine regarding the origin and spread of these
diseases. We could only infer what might be the proper-
ties of the infectious agents from the study of phenomena
often obscure and difficult of interpretation. Chiefly by
this method of investigation the science of epidemiology
has been built up. It has established facts and laws no
less of practical than of scientific importance. But it has
left unsolved many problems, and has filled gaps with
speculations. Admitted epidemiological facts are often
open to various interpretations.
We are evidently at a great advantage when we can
study the epidemiological facts with a knowledge of the
substances which actually cause infection, and this we are
now enabled to do for a limited number of the infectious
diseases. ‘This new method of research, which thus far
has been mainly bacteriological, has aided us not so much
by simplifying the problems of etiology, which still remain
complicated enough, as by affording greater accuracy to
the results.
It is my aim in this address to consider some results of
the modern studies of pathogenic micro-organisms in their
bearing upon preventive medicine, more particularly upon
the sources of infection. It is, of course, impossible
within the limits of the address to attempt a complete
survey of this important field. Time will permit the pres-
entation of only some of the salient points.
Infectious diseases are those which are caused by the
multiplication within the’ body of pathogenic micro-organ-
isms.
It has always been recognized that some infectious dis-
eases, such as the exanthematous fevers, are conveyed
directly from the sick to the healthy. It is not disputed
that in these evidently contagious diseases the infectious
germ is discharged from the body in a state capable at
once of giving rise to infection.
In a second group of infectious diseases, of which ma-
laria is the type, the infected individual neither transmits
the disease to another person, nor, so far as we know, is
capable of infecting a locality. Here there is reason to
believe that the infectious germ is not thrown off in a liv-
ing state from the body, but is destroyed within the body.
In this group the origin of infection under natural con-
ditions is always outside of the body.
In a third group there is still dispute whether the dis-
ease can be transmitted directly from person to person,
but all are agreed that the infected individual can infect
a locality. It is especially fortunate that the bacteria
which cause cholera and typhoid fever, the two most im-
portant representatives of this group of so-called mias-
matic contagious diseases, have been discovered and isolat-
ed in pure culture. ‘These are the diseases about whose
origin and epidemic extension there has been the greatest
controversy. They, above all other diseases, have given
the impulse to public sanitation during the last half-cen-
tury. The degree of success with which their extension
in a community is prevented is an important gauge of the
excellence of the local sanitary arrangements. A clear
comprehension of the origin and spread of these diseases
signifies a solution of many of the most vexed and im
portant problems of epidemiology and of State hygiene.
86
THE MEDICAL RECORD.
[July 27, 1889
It is difficult to understand how those who accept the
discovery that the bacteria causing typhoid fever and
cholera have been found and cultivated from the stools
of patients affected with these diseases can doubt that
these patients are possible sources of contagion, or can
entertain the view, once so widely prevalent, that the infec-
tious germs of these diseases are discharged from the
body in a condition incapable of producing immediate in-
fection. In an address delivered on another occasion, I
have endeavored to present the considerations which rec-
oncile the comparative infrequency of direct contagion
for these diseases with the belief in the elimination of the
causative germs in an active state from the body, and
. - have there pointed out several well-known factors which
determine the frequency of conveyance of an infectious
disease by contagion. ‘There are reasons, some of them
very obvious, why diseases in which the infectious sub-
stances are operative only when received into the diges-
tive tract, and are discharged usually only with the fæces,
are less likely to be transmitted by immediate contagion
than those diseases in which the virus is thrown off from
the skin on epidermal scales.
But the field of operation of direct contagion for those
so-called miasmatic contagious diseases is at most a re-
stricted one, and the chief sources of infection are outside
of the body from which primarily the infectious germs
may have been derived. It is to these external sources
of infection, which are of such importance in public hy
giene, that I wish especially to direct attention.
A fall comprehension of the sources of infection is, of
course, to be obtained only by a detailed study of the eti-
ology of the individual infectious diseases; but this is, of
course, impossible within the limits of an address. It
may, however, be useful to present some of the facts
which have a general bearing upon the subject. Let us
consider, then, from the point of view of modern bacteri-
ological studies, what rôle in harboring or transporting
infectious agents may be played by those substances or
media with which we necessarily come into intimate con-
tact, such as the air, the ground, the water, and our food.
It is universally admitted that many infectious agents
may be transported by the air, but the extent of danger
from this source has often been exaggerated. It is a pop-
ular error to suppose that most of the minute particles
of dust in the air either are or contain living organisms.
The methods for determining the number and kind of
bacteria and fungi in the air are now fairly satisfactory, al-
though by no means perfect. ‘These have shown that
while the number of living bacteria and fungi in the atmo-
sphere in and around human habitations cannot be con-
sidered small, still it is greatly inferior to that in the
ground or in most waters. Unlike fungus spores, bacteria
do not seem to occur to any extent in the air as single
detached particles, which would then necessarily be ex-
tremely minute, but rather in clumps or attached to par-
ticles of dust of relatively large size. As a result, ina
perfectly quiet atmosphere these comparatively heavy par-
ticles which contain bacteria rapidly settle to the ground
or upon underlying objects, and are easily filtered out
by passing the air through porous substances, such as
cotton-wool or sand. Rain washes down a large number
of the bacteria from the air. ‘That the air-bacteria are
derived from the ground, or objects upon it, is shown by
their total absence, as a rule, from sea-air at a distance
from land, this.distance naturally varying with the diréc-
tion and strength of the wind.
A fact of capital importance in understanding the rela-
tions of bacteria to the air, and one of great significance
for preventive medicine, is the impossibility of currents
of air detaching bacteria from moist surfaces. Substances
containing pathogenic bacteria, as, for instance, sputum
containing tubercle bacilli, or excreta holding typhoid ba-
cilli, cannot, therefore, infect the air unless these sub-
stances first become dry and converted into a fine powder.
We are able to understand why the expired breath is free
from bacteria and cannot convey infection, except as
little particles may be mechanically detached by acts of
coughing, sneezing, or hawking. Those bacteria, the
vitality of which is rapidly destroyed by complete desicca-
tion, such as those of Asiatic cholera, evidently are not
likely to be transported as infectious agents by the air, if
we except such occasional occurrences as their convey-
ance for a short distance in spray.
The only pathogenic bacteria which hitherto have been
found in the air are the pus-organisms, including the
streptococcus found by Prudden in a series of cases of
diphtheria and tubercle bacilli; but no far-reaching con-
clusions can be drawn from the failure to find other in-
fectious organisms when we consider the imperfection of
our methods and the small number of observations di-
rected to this point. The evidence in other ways is con-
clusive that many infectious agents—and here the malarial
germ should be prominently mentioned—can be, and often
are, conveyed by the air. While we are inclined to re-
strict within narrower limits than has been customary
the danger of infection through the air, we must recognize
that this still remains an important source of infection for
many diseases. All those, however, who have worked
practically with the cultivation of micro-organisms have
come to regard contact with infected substances as more
dangerous than exposure to the air, and the same lesson
may be learned from the methods which modern surgeons
have found best adapted to prevent the infection of
wounds with the cosmopolitan bacteria which cause sup-
puration.
We are not, of course, to suppose that infectious germs
floating in the form of dust in the atmosphere are danger-
ous only from the possibility of our drawing them in
with the breath. Such germs may be deposited on sub-
stances with which we readily come into contact, or they
may fall on articles of food where they may find con-
ditions suitable for their reproduction, which cannot
occur when they are suspended in the air, in consequence
of the lack of moisture.
From the facts which have been mentioned concerning
the relations of bacteria to the air, what points of view
present themselves to guide us in preventing infection
through this channel? Surely something more than that
this purpose is accomplished simply by abolishing foul
odors.
Certain indications are so plain as to need only to be
mentioned in this connection, such as the disinfection
and removal, as far as possible, of all infected substances,
an indication which applies equally to all channels of in-
fection, and which is much easier to mention than it is to
describe how it shall be realized. But there are two indi-
cations which apply especially to the prevention of the
transportation of disease-germs by the air. One js the
necessity of guarding, so far as practicable, against the
desiccation, when exposed to the air, of substances which
contain infectious germs not destroyed by drying, and an-
other is free ventilation.
For no disease is the importance of the first of these
indications so evident and so well established as for tuber-
culosis, the most devastating of all infectious diseases.
Against this disease, formidable as it may seem to cope
with it, the courageous crusade of preventive medicine
has begun and is destined to continue.
It is now generally recognized that the principal, al-
though not the sole, sources of tuberculous infection are
the sputum of individuals affected with pulmonary tuber-
culosis and the milk of tuberculous cows. Cornet, who
has made a laborious and most instructive experimental
study of the modes and dangers of infection from tuber-
culous sputum, has also elaborated the practical measures
which should be adopted to diminish or annihilate those
dangers. These measures have been so recently and so
widely published in medical journals, and so clearly pre-
sented before a Section of this Association, that I mention
them only to call the attention of practitioners of medicine
to their importance, and to emphasize the fact that they
are based chiefly upon the principle that infectious sub-
July 27, 1889]
stances of such nature as tuberculous sputum should not
be allowed to become dry and converted into dust when
exposed to the air.
By means of free ventilation disease-producing micro-
organisms which may be present in the air of rooms are
carried away and distributed so far apart that the chance
of infection from this source is removed or reduced to a
minimum. It isa well-established clinical observation
that the distance through which the specific microbes of
such diseases as small-pox or scarlatina are hkely to be
carried from the patient by the air, in such concentration
as to cause infection, is small, usually not more than a
few feet, but increase by crowding of patients and absence
of free ventilation. The well-known experiences in the
prophylaxis and treatment of typhus fever are a forcible
illustration of the value of free ventilation.
It is, of course, not to be understood that by ventila-
tion we accomplish the disinfection of a house or apart-
ment. Ventilation is only an adjunct of such disinfection,
which, as already mentioned, is of first importance. Time
will not permit, nor is it in the plan of this address, to
discuss the details of such questions as house disinfection,
but I may be permitted to say that the methods for disin
fecting apartments have been worked out on a satisfactory
experimental basis, and should be known, at least, by all
public-health officers. Whether it be pertinent to this
occasion or not, I cannot forbear to add my protest to
that of others against placing reliance upon any method
hitherto employed of disinfecting houses or apartments by
fumigation. And I would furthermore call attention to
the lack in most cities of this country of public disinfect-
ing establishments such as are in use with excellent results
in most cities of Europe, and which are indispensable for
the thorough and convenient disinfection of clothing, bed-
ts, curtains, etc.
After this short digression, let us pass from the con-
sideration of the air as a carrier of infection to another
important external source of infection, namely, the ground.
That the prevalence of many infectious diseases depends
upon conditions pertaining to the soil cannot be ques-
tioned ; but the nature and the extent of this influence have
been and are the subjects of lively discussion. The epi-
demiological school led by Pettenkofer assigns, as 1s well
known, to the ground the chief, and even a specific and
indispensable influence, in the spread of many epidemic
diseases, particularly cholera and typhoid fever. The
Statistics, studies, and speculations of epidemiologists
relating to this subject probably surpass in number and
extent those concerning any other epidemiological factor.
The exclusive ground-hypothesis has become an ingenious
and carefully elaborated doctrine with those who believe
that such diseases as cholera and typhoid fever can never
be transmitted by contagion. These authorities cling to
this doctrine with a tenacity which indicates that on it
depends the survival of the exclusively localistic dogma
for these diseases.
To all who have not held aloof from modern bacterio-
logical investigations it must be clear that views which
have widely prevailed concerning the relations of many in-
fectious germs to the soil require revision. The question
is still a difficult and perplexing one, but on some hither-
to obscure or misunderstood points these investigations
have shed light, and from the same source we may expect
further important contributions to a comprehension of the
relations of the ground to the development of infectious
The ground, unlike the air, is the resting- or the breed-
ing-place of a vast number of species of micro-organisms,
including some which are pathogenic. Instead of a few
bacteria or fungi in a litre, as with the air, we find in
most specimens of earth thousands, and often hundreds of
thousands, of micro-organisms in a cubic centimetre.
Fraenkel found the virgin soil almost as rich in bacteria
and fungi as that around human habitations. This vast
richness in micro-organisms belongs, however, only to the
superficial layers of the earth. Where the ground has not
THE MEDICAL RECORD. 87
been greatly disturbed by human hands there is, as a rule,
about three to five feet below the surface an abrupt dim-
Inution in the number of living organisms, and at the
depth where the subsoil water usually lies bacteria and
fungi have RA or entirely disappeared. Fraenkel, who
first observed this sudden diminution in the number of
micro-orgaħisms at a certain level beneath the surface,
explains this singular fact by the formation at this level of
that sticky accumulation of fine particles, consisting largely
of bacteria, which forms the efficient layer in large sand-
filters for water. Of course, the number of bacteria and
the depth to which they penetrate will vary somewhat with
the character, especially the porosity of the soil and its
treatment ; but the important fact that all, or nearly all,
of the bacteria and fungi are retained in the ground above
the level of the subsoil water will doubtless hold true for.
most situations.
The conditions are not favorable for the multiplication
of bacteria in the depth of the ground, as is shown by the
fact that in specimens of earth brought to the surface
from a depth of a few feet, the bacteria which are at first
present rapidly multiply. What all of the conditions are
which prevent the reproduction of bacteria in the deep
soil has not been ascertained, but the fact necessitates
similar precautions in the bacteriological examination of
the soil as in that of water.
We have but meagre information as to the kinds of
bacteria present in the ground in comparison with their
vast number. Many of those which have been isolated
and studied in pure culture possess but little interest for
us, so far as we know. To some of the micro-organisms
in the soil appears to be assigned the rôle of reducing or
of oxidizing highly organized substances to the simple
forms required for the nutrition of plants. We are in the
habit of considering so much the injurious bacteria that it
is pleasant to contemplate this beneficent function so es-
sential to the preservation of life on this globe.
Among the pathogenic bacteria which have their natural
home in the soil the most widely distributed are the
bacilli of malignant cedema and those of tetanus. I have
found some garden-earth in Baltimore extremely rich in
tetanus bacilli, so that the inoculation of animals in the
laboratory with small bits of this earth rarely fails to
produce tetanus. In infected localities the anthrax bacil-
lus, and in two instances the typhoid bacillus, so far as it
was possible to identify it, have been discovered in the
earth. There is reason to believe that other germs infec-
tious to human beings may have their abiding-place in the
ground ; certainly no one doubts that the malanal germ
lives there. As the malarial germ has been shown to be
an organism entirely different from the bacteria and the
fungi, we cannot apply directly to its behavior in the soil,
and its transportation by the air, facts which have been.
ascertained only for the latter species of micro-organisms,
and the same precautions must be observed for other dis-
eases with whose agents of infection we are not ac-
quainted ; as, for instance, yellow fever.
In view of the facility with which infectious germs de-
rived from human beings or animals may gain access to
the soil, it becomes a matter of great importance to deter-
mine how far such germs find in the soil conditions favor-
able for their preservation or their growth. We have, as
is well known, a number of epidemiological observations
bearing upon this subject, but with few exceptions these
can be variously interpreted, and it is not my purpose to
discuss them. ‘Ihe more exact bacteriological methods
can, of course, be applied only to the comparatively small
number of infectious diseases, the causative germs of
which have been isolated and cultivated, and these methods
hitherto have been applied to this question only imper-
fectly. We cannot regard the soil asa definite and un-
varying substance in its chemical, physical, and biological
properties. What has been found true of one kind of
soil may not be so of another. Moreover, we cannot in
our experiments, bring together all of the conditions in
nature which may have a bearing on the behavior of spe-
88
THE MEDICAL RECORD.
[July 27, 1889
cific micro-organisms in the soil. We must, therefore, be
cautious in coming to positive conclusions on this point on
the basis of experiments, especially those with negative
result. With these cautions kept constantly in mind, the
question, however, is one eminently open to experimental
study.
The experiments which have thus far been ntade to de-
termine the behavior of infectious micro-organisms in the
ground have related especially to the bacilli of anthrax, of
typhoid fever, and of cholera, and, fortunately, these are
the diseases about whose relations to the ground there has
been the most discussion and concerning which we are
most eager to acquire definite information.
As regards anthrax bacilli, it has been determined that
in ordinary garden or field earth they do not multiply, but
in earth contaminated by blood, urine, or fæces their re-
production can occur. ‘They can grow on various vege-
table substrata. ‘There is no reason to doubt, therefore,
that the anthrax bacilli can find in or on the ground suit-
able conditions for their multiplication, although such con-
ditions are not everywhere present. For durable infec-
tion of the soil with anthrax bacilli it is, however, more
important that these bacilli should find there suitable con-
ditions for the formation of spores than that they should
be able simply to multiply. The vegetative forms of an-
thrax bacilli would not, as a rule, be able to survive for a
great length of time the hostile influences which they are
likely to encounter in the ground, such as insufficient cr
exhausted nutriment, absence of sufficient moisture, and
the attacks of saprophytic organisms. On the other hand,
against these injurious influences the anthrax spores have
great resistance. In the superficial layers of the ground
the anthrax bacilli may often find those conditions of
moisture, of temperature, of oxygen supply, and of insuffi-
cient food which we know are most favorable for the de-
velopment of their spores ; indeed, Soyka has shown that
the ground presents often these conditions better than our
culture media. A circumstance discovered by Feltz,
which, however, needs confirmation, is, if true, of not little
significance. He finds that anthrax bacilli may under-
gO a progressive diminution in virulence in the soil. If
this should be true likewise of other infectious micro-
organisms, we should be able to account in some instances
for the variable degree of virulence which clinical obser-
vation indicates that certain agents of infection acquire.
So far as anthrax bacilli are concerned, we may conclude,
therefore, that the ground occasionally offers suitable con-
ditions for their reproduction, but what is of greater im-
portance, it offers especially favorable conditions for their
long-continued preservation in the form of spores. I must
forego here the further consideration of the special cir-
cumstances inherent in the soil which control the origin
and spread of epidemics of anthrax in cattle, although
many interesting investigations have been directed to
this subject.
Of greater interest to physicians is the behavior of ty-
phoid and of cholera bacteria in the ground. As has
already been intimated, the ground is regarded by Petten-
kofer and his school as the principal breeding-place of
these micro-organisms outside of the body. ‘This view,
however, is not supported by bacteriological investigations.
Inasmuch as the cholera and typhoid bacilli may multiply
on various vegetable substrata and substances derived
from animals at temperatures often present in the ground,
it is evident that here and there conditions may be
present for their growth in the ground, but this growth is
likely to be soon interrupted by the invasion of ordinary
saprophytic organisms and other harmful influences. The
typhoid bacilli are more hardy in resisting these invaders
than are the cholera bacteria, which easily succumb, but
even for the former, so far as our present knowledge ex-
tends, the ground can rarely serve as a favorable breed-
ing-place.
It is not, however, necessary that these organisms should
multiply in order to infect for a considerable time the
ground ; i is sufficient if their vitality is preserved. As
to this latter point, the reports of different investigators
are not altogether concordant. Such excellent observers
as Koch, Kitasato, and Uffelmann found that the cholera
bacteria, when added to faces, or a mixture of fæces and
urine, rapidly diminished in number, and at the end of
three or four days, at the most, had wholly disappeared.
In a mixture of the intestinal contents from a cholera
corpse with earth and water, Koch found numerous cholera
bacteria at the end of three days, but none at the end of
five days. On the other hand, Gruber reports the detec-
tion of cholera bacteria in cholera dejecta fifteen days
old. The weight of bacteriological evidence, therefore,
is opposed to the supposition that the bacteria of Asiatic
cholera preserve their vitality for any considerable time in
the ground or in the excreta.
With respect to the bacilli which cause typhoid fever,
it has been shown by Uffelmann that these may live in
fæces, a mixture of fæces and urine, and a mixture of gar-
den earth, fæces, and urine for at least four and five months,
and doubtless longer, although they may die at the end of
a shorter period. He also finds that under these appar-
ently unfavorable conditions some multiplication of the
bacilli may occur, although not to any considerable extent.
Grancher and Deschamps found that typhoid bacilli may
live in the soil for at least five months andahalf. Unlike
the cholera bacteria, therefore, the typhoid bacilli may
exist for months at least in the ground and in fecal mat-
ter, holding their own against the growth of multitudes of
saprophytes, ‘This difference in the behavior of cholera
and of typhoid germs is in harmony with clinical experi-
ence.
As regards other infectious bacteria than those which
have been considered, I shall only mention that tubercle
bacilli, although incapable of multiplication under the or-
dinary conditions of nature outside of the body, may pre-
serve their vitality for a long period in the ground, on
account of their resistant character, and, furthermore,
that the pyogenic cocci, on account of their considerably
resistant nature and their modest demands in the way of
nutriment, can be preserved and sometimes probably grow
in the ground. Indeed, the staphylococcus pyogenes
aureus has been found in the earth by Liibbert.
The conclusion which we may draw from the observa-
tions mentioned is that, in general, the soil is not a good
breeding-place for most of the infectious bacteria with
which we are acquainted, but that it can retain for a long
time with unimpaired vitality those which produce spores
or which offer considerable resistance to injurious agen-
cies, such as anthrax bacilli, typhoid bacilli, tubercle ba-
cilli, and the pyogenic cocci.
In order to become infected with bacteria in or on the
ground, these bacteria must in some way be introduced
into the body, and we must, therefore, now attempt to
determine how bacteria may be transported to us from
the ground. So various and intricate are the possibilities
for this transportation that it is hopeless to attempt to
specify them all.
There occurs to us, first, the possibility of the convey-
ance of infectious micro-organisms from the soil by
means of: currents of air—a mode of ing infec-
tion which has already been considered. Here I shall
only repeat that the wind can remove bacteria from the
ground only when the surface is dry and presents particles
of dust, and that the sole, perhaps the chief, danger is
not that we may inhale the infected dust.
Manifold are the ways in which we may be brought
into contact with infectious bacteria in the ground, either
directly or by means of vegetables to which particles of
earth are attached, by the intervention of domestic ani-
mals, by the medium of flies or other insects, and ina
variety of other ways, more or less apparent.
An important, doubtless for some diseases the most im-
portant, medium of transportation of bacteria frum an
infected soil is the water which we drink or use for
domestic purposes. From what has been said, it is
evidently not the subsoil water which is dangerous, for
July 27, 1889]
infectious, like other bacteria, cannot generally reach this
in a living state, but the danger is from the surface-water,
and from that which trickles through the upper layers
of the grourd, as well as from that which escapes from de-
fective drains, gutters, cesspools, privy-vaults, and wrongly
constructed sewers or improper disposal of sewage. I
shall have something to say presently of water as a
source of infection, and shall not further elaborate here
the dangers of infection of drinking-water through con-
taminated soil; dangers which, especially as regards
typhoid fever, are widely appreciated in this country,
even if often imperfectly counteracted.
A point which has been much discussed, and one of
interest, is whether bacteria which are in the depth
of the ground can come to the surface. Two agencies,
especially, have been considered by some as capable of
transporting bacteria from the depth to the surface. One
is ascending currents of air in the ground, and the other is
the capillanity of fluids in the minute pores of tne ground.
The first of these suspected agencies must be unquestion-
ably rejected, in view of the fact that even a few inches
of sand is sufficient to filter all of the bacteria out of the
air, even when it is in much more rapid motion than can oc-
cur within the ground. Moreover, that degree of dryness
which is essential for the detachment of bacteria by air-
currents is not likely to be present much below the surface
of the ground. The experiments which have been made to
determine to what extent bacteria may be carried upward
by the capillarity of fluids in the ground have not yielded
harmonious results, but the weight of evidence is opposed
to the belief that this is a factor of any considerable im-
portance for this purpose.
From what has been said concerning the growth of
pathogenic bacteria in the soil, we shall not be inclined to
attribute to the multiplication and the motility of these
organisms much influence in changing their place in the
ground.
The somewhat sensational rôle assigned by Pasteur to
earthworms, of bringing bacteria to the surface, cannot be
wholly ignored, and has received support from observa-
tions of Bollinger regarding anthrax, but it is question-
able whether much importance is to be attached to this
agency. |
Regarding the depth to which typhoid bacilli may pen-
etrate in the soil, the experiments of Grancher and Des-
champs show that at the end of five weeks they may reach
a depth of sixteen to twenty inches below the surface. As
Hoffmann has demonstrated the extraordinary slowness
with which fluids and fine particles penetrate the soil, it is
probable that in the course of time a greater depth than
this may be reached. Indeed, Macé claims to have found
in the neighborhood of a well, suspected of . infection, ty-
phoid bacilli, together with ordinary intestinal bacteria, at
a depth of at least six and a half feet below the surface.
There are a number of instances recorded in which there
is good reason to believe that turning up the soil, and
cleaning out privies or dung-heaps in which typhoid stools
have been thrown, have given rise to typhoid fever, even
after the infectious excreta have remained there a year and
more.
It cannot be said that bacteriological investigations have
as yet shed much light upon a factor which plays a great
rôle in epidemiology, namely, predisposition to infection
from the ground, according to locality and time, and this
deficiency receives constant and vehement emphasis from
the localistic school of epidemiologists. We can, how
ever, readily understand that varying conditions, such as
temperature, moisture, porosity, quality of soil, may exert
a controlling influence in determining the behavior of in-
fectious germs in the soil, and the facility of their trans-
portation to human beings or animals. As regards that
much discussed question, the significance of variations in
the height of the subsoil-water, in relation to the preva-
lence of cetain epidemic diseases, particularly cholera and
typhoid fever, we now know that this cannot depend upon
the presence of bacteria in the subsoil-water itself, or in
THE MEDICAL RECORD.
89
the capillary layers immediately above it. It has been
plausibly suggested that with the sinking of the subsoil-
water fluids from infected cesspools, privy-vaults, and
other localities may more readily be drawn into wells or
other sources of water-supply, and that by the same cause
the surface of the ground becomes dry, so that dust-par-
ticles may be lifted by the wind. Other more or less
plausible explanations have also been offered, but it must
: be confessed that our positive information on this point is
meagre. There can, however, be little doubt that this
significance of the variations in subsoil-water is apparent
only for certain localities, and has been considerably ex-
aggerated and often misunderstood. It is not, however,
pertinent to my theme to discuss this or other purely epi-
demiological observations concering the relations of the
ground to the spread of epidemic diseases, interesting and
important as are many of these observations.
Before leaving the subject of the ground as a source of
infection, permit me to indicate briefly some conclusions
which may be drawn from what has been said, as to the
principles which should guide us in preventing infection,
directly or indirectly, from the ground.
First in importance is to keep infectious substances as
far as possible from the ground. ‘This implies the early
disinfection or destruction of such substances as typhoid
and cholera excreta and tuberculous sputum.
Second, the ground should be rendered, so far as
practicable, unsuitable for the continued existence of in-
fectious germs. This, at least for some diseases, is accom-
plished by a proper system of drainage, which, moreover,
for other reasons, possesses hygienic importance.
Third, means should be provided to prevent waste
products from getting into the ground around human
habitations, or from gaining access to water used for
drinking or domestic purposes. In cities this can be ac-
complished only by a properly constructed system of
sewers. The system of storing waste products in cess-
pools, whence they are to be occasionally removed, can-
not be approved on hygienic grounds. ‘There are condi-
tions in which the disposal of waste products in deep wells
only used for this purpose, and whence these products
can filter into the deep layers of the ground, may be per-
missible, but this can never be considered an ideal meth-
od of getting rid of excrementitious substances, and is
wholly wrong in regions where wells are used for drinking-
water. But I am trespassing with these remarks upon a
province which does not belong to me, but rather to prac-
tical sanitarians and engineers. I shall only add that the
advantage gained by preventing organic waste from soak-
ing into the ground is not so much that the ground is
thereby rendered better adapted for the existence of in-
fectious micro-organisms, but is due rather to the fact that
this waste is likely to contain infectious germs.
Finally, in cities, good pavements, absence of unneces-
sary disturbance of the soil, cleanliness of the streets, and
laying of dust by sprinkling are not only conducive to
comfort but are sometimes hygienically important in pre-
venting infection from the ground and dust.
In passing from the consideration of the ground to that
of water, one feels that he now has to do with a possible
source of infection against which, in this country and in
England, he is at liberty to make any accusation he
chooses without fear of contradiction. There is reason
to believe that such accusation has been repeatedly made,
without any proof of misdemeanor on the part of the
water. It is not, therefore, with any desire to awaken
further the medical or the public conscience that I wish
to say a few words concerning the behavior of bacteria in
water, and the dangers of infection from this source.
That such dangers are very real must be apparent when
we consider the universal employment of water, and its
exposure to contamination from all kinds of sources.
Ordinary water, as is well known, contains bacteria in
large number. Not a few species of bacteria can multiply
rapidly, and to a large amount, even in distilled water.
These are the so-called water-bacteria, and, like most of
go
the micro-organisms found in ordinary drinking-water, are
perfectly harmless saprophytes. What we wish to know
is, how pathogenic micro-organisms conduct themselves
in water. Can they grow, or be preserved for any length
of time in a living condition in water? As regards the
multiplication of pathogenic bacteria in water, the results
of different experimenters do not altogether agree.
Whereas Bolton failed to find any growth, but rather a
progressive diminution, in number of pathogenic bacteria
planted in sterilized water, Wolffhiigel and Riedel ob-
served a limited reproduction of such bacteria, including
those of typhoid fever and of cholera. This difference is
due probably to the methods of experimentation employed.
According to Kraus, these latter bacteria diminish rapidly
in number in unsterilized spring or well water kept at a
low temperature. These experiments indicate that water,
even when contaminated with more organic impurities
than are likely ever to be present in drinking-water, is not
a favorable breeding-place for pathogenic bacteria. Still
it is to be remembered that these laboratory experiments
do not reproduce exactly all of the conditions in nature,
and it may happen that in some nook or cranny, or vege-
table deposit at the side of a well or stream, some patho-
genic bacteria may find suitable conditions for their mul-
tiplication.
But, as has been repeatedly emphasized in this address,
it is not necessary that pathogenic bacteria should actu-
ally multiply in a medium in order to render it infectious.
It is sufficient if their life and virulence are not destroyed
in a very short time. As to this important point Bolton
found that in sterilized water typhoid bacilli may preserve
their vitality for over three months, and cholera bacteria
for eight to fourteen days, while Wolffhiigel and Riedel
preserved the latter in water for about eighty days.
Under natural conditions, however, these organisms are
exposed to the overgrowth of the water bacteria, so that
Kraus found in unsterilized water kept at a temperature
of 10.5° C. the typhoid bacilli no longer demonstrable
after seven days, and the cholera bacteria after two days.
The conditions in Kraus’ experiments were as unfavorable
as possible for the continued existence of these pathogenic
bacteria, more unfavorable than those often present at the
season of prevalence of cholera and typhoid fever; never-
theless I do not see that they justify the conclusions of
Kraus as to the slight probability of drinking-water ever
conveying infection with the germs of typhoid fever and
of cholera. To render such a conclusion probable it
would be necessary to demonstrate a much shorter pres-
ervation than even Kraus himself found. In judging
this question it should not be overlooked that infection of
drinking-water with the typhoid or the cholera germs is
not so often the result of throwing typhoid or cholera
stools directly into the source of water-supply as it is the
cons2quence of leaky drains, cesspools, privy-vaults, or in-
fected soil, so that there may be continued or repeated
accessions of infected material to the water.
In view of the facts presented, there is no sufficient
reason, therefore, from a bacteriological point of view, of
rejecting the transmissibility of typhoid fever and cholera
by the medium of the drinking-water. This conclusion
seems irresistible when we call to mind that Koch once
found the cholera bacteria in large numbers in the water of
a tank of India, and that the typhoid bacilli had been re-
peatedly found in drinking-water of localities where typhoid
fever existed. Nor do I see how it is possible to inter-
pret certain epidemiological facts in any other way than
by assuming that these diseases can be contracted from
infected drinking-water, although I know that there are
still high authorities who obstinately refuse to accept this
interpretation of the facts.
In this connection it may be mentioned that pathogenic
bacteria may preserve their vitality longer in ice than in
unsterilized drinking-water. Thus Prudden found typhoid
- bacilli still alive which had been contained in ice for one
hundred and three days.
When we come to consider the ways in which water
THE MEDICAL RECORD.
[July 27, 1889
eC
may become infected with pathogenic micro-organisms we
recognize at once a distinction in this respect between
surface-water and subsoil-water. Whereas the subsoil-
water may be regarded under ordinary circumstances and
in most places as germ-free, the surface-water, such as
that in rivers and streams, is exposed to all manner of in-
fection from the ground, the air, and the direct admission
of waste substances. Unfortunately, in the ordinary way
of obtaining sybsoil-water for drinking purposes by
means of dug wells, this distinction is obliterated, for the
water which enters these wells free from bacteria is con-
verted into a surface-water often exposed, by the situ-
ation of the well, to more dangerous contamination than
other surface-waters used for drinking purposes.
Now let us turn our attention, as we have done with
other sources of infection, to a brief outline of certain gen-
eral principles which may help us in avoiding infection
from the water.
We shall, in the first place, avoid, so far as possible, the
use of water suspected of infection, especially with the
germs of such diseases as typhoid fever and cholera.
When it is necessary to use this suspected water it should
be boiled.
As regards the vital question of water-supply, it may be
stated as a general principle that no hygienic guarantee
can be given for the purity of surface-water which has
not been subjected to a proper system of filtration, or for
the purity of spring- or well-water fed from the subsoil, un-
less such water is protected from the possibility of infec-
tion through the upper layers of the soil or from the air.
This is not saying that water which meets certain chem-
ical and biological tests, and which is so situated that the
opportunities for its contamination appear to be absent or
reduced to a minimum, is not admissible for the supply of
drinking-water, but the possibility of infection can be re-
moved only by the fulfilment of the conditions just named,
and upon these conditions the hygienic purist wall always
insist.
Unfortunately we have at present no domestic filters
which are satisfactory, and most of those in common use
are worse than none, as they soon furnish a filtrate richer
in bacteria than the original water. The only effective
method of water-filtration for the general supply is by
means of large sand-filters, such as are in use with excel-
lent results ın Berlin and some other cities. These re-
quire skilled attention. I cannot on this occasion discuss
the construction or working of these filters, but would re-
fer those who are interested to the full and careful inves-
tigations of the Berlin filters by Wolffhiigel, amd by Plagge,
and Proskauer. |
What is accomplished by these artificial sand-filters 1s
accomplished under natural conditions also by the ground,
which furnishes a subsoil-water free from micro-organ.
isms, and to obtain pure water we have only to devise
means by which this subsoil-water may be secured with-
out the chance of contamination. Just as the water
which has passed through the sand-filters is collected in
suitable reservoirs and is distributed in pipes which do
not admit contamination from without, so by means of
properly constructed artesian or driven wells we may se-
cure the naturally filtered subsoil-water with the same
freedom from the chances of infection.
It is well to bear in mind that no biological or chemical
tests of water can replace those measures which have
been mentioned as necessary to secure purity of water-
supply. These tests are of value only when applied
with proper precautions and with due consideration of the
special circumstances of each case for which they are em-
ployed. ‘There has been much profitless discussion as to
whether greater significance is to be attached to the chem-
ical or to the bacteriological examination of water. Each
has its own special field of application, and in this the one
cannot replace the other method. The bacteriological
examination has for hygienic purposes the advantage that
it may enable us to detect the specific agents of infection
in the form of micro-organisms, as has already been done
July 27, 1889]
THE MEDICAL RECORD.
QI
for cholera bacteria and typhoid bacilli, but this is a com-
paratively rare result and does not at present afford a
wide field of application for this method. The signifi-
cance of the bacteriological test is to be based more fre-
quently upon the fact that it concerns itself with the same
class of micro-organisms to which some of the recognized,
and, doubtless, many of the undiscovered, infectious agents
belong, and from the behavior of which, in some respects,
conclusions can be drawn as to the behavior of the
pathogenic organisms. Thus the bacteriological test is
the only one which enables us to judge correctly of the
efficacy of those methods of filtration of surface-water
and of construction of wells which insure purity of water-
supply. The points of view from which we can estimate
correctly, according to our present knowledge, the relative
merits and fields of application of the chemical and of
the bacteriological methods of water-examination have
been clearly indicated by Plagge and Proskauer and by
Wolffhügel. The theme is one beyond the limits or the
scope of this discourse, and I have referred to it chiefly to
emphasize the fact that we cannot rely upon chemical or
bacteriological tests of water to the exclusion of those
protective measures which have been mentioned, although
I do not intend to imply that each of these tests, when
properly employed, does not afford important information
and is not of great value in many cases. ,
I have already taxed so largely your time and patience
that I must pass over with brief mention the food as a
source of infection. Unlike those external sources of
infection which we have hitherto considered, many articles
of food afford an excellent nutritive medium for the
growth of a number of species of pathogenic micro-
organisms, and in many instances this growth may be
abundant without appreciable change in the appearance
or taste of the food.
When we consider in how large a degree the certainty
and the severity of infection with many kinds of patho-
genic micro-organisms depend upon the number of such
organisms received into the body, we can appreciate that
the danger of infection from food which contains a mass
of growing pathogenic bacteria may be much greater than
that resulting from the reception of infected water or air,
media in which infectious organisms are rarely present in
other than a very dilute condition. The entrance into
the body of a single infectious bacterium with the in-
spired air is, at least in the case of many diseases, not
likely to cause infection ; but let this bacterium fall upon
some article of food, as, for instance, milk, where it can
multiply in a short time at a favorable temperature many
thousand-fold, and evidently the chances of infection be-
come vastly increased.
Among the various agencies by which infectious or-
ganisms may gain access to the food may be mentioned
the deposition of dust conveyed by the air, earth ad-
hering to vegetables, water used in mixing with or in the
preparation of food, in cleansing dishes, cloths, etc., and
contact in manifold other ways with infected substances.
Fortunately a very large part of our food is sterilized
in the process of cooking shortly before it is partaken,
so that the danger of infection from this source is greatly
diminished, and comes into consideration only for un-
cooked or partly cooked food, and for food which, al-
though it may have been thoroughly sterilized by heat,
is allowed to stand for some time before it is used.
Milk, in consequence of its extensive use in an unsterilized
state, and of the excellent nutritive conditions which it
presents to many pathogenic bacteria, should be empha-
sized as especially liable to convey certain kinds of m-
fection, a fact supported not less by bacteriological than
by clinical observations. Hesse found that also a large
number of ordinary articles of food, prepared in the
kitchen in the usual way for the table, and then sterilized,
afford a good medium for the growth and preservation of
typhoid and cholera bacteria, frequently without ap-
preciable change in the appearance of the food. :
Upon solid articles of food bacteria may multiply in
separate colonies, so that it may readily happen that only
one or two of those who partake of the food eat the infected
part, whereas with infected liquids, such as milk, the in-
fection is more likely to be transmitted to a larger number
of those who are exposed.
In another important particular the food differs from
the other sources of infection which we have considered.
Not only the growth of infectious bacteria, but also that
of bacteria incapable of multiplication within the body
may give rise in milk and other kinds of food to various
ptomaines, products of fermentation, and other injurious
substances, which, when ingested, are likely to cause more
or less severe intoxication, or to render the alimentary
tract more susceptible to the invasion and multiplication
of genuinely infectious organisms.
It is plain that the liability to infection from food will
vary according to locality and season. In some places
and among some races the proportion of uncooked food
used is much greater than in other places and among
other races. In general, in summer and in autumn the
quantity of fruit and food ingested in the raw state is
greater than at other seasons, and during the summer and
autumn there is also greater danger from the transporta-
tion of disease-germs from the ground in the form of
dust, and the amount of liquids imbibed is greater. The
elements of predisposition, according to place and time,
upon which epidemiologists are so fond of laying stress,
are not, therefore, absent from the source of infection
now under consideration.
I have thus far spoken only of the secondary infection
of fond by pathogenic micro-organisms, but, as is well
known, the substances used for food may be primarily in-
fected. Chief in importance in the latter category are
the various entozoa and other parasites which infest an-
imals slaughtered for food. The dangers to mankind re-
sulting from the diseases of animals form a separate
theme, which would require more time and space than
this address affords for their proper consideration. I
shall content myself on this occasion with only a bref ref-
erence to infection from the milk and flesh of tuberculous
cattle.
It has been abundantly demonstrated by numerous ex-
periments that the milk from tuberculous cows is capable,
when ingested, of causing tuberculosis. How serious is
this danger may be seen from the statistics of Bollinger,
who found with cows affected with extensive tuberculosis
the milk infectious in eighty per cent. of the cases; in cows
with moderate tuberculosis the milk infectious in sixty-six
per cent. of the cases ; and in cows with slight tuberculosis
the milk infectious in thirty-three per cent. of the cases.
Dilution of the infected milk with other milk, or with
water, diminished, or, in sufficient degree, it removed the
danger of infection. Bollinger estimates that at least five
per cent. of the cows are tuberculous. From statistics
furnished me by Mr. A. W. Clement, V.S., it appears
that the number of tuberculous cows in Baltimore which
are slaughtered is not less than three to four per cent.
Among some breeds of cattle tuberculosis is known to be
much more prevalent than this.
There is no evidence that the meat of tuberculous cat-
tle contains tubercle bacilli in sufficient number to convey
infection, unless it be very exceptionally. Nevertheless
one will not willingly consume meat from an animal
known to be tuberculous. This instinctive repugnance,
as well as the possibility of post-mortem infection of the
meat in dressing the animal, seem to be good ground for
discarding such meat. ‘The question, however, as to the
rejection of meat of tuberculous animals has important
economic bearings and has not been entirely settled. As
to the rejection of the milk from such animals, however,
there can be no difference of opinion, although this is a
point not easily controlled.
The practical measures to adopt in order to avoid in-
fection from the food are, for the most part, sufficiently
obvious. Still, it is not to be expected that every possi-
bility of infection from this source will be avoided. It is
92 THE MEDICAL RECORD.
difficult to discuss the matters considered in this address
without seeming to pose as an alarmist. But it is the su-
perficial and half knowledge of these subjects which is
most likely to exaggerate the dangers. While one will not
under ordinary circumstances refrain from eating raw
fruit or food which has not been thoroughly sterilized, or
from using unboiled or natural waters in the fear that he
may swallow typhoid or cholera bacteria, still, in a locality
infected with cholera or typhoid fever, he will, if wise, not
allow himself the same freedom in these respects. Cows
milk, unless its source can be carefully controlled, should,
when used as an habitual article of diet, as with infants,
be boiled, or the mixed milk of a number of cows should
be selected ; but this latter precaution offers less protec-
tion than the former.
In most places in this country we are sadly lacking in
good sanitary inspection of the food, especially of the
animal food, offered for sale. One cannot visit the
slaughter-house in Berlin or in Munich, and doubtless
similar ones are to be found elsewhere, and watch the in-
telligent and skilled inspection of the slaughtered animals
without being impressed with our deficiency in this respect.
In large cities an essential condition for the efficient sani-
tary inspection of animal food is that there should be only
a few places, and preferably only one place, where animals
are permitted to be slaughtered. Skilled veterinarians
should be selected for much of the work of inspection.
It may reasonably be asked that the National govern-
ment, which has already spent so much money for the
extermination of such diseases as pleuro-pneumonia of
cattle and hog cholera, which are not known to endanger
the health of mankind, should turn its energies also to
means for eradicating tuberculosis from cattle, which is a
scourge not only to the economic interests of farmers and
dairymen, but also to the health of human beings.
Without any pretension to having done more in this
address than to sketch here and there a few principles
derived from bacteriological researches concerning only
some of the most widely distributed external sources of
infection, I trust that enough has been said to show the
folly of any exclusive dogma as to modes of infection.
The ways of infection even in one and the same disease
are manifold and various, and can never be resolved into
exclusive hypotheses, such as the drinking-water hypo-
thesis, the ground hypothesis, etc.
It follows, therefore, that it is not by sanitary improve-
ments in one direction only that we can control the
spread of preventable epidemic diseases. In one situa-
tion improvements in the supply of drinking-water check
the prevalence of typhoid fever, in another place similar
measures show no such influence; or again, in one city
the introduction of a good system of sewerage diminishes
epidemic diseases, and in another no similar result follows.
We should, therefore, aim to secure, as far as possible,
good sanitary arrangements in all directions and in all
respects.
It has also been rendered evident in what has been
said, that infectious agents differ markedly from each
other in their behavior, so that while public sanitation
aims at those measures which are found to be most widely
beneficial, it should not forget that each infectious disease
is as much a separate problem in its prophylaxis as in its
symptomatology, etiology, and treatment. It will not aim
to combat cholera with the means found best adapted to
scarlet fever, but it will adapt preventive measures as
directly to the specific end in view as possible. In pre-
senting to you the results of researches chiefly bacterio-
logical concerning the scientific basis of preventive medi-
cine, I hope to escape the accusation of one-sidedness
and narrowness by the statement that I do not for a
moment intend to imply that the bacteriological method
is our only source of accurate knowledge on the subjects
which have been considered. My aim is accomplished
if I have succeeded in making clear that this method has
established facts which aid in a clearer conception of the
[July 27, 1889
causes of some important infectious diseases, in a better
understanding of the sources and dangers of infection,
and in a more efficient selection and application of sani-
tary measures.
If this science of only a few years’ growth has furnished
already acquisitions to knowledge so important, so far
reaching, may we not look forward with assurance to the
solution of many dark problems in the domain of infec-
tious diseases—problems the solution of which may yield
to preventive medicine a future of usefulness and success
which we cannot now foresee ?
A CLINICAL STUDY OF SOME ANTISEPTICS IN
THE TREATMENT OF OTORRHGA.’
By ROBERT L. RANDOLPH, M.D.,
PATHOLOGIST AND ASSISTANT SURGEON TO THE PRESBYTERIAN EYE AND RAK
CHARITY HOSPITAL, BALTIMORE, MD.
In considering the treatment of inflammations of the
middle ear by means of antiseptic agents, it is desirable
to call to mind the distinction between the prophylactic
-and the curative uses of antiseptic applications. We
employ prophylactic antisepsis in order to prevent the
entrance of micro-organisms into wounds, while by means
of curative antisepsis we endeavor to render aseptic
wounded or diseased areas in which micro-organisms have
already secured lodgement.
The anatomical structure of the ear renders compara-
tively narrow the field of application of antiseptics for
prophylactic purposes. In operations and wounds involv-
ing the tragus, helix, and the periosteum of the mastoid
process, antisepsis can be employed with prophylactic
effect. Indeed, in operations in the external auditory
canal we may hope for the same effect, although here, for
manifest reasons, it is more difficult to secure and retain
a perfectly aseptic condition. If there be perforation of
the drum membrane, the possibility of keeping the organ
completely free of germs is practically out of the question,
for the connection between the tympanic cavity and the
throat—namely, through the Eustachian tubes—is always
a way open for the bacteria which pass into the mouth
with every inhalation and with every mouthful of food.
From the anatomical structure of the ear, then, com-
paratively little is to be expected from the employment of
antisepsis as a prophylactic. As a curative agent it does
admirable work. l
There are two ways by which an antiseptic fluid may
reach the middle ear. First, by way of the external audi-
tory canal through a perforation of the drum-membrane ;
and second, through the Eustachian tube. Through this
latter channel the fluid can reach the middle ear, but
owing to the small opening and the difficulty of its access
the operation becomes tedious and frequently impractica-
ble. And furthermore, there is necessarily a good deal of
the liquid swallowed by the patient. Now, some of our
most valuable antiseptics, when taken internally, even in
small doses, produce toxic symptoms. ‘The external ear,
then, is the safest and simplest road to the middle ear. _
It is not surprising, in cases of obstinate suppurative in-
flammations of the middle ear, that these affections do not
yield promptly to treatment, for the different parts of this
division of the ear are singularly difficult of access. The
middle ear is simply a series of channels, spaces which are
divided and subdivided into an infinite number of smaller
spaces. ‘lhe drum-cavity, the centre, with its irregular and
angular walls, is the point from which ramify the divisions
of.the middle ear. Here are numerous pockets where a
discharge can rest and engender organisms. On the
posterior wall there is the opening into the antrum masto-
ideum, or horizontal portion of the mastoid process, an-
other point where secretions can accumulate. From
thence we pass on into the mastoid process itself, where
are located the mastoid cells. Here we have an array of
pockets, chambers, recesses in which micro-organisms
1 Read before the Clinical Society of Baltimore, February 1, 1889.
July 27, 1889]
can secure lodgement. It is thus evident how difficult,
nay, almost impossible, it is to obtain an antiseptic condi-
tion of the middle ear.
After these preliminary considerations concerning the
general uses of antiseptics, and the difficulties inherent in
the anatomical structure of the ear regarding their appli-
cation, I will now mention the antiseptics which ï have
employed during the past fifteen months in treating sup-
purative processes of the ear.
Carbolic acid gave most indifferent results. A disad-
vantage peculiar to carbolic acid is its tendency, says
Kretschmann,’ in a one per cent. solution, to produce
eczema and otitis externa, accompanied with great pain.
I cannot say that my experience entirely confirms this
statement, but what I have seen of its action in otorrhoea
has convinced me that it is, comparatively speaking, an in-
ferior agent. Koch's investigations show that the spores
of the anthrax bacillus, when exposed to a one per cent.
solution of carbolic acid, are not destroyed. Only after
exposure for twenty-four hours to a five per cent. solution
is their activity destroyed. The pus micro-organisms,
however, are much less resistant than the spores of
anthrax bacilli, so that we cannot reject the use of car-
bolic acid in the treatment of most cases of suppurative
otorrhcea simply on the ground of its inferior antiseptic
powers ; but its irritating properties, as cited by Kretsch-
mann, form a positive objection to its employment.
Moreover, it has not yielded in my hands so satisfactory
curative results as some other agents.
As regards iodoform, though I have used it in several
cases, I must confess I have not given it an extended trial.
Very few patients in private practice will tolerate its pres-
ence, particularly in the ear, where, from the exposed posi-
tion of the organ, it is more difficult to suppress the odor.
This objection I have found a not infrequent one, even
among the better class of dispensary patients. In those
cases where I used it the patients were undoubtedly bene-
fited, for the discharge was clearly lessened by daily appli-
cations of the powder. The question as to the antiseptic
value of iodoform is such a vexed one, and laboratory ex-
periments and clinical experience differ here so widely, that
I will not attempt a discussion of the subject from this
point of view. It is claimed that iodoform owes most, if
not all, of its antiseptic value to its property of destroying
ptomaines. For an interesting survey of the present
status of the 1odoform question, I would refer to a recent
article in the Annals of Surgery? by William W. Van
Arsdale, M.D.
In 1880 Bezold advised the use of finely pulverized
boracic acid for acute and chronic suppurating diseases
of the drum-cavity with perforation. This agent is
recommended mainly for its value as an antiseptic. It is
supposed to act not only by disinfecting the secretion, but
also by preserving an aseptic condition of the mucous
membrane. Again, it is urged that its freedom from irri-
tating qualities permits its use with perfect impunity by
laity and physician alike. And, finally, the persevering use
of boracic acid is claimed, with few exceptions, to cure
every discharge from the ear. Such promises naturally
provoked an unqualified use of this agent, but it was not
long before reports appeared which showed that boracic
acid fell far short of doing in every case what was ex-
pected of it; that there were limitations to its use, certain |
kinds of cases where it was indicated, others where it did
absolutely no good, others agun where ìt was positively
erous.
Professor Schwartze, of Halle, in his treatise, “ Die
Chirurgischen Krankheiten des Ohres,” says that in certain
cases of chronic otorrhoea, boracic acid, when introduced
in small quantities into the ear, will effect a cure. Such
cases are those in which the perforation is large and sit-
uated in the lower quadrant of the drum-membrane, and
in which the secretion is not very abundant. He advises
1 Archiv fur Ohrenheilkunde, Bd. xxvi., S. 109.
2 Vol. ix., No. 3, pp. 201-216,
THE MEDICAL RECORD. 93
against the use of boracic sca when the secretion is very
abundant and thick, for here a sticky mass will be formed
which adheres to the walls of the cavity and stops up and
prevents the egress of the discharge, and which sometimes
results in retention of pus, inflammation of the mucous
membrane covering the bones, and, finally, of the bones
themselves. Schwartze thinks that the use of boracic acid
is contra-indicated in acute otorrhoea of the drum-cavity.
Here we have a thick muco-purulent discharge, and gen-
erally a very small perforation, and just such a condition
may arise as described above, namely, retention and all its
unfortunate consequences.
Dr. Stacke,’ in an article on the subject, mentions a
case of chronic otorrhcea with medium-sized perforation,
situated on the upper portion of the drum-membrane.
Inasmuch as the mucous membrane seemed pale and
smooth and the discharge was slight, only a small quantity
of powder was blown into the ear. After four weeks,
during which period he had not seen the patient, the latter
came back for an examination. ‘There had been no dis-
charge for some time. ‘The drum-membrane was coated
with a fine adherent scale, and, on using the Politzer bag,
a moist râle was heard. A closer examination revealed a
drum-cavity full of pus. In this case there existed a con-
dition unfavorable for the free exit of the discharge, the
slight secretion in the beginning had formed over the per-
foration a thin scale which, with time, became stronger
and more resistant, and when the secretion increased in
quantity, the scale which covered the perforation was too
strong to give way, and hence retention followed. Timely
discovery prevented dangerous consequences. In two
cases he observed brain-symptoms after three weeks’ use
of the powder. Stacke mentions four other cases of
chronic otorrhoea, which he had treated for a long time
with boracic acid. In all four cases the discharge was
brought to a standstill, but suppuration continued, and
before he obtained complete recovery he was obliged in
two cases to trephine the mastoid, and in the other two,
excise the malleus.
Dr. Griining,” of New York, reports three cases of
death from retention of pus after a long use of boracic
acid in the powder form. In the course of the disease
nothing unusual was observed in either case, till after they
had been for some time under the boracic-acid treatment.
Two cases died of meningitis, and the other one of py-
æmia. In one of the cases the mastoid process was
opened the day before death, and it was found full of
pus.
I have not met with such unfortunate results in my ex-
perience with boracic acid, although entire paralysis of
one side of the face occurred ina child that had been seen
by me not long ago, and which condition might readily be at-
tributed to having packed the external ear with the powder.
The case was that of a child aged eight years, that had
been troubled with a persistent otorrhoea for three years.
An examination showed that the entire drum-membrane
was gone, and that the tympanic cavity was full of granu-
lations. I touched the latter with chromic acid and
prescribed an acid sublimate solution, to be poured into
the ear three times daily, and to remain in the ear five or
ten minutes at a time. I heard nothing more of the
patient for a month, when I received a letter from the
tamily physician stating that the child was paralyzed on
the left side of the face. For the first three or four days
after using the sublimate solution the discharge, from
having been copious, had Jessened to a few drops a day,
and the fetor had entirely disappeared. The doctor
said that, not being able to stop the discharge completely,
he thought he would pack the ear with powdered boracic
acid. ‘This was done, and ten days later he noticed the
facial palsy. Facial paralysis as a result of otitis media is
1 Die Behandlung der Otorrhoe mit Borsdurepulver, Deutsche
Med. Wochenschr., No. 49, S. 1062, 1887.
2 Three Fatal Cases of Middle-ear Suppuration after Treatment
with Boric-acid Powder. Transactions of the American Otological
Society Vol. iv., Part i., 1887.
94
not a very rare occurrence, and it is quite possible that,
even had the boracic acid not been used, the paralysis
would have shown itself sooner or later. In this case,
however, the disease for three years had been marked by
no unusual symptoms, and for two weeks was so improved
by a certain line of treatment that the otorrhcea had
nearly ceased, and the accompanying odor had entirely
disappeared. A new treatment was then adopted, and a
few days later the case presented a more unfavorable out-
look than at any time during the three years. It is quite
fair to conclude that the powder offered a mechanical
obstruction to the small discharge that was still going on,
and that this latter, accumulating in the bottom of the
cavity, produced pressure upon the chorda tympani and
hence paralysis, or, possibly, an actual extension of the in-
flammation to the nerve itself ensued. This is the only in-
stance in my experience when the use of boric acid was
attended with unfortunate consequences. Both in the
powder form and in solution this agent has done me good
service, and many persistent otorrhceas have been per-
manently cured.
I have found no agent, however, which has yielded such
good results as the bichloride of mercury. I use it in
solutions varying in strength from 1 to 3,000 to 1 to 8,000
and 10,000.
Koch’s investigations show that the spores of the anthrax
bacillus are rendered perfectly innocuous after a few min-
utes’ immersion in a 1 to 20,000 sublimate solution. In
experiments made with a sublimate solution of 1 to 1,000
the following organisms were destroyed in eight seconds :
Anthrax bacilli (free from spores) ; the bacilli of diphtheria,
glanders, and typhoid fever ; streptococci from puerperal
fever and from pus, the staphylococcus aureus and albus,
and the organism of erysipelas. A solution of such
strength is, of course, much too strong for the ear. The
strongest solution that I have ever used is 1 to 3,000, and
even this has caused pain when poured into the ear. ‘The
strength of the solution that I generally use is 1 to
5,000, and with this I have never had any complaints
from the patients. It is well known that when a subli-
mate solution comes in contact with a substance contain-
ing albumen that a precipitate is thrown down which is
usually regarded as the albuminate of mercury. ‘This re-
action is supposed to take place when we pour such a so-
lution into an ear from which there is a purulent dis-.
charge, and here I would allude to the contradictory
experiments of Drs. Laplace * and Behring.’ ‘The first of
these investigators proved that when the albuminate of mer-
cury is precipitated that the sublimate solution has lost
much of its germicidal property. The same investigator
has shown that this precipitate may be prevented by
making the sublimate solution slightly acid. This solu-
tion, Dr. Laplace says, has lost none of its antiseptic value
by the addition of the acid ; on the contrary, it is a more
powerful germicide than ever. Either tartaric or muriatic
acid wasused. According to Dr. Behring, this albuminate
of mercury does not exist, or, rather, does not in the slight-
est degree resemble the insoluble albuminous coagulum
produced by acids or heat. The so-called albuminate of
mercury redissolves easily in acids, in iodide of potash,
cyanide of mercury ; in short, in all bodies which have the
property of redissolving precipitates of mercury obtained in
an aqueous solution. Furthermore, one can obtain from
the serum of blood containing sublimate, dissolved by
means of tartaric acid, the same reactions as those which
an aqueous solution of sublimate will give. Again, all
the reagents capable of dissolving the chloride of silver, as
ammonia and cyanide of potash, are equally capable of
preventing chloride of silver from producing a precipitate
in blood-serum, and are capable of dissolving such a pre-
cipitate when it does occur, all of which goes to prove
! Säure Sublimatlésung als desinficirendes Mittel und ihre Ver-
wendung in Verbandstoffen, Deutsche Med. Wochenschr., No. 40, S.
866, 1887,
2 Ueber Quecksilbersublimat in eiweisshaltigen Flussigkeiten,
Centralblatt för Bakteriologie u. Parasitenkunde, 2, Jahrgang, Bd.
iii, Hft. 1, 2.
THE MEDICAL RECORD.
[July 27, 1889
that the salts which are present in the blood play an im-
portant part in the existence of metallic precipitates, and
that the albumen found in the precipitate is, so to speak,
carried along mechanically. Dr. Behring further finds
that the acid sublimate solution is a quarter less active as
a germicide than the non-acidulated sublimate solution.
So much, then, for the question as viewed from the light
of laboratory experiments. Clinical experience is not yet
so divided, and I am every day, as surgeon in charge of a
large ear clinic, together with frequent confirmations
from my colleagues—being convinced of the positive good
effected by the acid sublimate solution.
The following is the prescription used :
B. Hydrarg. bichlor......... Sue ws ese T gr. Ss.
Acid tartar. Saccw oc deesss dene sees sa ee's grs. Xx,
AGUE 5 sie scars oe ase barn ce oS Geese q.s. ad $v
The patient is first required to syringe the ear out with
warm water, and then to pour the sublimate solution into
the ear till the latter is quite full. The fluid is allowed to
run out after remaining in the ear ten or fifteen minutes.
A piece of cotton is then moistened with the solution, and
with it the external opening of the ear is closed. This
treatment is repeated two or three times a day. As far as
possible, then, the tissues of the drum-cavity, its remote
connections, and the whole external auditory canal are
kept in a condition unfavorable for the growth of organ-
isms. A marked diminution in the discharge is seen almost
‘Immediately, and not infrequently a patient will remark
upon the absence of odor after the first day’s applica-
tions. In granulations and in polypi sublimate solutions
have only the effect of removing the fetor; the dis-
charge is not lessened to any extent. Such conditions de-
mand special treatment. But in the ordinary otorrheea
resulting from otitis media, which affection forms so
large a percentage of the dispensary patients, the acid
sublimate solution has given me most satisfying results.
About seventy-five cases have been collected by me dur-
ing the past year; but, unfortunately, I have not been able
to follow up more than forty to the point of complete re-
covery.
As regards relapses, since I began treating the major-
ity of suppurating diseases of the ear with an acid subli-
mate solution, I think I can safely say that the good done
here has been no less permanent than when the majority
of cases were treated with boracic acid or other agents. I
may say that the greater part of the time a similar case was
always kept on the boric-acid treatment, to judge of its rel-
ative merits, and in by far the majority of cases the im-
provement was quicker when the sublimate solution was
used. Certainly the fetor disappeared more promptly
when the latter agent was employed. The following cases
may be regarded as fairly typical of the efficacy of this
mode of treatment :
Case I.—C. K—, thirteen years of age. Chronic oti-
tis media. Medium-sized perforation. Otorrhcea for two
years. ‘Treated with insufflations of boric acid for two
weeks with no visible improvement. Commenced to use
the sublimate solution, and the di e had stopped on
the eighth day. The perforation had become smaller, and
subsequently healed over entirely.
Case II.—F. O , thirty-three years of age. Chronic
otitis media. Otorrhcea twelve years. Drum-membrane
nearly gone. No sign of discharge on the tenth day. ‘The
patient was seen for three or four days after this, and as
the otorrhcea had not returned he was discharged, with
the injunction to come back if he had any further trouble.
It is now at least six months since he was last seen.
Case III.—P. K , eight years of age. Otitis media.
Otorrhoea six weeks. Small perforation in upper and an-
terior quadrant of drum-membrane. The ear stopped
discharging after using the sublimate solution for four
days. As usual, the patient was kept under observation
for several days after the discharge had ceased, at the end
of which time he was allowed to go, and he has not been
seen since.
July 27, 1889]
= THE MEDICAL RECORD.
95
Case IV.—J. B , five years of age. Acute suppura-
tion of the middle ear. Small perforation and otorrhœa
for one week. ‘There was no sign of the discharge on
the tenth day.
Case V.—Mrs. R , fifty years of age. Chronic in-
flammation of the middle ear. Large perforation and
otorrhoea for four months. The discharge stopped on the
seventh day. There was no closing up of the perforation
though the ear remained free of any discharge, and the
patient was allowed to go after having been about two
weeks under observation.
Case VI.—A. W , two months old. Otorrhæa first
noticed about ten days after birth, and, furthermore, in
both ears. In eight days the discharge from both ears
had ceased.
Unfailing success was claimed by the author of the
boric-acid treatment, but the experience of many aural
surgeons has not borne out the truth of this promise.
Certainly no such claim can be made for the sublimate
solution. To succeed always is the lot of no drug. Some
cases get well with no other treatment than syringing out
the ear with warm water several times daily. This,
however, is the exception. It will be observed that four
days was the quickest period of time in which the dis-
charge was stopped by the sublimate solution. I once
stopped the discharge from an ear with two insufflations
of boric acid. But this, again, is a very rare exception,
and proves nothing as to the relative superiority of boric
acid to other agents. It is impossible to explain how an
agent which will put a stop to an otorrhcea in two days,
and that, too, with a single daily application, will, in a
dozen other cases which present to examination almost the
same objective features, demand many days to do any
good, and frequently fail to cure completely.
Bacteriological researches in cases of suppurative in-
flammation of the middle ear have been recently made by
Zaufal,' Moos,’ Rohrer,’ and Netter.‘ According to these
investigators, four distinct species of pathogenic micro-or-
ganisms are concerned in the production of suppurative
inflammations of the middle ear, sometimes one and some-
times more than one variety being found in the same case.
These organisms are the micrococcus Pasteuri, discovered
by Sternberg in his own saliva, and recognized by him as
the cause of sputum septicemia in rabbits—and subse-
quently by Fraenkel, Weichselbaum, and others as the
cause of croupous pneumonia in human beings (diplococ-
cus pneumoniæ); the bacillus pneumoniz of Friedlander,
the staphylococcus pyogenes, and streptococcus pyogenes.
In fetid otorrhoea bacilli and cocci are always found; in
non-fetid cases only cocci (Zaufal). The streptococcus
are found most often associated with serious complications,
as, for instance, subcutaneous abscesses, mastoiditis, men-
ingitis, purulent infection. That we possess in bichloride
of mercury the most perfect of germicides has been am-
ply proven, and upon theoretical grounds, then, did
Kretschmann, a little over a year ago, suggest that a sub-
limate solution be employed in suppuration of the middle
ear. From experience I can testify to the value of the sug-
gestion, and from an antiseptic point of view the question
hardly admits of argument.
To sum up: 1. Carbolic acid, to get its full antiseptic
value, must be employed in a solution too strong to be
used in the ear without doing positive harm. 2. Iodoform
will not be tolerated by the majority of patients, and did not
give me as good results as boricacid. 3. Inasmuch as the
recent experience of aural surgeons has shown that the use
of boric acid in the powder form is associated with danger,’
I comparatively seldom use the agent in this form. In the
saturated solution boric acid is a valuable agent. 4. If
2 . Med. Wochenschrift, 1887, No. 27; 1888, No. 8.
3 Zur bacteriellen Diagnostik u. Prognostik der Mittelohreiterungen.
Deutsche Med. Wochenschr., November 1, 1888.
> Ueber die Pathogenitat der Bakterien bei eitrigen Processen des
Ohres. Ibid.
4 Annales des Maladies de l'Oreille. October, 1888.
® Antisepsis in der Ohrenheilkunde, Archiv f. Ohrenheilkunde, Bd.
xxvi., S. 113.
the ear be thoroughly cleansed with warm water, and the
acid sublimate solution be allowed to remain in for ten
minutes or more, and the ear then closed with a pledget
of cotton which has been moistened with the solution, the
clinical observations of the past few months have led me
to conclude that this solution has a somewhat larger field
of usefulness, and will show a somewhat larger percentage
of cures than the other three agents.
THE TREATMENT OF PULMONARY TUBER-
CULOSIS.
By E. LICEAGA, M.D.,
PROFESSOR OF THE SCHOOL OF MEDICINE, PRESIDENT OF THE BOARD OF HEALTH,
DIRECTOR FOR THE HOSPITAL FOR CHILDREN, AND MEDICAL DIRECTOR FOR THE
MUTUAL LIFE INSURANCE COMPANY OF NEW YORK, COMPANY’S AGENCY IN THE
CITY OF MEXICO.
BEFORE expressing my views in relation to the treatment
of pulmonary tuberculosis by the use of calomel, I will
explain how I arrive at the application of mercurials in
tubercular affections of the lungs.
From time immemorial tubercular meningitis in chil-
dren has been treated with calomel as well as with the
application of mercurial ointment, and favorable results
have been obtained. I, myself, have succeeded in curing
a child when already in an advanced stage of this malady,
and also many other cases, provided no serious effusion
had taken place in the arachnoids, or, at least, when such
effusion was not copious.
It will be remembered that Dr. O’Beirne recommended
the use of mercurial preparations for combating scrofu-
lous arthritis of the hip and knee, and that this treatment,
employed by many physicians, was sufficient to arrest the
progress of so terrible a complaint, provided it had not
reached the ulcerative period.
Mr. Graves, the intelligent Dublin clinician, well ac-
quainted with Dr. O’Beirne’s views upon the subject, was
inspired with the idea of treating scrofulous bronchitis
and pneumonia by the use of mercurials. Mr. Graves
advises their employment whenever the illness com-
mences with a scrofulous inflammation of the lungs.
“ Only in such cases are mercurials to be tried, and even
then they are of no service, except when the pulmonary
affection has suddenly commenced under the influence of
an efficient and well-known cause—such as cooling off,
or an hæmoptysis.”—“ Lessons on Medical Clinics,” by
Dr. R. J. Graves, translated into French by Dr. Jaccoud.
Paris, 1863. Lesson 45, p. 172.
I cannot attempt to follow the author in his demon-
stration that mercurials have to be employed in scrofu-
lous bronchitis and pneumonia, in persons predisposed to
phthisis, but prior to the development of the general
phenomena ; in a word, when in his judgment there is as
yet no phthisis. Notwithstanding, I cannot abstain from
quoting the following: “ When, in a scrofulous person, a
sudden cold has determined the inflammation of the
bronchial mucous membrane, or of the pulmonary tissue,
in case the cold is recent and there is no reason to sus-
pect the existence of tubercles, mercury succeeds admir-
ably in arresting the progress of this malady, which,
neglected or improperly treated, would most probably
end in phthisis.” Ibid., page 176.
Should any doubt be entertained relative to the au-
thor’s views, Mr. Jaccoud, the translator, removes it in a
note on the same page of the quoted work, commenting
on this phrase of M. Graves:
“In spite of this restriction this method is, in my opin.
ion, a most valuable acquisition for certain complaints
which have a tendency to degenerate into phthisis.” Mr.
Jaccoud’s annotation runs thus: “I expressly call atten-
tion to this last phrase, in order to prevent attributing to
the author any idea of treating phthisis by mercurials, a
fact which might happen by resorting to any of those er-
roneous interpretations which are so common. Mr.
Graves reserves this medicament for inflammatory affec-
96
tions which develop in scrofulous individuals, and have a
tendency to degenerate into phthisis.”
Resting upon this opinion, and upon the fact, often ob-
served by me, that fabes mesenterica can be cured by the
use of English blue mass, I resolved to apply mercurial
preparations in the case of persons undoubtedly affected
with tubercles. |
The first individual coming under my observation was
a young lady eighteen years of age, who, up to that time,
had enjoyed good health, and in whom an intense bron-
chitis appeared, which was soon accompanied with fever,
sweats, marked loss of flesh and appetite, and other dis-
turbances of the digestive apparatus. When convinced
that the disease would not yield to the remedies pre-
scribed in these cases, an examination of the patient led
me to discover that there was an induration in the apex
of the right lung; and then I subjected her to the use of
calomel internally administered, by frictions of mercurial
ointment, and to applications of light blistering plasters
in the subclavian region and adjacent parts. When gin-
givitis showed itself I discontinued the application of
mercurials. Due either to the use of these preparations,
or because the inflammation of the gums prevented the
patient from eating, her strength was diminished, and in
her countenance might be noted the deterioration which
her organism had undergone; but her condition in gen-
eral soon improved, fever and sweats ceased, the appetite
returned, the cough rapidly diminished, her strength came
back, and the indications of pulmonary induration grad-
ually and totally disappeared. ‘This, which was the first
application of mercurials made by me, occurred in the
beginning of, 1871. The patient is still alive and enjoys
perfect health. I communicated the result to the mem-
bers of the Sociedad Familiar de Medicina, and in sub-
sequent cases treated by me, I took especial care that the
same gentlemen, or other distinguished physicians of this
city, should verify the existence of pulmonary tuberculous
infiltration ; and when we agreed in the diagnosis, I pro-
ceeded to the application of the method.'
The results obtained were, in every case, the more or
less rapid cure of the patients, with the exception of
two cases—one treated by me and the other by Dr. Bras-
setti—both of which cases had reached the period of pul-
monary ulceration, and in whom wide cavities were en-
countered.
It would be impossible, in a short communication, to
state the numerous observations collected by me from
patients in similar conditions to the one I have used as a
type, but as I wish to be exact relative to the circum-
stances in which the employment of mercurials gives a
certain result, I will fix the conditions under which I have
used them :
A.—Whenever there are indications of pulmonary in-
duration of a tuberculous nature. (Until lately, for my
diagnosis, I have resorted to the clinical characteristics
accepted by all physicians; but since the daci//us in
tuberculosis has been generally known, I have added to
these means the demonstration of the presence of this
microbe in the sputa.
4.—The tuberculous infiltration of the lung, either ac-
companied or not with intense bronchitis, requires the
use of mercurials and blisters.
C.—Tuberculous bronchitis requires the same treat-
ment.
_D.—1 employ this method in pulmonary tuberculosis,
either recent or of long standing, providing it has not
reached the period of ulceration.
£.—I also use it when there is either intermittent or
remittent fever ; whatever may be the state of the digest-
ive apparatus ; only if there is diarrhcea I advise a milk
diet, and afterward the attack intestinal disturbance with
suitable remedies.
I know of but two contra-indications: one is when
! In 1881 I delivered a lecture on this subject before the majority of
the physicians of the City of Guanajuato, my native town,
THE MEDICAL RECORD.
[July 27, 1889
ulceration of the lungs has led to the formation of large
cavities, and the other the complete exhaustion of the
patient, since in these cases the sick, instead of being
benefited, succumb more rapidly than without such treat-
ment, as happened in the two cases to which I have pre-
viously referred.
I should state that the treatment by mercurials and
blisters modifies in a rapid and favorable manner the local
and general condition of the patient, to such an extent
that the patients in many cases have their health entirely
restored. ‘This happens in persons who have not been ill
long, or when the sickness is of lesser intensity; but in
other cases the method indicated opens the way to heal-
ing ; and, in order to complete the cure, it is necessary to
have recourse to other means, which vary according to
circumstances. I will enumerate those which I more fre-
quently employ.
To begin with hygiene: A residence in the country ; if
it be possible, the dwelling facing south or east; breath-
ing a pure atmosphere, exercise in the open air; hydro-
therapy when the fever has disappeared ; nutritious and
wholesome food.
I intentionally omit mentioning the advantage of living
in climates of elevated countries, since I wish to make
this the theme of another paper, which I will have the
honor to forward soon.
After using mercurials I constantly employ iodide of
sodium, according to this formula :
B. Aquaedestill...........ccsesess eegrams 50
Todid, sodik sssusa srat usred deris “ io
Sig.—Used in drops, to commence with ten, increasing by ten
each day, and having reached two hundred, to be recommenced ;
always administered either in pure or in sugared water. The use of
this substance is to be continued for many months.
If this treatment by mercurials has failed to satisfy me,
I add to the use of the iodide that of English blue mass.
The frequent use of blisters is suitable, but in order
not to fatigue the patient, I recommend the weekly ap-
plication of a light one (that is to say, not producing
suppuration) in different parts of the thorax, giving the
preference to the affected side. There are persons who
need many of them, but commonly ten or twelve are
sufficient in incipient cases. As in some patients the
repetition of the blisters causes boils around these blisters,
they constantly refuse to continue with the treatment; in
such cases I substitute blisters by cautery-points at twenty
or thirty different places in a limited space of the thorax,
using the acute cone of the thermo-cautery of Paquelin ;
and in this case I repeat more frequently the applications.
As long as there exists any point of the lung indurated,
I continue the blister, even should it have to be pro-
longed for several months.
I always employ blisters for simple bronchitis in tuber-
culous persons.
Should the pulmonary lesion, although ameliorated,
remain stationary, I occasionally return to the use of cal-
omel, administered internally, and mercurial ointment,
externally.
Should the patient not recover his previous robust
health, but remain delicate, I employ arsenic, in the form
of the arseniate of strychnine :
B. Extracti cinchonz.............--e0e00: gt. 4
Arseniatis strychnici,........6-..0000. gr. 0.03
in thirty pills. Sig-—To commence with one daily at dinner, in-
creasing one every four days. Having reached five pills a day, re-
commence, using one.
This treatment I also continue for a long period.
I have, unconsciously, come to treat slow developing
phthisis, and in a chronic form; but as it often happens
that the mercurial treatment, when it does not at once
cure, favorably modifies the malady, it becomes imperative
to perfect the cure by resorting to less energetic means.
Many patients, and even physicians, become frightened
at the deterioration undergone by the health of the sick,
while under mercurial treatment ; but fever disappears
July 27, 1889] —
soon after, sweats cease, cough diminishes in frequency
and intensity, appetite and physical strength return, and
the patient begins to recover his weight, and becomes con-
vinced of the benefit received.
I do not wish to enter into the theoretical considera-
tions which induced me to employ mercury in the healing
of pulmonary tubercles, but I should state that, now
that the dacillus tuberculosus has become known, every
physician has endeavored to find parasiticides which,
operating directly upon the microbe, may prevent its de-
velopment and propagation ; creosote, iodine, iodoform,
phosphate of copper, tannin, and menthol have been alter-
nately employed, with this object. Antiseptic inhalations
and pulverizations with iodine vapors, iodide of ethyl,
benzoate of sodium, camphor, turpentine, resin, iodoform ;
with a solution of biniodide of mercury, with solutions of
picric acid, of boric acid, etc. ‘The inhalations of fluor-
hydric acid have been more carefully studied, and tried
on a greater scale. Those of sulphurous acid, those by
the rectum with carbonic acid mixed with sulphuretted
hydrogen. Hypodermatic injections of different sub-
stances have also been used, and even intra-parenchyma-
tous ones, which results do not appear to have been ad-
van us.
As to the use of mercurials, I do not find any other
references than those of which I am about to speak. In
a very recent work (“ Practical Treatise on Antisepsia,” by
Le Gendre, Barette and Lepage, Paris, 1888), Mr. Gosse-
lin reports some experiments undertaken in the endeavor
to render sterile the organism, either before or after the
tubercular inoculation. In the first case, organic impreg-
nation by bichloride and biniodide of mercury did not
prevent the development of the bacillus; it rather ap-
peared to hasten the subject’s death, debilitating his organ-
ism. The administration of the sublimate subsequent to
the inoculation has produced the same results. These
experiments were made in animals. Hiller made subcu-
taneous injections of sublimate, which did not succeed in
tuberculous patients.
At a meeting of the Hospitals Medical Society (January
8, 1886), Gougenheim made known the results of thirty-
three cases, in which he used antiseptic injections in tu-
bercular cavities of the lungs, with solutions of sublimate
in the proportion of one to five hundred, to one thousand,
or to two thousand, according to the severity of the lesions.
No ill results followed, even the cough diminished ; when
the injection is gradually administered, the first and sec-
ond intercostal spaces should be selected. In twenty-one
cases a very marked improvement was observed in regard
to local aspects, but the patient’s general condition did
not appear to have proportionately improved.
The sole applications made, previous to the discovery
of the bacillus, for the cure of phthisis with mercurials,
are those which refer to the employment of bichloride of
mercury, the iodide of potassium, and the sesquicarbonate
of sodium. I intend to follow these suggestions and com-
municate any results which I may obtain.
In the Therapeutische Monatshefte, Prof. Dochmann
wrote under date of September 15th, that he had com-
menced the use of mercury in phthisis, taking into con-
sideration the microbic nature of the malady, and assert-
ing that no one previous to himself had resorted to this
treatment.
The contents of this communication prove that before
the year 1871, not only had it been tried, but that the
mercurial treatment had also been successfully applied in
Mexico.
City or Mexico, January 10, 1889.
THE ONE WHO TREMBLED.— Madame de Sévigné in one
of her letters sent the following anecdote to a friend:
“ The Prince once said to his new surgeon: ‘ Do you not
tremble when you bleed me?’ And the little surgeon an-
swered : ‘ Pardon, sir, it is you who tremble !’ and he told
the truth.” à
THE MEDICAL RECORD.
97
Clinical Department.
AN UNUSUAL CASE OF LARYNGEAL INTUBA-
TION.
By A. BROTHERS, M.D.,
ATTENDING PHYSICIAN FOR DISEASES OF CHILDREN, OUT-DOOR DEPARTMENT,
BELLEVUE HOSPITAL, NEW YORK CITY.
INTUBATION of the larynx has, according to Dillon Brown,
been performed in two thousand three hundred and sixty-
eight cases, and is fast replacing tracheotomy, in this
country, as the operation to relieve laryngeal stenosis. As
the method, however, is still comparatively new, every case
with unusual features deserves being placed on record for
the guidance of others.
On April 6, 1889, I was requested to take charge of
the seventeen months old baby of Mr. S . Two weeks
previously—on March 23d—Dr. F. Huber, assisted by
Dr. A. Schlesinger, intubated the child for. laryngeal ob.
struction due to ascending croup. ‘This was followed by
immediate relief. A week later (March 30th) Dr. Huber
removed the tube but, owing to recurring dyspnecea, it was
immediately re-inserted. On April sth the tube was
coughed out, and during the ensuing twenty-four hours
the difficulty in breathing grew worse and worse. When
I assumed charge of the case, on April 6th, the child was
in a desperate condition, with all the evidences of ad-
vanced croup. I succeeded in introducing a two-year
tube, with instantaneous relief. Next day the breathing
and temperature were normal, and the child was nursing
with perfect ease. A week elapsed and the child being
apparently entirely well, I removed the tube (April 13th),
but within an hour I was obliged to reinsert the same tube.
Eight days later (April 21st) I removed this tube and, at
the same sitting, replaced it by a one-year tube. This
double procedure, done with the assistance of Dr. A. T.
Joyce, occupied less than a minute. My object was to
have the child cough out this smaller tube, as my experi-
ence has taught me to prefer this termination to extrac-
tion. Three days later (April 24th), as the child had not
coughed out the tube, I felt justified in removing it. Drs.
Muldberg and Finklestein were present at the time. After
some difficulty—for the tube seemed imbedded in oedema-
tous tissues—the tube was extracted, and this was fol-
lowed by the coughing out of bloody mucus in larger
quantity than I had ever before witnessed. ‘The breath-
ing at once became very labored, and in three minutes the
child was suffocating and cyanotic. On the spur of the
moment I attempted to introduce a tube without mouth-
gag or thread, but the tube slipped down the cesophagus
and was swallowed—an accident which had never hap
pened to me before. The gag was at once placed be-
tween the teeth, and as the child seemed to breathe its
last, I succeeded in getting the small tube into the larynx.
The tube which entered the stomach was not noticed by
the parents during the excitement of the terrible moment,
and I did not wish to alarm them by calling their atten-
tion to it. At all events I never heard of it afterward,
and presume it was passed unnoticed with a movement
from the bowels and thrown away. On the night of April
gth the last tube was coughed out, but as the breathing
was somewhat difficult, and as I feared trouble during the
night, I preferred to re-intubate. This tube was worn
continuously for three weeks—from April 29th to May
2oth—when it was expelled during a severe paroxysm of
coughing. Since then the child has been in perfect
health.
A few reflections on this remarkable case may not be
out of place. One of the most interesting questions was
in regard to diagnosis. Dr. Huber informed me that, at
the time of the first operation, the child was suffering from
ascending diphtheritic croup ; and I accepted his diagnosis
without question. When I first saw the child, two weeks
later, the throat was perfectly clear, temperature normal,
and beyond some bronchial catarrh, the only condition
98
THE MEDICAL RECORD.
[July 27, 1889
present was that of laryngeal stenosis, for which I in-
tubated. After the child passed through the alarming
experience of April 24th, when it almost died in my pres-
ence, I wrote to Dr. O’ Dwyer asking his opinion in regard
to the diagnosis and subsequent treatment of the case.
He promptly responded, and suggested paralysis of the
abductors, or persistent inflammatory cedema as the causes
of the long continuance of the stenosis. As the child
subsequently coughed the tube out without immediate suf-
focation ensuing I excluded paralysis, and attributed the
stenosis to simple cedema of the larynx. In this view I
was supported by Dr. A. Jacobi, who saw the child while
it was wearing the tube. Dr. O’Dwyer suggested leaving
the tube i situ, if necessary, for three or four weeks.
This suggestion I carried out, leaving the child alone for
three weeks, when it coughed out the tube.
While carrying the tube, it was wonderful to see with
what perfect ease the child nursed at the mother’s breast.
It was only after drinking from the spoon or cup that
liquids would enter the larynx, and excite coughing. For
several days, while wearing the last tube, a general urti-
carial eruption made its appearance, but passed away
without special treatment.
In looking over the records of published cases, I find
that the longest period during which a child carried a
laryngeal tube was nineteen days. ‘This was in a child of
twenty-six months, intubated by Dr. J. A. Anderson
(THE MepicaL ReEcorpD, July 23, 1887, p. 87). As in
my case the tube was worn with interruptions for nearly
fifty-eight days, and continuously at the end for twenty-
one days, it is the longest case on record in this respect.
Finally, it is interesting to note that the laryngeal
cedema undoubtedly present in this case was successfully
dissipated by the gentle and continuous pressure exerted
by the O’Dwyer tube.
93 MADISON STREET.
POISONING BY TINCTURE OF IODINE.
Dr. A. N. Coruins, of Detroit, Mich., reports the follow-
ing case: “I saw the patient, a young woman about
twenty years of age, fifteen or twenty minutes after the
drug had been swallowed. I found the patient suffering
with symptoms of acute gastric irritation and burning of
the throat. No other symptoms were marked except
those arising from fright at the discovery that the drug
was labelled ‘Poison.’ The patient stated that she had
taken at one dose 3 ss. tincture of iodine, which she pur-
chased that day, and showed me a half-ounce bottle con-
taining a small quantity of tincture of iodine. She
had taken the drug by mistake, intending to take med-
icine from another bottle standing near it. Before taking
a little water had been added in a glass, and the whole
mixture taken ‘at a gulp.’ Immediately I gave her
a draught of water made thick with starch, followed
by a teaspoonful of mustard flour given in water. ‘This
was followed by a copious draught of warm water. Vom-
iting was immediately produced, the vomited matter
having the blue color of iodide of starch. I repeated the
dose several times until no color-change was produced on
the starch, and then gave, hypodermatically, morphine sul-
phate, gr. 4; atropine, gr. z$,. I left the patient free
from pain. Saw her next day and found no trouble be-
yond an indisposition to take food, and soreness over the
epigastrium. ‘The next day the patient was about her
work seemingly as well as before her mistaken medication.
Judging from this case, I draw the conclusion that tr.
iodine, when antidoted, is not so harmful in effect as has
been reported. The patient had taken no food for six
hours before taking the drug.”
AN Cipemic ‘Tipg.—The Boers of South Africa believe
that the moon exercises an influence over dropsy, and that
the water is always worse at full-moon and wanes as the
moon wanes.
Progress of Medical Science.
A New METHOD oF AuscuLTaTion.— Dr. Carlo Gior-
geri has recently described (Gaz. degli. Ospitali— British
Medical Journal) an addition to the methods of physical
examination at present in use, of which a short prelim-
inary account was given by Professor Aurelio Bianchi, at
the Medical Congress held at Rome in October, 1888.
That gentleman, on passing an cesophageal tube into a
patient’s stomach, and applying his ear to the upper end,
heard various sounds as the instrument travelled down the
gullet, and when its lower end was in the stomach. By
fixing a bifurcated, gum-elastic tube, provided with ear-
pieces like those of a binaural stethoscope, to the upper
end of the cesophageal sound, he contrived an instrument
with which he was able to practise what he calls “ endo-
auscultation,” both of the cesophagus and the stomach.
Dr. Giorgeri divides the sounds heard in this mode of ex-
amination into (1) oesophageal, (2) gastric, (3) respiratory,
and (4) cardiac. ‘The cesophageal sounds are produced
by the rubbing of the instrument against the walls of the
gullet ; they are loudest at the two narrowest points of
the cesophagus, namely, at its upper aperture opposite the
posterior surface of the cricoid cartilage, and at the
cardiac orifice. There may also be one or more stric-
tured portions where the sounds are heard with special in-
tensity. Peculiar sounds are caused by abnormal condi-
tions of the walls of the oesophagus, or by foreign bodies
adherent to them; and gurgling may be heard if the in-
strument enters a diverticulum containing fluid or solid
food. The sounds heard in the stomach are chiefly of a
gurgling nature, or they may be caused by friction against
foreign bodies, or against the walls of the viscus altered
by organic disease, or by sudden sharp contractions of the
organ. ‘The respiratory sounds begin to be heard as soon
as the instrument enters the upper aperture of the ceso-
phagus, and increase in intensity as it travels downward,
being most distinct a little above the cardiac orifice. If
the walls of the stomach or cesophagus are the seat of
structural changes, the transmission of the breath-sounds
is interfered with to a greater or less extent. The heart-
sounds are heard from the middle of the cesophagus down-
ward, and inthe stomach. ‘Ihe two sounds are distinct,
but more blowing in character than when heard in the
ordinary way. Professor Bianchi made some experiments
on the effect of the introduction of fluid into the stomach
on the sounds heard by endo-auscultation. For this pur-
pose he modified the instrument, by fixing a bifurcated
tube to the upper end of the cesophageal sound, one arm
of which was of considerable length, and was fitted witha
glass funnel at its free extremity, while the other arm was
again bifurcated, the two ends being provided with ear-
pieces as before. If, after introducing the instrument,
fluid was poured through it into the stomach, the cardiac
and respiratory sounds at once ceased, and could not
again be heard, even on drawing up the cesophageal tube
so that its lower end was above the level of the fluid in the
stomach, while in the cesophagus itself the heart- and
breath-sounds were very indistinct. If the stomach was
then emptied, and the instrument again introduced, some
time elapsed before any sounds were audible. Professor
Bianchi offers as an explanation of this curious effect that,
as the vibration of membranes is more perfect the dner
and more tense they are, the introduction of fluid impairs
the vibratory power of the stomach-walls. He believes
that endo-auscultation may prove of great service in the
study of diseases of the stomach and cesophagus, and pos-
sibly of the circulatory system in the thorax.
New REMEDIES FOR Skin DiseEases.—Schwinmmer has
lately, in the Wiener medizinische Wochenschrift, published
the results he has obtained in certain skin diseases by the
use of salol, oxynaphtholic acid, salicylate of mercury, and
anthrarobin. Salol mixed with starch in the proportion
1 Of two to one he finds a very effective remedy in all forms
July 27, 1889] |
THE MEDICAL RECORD.
99
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of venereal sores and in the buboes resulting from them.
iodoform seems to have a more rapid action, but salol
has the superiority of possessing no smell. The drug also
appears useful in conditions of the mucous membrane of
the bladder, when given internally in doses of forty-five to
ninety grains distributed through the day. Oxynaphtholic
acid did not give good results in venereal cases, acting as
an irritant. In scabies, however, it did not irritate, and
was an effective remedy. It may be mixed with chalk
and soft soap, each ten per cent., with lard. It acted well
also in the secondary eczema of scabies, and allayed itch-
ing in prurigo. Salicylate of mercury possesses no supe-
riority over the ordinary remedies used in gonorrhoea and
venereal sores. Given internally in doses of one and a
half to two grains, it was an effective antisyphilitic drug,
although apt to cause irritation of the intestine and sto-
matitis. Anthrarobin was found to have no beneficial
effect in psoriasis, but in herpes tonsurans, eczema mar-
ginatum, and pityriasis versicolor it acted well, being
mixed with collodion in the strength of one in ten.— Brit.
Med. Journal.
THE INFLUENCE OF MORPHINE ON THE UTERINE AP-
PARATUS.—Dr. Lutaud communicated to the Paris So-
ciété de Médicine, three years since, a paper drawing
attention to a hitherto unrecognized symptom of the
morphine habit. He had found, in a limited number
of observations, that morphine exercised a peculiar in-
fluence on the ovaries, diminishing and even abolishing
menstruation. He now publishes a further and extended
series of observations of the same kind, which not only
confirm his previous assertions, but afford several thera-
peutical indications of value. He has remarked the total
suppression of the menses in eighteen cases as soon as the
amount of morphine attained a certain dose (Zhe Lon-
don Medical Recorder). All the patients had taken to
morphine on the advice of their medical attendant for
the relief of uterine disorders, which, however, had
in every case ceased to exist when they came under
observation. The suppression of the flow was there-
fore due to the influence of the drug and not to the
primary ailment. He gives the history of eight charac-
teristic cases of women, under forty years of age, in whom
suppression of the menses had taken place with a mini-
mum daily dose of four and a half grains of morphine.
He concludes (1) that morphine has an elective action on
the uterus, suppressing menstruation and extinguishing
the reproductive function ; and (2) that this elective in-
fluence is characterized by the extinction of all sexual
desire. He suggests, therefore, that morphine would
prove of service in the treatment of women suffering from
affections which are aggravated by the menstrual flow,
such, for instance, as fibroid. He has put it to the test
in cases of fibroid and cancer of the uterus, and the re-
sults appear to him to have been satisfactory.
MALARIAL PAROXYSMS IN THE Faetus oF A HEALTHY
Woman.—In the Edinburgh Medical Fournal, June, 1889,
Dr. Felkin relates two cases in which he observed mala-
rial paroxysms in the foetuses of healthy women. He sug-
gests the rather striking explanation that the malarial poi-
son was introduced in the semen of the diseased father at
the time of conception of the foetus. In one of the two
cases the mother, an English lady, more than eight months
pregnant with her first child, consulted him for “ pain and
a curious sensation in her abdomen.” She said she had
had 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 night, 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 forceps, and easily delivered the
head. The body was extracted with difficulty, on account
of the great distention of the abdomen 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 intermit-
tent and remittent ague attacks while living in a distant
part of the country, and was suffering from them at the
time of the conception of the child. In the second case,
a Scotchwoman, seven and one-half months pregnant, was
ill with pleurisy and bronchitis, and the effects of a beat-
ing which her 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 ab-
domen like a bad quickening.” Being called the evening
of the same day at the same hour, he found her in a con-
dition 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 examination the kidneys showed marked cloudy
swelling in the epithelium of the convoluted tubules, the
nuclei of the cells continuing to stain while the surround-
ing protopasm was highly granular. The nuclei of the
glomerular cells stained distinctly. In the liver many
leucocytes were seen to contain very numerous fine granules
of a dark brown color. ‘The venous sinuses of the spleen
were dilated. Dark pigment granules were observed in
many of the leucocytes contained in the sinuses, as well
as in 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. He then went abroad and con-
tracted severe malarial fever. Ten months after his re-
turn 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 that these cases show that malaria 1s a
specific disease, due to a micro-organism, which may be
transmitted by the father to his offspring, just as syphilis
may be transmitted.
PSOROSPERMIAL CYSTS OF URETERS.—At a recent meet-
ing of the London Pathological Society (The British Medi-
cal Journal) Mr. Eve showed a specimen which had
been sent by Dr. J. Arnallt Jones, of Aberavon, to Mr.
Hurry Fenwick, who had handed it to Mr. Eve for exam-
ination. ‘The upper parts of both ureters were studded
with small miliary cysts full of milky contents. Trans-
verse microscopical sections of the ureters showed cysts
of various sizes filled with colloid material, in which were
many ovoid bodies which corresponded in appearance and
size to psoro-navicellz. The patient was a woman, aged
fifty-one, who had a sudden attack of hematuria, with
frequent and painful micturition. Death had taken place
from exhaustion and anzmia seventeen days after the
onset of symptoms. ‘The kidneys and bladder were
healthy. Psorospermial cysts had been found beneath the
capsule of the human kidney and in the liver. The dis-
ease was not uncommon in some domestic animals, and it
was very common in the livers of rabbits.
MEDICAL SCEPTICISM.—At the time when Russian so-
ciety was at the height of scepticism, the eminent Profes-
sor, N. G. Pirogoff, said in one of his celebrated public
speeches that the life of every physician may be divided
into three periods. The first, when he religiously believes
in what he has been taught at the university ; the second,
when he only believes in what his own experience taught
him ; and the third, when he believes neither in one nor
in the other.
100
THE MEDICAL RECORD.
[July 27, 1889
a a
THE MEDICAL RECORD:
A Weekly Fournal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., EDITOR.
PUBLISHED BY
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
New York, July 27, 1889.
THE HISTORY AND COST OF THE DIDAC-
TIC LECTURE.
Ir is evident to anyone who has watched the progress of
medical education in recent years that the didactic lecture
has suffered a great decline in relative importance, as com- |
pared with other methods of imparting professional knowl-
edge. Indeed, it is not hazardous to prophesy for it a
still further decline in the near future. Nevertheless, it
is of interest to study its origin, as its history illustrates an
important phase of evolution in the educational world.
We understand, by a didactic lecture, a teaching of ab-
stract truth relative to disease, while the clinical lecture
supplies‘ its concrete correlative. ‘The former is a heri-
tage from our fathers. It sprang into being even in the
early ages of the world. In our own country it antedates
schools and colleges. It had its origin at a time when
the minister and the doctor were the only learned men
in the community. Books were scarce. Access to the
fountains of printed knowledge, particularly in the profes-
sions, was granted to but few. Hence came the imparting
of information by the physician to his office assistants dur-
ing the consulting hour, and during the lonely ride. ‘The
number of those giving and those receiving instruction
gradually increased, so that, to avoid duplicating instruc-
tion, the teacher met al) his pupils at one place. ‘That
was the beginning of a college, and from that origin has
been gradually wrought out the medical school of to-day.
That was the best system for its day. In fact, it was the
only possible one under the existing conditions. Infor-
mation was locked up in the brains of a very few. It
was not accessible to the many. Now all is changed.
The multiplication of the printed page has brought the
best and ripest scholarship within the reach of all. Yet
the average didactic lecture has run on in the old groove.
' In view of this modern progress, the lecturer who has
maintained the old reputation of his craft has had to
possess an endowment of personal magnetism and en-
thusiasm to hold his audience. A notable illustration of
this was the late Dr. Dalton. His text-book contained
practically all that was said in his lectures; but who can
forget that breadth of explanation, that contagious love
of the subject which pervaded his class-room utterances ?
It is not given to all lecturers to possess this quality.
Now and then a man has the art of expounding his sub-
ject well, of making students think for themselves. But
the average didactic lecture is dry and, unless the lecturer
is an original worker, unmistakably dull. It is retailed
out so many times in the course of a session for so much.
The information is generally crammed up from a large
collection of text-books, flavored with a little experience,
and doled out by the hour: price, twenty dollars per
session.
No wonder, then, that many didactic lectures are poorly
attended. The student knows that he can find all the
information in text-books, and sees no reason why he
should listen to another’s reading of the same. Particu-
larly is this true of a subject like anatomy. It is not a
fault of any one man or any one institution. It is a uni-
versal one.
The average medical session lasts about twenty-four
| weeks. The total number of lectures will average, in any
one branch, about eighty. ‘The prevailing price for any
one study is twenty dollars. The didactic lecture, there-
fore, has a market-value of twenty-five cents. Inasmuch
as a student is compelled to attend two courses of lectures
which, in the primary branches, are practically duplicated,
he is obliged to buy the article twice over. In a college
of six hundred students the gross revenue will, on the
above basis, amount in each of the seven departments to
about eight thousand dollars.
The successful medical curriculum should be arranged
on such a broad basis that to pass in a given subject
should not necessitate attendance on the lectures of any
one man. It should be broad enough to include knowl-
edge in that branch generally. The didactic lecture will,
we believe, gradually give way in the future to a judicious
and well-ordered system of recitations. A lesson will be
assigned in a text-book and recited, and the medical in-
structor will assume the functions of the regular teacher
of science. ‘This is already the method in the medical
departments of Harvard, Yale, the University of Virginia,
and some other institutions we might name. Collateral
reading is encouraged, and a much broader foundation is
laid than by the system so widely prevalent.
CHROMIC ACID IN SWEATING OF THE FEET.
Ir all remedial measures could be subjected to such ex-
tensive and compulsory tests as has the chromic-acid
treatment of sweating feet, we should soon arrive at many
therapeutical certainties.
On July 9, 1888, orders were sent out to all the military
surgeons of the Prussian army to use chromic acid in all
cases of sweating feet. The directions Were that if there
be any broken surface the solution must not exceed five
per cent. till it heals, after which the solution may be in-
creased to ten. If the sweating be of a moderate char-
acter the application must not be made oftener than every
six or eight weeks, but if very intense it has to be applied
every fortnight for the first month. In the height of
summer the whole body may be similarly treated, but two
applications are considered sufficient to relieve the most
obstinate cases, and it is said to leave no bad effects.
This assertion must, however, be received with a certain
amount of caution, says the Medica’ Press, as a death fol-
lowing its use caused the order from headquarters to be
modified, though it has been assumed that the death was
caused by the use of an impure solution. The first order
was sent out July 9, 1888, and this modification on No-
July 27, 1889]
THE MEDICAL RECORD.
IOI
vember 30th of the same year. Since then its use was
limited to the five per cent. solution in all cases till they
proved obstinate.
A report on the results of the use of this remedy was
sent in in January, 1889. There were upward of 18,000
soldiers treated by chromic acid during the six months
over which the report extends, and the result of the ex-
periment is decidedly favorable. Of these 18,000 patients
forty-two per cent. were cured, fifty per cent. improved,
and eight per cent. unaffected.
The report subdivides the cases into three degrees of
severity : 1. A severe form in which the skin of the foot
is constantly wet, red, and swollen, particularly between
the toes, the foot tumid and macerated, in which cases
the sweat rapidly decomposes and produces an intolerable
stench. 2. A middle class is given, of cases in which the
sweating is confined to the sole of the foot, which also
produces dampness and fetor. The third class comprises
cases due to much walking on very hot days. The solu-
tion must not be applied by means of brushes made with
metal holders, as the chromic acid is apt to decompose
the latter, and on this account wood is to be preferred.
Again, if bathing the feet be allowed, it must be done in
an earthenware utensil for the same reason; but the
brush is by far the best means of applying the solution.
DILATATION OF THE MALE URETHRA FOR THE RE-
MOVAL OF VESICAL CALCULI.
Dr. LAPLACE (New Orleans Medical and Surgical Four-
nal, June, 1889) reports a case of vesical calculus in a
feeble patient, aged fifty-six, who came under his care in
October, 1888. He complained of great difficulty in
passing water, the stream being full at first, but suddenly
stopping before the bladder had become quite empty.
Micturition was accompanied by a burning pain at the
neck of the bladder. His urine contained about three
per cent. of albumen, some pus, and a large quantity of
mucus, the bladder being evidently inflamed. His tem-
perature was constantly above 99° F. Upon exploration,
calculi about the size of a chestnut were discovered in the
bladder. Influenced by the good results claimed last
year by Küster, from Küster’s modification of Delbeau’s
operation, which is a para-prostatic section of the ure-
thra with subsequent dilatation of the prostatic urethra
and neck of the bladder, Dr. Laplace determined to at-
tempt removal of the calculi by this method. Chloro-
forming the patient, and placing him in the lithotomy
position, he introduced the index of the left hand into
the rectum, so as to feel the anterior edge of the pronati,
and cut, in the median line, through the perineum, directly
upon the guide in the urethra, and, having reached the
guide, continued his incision to within a quarter of an
inch of the prostate. The whole incision was an inch
and a half in length. ‘The guide was then withdrawn from
the urethra, and the operation of dilating the prostatic
urethra and the neck of the bladder was begun. The
whole urethra had been somewhat dilated already by the
passage of sounds during several preceding days. Through
the perineal incision Simon’s dilators were introduced, be-
ginning with No. 1 and ending with No. 8, each being
left in position-five minutes. When No. 8 was removed,
two fingers were easily passed into the bladder, and, after
the two calculi had been accurately located, an ordinary
forceps was introduced, and they were easily removed.
The bladder was thoroughly explored by the fingers, to
make sure that no fragments were left behind, and the
viscus was then washed out with carbolized water. Two
sutures were applied at the extremities of the perineal
wound, and the case was treated subsequently as one of
simple external urethrotomy. For ten days the urine was
passed through the wound in the perineum, but gradually
began to flow through the urethra, and on the twenty-sixth
day after the operation the perineal wound healed. Fora
few days after the operation the bladder was washed out
through the incision. The patient recovered completely.
Sounds were passed daily, after the wound had healed,
for the purpose of securing a permanent open condition
of the urethra.
Dr. Laplace thinks that this operation, though as yet
but little known, will lead to a great improvement in the
surgery of the urinary bladder. He concludes with a
summary of the points of greatest interest.
1. The operation is very simple ; little more, really, than
an easy external urethrotomy.
2. The prostatic urethra may be dilated very greatly,
with ease and with impunity. This might be naturally
inferred from the muscular structure of the prostate, and
from the great dilatation of which the uterus, which in the
female corresponds to the prostate, is capable.
3- Having now a safe means of access to the male
bladder, free from danger to that viscus, there is no rea-
son why we should not, to a very great extent, abandon
the old methods of extracting calculi from the male blad-
der, and employ instead this new method, by which we
may with facility extract calculi of any size, with or with-
out crushing, avoiding the serious risks of the older opera-
tions. It is suggested that this is a very safe and easy
method for the removal of foreign bodies from the ure-
thra and the bladder.
LATE PREGNANCIES.
A CORRESPONDENT writes us regarding the age at which
women cease to bear children ; or, more specifically, he
raises the medico-legal question whether there is an age
at which a virgin may be pronounced incapable of bear-
ing a living child, if afterward married or deflowered.
There have been several English decisions to the effect
that women of fifty-three or fifty-five years have passed
the childbearing age, and if any definite limit can
be laid down it is probably about this time. Cases of
pregnancy up to the fiftieth year are not very uncommon,
according to Tidy. In the famous Douglass peerage case
it was established that Lady Jane Douglass, when fifty
years of age, gave birth to twins, both of whom lived.
Briand cites two cases of delivery, one at sixty-three and
one at seventy years of age. There are several cases on
record, some well authenticated, of pregnancies occurring
between the ages of fifty and sixty. Orfila, for example,
cites the case of a woman who had seven children, one at
forty-seven, the seventh at sixty. She menstruated until
she waseninety-nine years of age! In many of the cases
of late pregnancies the whole childbearing period seems
to be delayed, so that they cannot be brought up as il-
lustrations of the possibilities of the average woman.
Reports of cases of pregnancy occurring after the age of
sixty are but few, and not well substantiated. So that the
102
extreme limit of possible childbearing n may be put at
sixty ; the limit rarely exceeded, at fifty-five; and the
limit ordinarily not exceeded, at forty-five.
As the limit of early pregnancy is eight years, it follows
that childbearing is possible in woman between the ages
of eight and sixty years.
THE SURGICAL TREATMENT OF TUBERCULAR PERI-
TONITIS.
SURGEONS have somewhat blindly stumbled upon the fact
that tubercular peritonitis is a disease which is sometimes
amenable to treatment. In 1862 Sir Spencer Wells
opened the abdomen to remove a tumor, and found tuber-
cular peritonitis. He drained it and the patient got well.
In 1879 Mr. Tait diagnosticated a case of tubercular peri-
tonitis, and treated it by opening the abdominal cavity
and washing out the peritoneum. Schwartze has collected
seventeen cases in which surgeons have opened the ab-
dominal cavity, discovered tubercular peritonitis, and
treated it by washing or drainage, or both. In 1887,
Kiimmell collected forty cases in which the diagnosis of
tubercular peritonitis was first made, and operation for its
relief performed. Mr. Robert O’Callaghan, in the June
number of the Dublin Fournal of Medical Science, re-
ports four cases, three of which were successful, and he
calls attention to the importance and value of surgical
treatment.
Chronic tubercular peritonitis is not a frequent disease,
and little is said about it in most standard works. Lapa-
rotomists have apparently shown, however, that it is not
so rare a trouble as has been supposed, and most impor-
tant of all, they have shown its curability in a minority of
cases. Mr. Tait, we believe, claims that tubercular peri-
tonitis is not really tubercular, but on what grounds we
are unable to say.
It has to be borne in mind that some cases of tuber-
cular peritonitis recover spontaneously. Deschamps be-
lieves that those cases in which the infection occurs
through the genital or intestinal canal have a more
favorable prognosis. On the other hand, Treves has
shown that laparotomy for tubercular peritonitis has
always been unsuccessful in young children.
The diagnosis of the disease is not always easy. Pri-
mary tubercular peritonitis runs a somewhat obscure
course. ‘Ihe principal diagnostic symptoms, according to
Cimbali, are low temperature, comparative absence of
pain and tenderness, and copious ascites.
METHACETIN—A NEw ANTIPYRETIC.—Dr. Franz Mah-
nert, assistant to Professor von Jaksch, describes, in the
Pharmaceutische Post for April 7, 1889, the most recent
addition to our rapidly growing list of synthetic medicinal
compounds. ‘This time it is an antipyretic, and in com-
position might be described under the name of para-
acetanisidin, its formula being
OCH
CoH, 1 NH.C3H,O.
In doses of from two to three grains, given to thildren,
it exerts a marked antithermic action, the reduction of
the temperature being gradually produced, remaining for
several hours at the lowest point, and then gradually in-
creasing. Frequently marked perspiration is produced by
its use within an hour after its administration.
THE MEDICAL RECORD.
[July 27 27. ied
> ee tat _-*— Saimin ies arte fae ——
Hews of the GWeek.
THE LIBRARY OF THE LATE DR. JEWELL, OF Cui-
CAGO, numbering about 3,000 volumes, has been se-
cured as the nucleus of a medical library. Dr. Jewell’s
portrait, it may be remembered, was purchased by the
New York Neurological Society and presented to the
Academy of Medicine.
THE GOVERNMENT OF CHILI has created a “ Su-
perior Council of Public Hygiene,” consisting of seven
members, whose duty it shall be to advise the Govern-
ment in everything that relates to the public health
throughout the Republic. The Council has a laboratory
for chemical analysis under its control.
THE recent legislature of Texas voted $50,000 for the
establishment, at Galveston, of a medical branch of the
State University.
M. Brown-SEQUARD announces that the injection of
ovarian tissue-juice into debilitated women has been tried
and without bad effects. He also says that the stimulat-
ing effect of the hypodermic injections made upon him-
self continues, he having now gune sixteen days without
any repetition of the injection.
ZOSTER-EPIDEMICS.—Professor M. Kaposi, in a recent
clinical lecture, says that nearly every spring and fall there
occur epidemics of herpes zoster in Vienna ; the favorite
months are March and April, October and November.
DISPENSARIES IN CHINA.—The China Medical Mission-
ary Journal says: “In Southern China, numerous preach-
ing halls are opened to counteract the influence of Gospel
halls, and dispensaries are established to render the de-
pendence of the people on foreign doctors unnecessary.
Girls’ schools, too, are opened in Canton, near to those
of our missionary ladies, with a view of taking away the
scholars and saving them from contamination by false
doctrines.” An account is given of a hospital for incu-
rables, established in Canton, to which there were, during
one year, nine hundred and thirty-seven admissions with
six hundred and seven deaths.
A GOVERNMENT HELPps A MEDICAL JOURNAL.—The
Chilian Government having agreed to increase the grant
to the Medical Society for the expenses of their journal,
the Revista Médica, the editor promises that it shall be
very much enlarged and improved. It has been in exist-
ence for some seventeen years, but has not obtained a
‘sufficient circulation to enable it to attain financial] suc-
cess.
AN ATTEMPT AT BLACK-MAIL of the most serious and
despicable character was recently made against Mr. Mal-
colm Morris, of London, by a black-mailer named Grandy
and a prostitute co-conspirator. They charged Mr. Mor-
ris with having, after immoral relations with the female
prisoner, broken a promise of marriage made to her, but
they were met, unexpectedly, by Mr. Morris handing them
over to the police. It was then ascertained that this was
not by any means tlie first speculation of this sort by the
pair, and, notwithstanding the plea of their lawyer, that
they had simply mistaken Mr. Morris for some other per-
son, they were “sent up” for five years and eighteen
months respectively.
July 27, 1889]
EXECUTION BY ELECTRICITY.—Dr. B. Sachs, of this
city, writes: “ Your short editorial in the Recorp of July
20, 1889, on ‘ Death by Electricity’ contains, among other
Statements in which I concur, the remark that ‘the ques-
tion is really and solely one of zsthetics.’ As one of the
expert witnesses in the Kemmler case, I beg permission
to give a few figures which are intended to show that the
zesthetic difficulties are not greater than the mechanical
ones. Few medical men, I am sure, realize the data in-
volved in this problem of execution by electricity. It
has been proposed to use a dynamo yielding 1,500 volts.
According to Jolly, Gärtner, and others, human resistance
is often equal to 500,000 ohms (in round numbers).
Now what would happen in case a criminal offering such
resistance were subjected to the current of 1,500 volts ?
Ohm’s law reads: Current strength equal electro-motive
In the above
case C = x}$$8,, or zth5, Or itoy amp. Instead of
being killed, the criminal would receive at the start a
current of 3 m.a. Inasmuch as the resistance diminishes
quickly, leaving aside the fact that death should be instan-
taneous, let us suppose that after thirty seconds the re-
sistance had been reduced to 50,000 ohms, the equation
would then read: C = 7690, = +3, amp., or about
30 m.a. ; still a very small current, and far below the 150
or 200 m.a. which many gynecologists use. It is not suf-
ficient to know that a current may kill; it must kill. A
current of fully two ampéres would be certain to kill; to
send such a current through the body would require a
dynamo at least one hundred times stronger than any
which has been constructed up to date. You will there-
fore grant that, in view of such facts, killing ctto et jucunde
by electricity is not as easy a matter as most people sup-
pose ; and there is no escape from the conclusion that the
gentlemen who proposed using electricity, and those who
ordered the plant for the Auburn prison, were not acquaint-
ed with the known facts regarding human resistance.
[The question is either misapprehended or not quite
properly stated by our correspondent. It is the question
of what is the resistance of the human body when proper
contact with large, well-moistened electrodes is made.
Under these conditions the electrical resistance is neither
very great nor very variable. ‘The electrical experts who
have referred to the enormous resistances of the human
= body refer to it as taken under peculiar conditions, and
their evidence is consequently not at all to the point.
With proper contact the human electrical resistance is
not likely to exceed 2,500 ohms, and this is instantly and
verv much reduced. A current represented by the for-
mula CS = 345%,>, passed through the brain, instantly
kills, as experiments on animals show. In consideration
of the fact recently shown by Mr. Edison, after testing 250
persons, that the resistance of the human body with proper
contact ranges from 660 to 1,500 ohms, and averages
only 1,000 ohms, the “ expertness” of the testimony which
intimates that the resistance is 500,000 ohms may be se-
niously doubted.— Ep. ]
force, divided by resistance ; or, C = —.
Dr. Puiuip F. BRAKELEY died at his home in Belvidere,
pn July 3d, of heart disease. He was for many years
Secretary of the Warren County Medical Society, and
was a prominent member of the State Society. He was
seventy-four years of age at the time of his death.
THE MEDICAL RECORD.
103
THE FLoaTinc HospiTaL oF St. JoHNn’s GuiLp has
been making regular trips since July gth.
THE SEA-SIDE HOSPITAL FOR CHILDREN at New Dorp,
S. I., was opened for the reception of patients on July oth.
THE Weekly Medical Review comes to us in an en-
larged and improved condition.
AN AMBULANCE SYSTEM FOR Lonvon.—A scheme has
been brought before the Sanitary Committee of the Lon-
don County Council for the establishment of an organ-
ized ambulance system throughout the metropolis.
Dr. THEODORE Dimon, of Auburn, N. Y., died July
23d, aged seventy-two years. He was an old army sur-
geon, prison physician, and ex-Superintendent of the State
Insane Asylum at Aubum.
AT a special meeting of the staff of the Orange Memo-
rial Hospital, held Tuesday, July 9, 1889—all the mem-
bers being present—the following action was taken upon
the death of Dr. Stephen Wickes :
Whereas, In His infinite wisdom, our Heavenly Father
has taken to himself our beloved colleague, Dr. Stephen
Wickes ; -
Resolved, That this staff has lost a most faithful co-la-
borer. He was zealous and devoted to all the duties per-
taining to his office as a medical attendant of this institu-
tion. He was an earnest Christian gentleman whose
character and disposition were moulded by Christian grace.
He was modest, retiring, kind, considerate, charitable,
and always ready to give of his time and strength to those
in need. He was beloved by those to whom he minis-
tered, and by those with whom he was associated in reliev-
ing the sufferings of the sick. Words do not truly express
the veneration, respect, and esteem which were accorded
to our deceased friend and professional brother by all
who knew him within medical circles and by the general
community. His literary labors have resulted in the pro-
duction of much valuable matter, especially of an histori-
cal nature, that will serve as a memorial of a useful life.
To his family we offer our heartfelt sympathy in their
great sorrow, but they still will share with us a joy and
comfort that Dr. Wickes was ripe in years, rich in honors,
and sure of a reward for a helpful and blameless life.
T. R. CHAMBERS,
Tuos. W. HARVEY,
GEO. BAYLES,
Committee.
THE AMERICAN RHINOLOGICAL ASSOCIATION will hold
its seventh annual meeting at Chicago, Ill., August 28, 29,
and 30, 1889. The Committee on the Examination of
the Inmates of Insane Asylums will make their report, * On
the Relations of Rhinal Inflammations to Mind Affec-
tions,” at this meeting.
TRAINED NuRSES.—The Memphis School for Trained
Nurses recently graduated its first class. ‘This is the pi-
oneer training school of Tennessee.
THE STATE OF MINNESOTA, like the State of New York,
organized and built an inebriate asylum ten years ago ;
then they changed it to an insane asylum. A law was
passed confining inebriates to insane asylums, and now
one of the released inebriate patients makes a protest
against this practice.
104
EUCALYPTOL IN HEADACHE.—Dr, M. J. Lewis (Medical
News) states that eucalyptol, in doses of five grains, six
times daily, is useful in headaches, particularly those of a
congestive character. :
SIR GEORGE PORTER, of Dublin, who was knighted two
years ago, received the higher and hereditary distinction
of a baronetcy on the Queen’s birthday. It was thought
that Dr. Banks, of Dublin, late President of the British
Medical Association would be honored in the same way.
But he declined a knighthood two years ago, and that
is probably the reason why a baronetcy was not offered
him. |
THE CARTWRIGHT PRIZE Essay.—-At the recent Com-
mencement of the College of Physicians and Surgeons of
New York, it was announced that the Cartwright Prize
had been awarded to an essay written conjointly by Dr.
Hobart A. Hare and Dr. Edward Martin, of Philadel-
phia. But the successful competitors voluntarily surren-
dered the prize because their essay had just been awarded
a prize elsewhere. It appears that the essay had been put
into competition for both prizes, with the expectation that
the decision of one prize would be made early enough to.
permit them to withdraw from the second competition in
case they were successful in the first. But owing to delay
in the decision of the prize which should have been an-
nounced first, and to absence of the authors from home
when the announcement was finally made, there was no
opportunity for the intended withdrawal before the award
of the Cartwnght prize was published. The award of the
Cartwright prize has consequently been reconsidered, and
the prize has been granted to Dr. Ira Van Gieson, Assist-
ant Instructor in Normal Histology in the College of
Physicians and Surgeons of New York, for his essay en-
titled “Studies in Neural Pathology, embracing (1) A
Report of a Case of Syringomyelia; and (2) A Contribu-
tion to the Pathology of the Laryngeal and other Crises
in Tabes Dorsalis.” Signed, Charles McBurney, M.D.,
President of the Council of the Alumni of the College of
Physicians and Surgeons of New York; George C. Free-
born, M.D.; W. P. Northrup, M.D.; and B. Farquhar
Curtis, M.D., Prise Committee.
THE VARIOUS CONGRESSES OF LEARNED SOCIETIES have
begun their work in Paris. A Medical Section was
opened on June 11th, under the presidency of M. le Dr.
Leroy de Méricourt, and some interesting papers were
read. Among them was one by Dr. Florain, on the
curious subject of the “Action of Human Saliva on
Plants,” one by M. le Dr. Moreau on the “ Contagious-
ness of Crime,” and one by Dr. Motais on “ Heredity and
Myopia.” Dr. Montessus tried to show a “ frequency of
metritis in young girls”—he might have been in better
business. Dr. Fabre presented a lengthy treatise on the
“ Hygiene and Diseases of Miners.” M. Guelpa com-
municated the results of a study of tetanus.
CURES FOR THE Opium Hasit IN Cuina.—Dr. A. P.
Peck writes in the China Medical Misstonary Journal:
‘‘ As no one is aware of the extent of the traffic in opium
among the Chinese, or of the use of it as an intoxicant,
so no one knows the extent of the trade in opium-cures
among the natives, or of the demand for them by opium-
users. ‘The writer has met with frequent instances of
breaking off the opium habit by smokers, both by force of
THE MEDICAL RECORD.
[July 27, 1889
will without the aid of medicine, and also in connection
with the use of some native remedy prepared for the pur-
pose. There are, doubtless, hundreds of such formule
scattered through the country, jealously guarded by the
owners, or only transmitted to a favored few. But be-
sides these, there are large dealers in this line ; there is at
least one firm dealing in nothing but anti-opium pills,
which has branches in every province of the Empire.
The account of their operations reads like the record of
some of our great Western houses. ‘Their employees are
numbered by hundreds, and their advertising bills foot up
into a surprising number of thousands of taels. There is
said to be hardly a mart in the Empire, from the small
village fairs to the largest ‘uis, where their posters can-
not be found.”
A New HEartT-Poison was at the June 17th sitting
brought to the attention of the Academy of Sciences by
Dr. Amaud, of the Museum, already known for his re-
searches on ouabaine and strophanthine. The active prin.
ciple there shown in fine colorless crystals has been by
him extracted from “ tonguin,’’ an ordeal poison of the
Madagascar natives, and named tonghinine, from the
botanical name, Zonghinia toxifera, of the plant pro-
ducing the substance. A limited number of physiological
experiments instituted by Dr. E. Gley, show the new
chemical to be very poisonous, and to act on the heart,
much after the fashion of ouabaine and strophanthine.
The resemblance will astonish no one, considering that
tonghinia belongs, like the plants furnishing these, to the
Apocynez family.— 7 herapeutic Gazette.
ANOTHER DISCOVERER OF THE MICROORGANISM OF
CaNncEeR.— Dr. Thoma, of Dorpat, in a recently published
paper, claims to have discovered singular microbic organ-
isms in the epithelial cells of carcinomatous tumors. The
observer found small cell-like structures in the epithelial
nuclei of carcinomata which differed so materially from
all known kinds of cells that he felt compelled to classify
them. among the parasitic organisms. These microbes,
for which thus far no pathogenic claim has been extended,
are one-celled organisms measuring four to fifteen micro-
millimetres in diameter, and can be seen distinctly with
the aid of hematoxylin, safranin, eosin, and alum-car-
mine. ‘They consist of protoplasm and a nucleus, have a
regular round or oval form, and show a strong refraction
of light. Thoma has repeatedly seen them single or in
clusters of four to six embedded in the epithelial nuclei
of carcinomata of the breast, of the stomach, and the in-
testinal tract. No pure cultures, nor other experiments
which might serve to determine the exact nature of these
microbes, have thus far been reported by Thoma.— 7 hera-
peutic Gazette.
GLYCERINE IN Dyspepsia.—Dr. J. A. Pollard claims
(Therapeutic Gazette) that glycerine, in drachm doses,
will be found most valuable in preventing stomach
troubles in convalescence from debilitating diseases; that
it will often cut short an attack of indigestion, and that it
will prevent and cure a large proportion of cases of “ sum-
mer diarrhoea” of children. It will also to a great extent
control the vomiting of pregnancy.
THE SMALL-POX SCARE, which caused so much excite-
ment at Castle Garden last Sunday, on investigation
proved to be a case of measles.
July 27, 1889]
Society Reports.
AMERICAN NEUROLOGICAL ASSOCIATION.
Fifteenth Annual Meeting, held at Long Branch, N. J.,
June 26 and 27, 1889.
First Day, JUNE 26TH—MORNING SESSION.
Dr. E. C. SEGUIN, PRESIDENT, IN THE CHAIR.
Dr. Morton Prince, of Boston, presented a paper on
MALARIA AS A CAUSE OF DEGENERATIVE DISEASES OF THE
SPINAL CORD.
He spoke of the frequency of tabes and other spinal de-
generations in cases which also presented a history of
malaria. The first case he had recorded was one of loco-
motor ataxia with typical) tabetic crises before each ma-
larial chill. Another had gastric crises regularly once
monthly; and another, crises beginning with rigor
and followed by diarrhoea, this occurring every three
weeks. The latter case had been diagnosticated as ma-
laria by the family physician. Altogether the author re-
ported in detail six cases showing the coexistence of tabes
with malaria, and six cases where the malarial history was
associated with disseminated sclerosis. Besides these he
had notes of three other cases of multiple sclerosis, two of
locomotor ataxia, and one of lateral sclerosis with a sim-
ilar relation. Generally the malarial poison was present
In the system previous to the development of spinal
symptoms. He pointed out coincidences in the course
of syphilis and malaria, such as the slowness of action of
the poison and amenability to treatment ; and also called
attention to the relation of the syphilitic virus to tabes.
He had found but little to support his etiological theory
in literature. Erb, following Schulze, had stated that
tabes may occur as a sequel to intermittent fever. ‘I'uczek
had proven that tabes could be caused by the ergot para-
site. Many nervous disorders are undoubtedly due to
malaria, such as neuralgias, anzesthesias, severe psychoses,
etc. He alluded to the deposition of pigment in the
brain in some cases of pernicious malaria. It would be
very important for many army pensioners if it could be
definitely determined that tabes and sclerosis might be se-
quelz of malaria.
Dr. N. E. BRILL said that his attention had never before
been directed to the possibility of such a relation, but he
thought the details presented were rather too meagre for
an absolutely correct decision to be made in the matter.
As neuritis and malaria were frequently associated, possi-
bly some of these spinal cases might be coincident in the
same manner. Both malarial and cord disorders are very
common.
Dr. L. C. Gray saw no reason why the malarial poison
should not cause spinal diseases. We do not yet know
the exact character of the poison. But there is a sort of
periodicity in many spinal and cerebral disorders, as well
as in peripheral nervous affections, which is often as
marked as that of fever and ague. He had noticed this
particularly in intracranial syphilis. Some of these neu-
ropathies were even relieved by quinine, as he had ob-
served in cases of tabes. When we speak of latent
malaria and rest our diagnosis merely upon periodicity,
there is danger of error. If Laveran and Councilman
were right in their discovery of the malarial germ, this
should be looked for in such cases as the author had de-
scribed in order to corroborate with certainty the diagno-
sis. Improvement or recovery under the use of quinine
was no criterion.
Dr. E. C. SPITZKA saw nothing in the nature of the case
to forbid an etiological association between malaria and
cord disorders, but he agreed with the preceding speakers
that sufficient proof of such relation had not been ad-
duced. To show an etiological significance, it was nec-
THE MEDICAL RECORD.
105
essary to present absolute and intrinsic proof of it. If it
could be shown that, as in syphilis, there were at the time
of the malarial attack nervous symptoms, it would be a
different matter. In the secondary fever of syphilis there
was absence of the knee-jerk. Most nervous symptoms in
malaria were of a neuralgic character. ‘The anzsthesias
differ from those of tabes. It had been found that pig-
mentary thrombosis and embolism were the most frequent
causes of serious nervous disturbances in malaria. He
believed, however, that, like any other cachexia, antecedent
malaria might predispose to spinal affections. He had
observed a case of paretic dementia of the tabetic type
which was probably influenced etiologically by severe ma-
laria.
Dr. H. M. Lyman, of Chicago, could recall but two
cases where it had been intimated to him that the origin
of tabes had been malarial. In one he traced the actual
cause to a subacute spinal meningitis coming on after ex-
posure to wet and cold. ‘The other case, instead of being
true tabes, had proved to be a rheumatic neuritis. He
had in his experience seen nothing to support the idea of
a malarial etiology in tabes. A complete and perfect
history, together with a microscopical examination of the
blood, should be required for an indisputable diagnosis
of malaria.
THE PRESIDENT could not recall a single case of tabes
or multiple sclerosis which presented any relation to
malaria.
Dr. PRINCE thought there could be no question as
to the correctness of diagnosis as regarded the ner-
vous symptoms in his cases; and as to the antecedent
malaria, all of his cases were men who had been in army
service, and he had documentary proof of their having
suffered from that poison, in the shape of government
records. The really doubtful question was whether the
malarial poison still existed in the system at the time of
the development of spinal disorders. In some of them
there was evidence of its persistence in the shape of typ-
ical malarial rigor and pyrexia. He did not consider his
etiological explanation decisive, but merely suggestive.
Dr. SpitzKa thought that there were many cases of
nervous disease owing their origin to exposure during
the war which were contemptuously rejected by the
Pension Bureau. It seemed to him that the Association
ought to call the attention of the Government to the great
injustice which might be done.
THE PRESIDENT, although once an army surgeon, and
therefore prejudiced in favor of the soldiers, had been, on
the contrary, struck by the vast number of fraudulent ner-
vous cases which were awarded pensions.
Dr. W. M. Leszynsky, of New York, was then elected
to active membership, and Mr. Victor Horsley and Dr.
David Ferrier, of London, were elected to honorary mem-
bership. ‘The resignation of Dr. A. D. Rockwell, of New
York, was accepted.
AFTERNOON SESSION.
Dr. B. Sacus, of New York, reported a case of
NUCLEAR OPHTHALMOPLEGIA WITH POLIOMYELITIS (POLI-
OENCEPHALITIS SUPERIOR AND POLIOMYELITIS).
The relation between these two forms of disease, which had —
been suspected by Hutchinson, Mauthner, and others,
was proven by this case. But one other was on record,
that of Seligmuller. The history of the patient was, briefly,
that a ptosis of the right eye gradually developed, followed
after a few months by ptosis of the left eye also, and
soon after a paresis of all the external ocular muscles of
both eyes appeared. ‘This resulted in almost absolute
fixation of the right eye, but left a shght inward and up-
ward movement of the left. ‘There was immobility of
the left pupil to light, but not to accommodation. The
right could not be examined because of corneal opacity.
During the development of this nuclear ophthalmoplegia,
Pa
106
a subacute poliomyelitis affecting the entire right leg
supervened. There was now marked atrophy of the en-
tire right leg. The knee-jerk was lost on both sides.
There were no sensory disturbances. ‘There were no
tabetic symptoms, and the patient’s condition was normal
in all other respects. This case proved that the affection
of the nuclei in the floor of the third and fourth ventricles
was due to the same pathological process which gives rise
to a aaa when it affects the gray matter of the
cord.
Dr. SPITZKA said the report of the case had been so
complete, and there being but one other such case on
record, it did not admit of either criticism or compari-
son. He referred to Thomsen’s case of unilateral nuclear
paralysis, where there was a gummatous infiltration on
both sides, and the explanation of which was to him quite
impossible.
Dr. Sacus asked if fibres could be traced up through
the ciliary nuclei.
Dr. SPITZKA answered in the affirmative, and made
black-board drawings illustrative of their course.
Dr. W. N. BULLARD, of Boston, then presented, for
i J. J. Putnam, a skull which was a remarkable example
o
HYPEROSTOSIS CRANII.
The case had been reported to the Association two
years ago. The patient was a woman, thirty-one years of
age at death. The chief symptoms were headache, broad-
ening of the head, dropping out of the teeth, loss of hear-
ing, vertigo, beginning gradually some years ago. There
was extreme exophthalmos. There were no retinal
changes. Extensive pachymeningitis was discovered at
the autopsy. There was thinning and atrophy in parts of
the skull. The orbital cavities were greatly diminished in
size. Virchow considered hyperostosis cranii due to in-
flammatory changes. In this case, probably, the inflam-
mation originated at the ear. Dr. Putnam had a patient
now with similar symptoms, in whom the exostoses were
first noticed in boyhood, and desired the opinion of mem-
bers as to the justifiability of removal of certain exostoses
for the relief of pain. Dr. Bullard himself thought it
might be difficult to determine which of the exostoses
produced the pain. Some of the exostoses were very dif-
fuse, and the operation might have to be extensive.
THE PRESIDENT believed that the pain would be more
apt to originate from basal lesions, possibly dural inflam-
mation about the issuing nerves. The jaw in this case was
interesting because of its senile conformation and angle,
despite the youth of the patient.
l i W. N. Leszynsky, of New York, read a paper en-
title
SPONTANEOUS DEGENERATIVE NEURITIS OF THE BRACHIAL
PLEXUS. :
The patient was a laborer, aged thirty-eight. He first had
pain in the left shoulder, shooting down the arm, which
was ascribed to exposure to wet. ‘There was then no in-
volvement of the shoulder-joint and the motility of the arm
was unimpaired. All the muscles reacted well to fara-
dism, except the deltoid, which was atrophied. There
was no sensory disturbance, but there was pain on press-
‘ure. Gradually other muscles became paralyzed, until a
large number of the arm-muscles were useless. ‘The pa-
ralysis was accompanied by pain so excruciating that the
patient could not sleep at night. A feeling of numbness
extended from the shoulder down the arm over the radial
distribution, and a gradual anesthesia and analgesia super-
vened throughout the same area. The faradic excitability
disappeared, and there was galvanic hyperexcitability.
Then he began gradually to improve, and will ultimately
recover, The case was remarkable in its severity, in its
idiopathic origin, and in the escape of the median and
ulnar nerves from the inflammatory process. Not more
than one case had, to his knowledge, been found in litera
ture.
THE MEDICAL RECORD.
[July 27, 1889
Dr. Prince thought it would be difficult in: the early
stages of such a case to distinguish it from progressive
muscular atrophy of the shoulder type. He recalled a
case of his own in which there was every reason for con-
sidering it to be neuritis. It began with cramps such as
are observed in writer’s cramp, and it was several years
before other symptoms proved the case to be one of pro.
gressive muscular atrophy. The most common cause in
such cases as the author’s was traumatic arthritis, but gen-
erally the results are slight.
Dr. W. R. BIRDSALL had seen this case before, and
was impressed with the idea that it might be a penarth-
ritic affection, but the author's careful study of the case
seemed to exclude this. He recollected that at that time
there was some anchylosis of the shoulder-joint in the
case.
THE PRESIDENT considered the study of the differing
resistances in the healthy and diseased arm made by the
author interesting, and asked if any member had had ex-
perience in such measurements.
Dr. Gray had noticed much variation in resistance in
many of his patients from day to day.
Dr. STARR had measured the resistance in Basedow’s
disease, and had found it to vary within a thousand ohms,
in the same cases, from time to time. Electricity was dif
fused through muscular better than any other tissue. ‘The
chief resistance was in the skin. Probably but little of
the current permeated nerves, and hence alterations of
nervous tissue would not have much to do with the varia-
tions mentioned by the author.
Dr. G. M. HAMMOND stated that it was well known
that the resistance differs from day to day.in animals.
He asked if in this case it had been measured for a num-
ber of times, and was answered that eight trials had been
made.
Dr. BIRDSALL thought the question of resistance had
little to do with our study of disease. It was easy to ex-
plain the numerous variations by the wide differences in
vascularity and moisture of the tissues at different times.
It might be due in this case to paralysis affecting the
physical condition of the tissues. The saturation of the
epidermis by perspiration would explain the variations
mentioned by Dr. Gray. He had made measurements in
cases of Basedow’s disease some time ago, and believed
the diminished resistance found due to the moisture of
the skin. It could not depend on dynamic conditions in
the nervous system, but was purely a matter of physics, -
about which there was no great mystery.
Dr. Gray said the explanation by moisture of the skin
was not applicable in his cases. The differences which
he had observed were not owing to the humidity of the
atmosphere, although atmospheric conditions might pos-
sibly induce dynamic changes in the body.
Dr. SACHS pointed out that on one day the author's
case showed 580 ohms increase on the diseased side, and
on another day 1,170 ohms increase on the sound side.
Such variations evidently had little to do with the patho-
logical process in the patient. Eulenberg had measured
the resistances in cases of paralysis agitans and of Base-
dow’s disease, but without any practical results. As such
measurements were very complex, they required exceed-
ingly great care.
Dr. PRINCE objected to the use of the palm of the
hand for precise experimentation, owing to the great
variability of the thickness of the skin, and consequently
of the resistance. He thought the forearm ought to be
used.
Dr. Leszynsky had not brought forward the question
of resistance in this case as a diagnostic symptom. It
was increased in the affected arm at every examination.
With subsidence of the symptoms the resistance gradually
diminished, but there was a difference between the sound
and morbid side throughout the disease. As to the ques-
tion of moisture, there was excessive perspiration upon
the paralyzed arm, while the normal arm was dry ; in spite
of which, the resistance was greater upon the former. He
July 27, 1889] .
THE MEDICAL RECORD.
107
thought it better to place the electrode upon the wrist
than in the hand. There was no antecedent traumatism
in the case ; the roughening of the shoulder-joint was the
result of the paralysis.
Dr. M. ALLEN STARR, of New York, then presented a
specimen of an
INTERPEDUNCULAR MYXOSARCOMA.
It lay in the middle cranial fossa in the median line be-
tween the crura cerebri, which it separated. It extended
into the lateral ventricles, separating widely the caudate
nuclei and optic thalami. The patient was a male, aged
twenty-one months at death. At the age of thirteen
months, in October last, a lateral nystagmus had been ob-
served in both eyes, varying from time to time. Drs.
Knapp and Roosa found aslight pallor of the optic disks,
which they considered normal. Later exophthalmos de-
veloped, gradually increasing until death. Convergence
of the eyes was impossible, although no paralysis of a
cranial nerve was discoverable. ‘The reflexes of the iris
were lost. ‘Toward the middle of April, this year, the
child became unable to walk. The knee-jerks were ex-
aggerated, there was ankle clonus, and typical spastic
rigidity. Finally, the back could not be held up, and later
the head could not be supported. There was gradual
emaciation. ‘There was no apparent headache. From
time to time the scalp was congested. About this time
the pallor of the optic discs indicated atrophy. ‘There
was no blindness, no hemiopia, no aphasia, as far as could
be ascertained, in so young a child. ‘Toward the middle
of May ataxia of the arms developed, but without loss of
muscular power. June 8th, vomiting and Cheyne-Stokes
respiration came on, and the child died in nine hours.
The diagnosis of tumor had been made, but the question
of localization was of great interest. Nystagmus was not
a localizable symptom, but had been found most fre-
quently in lesions of the corpora quadrigemina. The
exophthalmos indicated intracranial pressure; the gait
disturbance led one to think of a cerebellar lesion ; while
the ataxia of the hands pointed to a basilar trouble af-
fecting symmetrically either the pons or the medulla.
The question of operative interference had been consid-
ered, but he had opposed that proposition because of the
difficulty of localizing the tumor. The autopsy proved
that the pons was not even pressed upon, and that the
cerebellum was normal. ‘There were twenty ounces of
fluid in the ventricles. He would ask if there was any
localizing value in nystagmus or exophthalmos, and what
was the probable cause of the ataxia.
THE PRESIDENT, in referring to the question of ataxia,
recalled a case of remarkable bilateral ataxia, with optic
atrophy, where a large interpeduncular tumor was found
between the crura. He thought such ataxia was to be ac-
counted for by pressure upon the motor tracts or motor
nuclei. ‘To him the most puzzling feature of Dr. Starr’s
case was the absence of blindness. As to the nystagmus,
it had as yet, in his opinion, no localizing value. He had
seen two cases with lesions of the quadrigeminal bodies,
but without nystagmus.
Dr. LEszynsky said the child may have had only central
vision, which might explain the presence of nystagmus;
but Dr. Starr answered that the visional fields were
normal.
Dr. SACHS was reminded of Meynert’s case of tumor
in both optic thalami, with ataxia similar to that of Dr.
Starr’s case. He thought the thalami might have been
pressed upon in the latter, but still was not sure that that
would cause the ataxia. He considered nystagmus very
frequent in many central disorders. of children.
Dr. H. M. Lyman referred to a case he had seen re-
cently of defective cerebral development in a child where
there was also nystagmus.
Dr. Gray asked how a diagnosis of intracranial tumor
had been made so early in this case, and was answered
that the diagnosis had not been made until all the symp-
toms described had made their appearance.
Dr. HAMMOND thought ataxia depended upon injury
to. the optic thalami or corpora striata, and referred to a
case of Weir Mitchell’s in which there was a remarkable
unilateral ataxia, with a lesion of the optic thalamus and
corpus striatum upon the opposite side.
Dr. LeszyNSKY saw a child, several years ago, with well-
marked nystagmus, which disappeared in the course of
time. There was no discoverable cause.
The following gentlemen were then elected to active
membership: Dr. C. Eugene Riggs, of St. Paul, Minn.;
Dr. H. S. Upson, of Cleveland, O.
SECOND Day, JUNE 27TH—MORNING SESSION.
Dr. E. C. SEGUIN, PRESIDENT, IN THE CHAIR.
Dr. GEORGE W. Jacosy, of New York, opened with a
paper entitled
A CONTRIBUTION TO THE STUDY OF ANASTHETIC LEPROSY,
WITH SPECIAL REFERENCE TO PARTIAL SENSORY DIS
ORDERS.
The points to which particular attention should be paid
in all cases were the electrical excitability of the muscles,
the condition of the reflexes, the presence ar absence of
fibrillary twitchings, and the condition of sensation. Upon .
these data depended the diagnosis between anesthetic
leprosy and syringomyelia, as well as that of the central
or peripheral localization of the leprous process. ‘The
conclusions arrived at by the author from the analysis of
his own and other cases were that the differential diag-
nosis between the two diseases could not always be made ;
that partial sensory disorders are not characteristic of
syringomyelia, but may occur in anesthetic leprosy as
well as in purely peripheral affections ; and finally, that a
differential diagnostic point between central and peripheral
loss of temperature sense may lie in its complete loss in
the one case and its partial loss in the other.
Dr. STARR said that the same question as to the differ-
ential diagnosis between syringomyelia and anesthetic
leprosy hid only recently occurred to him. Three weeks
ago he had seen a case, with Dr. Prince A. Morrow, of
New York, in which there had been a gradual onset of an
atrophic and anesthetic affection of the right arm. He
came from the Sandwich Islands and had been exposed
to leprosy. There was anzsthesia to temperature and
pain, but not wholly to touch, along the hand and part of
the arm. There were three small reddish-brown spots on
the arm, which Dr. Morrow considered leprous in character.
The idea of syringomyelia at once occurred to him, but
the history of exposure in a leprous country sufficed to
make anesthetic leprosy at least the more probable nat-
ure of the disease; but without such history it would
have been almost impossible to make the diagnosis. As
to the matter of partial loss of sensation in the cases of
multiple neuritis and beriberi he had seen, the sensory
loss was complete, with the exception, however, of mus-
cular sense. _
THE PRESIDENT remarked that he had now under ob-
servation a case of leprosy, but had as yet made no
careful examination of the temperature sense. His case
illustrated the ease of diagnosis at an early period, when
confusion with syringomyelia could not occur. ‘The pa-
tient had a wine-colored eruption on the entire left leg
and part of the thigh, the foot being free, and there were
three or four similar spots on other parts of the body.
There was distinct analgesia and some anesthesia in these
areas, but there was no paralysis or atrophy. The patient
had come from the Sandwich Islands. The well-defined
limitation of anesthetic areas showed that it could not
be neuritis. Of late the anterior leg muscles had become
paretic, but there was no reaction of degeneration. The
left hand was beginning also to manifest similar symp-
toms. There were no ulcers.
Dr. C. K. Mitts had seen two cases of leprosy. He
thought the author’s point with regard to partial sensory
disorder very interesting, but he did not see why there
108
should not be partial disturbance also in neuritis, and, in
fact, in traumatic neuritis it was quite frequent. The
nature of the sensory disturbance depended upon the ex-
tent of the injury to the nerve. In ordinary multiple
neuritis it might be true, as Dr. Starr insisted, that there
was complete loss of sensation, through destruction of all
the sensory fibres. He did not see, however, why the
sensation to cold should not be injured as much as any.
It should be borne in mind that in all infectious diseases
attacking the nervous system there was a tendency to
seize upon the central as well as the peripheral portions
at the same time.
Dr. Gray agreed with the last speaker as to partial
sensory disorders met with at times in peripheral neuritis.
He had observed it also in multiple neuritis, where, for
Instance, there was impairment of touch and temperature
sense, yet the pain was excruciating. He did not see that
it was easy to diagnosticate syringomyelia, and Wichmann
and Starr had given no rules for diagnosis in their pam-
phlets. He believed that no one had made a diagnosis of
syringomyelia in life.
Dr. STARR stated that Schulze had made the diagnosis
in three cases, which had been substantiated by autopsy.
The points for diagnosis were the general conclusions
drawn from a study of collected cases. Anna Baumler
had brought together one hundred and sixteen cases, to
which thirty or more had since been added.
Dr. Gray thought these diagnostic points would apply
to many other spinal lesions.
Dr. BrrpsaLt had had similar ideas to those of Dr.
Gray as regarded the diagnostic indications in syringo-
myelia until he had read Roth's collection of cases. Ina
certain number of such cases there were clinical pictures
differing altogether from other spinal lesions and from
peripheral neuritis. Disturbance of the temperature sense
was the particular characteristic. Stil the testing of this
sense had been constantly neglected in studying other
spinal cases, and it was possible that it might often be dis-
turbed in other spinal disorders. It was hard to see how
any other lesion could produce precisely the same symp-
toms as those of syringomyelia. It was a question whether
tracts for temperature and pain could be localized in the
cord. Peripheral nerve lesions might cause injury to some
sense fibres and not to others, although generally all are
injured, particularly where the inflammation is truncal in
character. ‘There might be partial sensory disturbance in
dermal] forms. =. AA
Dr. Gray said it was easy to localize disease in the an-
terior cornua, in the lateral and posterior columns of the
cord, but the diagnosis of central lesions was very difficult.
The fact that, out of one hundred and fifty cases of syrin-
gomyelia, only three had been diagnosticated during life,
proved the truth of his assertion. ‘The diagnostic sugges-
tions given were therefore empirical. The presence or
absence of temperature sense had not been sufficiently
tested as yet. How would one distinguish a chronic cen-
tral myelitis ?
Dr. BIRDSALL stated that central myelitis began acutely,
and thus differed from the slow advance of syringomyelia.
Dr. MILLs thought the question of partial sensory dis-
order most interesting. But he thought that there would
be more apt to be partial disturbance in a truncal neuritis
than in a dermal. |
Dr. PETERSON asked the President if the tendon re-
flexes were exaggerated in his case of leprosy, and was
answered in the affirmative. He had asked this because
he had recently read an interesting study of the reflexes
in anesthetic leprosy made by Dr. Suzuki, of Tokio, and
published in the Se:-a-Kwat Medical Fournal, in which
there was an analysis of seventeen cases. One had nor-
mal reflexes, while all the others had increased tendon
jerks, and in some of the cases there was even ankle
clonus. The conclusions arrived at by the author were
similar to those of Dr. Jacoby.
THE PRESIDENT called attention to the fact that so
mapy cases of leprosy were now being continually imported
THE MEDICAL RECORD.
[July 27, 1889
into the United States. It seemed as if the country were
threatened with its domiciliation. It was a question
whether it was not the duty of physicians having such
cases to report them to the authorities.
Dr. SINKLER mentioned the recent presence of two
cases in Philadelphia. The physician in charge had been
fined by the Board of Health for not reporting them.
Dr. PRINCE wondered at the manner in which leprous
patients were allowed to go about, and thought also that the
attention of the authorities ought to be called to the dis-
ease, and reports to the Boards of Health ought to be re-
ulred.
i Dr. Gray knew that in the East, where the disease is
prevalent, isolation is practised. He wished to know
what the actual danger of contagion was.
Dr. BRILL said that the attention of the New York
Board of Health had already been called to the matter.
DR. Jacosy, in closing the discussion, said that Schulze
was altogether too positive in his assertions. This author
went so far as to contend that cases of leprosy where cav-
ities had been found in the cord were not leprosy at all,
but syringomyelia. As for himself, he thought a central
lesion probably often exists in this disease, although it is
well known that the essential pathology lies in a truncal
neuritis. A simple dermal neuritis could not be assumed
in leprosy. In his case, for instance, the indurated and
swollen ulnar nerve could be distinctly felt. He did not
agree with Dr. Gray, that the diagnosis of syringomyelia
could not be made. ‘The only danger lay in mistaking it
for leprosy. He had only last evening come across a work
of Suzuki mentioned by Dr. Peterson, but had noticed the
identity of the conclusions of that author with his own,
although they were reached from different points of view.
Dr. F. X. Dercum, of Philadelphia, then presented
two contributions entitled, respectively,
A DESCRIPTION OF TWO CHINESE BRAINS,
and
A NOTE ON THE PLI DU PASSAGE INFÉRIEUR INTERNE
IN THE HUMAN BRAIN.
He exhibited the brains described. Dr. Mills had made
a morphological analysis of one in 1886, and descriptions
of three Chinese brains had been added to literature by
Moritz Benedikt. The six brains thus far analyzed ex-
hibited unusual complexity, due to excessive sinuosity of
the gyri, and a tendency to excessive transverse fissura-
tion. ‘The frontal lobes were especially large and com-
plex. 'There was unusual confluence of fissures, indicative
of a low degree of development, such as is often seen in
the negro’s, and sometimes in the white man’s, brain.
There was unusual length of the parallel and Sylvian
fissures, and eversion of the orbital and temporal lobes.
Dr. MILLS said that it was very important to keep
addine to our morphological descriptions of such brains,
until accurate deductions could be drawn from a very
large number.
Dr. SpiTzKa stated that the dictum that a tendency to
confluence of fissures indicated a low type of develop-
ment, was not accepted by most anthropologists. The
more brachycephalic the skull the greater was the develop-
ment of transverse secondary folds. ‘The elephant, which
stands among the highest of mammals, had a broad skull
and a tendency to confluence of fissures. The Chinese
were not low in development. The internal pli du pas-
sage in the negro and idiot was significant only when
the general cortical development was poor. The real
cause of the location of the chief sulci lay in the in-
herent architecture of the brain, and was due to the
arrangement of groups of cells and fibres ; but the sec-
ondary and tertiary sulci might be influenced by other
factors, such as the course of vessels. While we might
never be able to localize the higher functions of the
mind, there was something in the physiognomy of the
Chinese brain which struck him as differing altogether
from that of the Caucasian. But it was not the same
July 27, 1889] THE
MEDICAL RECORD.
109
AFTERNOON SESSION.
difference as was noticeable between the negro and
Caucasian brains. The peculiar moral attitude of the
Chinese pointed to some relation between the structure
of their brains and the character of their minds. Still he
had observed a great difference between these two Chinese
brains, and there was no feature in them which might not
be reproduced in the Caucasian brain.
Dr. DEeRcum had not wished to imply that transverse
fissuration was indicative of a low type, but thought the
unusual confluence showed a lack of cortical develop-
ment. He did not consider them brains of a low type,
but many features such as were found in the brains of
the negro and ape were found here also. ‘Ihe excessive
sinuosity, however, indicated a higher cortical develop-
ment. For instance, in one brain there were five well-
developed frontal gyn.
Dr. Spitzka had the same idea as Dr. Dercum. As
compared with the Caucasian brain, the Chinese was in
some respects inferior, and in others exhibited a super-
abundance of gyn. He spoke of the resemblance be-
tween the negro andape brains. ‘The differences between
the brains of the orang-outang and chimpanzee were
greater than those between the brains of the chimpanzee
and a human being. ‘There was no uniform appearance
of the ape’s brain. Vogt and another had classined the
human brain into three types—the Negro, Mongolian, and
Caucasian—corresponding somewhat to the three lower
types of the gorilla, chimpanzee, and orang-outang.
Dr. M. ALLEN STARR, of New York, then read a paper
entitled i
THE PATHOLOGY OF SENSORY APHASIA, WITH AN ANALYSIS
OF FIFTY CASES IN WHICH BROCA’S CENTRE WAS NOT
DISEASED.
In all of these cases collected by the author some form of
sensory aphasia was present, and in all the lesion lay in
the posterior lower third of the brain. In seven of the
cases there was pure word-deafness, and in these the lesion
was limited to the posterior portion of the first and second
temporal convolutions. In eleven cases there was pure
word-blindness, and in these the lesions were found dis-
tributed either in the angular gyrus, the occipital lobe, the
temporal convolutions, or the inferior parietal region.
In seven cases word-deafness and word-blindness were
co-existent, although the use of language was not lost ; and
in these the temporal convolutions were involved, extending
in some to the inferior parietal, angular, and occipital
convolutions. ‘The practical application of the localiza-
tion of aphasia lesions is obvious, for the regions con-
cerned iu speech are especially accessible to the surgeon.
Another fact of interest is that it seems to be proven
that there is no ideational centre. An idea may be im-
paired but cannot be wholly destroyed by a single cortical
lesion. ‘Thought, being regarded as the play of conscious-
ness along association-fibres between sensory centres, can-
not be localized.
Dr. LLoyp had now a case of simple homonymous
hemianopsia without psychical or word-blindness, and
wished to know whether there was any diagnostic im-
portance in this condition as to localization. Was there
a preponderance of one hemisphere over another as re-
garded sensory memories of language ?
Dr. STARR said that the matter of psychical blindness
had recently been discussed by Wernicke and another. A
lesion affecting bilaterally both occipital lobes or the as-
sociation tract produces psychical blindness, but a lesion
along either tract itself does not cause this condition.
Nine cases of psychical blindness from lesion of one hemi-
sphere alone had been reported.
The election of officers for the ensuing year being then
in order, the following were chosen: President—Dr. E.
C. Spitzka, of New York; Vice-Presidents—Dr. Wharton
Sinkler, of Philadelphia ; Dr. H. M. Lyman, of Chicago ;
Secretary and Treasurer—Dr. G. M. Hammond,.of New
York ; Councillors—Dr. Henry Hun, of Albany; Dr. C.
L. Dana, of New York.
. istic.
Dr. J. H. Luoyp, of Philadelphia, read a paper en-
titled
A LATER HISTORY OF A CASE OF FOCAL EPILEPSY, FOR
WHICH TREPHINING AND EXCISION OF THE MOTOR
CENTRES WERE PERFORMED.
Full details of the case had been recorded at the last an-
nual meeting of the Association. At that time but three
months had elapsed since the operation, and Dr. Ferrier,
of London, had stated in a discussion that the time was
too short for a decisive result as to the usefulness of the
operation. Now that more than a year had passed,
further details could be given. Before the operation the
patient had had many seizures daily. ‘There was no fit for
four months after the operation. Since that time, how-
ever, there had been some ten seizures in nine months.
Dr. SpirzKa said there was a minority, but a powerful
minority, of clinicians and physiologists who hesitated to
accept the dictum that spasms were always of cortical
origin when clonic in character and local in manifestation.
There were well-authenticated cases of spasms, such as
are generally described as cortical, which undoubtedly had
their origin in the pons or medulla. He therefore thought
it premature to advise surgical procedure when there was
still doubt as to the position of the convulsive centre.
He was of opinion that the seat of irritation in the great
majority of cases of epilepsy was in lower centres, such
as Nothnagel’s convulsive centre.
‘Dr. MILLS mentioned the case of a man subject to
unilateral convulsions beginning in the hand. ‘There was
a scar upon the head, and trephining was done at this
spot in order to relieve severe pain, probably due to trigem-
inal irritation in the scalp or dura. ‘This operation re-
lieved the pain, but caused the Jacksonian epilepsy upon
the other side. The operation was repeated in the same
spot, the membranes and cortex being removed to some
extent, and with great success. It was an apparent illus-
tration of the fact that convulsions may occasionally be
the result of operations themselves.
Dr. DERcuM had seen the same case, and stated that
the dura was not opened in the first operation. At the
second trephination the membranes were found united.
There was a pachymeningitis. The patient had surgical
epilepsy. Six months elapsed between the operations.
Dr. Luoyp said it was a question whether one could
have localized epilepsy from irritation of lower centres,
as Dr. Spitzka had intimated. He had always held the
idea that such spasms were of cortical origin. In the case
he had just described the absence of fits for four months
led him to believe that he had removed the parts con-
cerned in their manifestations. He had been ‘opeful of
the efficacy of this method in the relief of such a disorder,
and was not yet willing to give up the idea that soinething
may be accomplished in this way. He thought it would
be justifiable to operate again in this same case.
Dr. SpitzKa asked if the cortex removed had been ex-
amined microscopically, and what was the pathological
condition found.
Dr. Lioyp answered that the microscopist had re-
ported atrophy of the cortical cells.
Dr. SpitzKa remarked that atrophied cells could
scarcely be very potent in the production of epilepsy.
Dr. Lanpon C. Gray, of New York, then presented a
paper upon
THE DIAGNOSTIC SIGNS OF MELANCHOLIA,
in which he called particular attention to the difficulty of
diagnosis of simple melancholia at times. It was usually,
when in mild degree, confused with neurasthenia. He
had recently made a study of eighteen cases of this form,
and pointed out what he considered the three cardinal
symptoms, viz., depression, insomnia, and post-cervical
ache. ‘The last named he thought especially character-
This pain was sometimes neuralgic in character ;
at others, vague and continuous. Simple melancholia such
IIO
as this should not be confounded with neurasthenia, or
melancholy states dependent upon hepatic or nephritic
disease, or with non-typical forms of insanity.
Dr. H. S. Upson, of Cleveland, then read a paper in
which he considered the relation between
MULTIPLE NEURITIS AND INFECTIOUS CEREBRO-SPINAL MEN-
INGITIS.
Dr. Mills had first suggested the possibility of con-
nection between the two. His own case was, briefly, as
follows : A woman, aged twenty-seven, had intense pain
and tenderness in the extremities, together with stupor
and slight opisthotonos; no electrical examination could
be made because of the extreme hyperæsthesia. She had
had a multiple neuritis a year before, but recovered. The
autopsy revealed congestion of the pia of brain and cord
with marked serous effusion, and a microscopic examina-
tion of the ulnar nerve revealed interstitial inflammation
there. In the opinion of the author, the nerve-trunk in-
flammation was not parenchymatous, but rather of the
membranes, and was analogous to the process in the brain
and cord; the nerve-fibres were secondarily involved.
He had not looked for bacteria. He naturally felt inter-
ested in the case. He had had an autopsy on one of his
own cases. Portions of nerves and sections of the brain
and cord had been examined by Dr. Gray, of Washing-
ton, and this examination proved conclusively the associa-
tion of neuritis with the cerebro-spinal meningitis.
Dr. SpitzKa referred to the vacuoles in the author's
sections, and said retarded lymph-outflow might be. i impor-
tant in causing the death of tissue and the formation of
gas-bubbles which these vacuoles must be considered to
represent. He had noted, also, two bodies in the section
larger than ordinary leucocytes, very delicately stained,
which the author should have carefully delineated.
Dr. C. K. Mııs, of Philadelphia, then gave an ab-
stract of a paper by Dr. J. T. EsKRIDGE, of Denver, on a
CASE OF ABSCESS OF THE BRAIN ; OPERATION ; DEATH ON
THE NINTH DAY.
‘The patient had had typhoid fever. ‘Two months later
there was purulent inflammation of the middle ear, and
not long after symptoms of brain-irritation followed,
such as headache, delirium, persecutory delusions, together
with paralysis of the right hand and right angle of the
mouth. ‘The skull was trephined over the face and hand
centres, and a purulent inflammation was found under the
dura. ‘The wound was then dressed, and the patient died
nine days later. A wide-spread suppurative meningitis
was found at the autopsy. Dr. Mills thought the case of
great practical value. He thought trephining should have
been performed in two places, at the centre which had
been properly localized and also over the mastoid region
where the inflammatory process had originated.
Dr. B. Sacus, of New York, presented a paper on the
PERONEAL FORM OF PROGRESSIVE MUSCULAR ATROPHY.
The author reiterated his statement of last year that
this form was closely related to Duchenne’s type. He
gave very full details of the cases of two brothers that had
recently come under his observation through the kindness
of Dr. Gibney. ‘The boys were thirteen and ten years of
age. ‘There was a gradual development of double club-
foot in both at the age of five years, followed by an
atrophy proceeding upward, beginning in the leg and toe
muscles and spreading to those of the thigh, in one case
also involving muscles of the upper extremities. The
knee-jerks were present. In one there was general anæs-
thesia; in the other, parzesthesia. There was full degener-
ative reaction in some of the muscles in one boy; partial,
in the other. ‘The progressive wasting rendered treatment
of this form of club-foot less satisfactory than that of
congenital cases. He would suspect this peroneal form
in all cases where acquired club-foot was associated with
progressive wasting of the leg muscles, and particularly
THE MEDICAL RECORD.
[July 27, 1889
if heredity or family occurrence of the disease could also
be established.
Dr. SINKLER couid recall several similar cases ; one, in
particular, of two brothers. But doubtless more would be
seen if careful attention were paid to the matter.
Dr. BIRDSALL did not think the presence of knee-jerk
so important a diagnostic point as the author seemed to
regard it. He had seen a few cases of old poliomyelitis
where the paralysis and atrophy were below the knee, and
yet the knee-jerks were quite active on both sides. It
could not therefore be an essential point in diagnosis.
Dr. BuLLaRD had also observed the presence of the
knee-jerk in old cases of poliomyelitis. —
Dr. Prince asked if the author had said that the ab-
sence of pseudo-hypertrophy was a diagnostic point be-
tween this form and primary myopathies, and was an-
swered in the affirmative. He did not consider this true.
Dr. SprrzKa asked if the symmetry and the coincidence
of time and intensity as shown in the photographs were
always the case, and was answered in the affirmative.
Dr. SINKLER corroborated two of the speakers as to the
presence of the knee-jerk in cases of old poliomyelitis,
and cited an instance from his own experience
Dr. Gray objected to the division of progressive mus-
cular atrophy into groups. Why should there be an arm
type, a face type,a leg type? Such division might be car-
ried out indefinitely. - A more useful classification would
be upon the pathology of the disease—a division into cen-
tral, muscular, and peripheral nerve-lesions.
Dr. Sacus said he did not lay great stress upon the
presence or absence of the knee-jerk. Yet in extreme
atrophy of the vasti from poliomyelitis the knee-jerk was
always absent ; and if it were present, he should consider
it a case of progressive muscular atrophy. He had him-
self tried to discard subdivisions as much as possible, but
the present classification was a clinical necessity. A bet-
ter might be made when the pathology is more accurately
determined. At present there were spinal and non-spinal
cases, but there was no certainty as regarded peripheral
nerve cases.
Dr. MorTon PRINCE, of Boston, then exhibited some
microscopic specimens from the muscles of a case of
PSEUDO-HYPERTROPHY.
The patient was now twenty-eight years of age. The speci-
mens showed a large quantity of connective tissue, hyper-
trophy of a few fibres, and great atrophy of many of the
fibres. ‘There was also great loss of striation, but no fatty
or granular degenerations and no vacuolization.
The following papers were read by title: “A Series of
Cases of Cerebral Hemorrhage of Unusual Interest,” by
Dr. J. H. Lloyd, of Philadelphia; The Histological Ex-
amination of Nerves removed for Trigeminal Neuralgia,”
by Dr. J. J. Putnam, of Boston; “ The Pathological
Anatomy of Chorea,” by Dr. C. L. Dana, of New York ;
“ Paranoia in Two Sisters,” by Dr. Frederick Peterson, of
New York.
The following new active members were elected: Dr.
Hobart A. Hare, of Philadelphia; Dr. J. P. C. Griffith,
of Philadelphia.
The meeting then adjourned.
In the evening a banquet was given by the Association
at the place of meeting, the West End Hotel, at which
some thirty members were present.
A GARGLE IN Quinsy.—Dr. W. M. Beck, of Kensing-
ton, Kan., writes: “In your ‘ Medical Item’ column I
notice that Sajous recommends guaiac as a gargle for early
stages of quinsy. Chloral hydrate has been far more effi-
cient in my hands; in fact, nearer a specific than anything
recommended in the text-books. Three or four grains to
the ounce of glycerine may be used as a gargle. I men-
tion this because no reference is made by Ringer or other
therapeutists to this fact. Its efficiency and modus ope-
randi are at once apparent when we consider that it is
locally antiseptic, astringent, and sedative.”
July 27, 1889] |
THE MEDICAL RECORD.
III
Correspondence.
PERINEAL LACERATIONS.
To THe EpiTor or THe Mepicat Recorp.
Sır: I desire to call attention to some points consid-
ered by Dr. James K. King, in a paper entitled “ Surgical
‘Treatment for Lacerations of Perineum, with some Im-
portant Modifications,” which appeared in ‘THE MEDICAL
RECORD of June rst.
‘The paper would be a most valuable contribution were
lacerations of the posterior vaginal wall limited to the
median line, and were the wound resulting from his oper-
ation, which contains three rows of stitches, tolerably sure
of uniting ; but the contrary is usually true.
In studying the continuous support of the posterior
vaginal wall, it is unphysiological to attribute any of this
action to its muscles; then, as a consequence, connective
tissue alone remains to be considered.
The connective tissue is liberally attached to the bony
portion of the true pelvis, and is abundantly distributed
through the posterior vaginal wall. The tissue becomes
soft and yielding at parturition, and normally stretches at
this time, without separation, so as to permit passage of
the foetal head. ‘The head is moulded to the bony canal
in its passage, which demonstrates that the connective
tissue, during labor, is normally capable of stretching to the
dimensions of the cana]. Then when the posterior vaginal
wall separates during labor, it is due to one or more of the
three following causes: 1. Diseased connective tissue ; 2,
too great force brought to bear upon the posterior vaginal
wall before its connective tissue is sufficiently softened ; 3,
scraping or tearing of the connective tissue from its at-
tachment by passage of the foetal head.
Cicatricial contraction is the disease most apt to affect
the connective tissue. ‘This must be a rare complication
to labor, and can very seldom obtain in primipare.
Laceration of the posterior vaginal wall in rapid labor is
caused by the exertion of too great force upon the con-
nective tissue before it becomes softened. Scraping and
grinding of the connective tissue of the posterior vaginal
wall from its attachment have not before been recognized
as a cause of the so-called “laceration of the perineum.”
Strong evidence exists, however, that this is true. The
connective tissue attached to that portion of the ischium
around and including the spine is the portion most sub-
ject to this grinding between the foetal head and the bony
canal. This is the location of many tears described under
the heading of lateral lacerations. This location of lacera-
tion occurs usually in difficult and protracted labors, and
in patients in whom the mobility of the pelvic bones has
been diminished by age or disease; while in women be-
fore this has taken place, the laceration is more often me-
dian, occasionally including the sphincter ani, and seldom
- accompanied by any lateral separation.
Lacerations of the posterior vaginal wall are conven-
ently divided into the four following varieties: 1, Bilat-
eral; 2, unilateral; 3, median; 4, mixed.
In the bilateral variety the fourchette, perineal body,
and medio-recto-vaginal septum retain their normal di-
mensions ; yet this laceration causes most suffering from
lack of support. ‘The vagina is relaxed; the portion of
ischium around and including the spine apparently re-
mains covered by periosteum and vaginal mucous mem-
brane only. Rectocele exists as a result of the detach-
ment of the ends of the connective-tissue band, as it were,
which stretches across the pelvis in front and surrounds
the rectum. ‘The rectocele is obscured from view by the
perineal body, but want of support to the rectal wall is
felt by the patient while at stool, and recognized by digi-
tal examination when the abdomina] muscles are con-
tracted. ‘lhe transverse perineal muscles, being separated
from their attachment to the ischium, fail to perform
their function of assisting in counteracting the increased
pressure upon the anterior rectal wall during defecation,
and thus allow this connective-tissue band to relax and
double upon itself as the rectocele forms. Let it not be
understood that the ends of the separated fibres remain
free, for an adhesive inflammation takes place soon after
labor, forming a weak attachment at a variable distance
from their original location.
Cases are occasionally seen where the tear is nearly, if
not entirely, limited to one side ; all the physical signs are
the same on one side in the unilateral as in the bilateral
variety. ‘Co produce this, the laceration of tissue must
be at or near the point of attachment, where the tissue
easily becomes engaged between the ischium and feetal
head in its rotatory passage. This lesion strengthens the
evidence in favor of this origin of laceration.
Median lacerations involve principally the vaginal out-
let and occasionally extend through the sphincter ani.
When the tear is extensive, the labor producing it must
have been either rapid or instrumental. In rapid labors
the foetal head does not become firmly engaged in the
bony canal. As a natural consequence, the foetal head
does not grind the tissues against the ischii in its rotatory
passage, and, as would naturally be expected, the tissues
remain uninjured at this point. ‘The different varieties
often exist mixed, one predominating.
Dr. King still continues to make the great error of
attributing much of the uterine support to the perineal
body. This function its anatomy and clinical history
emphatically contradict.
- While interne in the New York State Woman’s Hospi-
tal I had the opportunity of observing in a large number
of cases the effects of lacerations of the vaginal outlet,
often including the sphincter ani, and also cases in which
incisions had been carried down to the rectal wall; yet
in none of these did any appreciable want of support
exist.
The following case well illustrates the non-support of
the perineal body : Miss W , a number of years be-
fore being admitted to Dr. Bozeman’s service in the New
York State Woman’s Hospital, had a cystotomy performed
for the relief of chronic cystitis. The vaginal outlet pre-
venting free escape of urine, it was incised down to the
rectal wall; as this gave no relief an incision was made
on each side of the rectum, exposing fully three-fourths of
its surface. She had been in this condition either three
or five years, as I recollect, before entering the hospital,
yet no want of support existed, and she had been able to
be up and around nearly the whole time.
Another strong clinical fact in oppostion to the old
theory of the support of the perineal body can best be
given in Dr. Emmet’s* words: “ We can realize that this
is not true from the statement of any woman who is suf-
fering from an extensive cellulitis, for she is unable to
take a single step without feeling the force transmitted
directly through the solid and inelastic tissue, which
should aid in giving the most perfect support from below,
if the perineum could exercise such a function.” And as
to the absurdity of such a belief, he says :* “It would be
as rational to assume that a man’s pantaloons were sup-
ported by the legs resting on the instep or foot.”
But the posterior vaginal wall assists in the support of
the anterior vaginal wall, which is a strong factor in de-
termining the position of the uterus. When the length of
the anterior vaginal wall is normal, the cervix is held so
near the sacrum that it is difficult for the uterus to be-
come seriously retroposed.
The anterior vaginal wall has other support besides the
posterior vaginal wall, for cystocele never forms when the
perineum is incised down to the rectal wall; and seldom,
if ever, after deep median lacerations of the posterior
vaginal wall. My impression is that cystocele, as a result
of labor, is usually, if not uniformly, associated with lat-
eral lacerations of the posterior vaginal wall ; that is, th?
lateral laceration and the cystocele have a common cause.
—— — a Ml
1 Principles and Practice of Gynecology, p. 365.
II2
Both usually occur after difficult and protracted labor ;
or after the mobility of the pelvis has been diminished by
age.
The anterior vaginal wall has its support from a band-
like formation of connective tissue which stretches across
the pelvis, and cystocele usually forms as a result of lac-
eration of this tissue. ‘This laceration may occur under
the same conditions, in the same manner, and at the same
time as does lateral laceration of the posterior vaginal
wall.
A movable retroposed uterus, resulting from laceration
of the posterior and, probably, of the anterior vaginal
wall, seldom retains its normal position after the usual op-
erations have been performed upon both of the vaginal
walls, without the use of a pessary. This fact is entirely
consistent with the fact that the anterior vaginal wall has
support from connective tissue as described, and that
cystocele is usually the result of leceration of this tissue.
The more the connective-tissue support of the anterior
vaginal wall is weakened, the more is the support of the
posterior vaginal wall needed.
The direction of stitches as Dr. King describes it is
the most rational for use in median lacerations only ; and,
were the resulting wound tolerably sure of uniting, it
would be a most admırable operation in tears at the vag-
inal outlet. But why take the greater risk of union by
first intention, and do the extra work, when the vaginal
outlet can be as well built up with one line of sutures ?
Dr. King’s operation in lateral lacerations seems to me
useless, as he apparently does not consider the folly of
uniting and rolling up tissue never torn. One who has
utterly failed to appreciate the teaching of Emmet would
be likely to agree with Dr. King.
Emmet’s operation does not fix the separated ends of
connective tissue and muscles in their natural location,
but practically accomplishes the same result by strength-
ening the union formed soon after labor, and by taking up
the slack tissue.
Dr. King gives the following objections to Emmet’s
operation: 1. Stitches are passed transversely to im-
portant perineal vessels, causing swelling and pain. 2.
Stitches passed in this manner draw down the posterior
vaginal wall, ‘‘ followed by the uterus,” causing increase of
the rectocele.
Dr. King evidently is not aware that the stitches in the
lateral triangles in Emmet’s operation are passed in a line
curved downward and backward (in practically the same
direction as Dr. King’s “ first stitch ”), the last of which
extend nearly to the skin, drawing the posterior vaginal
wall forward and inward. ‘This is the direction of the
greater number of stitches used by Dr. Emmet in his
operation on the vaginal outlet, as practised by him in the
New York State Woman’s Hospital, but not clearly stated
in his “ Principles and Practice of Gynecology.”
That the procedure causes swelling is the best recom-
mendation for the operation, as it demonstrates that it
has a curative action upon the diseased blood-vessels
which cause the “ bearing-down pains.” The abundant
collateral circulation of the posterior vaginal wall pre-
vents any danger from too great obstruction in the circu-
lation, and the swelling does not interfere with union.
_ In none of a large number of these operations observed
in the New York State Woman’s Hospital can I recall
the presence of sufficient pain to demand an anodyne.
There is little cause for pain, since none of the sutures in-
clude the skin in ordinary cases.
Dr. King’s ojection to the result of Emmet’s operation,
namely, the drawing down of the posterior vaginal wall,
may be explained by his failure to appreciate the direc-
tion of the sutures, unless he attributes this action to the
crown-stitch ; but, as the point of support is above, the
resultant traction elevates instead of depressing the pos-
terior vaginal wall.
Dr. King’s error, of attributing to Emmet’s operation
a drawing down of the utefus, is consequent upon his
non-recognition of its true support.
THE MEDICAL RECORD.
[July 27, 1889
Rectocele from lateral laceration cannot be increased
by Emmet'’s operation on the vaginal outlet, except in the
imagination of a misguided critic.
I doubt whether Dr. King’s operation will cure any
case of rectocele, as it is not clear that median lacerations
cause rectocele. I cannot recall a rectocele from lacera-
tion at the vaginal outlet, and do not see how it could
occur. The connective-tissue band, briefly described
above, crosses in front of and surrounds the rectum. This
band is not so tense as to make its rupture in the centre
probable ; and, if it did, would not the tissue surrounding
the rectum prevent a rectocele? And if the rectum does
not receive strong support from the sides and posterior
surface, what supports it when the anterior wall tears for
some distance above the sphincter ani, from within out-
ward, as Emmet ` describes ?
Dr. E. C. Dudley does a modified Emmet’s operation,
which seems to be an improvement. He uses silkworm
gut for sutures, which possesses all the advantages of the
silver suture, and, in addition, is more easily applied and
removed, and he has found that they may remain longer
without producing suppuration.
Dr. Dudley introduces the first suture in the lateral
triangles, after Emmet ; ties it, and makes traction upon
it upward and inward in the direction of the sulcus, while
the next suture is being introduced and tied. ‘The second
and each succeeding suture are introduced under the
same conditions ; #.¢., while a suture is being introduced
and tied, the one just before it is being firmly drawn up-
ward and inward in the direction of the sulcus by means
of a pair of Pean’s forceps.
After all the sutures have been placed in the two sulci,
the crown-suture is now introduced deeply through the
lowest myrtiform caruncle on the patient’s left, underneath
the upper portion of the remaining denuded surface on the
posterior vaginal wall, and is brought out through the op-
posite myrtiform caruncle. ‘This suture, when tied, re-
stores the annular hymen, unless the remains of that organ
have been obliterated. The remaining sutures close the
more external part of the wound, and make a median line
of union out over the posterior commissure of the vulva
toward the cutaneous portion of the perineum, and this
union may reach nearly or quite to the anus. ‘These last
sutures, external to the remains of the hymen, should be
introduced with the same method of traction used in the
sulci, the traction being toward the meatus urinanius.
Dr. Dudley informs me that he has pertormed this op-
eration in more than one hundred cases, and in no case
has the posterior vaginal wall failed to come well up
under the pubes.’ This failure, however, will sometimes
occur when the sutures are introduced without this
method of traction.
T. J. Warkins, M.D.
1355 WABASH Avenusg, CHICAGO, June 12, 1889.
ContTacious DisEASES—WEEKLY STATEMENT. — Re-
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending July 20, 1889:
| Cases. Deaths.
Typhus (EVEL ccckcname et scadan weds aversamerevenaes o
Typhoid fever ...... aunn nnnnannno rrene reren 23
Scarlet fever..........L os en aN ak oe AA Ren ae | 45
Cerebro-spinal meningitis.......... 2... ... esere] 3
Measles ii eos diene ao ba a e e waned Rees E Ea Ea ' 6o
DIpPRtneriavia isis sie aasor tile eae eed eae es / 8I
SINANM= POX iciaee o ni acai code eae ane eek sows re)
Yellow feverio4 cue cele itans coxa eedow lee caw’ °
Choléra. ocre ieee See endsed NEE aah i o
0006s ovun
ANY CURE FOR STAMMERING ?—A “ Constant Reader ”
writes: “ Will you kindly let me know through the
columns of Tue MEDICAL Record what means are used
at present to cure stammering ?”
1 Principles and Practice of Gynecology, p. 394.
‘The Medical Record
A Weekly Fournal of Medicine and Surgery
Vol. 36, No. 5
New YORK, AUGUST 3, 1889
“Whole No. 978
o --—— — m
Original Articles,
THE RELATIVE GERMICIDAL VALUE OF
THE SO-CALLED ANTISEPTICS.
By JOHN E. WEEKS, M.D.,
ASSISTANT SURGEON TO THE NEW YORK OPHTHALMIC AND AURAL INSTITUTE,
LATE INSTRUCTOR IN BACTERIOLOGY AT THE NEW YORK rOST-GRADUATE
SCHOOL. i
IN a recent address made by a very prominent surgeon of
this city, the statement was made that “ we cannot to-day
formulate a list of germicidal remedies as we thought we
could five years ago.” This.is in part true ; however, thee
investigations that are being made in this line are gradu-
ally bringing order out of chaos, and we are nearing a
stage where the germicidal effects of remedial. agencies
will be definitely known. ‘The object of this paper is to
submit the results of investigations made to this end, and
to render more complete a list of germicidal remedies
submitted by the author, in a paper which appeared in
the Arch. of Oph., vol. xvi., No. 4, p- 375. The experi-
ments (conducted for the most part in the laboratory of
the New York Ophthalmic and Aural Institute) from
which the conclusions following were drawn, were made
with pure cultivations of pathogenic germs, and corres-
pond very closely with what is known clinically of the ef-
fects of the remedies experimented with.
In the present stage of our knowledge, it is not neces-
sary to urge the causative relation of bacteria to disease,
to advance proof that the staphylococcus pyogenes is the
essential factor in the production of a large portion of
the suppurative processes, or that a certain bacillus is the
active agent in the production of typhus abdominalis.
These points have already been established by the able
work of Ogston, Rosenbach, Koch, Eberth, Gaffky, and
many others. |
As our knowledge of the actual value of remedial
agencies advances, it becomes more and more apparent
that the agents that are of most value—lI might say, that
are of any value—in the treatment of infectious or con-
tagious diseases, are those which, first, act directly on the
pathogenic germ to impair its vitality ; second, those which
convert the pabulum on which the germ feeds into a
condition which prohibits its development ; third, those
remedies that stimulate the general system and increase
the antagonistic, or phagocytic power of the animal cells,
To the first belong the germicides, to the second the
germicides and antiseptics, and to the third, tonic rem-
edies, either local or general, suitable alimentation, etc.
The line of investigation here reported is that of the
effect of certain remedial agencies on the vitality of
germs. It is an evident fact that any remedy, to be effec-
tive as a germicide, must be brought in contact with
the germ in sufficient concentration, and for a sufficient
length of time, to produce its germicidal action, and it is
very desirable to know the time and concentration re-
quired by the various remedies. ‘lhis knowledge is of
great importance to the general practitioner, but is of
greater value to the surgeon, and is quite different from
the knowledge of the proportion of a germicidal remedy,
contained in a substance suitable for the growth of germs,
required to prevent their development. Remedies that
prevent the growth of germs are not necessanly germi-
cidal, as instance boric acid and desiccating powders ; and
although capable of retaining an aseptic condition in sub-
stances already free from germs, are of no value as disin-
fectants, and will not prevent the further development of
the germs if their inhibitory presence is removed within
the time of the natural life of the germ. Foa the pur-
poses of surgical practice, in cases where the condition
requiring operative interference has no connection with
bacteria, simple aseptic solutions for the removal of
blood, etc., the condition embraced under the general
term of cleanliness is all that is indicated, and will in
almost all cases produce good results ; but in cases where
the operator must deal with germ-infected tissue, a germ-
destroying agent must be used to insure the best con-
ditions for recovery.
The germs employed for making these investigations
were the staphylococcus pyogenes aureus and the typhoid
bacillus, and the results arrived at with these germs are
applicable within very narrow limits to all pathogenic
germs, if the spores (formed only by a limited number of
bacilli) are not considered, as shown by the experiments
of Koch, Sattler, Sternberg, and others. The staphylo-
coccus pyogenes aureus was obtained by cultivations made
from abscesses and eczema pustules, and their virulence
tested by inoculations of the eyes of rabbits; the typhoid
bacillus from cultivations at the Hoagland Laboratory.
The methods employed for testing the various remedies
were as follows: For liquids, an emulsion of a pure culti-
vation of the germ was made in sterilized water, into which
sterilized platinum rods were dipped and immediately
transferred to a solution of the remedy to be tested. After
remaining in this solution for a certain length of time,
sterilized nutrient agar, contained in test-tubes, was inocu-
lated with the rods, the tubes placed in an incubator at a
temperature of 37° C., and the effect of the solution on
the vitality of the germs determined by their development
or non-development. Powders and ointments were tested
by intimately mixing a quantity of the germs with the
powder or ointment, and after the desired time had
elapsed, transferring a very small part of the mass to the
sterilized food medium. ‘The method employed by Koch,
Sattler, and others, of immersing sterilized pieces of silk
thread in an emulsion of the germs, transferring them to
‘the liquids, powders, etc., to be tested, and then introduc-
ing them to the food medium, was only used in a few in-
stances where the exposure was for a long time. In cases
where the exposure is for a fraction of a minute, this
method is faulty, since it requires an appreciable time for
the remedy to reach the interior of the thread. Straight
rods were employed, in order that the germs exposed
should come in contact with the substance experimented
with immediately.
Substances the names of which are marked with an as-
terisk (*) were experimented with two years ago, and the
results reported in the Arch. of Ophthal., vol. xvi., No. 4,
1887. ‘The staphylococcus pyogenes aureus only was
used in the first experiments. ‘The staphylococcus pyo-
genes and the typhoid bacillus were used in the subsequent
experiments. 3
*Bichloride of mercury. When a solution of the bi-
chloride of mercury in distilled water is made, a precipi-
tate forms on standing—usually of the mild chloride.
This may be obviated by adding a small amount of so-
dium or ammonium chloride to the solution.
500 destroys vitality in exposures of 10 seconds.
66 66 T v6 t4 66
I tO 1,000 ;
I to 2,000 ts (F) éé t6 66 I$ minute,
I to 4,cco ta ms i a ‘+ 2} minutes,
114
THE MEDICAL RECORD.
[August 3, 1889
1 to 5,000 destroys vitality in exposures of 3 minutes,
i to 10,000 p
I to 20,000 as is te ee
‘t 12 to r15 minutes.
*Bisulphate of mercury. Soluble in about 1 to 7,000 of
cold water (U. S. D.). 1 to 8,000 destroys vitality in
exposures of four minūtes. Very slightly irritating to
mucous membranes.
*Biniodide of mercury. Solubility in water 1 to
40,000 (?). Saturated watery solutions destroy vitality in
exposures of four days.
*Bromide of mercury. The saturated solution in water
(very sparingly soluble) destroys the vitality of the sta-
phylococcus in exposures of some days.
*Iodidg of mercury (green iodide), not soluble in water.
*Yellow oxide of mercury. A saturated solution in
water (very sparingly soluble) destroys vitality in expos-
ures of two to four days.
*Red oxide of mercury corresponds with the yellow
oxide in its antiseptic and germicidal properties.
Oxycyanide of mercury, highly extolled by Dr. Chibret
(Soc. de Biol., Paris, 1888, p. 585) as a germicide, and
placed by him about on a par with the bichloride, makes a
very poor showing in my hands. It is quite readily solu-
ble in water; 1 to 100 requires ten minutes’ exposure to
destroy the typhoid bacillus, and twenty to thirty minutes
to destroy the vitality of the staphylococcus aureus.
* « The mild chloride of mercury is not soluble in water ;
however, when mixed with water in the proportion of 1 to
500, the ordinary preparations are germicidal to a low de-
gree.” No bichloride could be detected on testing this
mixture.
*Nitrate of silver. In this salt we have an excel-
lent germicide, the value of which does not appear to be
recognized by the profession. Aside from the work by
Ratincoff and Miquel, who determined that in the propor-
tion of 1 to 10,oo0 it arrested putrefactive processes, little
has been done with the nitrate of silver in an experimen-
tal way. We may assign this salt to a position near
the head of the list of germicidal remedies, as the follow-
ing shows :
I to 10 destroys vitality i in exposures of 4 seconds.
I to 50 46 66 8 66
I to 100 66 (F) 66 ti (E 12 ti
I to 500 “ Per on ei “ 1} minute.
I to 1,000 ‘ ~~ is s“ 4 minutes.
‘These experiments explain its great efficacy in the treat-
ment of eczema, purulent affections of the eye, otorrhcea, etc.
Iodide of silver. Very slightly soluble in water. A
saturated watery solution destroys the vitality of the staph.
pyog. and the typhoid bacillus in exposures of ten minutes.
*Permanganate of potash. Readily soluble.
I to 50 destroys vitality i in exposures of 20 seconds.
I to 100 *" i: t: ‘so: minute.
I to 200 ‘ i Se ‘<5 minutes.
I to 500 t ot 6 66 66 20 t
Not a very stable preparation.
*Potassium hydrate, 1 to 5, destroys vitality i in exposures
of five minutes.
Creasote from the distillation of birch-wood (Merck) is
a very active germicide, and probably owesits good repute
in the treatment of tuberculosis, chronic bronchitis, zymo -
tic intestinal troubles, etc., to this property. The pure
creasote requires an exposure of less than ten seconds to
destroy the vitality of the staph. pyog. aur. and the typhoid
bacillus. It dissolves in water in the proportion of about
I to 250, and in this solution destroys vitality in exposures
of thirty seconds.
1 to 400 destroys vitality i in exposures of 5 minutes.
I to 5o00 66 66 +é té 10 66
I to 1,000 ‘S oe p: ‘“ 30 to 40 minutes.
The saturated watery solution is but slightly irritating
to mucous membranes.
Creolin. Much has been written in praise of the anti-
septic value of this product, from coal tar. ‘The results
of experiments here given show it to be inferior to car-
bolic acid.
Pure. Vitality destroyed i in exposures of less than 10 seconds.
I tolo °* si ss I minute.
I to 20 e 6é 66 66 6c t6 3 to 5 minutes,
to4o “ x A A o “ 10 minntes.
Ito too “' n s i j tt 20 to 30 minutes.
Trichlor. phenol. Chief product of the action of chlor-
ine on ‘phenol ; insoluble in water, soluble in oils and
ether.
Five per cent. solution in olive-oil, exposure of four
hours, failed to destroy the vitality of the staph. pyog.
and typhoid bacillus.
to r0 in ether, destroys vitality i in exposures of ro seconds.
: to 100 66 (F3 66 66 66 be 66
Naphthalin. Obtained by distillation from coal tar ;
not soluble in water, but soluble in oil and ether.
Five per cent. solution in olive-oil failed to destroy the
vitality of germs in exposures of four hours. Solutions in
ether.
10 per cent, destroys vitality i in exposures of 3 minutes,
a ~~ es ‘¢ 8 to 10 minutes.
5 minutes.
Oxynaphthoic acid. Also derived from coal tar. It
is the counterpart among the naphthaline derivatives of
salicylic acid, which is found among the benzole deriva-
tives, and it is said to be a more powerful germicide than
salicylic acid.
Dissolves in 1 to 30,000 of water; soluble in ether ;
saturated watery solution is effective in exposures of forty
minutes. Four per cent. in ether about the extent of
solubility ; four minutes.
*Carbolic acid.
I to 20 destroys vitality in exposures of + minute.
I to 40 ae ts t: te « $to1 minute.
1 to 60 i eh. cae es ‘e 4 minutes.
Aseptol (orthophenosulphonic acid) readily soluble
in water.
334 per cent. solution destroys vitality i in exposures of 30 seconds.
I to 12 * 3 minutes,
I to 100 CF et é¢ ee ($3 (F) 4 hours.
Thallin (methyloxybenzol). Derived from phenol ; 1 to
Io solution in water destroys vitality in exposures of three
hours.
Terebene. Derived by the action of sulphuric acid on
turpentine. Pure, it requires fifteen minutes to destroy
the vitality of germs.
“ Sanitas,” a product obtained by the passage of oxygen
through turpentine in the presence of water, is used
largely by the profession in England, and in quite a large
number of hospitals in this country. It is found on the
market in the form of oils, a disinfecting fluid, and some
other preparations. Although, according to Jewett (Med-
ical Register, Philadelphia, 1888, iii., 152), it is a complex
body, it probably owes its germicidal properties to the
presence of the peroxide of hydrogen which it contains.
It is non-poisonous and but slightly irritating to the tissues.
Oil No. 1, destroying vitality i in exposures of 20 seconds,
‘ crude,t * i “ i% minute.
Disinfecting fluid, aeo oi t 6 à
e fifty per cent., in ‘* “ 10 á
*Alcohol. “ Koch's conclusions that absolute alcohol
has little effect on dried germs is confirmed, by Sattler
and others ; on moist germs, however, the facts are quite
different.”
Absolute alcohol destroys vitality i in exposures of 4 to 12 seconds.
go per cent. sae ss ‘20 to 30 SS
66 et 66 € t t; ‘t “ io to I5 minutes,
*Salicylic acid. Dissolves in water in the proportion
of 1 to 600; ranks high in the list of antiseptics.
I to 709 destroys vitality in exposures of 1 minute.
Ito 1,000) “ re sad i “+ 4 to 5 minutes,
*Salicylate of soda, in solution of 1 to ro, destroys vital-
ity in ex ponure of eight to ten minutes.
1 Not used in medicine. In coarse disinfection.
be
August 3, 1889].
THE MEDICAL RECORD.
115
Salol.
1 to 10 in ether, destroys vitality in exposures of 15 minutes.
I to 20 66 t6 vt 66 b 6¢ 66 35 é>
*Chlorine water. Distilled water saturated with chlor-
ine gas is placed by Sattler at the head of the list of
germicidal remedies. It is certainly an excellent germi-
cide, causing but little irritation of the tissues with which
it comes in contact. Unless kept tightly corked, and in
a cool, dark place, the solution rapidy loses its germi-
cidal value by escape of the chlorine gas that it contains.
Fresh preparations destroy the vitalıty of germs in ex-
posures of one to one and half minute.
Chloride of lime, one of our best germicides, but not
very stable—destroys colors, metals, etc. |
Not soluble in water, soluble in ether.
I to 100 destroys vitality in exposures of 4 to 8 seconds.
gs t;
I to 200 tg te t6 10 be
I to 500 Gs t‘ <4 Le ¢ 30 (Ei
I to 1.000 es ne s A ‘1 to 2 minutes.
Chlorinated soda (Labarraque's solution) corresponds
very closely to the chloride of lime in regard to its sta-
bility and the actio on colors, metals, etc.
The fresh solution destroys vitality in exposures of 4 seconds.
1 to 2 t éb ‘6 oc 66 “g (g)
1 to 10 a ee ‘© minute.
*Hydrogen dioxide (H,O,). ‘‘Commences to decom-
pose at a temperature of 60° F., giving off oxygen and
being converted into water.” Prepared under a pressure
of two atmospheres and at a low temperature, the fresh
preparation destroys the vitality of germs in exposures of
one minute. When loosely corked, it loses its germi-
cidal value quickly. “It should be kept on ice and
tightly corked.”
Bete naphthol disolved in ether.
1 to 10 destroys vitality in exposures of 30 seconds.
I to 20 j pu o ý ‘“ t to 2 minutes.
Ichthyol (sulph. ichthyolate of sodium, or of am-
monium, according to the alkali used) is soluble in water.
It is said to be of great value in eczema, furunculosis,
erysipelas, arthritic rheumatism, etc. Its remedial
value is probably largely due to its germicidal properties.
It destroys the vitality of the staphylacoccus pyogenes and
typhoid bacillus in exposures of three to four minutes.
*Sulphuric acid, 1 to 10, destroys vitality in exposures
of three-fourths to one minute.
° Listerine. Mentioned because of its rather extensive
use by the profession as an antiseptic.
Undiluted destroys vitality in exposures of 1 minute.
t to2 STA " ‘< 8 minutes.
Chloride of iron.
1 to 10 destroys vitality in exposures of 3 minutes.
I toa 20 : oe OA j ‘* 5 to 7 minutes.
Liquor of the chloride of iron.
I to 20 destroys vitality in exposures of 3 minutes,
bo t6 bo ot so 4
I to 100 ** 30
‘Tincture of the chloride of iron.
Undiluted destroys vitality in exposures of 10 seconds.
I to 50 Je > ae “s t 5 gO 7 minutes.
I to 100 sig oe ORE ‘6 ** Iç minutes,
The acidity of the two last-mentioned preparations adds
to their germicidal value.
Balsam of Peru requires an exposure of three minutes
to destroy the vitality of the staphylococcus pyogenes. Its
efficacy when used to dress suppurating surfaces is very
probably due largely to its germicidal properties.
Iodoform and ether. Jodoform dissolved in ether, 1 to
10, destroys vitality in exposures of five to seven minutes.
*Boric acid. The staphylococcus pyogenes retained
their vitality when mixed with a saturated solution of
boric acid and allowed to remain ten days. Sternberg
claims that in the proportion of 1 to 400 boric acid pre-
vents the development of germs. It certainly does not
destroy their vitality, therefore is useless as a germicide.
*Strong’s water of ammonium. No effect in exposures
of ten minutes.
*Potassic sulphate of alum. No effect in exposures of
two hours.
Solutions of the substances mentioned below have no
effect on the vitality of the staphylococcus pyogenes in ex-
posures of twenty-four hours. Solutions in water unless
otherwise stated.
*Arsenious acid, sparingly soluble; *Bicarb. of soda
solution, 1 to 13; *Bromide of potash solution, 1 to 10;
*Chloral hydrate, 1 to 50; *Castile soap, 1 to 50;
*Common laundry soap, 1 to 50; *Camphor water ;
*Carbonate of ammonium, 1 to 5 ; *Chloroform ; *Ether,
sulphuric ; Glycerine ; *Bicarbonate of potassium, 1 to
20; *Chlorate of potassium, 1 to 16; *Ilodide of potas-
sium, 1 to 10; *Chloride of sodium, 1 to 3 ; *Bicarbon-
ate of sodium, 1 to 16 ; Hyposulphite of sodium, 1 to 5 ;
-*Sulphate of iron, 1 to 5; *Sulphate of copper, 1 to 5 ;
Tannic acid, 1 to ro; Tar water (Infus. picis liq.) ;
*Acetate of zinc, 1 to 10; *Sulphate of zinc, 1 to 10;
*Chlorate of zinc, 1 to 20.
Oils.—The oil of eucalyptus globulus destroys the vi-
tality of germs in exposures of one to one and a half
minute ; *Oil of cade, five minutes ; Oil of thyme, eight
to ten minutes.
Exposures of twenty-four hours do not suffice to de-
stroy the vitality of the staphylococcus pyogenes with the
oils mentioned below :
*Oil of cloves, *oil of turpentine, oil of santal, crude
petroleum, *thymol, pure and in watery solution; *ben-
zole.
Otntments.—The following ointments produce no effect
on germs, in a watery menstruum, although mixed with the
ointments and left so exposed for thirty-six hours :
*Mercurial ointment (officinal), *ointment of the yel-
low oxide of mercury, one and a half per cent. ; *oint-
ment of the benzoate of mercury, one and a half per
cent.; *ointment of iodoform, ten per cent. ; *ointment
of iodol, ten per cent.
This is in accord with the experiments made by Koch
and others. It is possible that the effect produced on
germs, on the skin and in the tissues, may be different.
Germicidal remedies combined with oils and fats are
probably less effective when combined with germs in a
watery menstruum, because of the difficulty of inducing
immediate contact.
Powders.—In nearly all cases an intimate mixture of
the germs with the powders was made and cultivations
taken from these mixtures.
*Calomel destroys vitality in exposures of three min-
utes ; *resorcin, eight to twelve hours ; *bete naphthol,
eight to twelve hours. *Iodoform retards development
after twelve hours’ exposure. *Iodol and the following
have no effect in exposures of thirty-six hours : *Chryso-
phanic acid, subiodide of bismuth, *subnitrate of bismuth,
*boric acid.
7hermal.—*Boiling water destroys the vitality of ma-
ture germs on contact.
Leaving out of consideration remedies that are not
germicidal in exposures of twelve hours, we have the
following-named effective germicides, ranged in the order
of their value :
Bichloride of mercury, chloride of lime (fresh), chlori-
nated soda (fresh), chlorine water (saturated), nitrate of
silver, salicylic acid, creasote from birch-wood (Merck),
alcohol (absolute), carbolic acid, “ Sanitas ” oil No. 1,
“ Sanitas ” crude, potassium permanganate, bisulphate of
mercury, “Sanitas” disinfecting fluid, creolin, trichlor.
phenol (in ether), hydrogen dioxide, aseptol, listerine, oil
eucalyptus globulus, iodoform and ether, balsam of Peru,
oil of thyme, chloride of iron, tincture chloride of iron,
liquor chloride of iron, iodide of silver, naphthalin in
ether, oxynaphthoic acid, ichthyol, oil of cade, biniodide
of mercury, oxycyanide of mercury, yellow oxide of mer-
116
ee nr a aa es
cury, red oxide of mercury, bromide of mercury, resorcin,
Sa naphthol, potassium hydrate, thallin, terebene, iodo-
orm.
It is thus seen that our list of effective germicidal
remedies is relatively large, arfd is, I think, sufficiently
complete.
43 WEST EIGHTEENTH STREET.
CONCERNING SOME UNUSUAL ERUPTIONS.
By CHARLES W. ALLEN, M.D.,
FORMERLY ATTENDING PHYSICIAN FOR SKIN DISEASES AT THE POST-GRADUATE
UNIVERSITY, NORTHEASTERN AND NORTHWESTERN DISPENSARIES.
IN practice one is apt to encounter interesting and in-
structive cases, and to make observations on the results of
treatment which, though perhaps worthy of record, are
not of sufficient scientific importance to warrant consider-
ation in separate articles.
In the following notes I will endeavor to give some im-
pressions recently gathered from practice :
Scarlatiniform Erythema.—Thisis an interesting and not
fully appreciated or understood condition, of which one now
and then sees instances. It may occur under a variety of
conditions, and be limited to a single attack or appear asa
recurrent affection. The resemblance which tbe eruption
bears to that of scarlatina is striking, and the subsequent
desquamation makes it still more resemble the latter dis-
ease. ‘Though in many cases this peculiar erythema is
due to the ingestion of drugs, in other instances this cause
cannot be assigned. It not unfrequently follows surgical
operations, and may in some cases be due to septic poison-
ing or pyeemia. ‘The following case has recently been
under my care: Mr. G complained on March oth
of intense headache, fever, chilly sensations, and coryza, |
and the tongue was thickly coated. A drachm of anti-
pyrin was given in four doses. ‘The next day the head-
ache had entirely disappeared and the patient felt well ;
but two days later a bright scarlet eruption appeared over
the back of the neck, in the bends of the elbows, and to
a limited degree upon the sides of the trunk. Tem-
perature, 102" F. Headache severe. Antipyrin, gr. xv.,
was ordered to be given every four hours. On the
following day the scarlatina-like eruption was rnore in-
tense, and an erysipelas of the face first showed itself,
beginning upon the nose and extending by the 15th to the
whole face and ears, and by the zoth to the lateral sur-
faces of the scalp. The erysipelas ran through a regular
course, creeping from one region to another, leaving crusts
where the bullae had been most noticeable upon the
cheeks and about the eyes, and being followed by exten-
sive falling off of the hair and beard.
The scarlet-like rash became confluent upon the back
of the neck, sides of chest, across the lumbar region, and
over the lower part of the abdomen and in the popliteal
spaces. Upon the arms it was almost wholly confined to
the flexor surfaces, and was but sparsely scattered over
the legs, backs of feet, hands, and chest. It had nowhere
an erysipelatous appearance, was not at all glazed, and
no sign of vesiculation existed anywhere excepting upon
the face.
Upon the chest, just in front of the axilla, and upon
the back and sides of the trunk there occurred a noticea-
ble mottling or measle-like eruption of bluish macules,
and just in front of the axillary fold there were pur-
plish hemorrhagic spots, from which the color disappeared
on pressure. ‘These persisted after the erythema had
disappeared, and in the subsequent desquamation, which
was not completed before April roth, these macules,
which had taken on a faint brownish color resembling a
fading macular syphilhde, were the last to lose their
epidermis. In some respects, especially in this subse-
quent measle-like eruption, the case resembled one of
antipyrine eruption of the. whole body which I saw two
years ago.
Just how much the drug had to do with it, and
_ THE MEDICAL RECORD.
[August 3 EA
- = =M m
—
what part ie erysipelas played in the process, I am
unable to say. That it was not scarlatina, though at
first very closely resembling it, I am sure. Five children,
none of whom had ever had scarlet fever were in the room
much of the time, and some of them would surely have
contracted it from what would have been a severe attack
if the case had been one of scarlatina. Furthermore, the
tongue and throat presented the appearances found in ery-
sipelas, and not those of scarlet fever, and the rash per-
sisted aftet the eighth day.
Pityriasis Maculata et Circinata.—This disease, to
which Gibert gave the -name “ Pityriasis Rosé,” has not
been so frequently described in this country that a few
words will be amiss. Possibly we may find here, as they
have found in France, that instances multiply as the con-
dition becomes better known and does not continue to be
confounded with eczema, psoriasis, tricophytosis, and syph-
ilis. The small, rosy, erythematous spots, covered with fine
scales, increasing at the periphery while the centre clears up,
just as in ringworm, forming irregular patches and circles,
characterize this disease, which affects primarily the upper
regions of the chest for the most part, but is capable of
extending to the arms and thighs, and may, in fact, occur
on any region of the trunk or extremities. The affection
runs a cyclic course, and ends in recovery after a few weeks
or months. It may recur, as instanced in one patient
whom I have treated for the affection, no less than four
times in as many years. The first attack was in 1884,
when the trunk was covered with irregular patches and
more or less complete circles. Sulphur baths produced
an irritant effect and appeared to aggravate the condition.
The second attack was in December, 1885 ; the third in
January, 1887 ; and the fourth in January, 1889, which
had disappeared by the first of February under applica-
tions of naphthol. None of the subsequent attacks were
as severe as the first.
Mr. V , twenty-one years of age, came under my
observation on December 13,1888. He had an acute
eruption of circular itching spots covered with fine dry
scales upon the upper portion of the chest, especially
above and below the clavicle, while upon the back the le-
sions took the form of circles and segments of circles, with
a smooth centre, which, however, also became scaly on
scraping. ‘Though resembling a seborrhoeal eczema in a
degree, the location, irregularity of form, dryness of the
scale, etc., served to distinguish it from this affection. By
January rst the spots had all disappeared, under sulphus
baths and applications of an ointment containing sulphur,
zinc oxide, and carbolic acid. Up to the present date
there has been no return.
Molluscum Contagiosum.—Many authorities persist in
teaching that this affection is not contagious. I have re-
cently had several cases of this soft, wart-like growth, oc-
curring upon the face and elsewhere in children, which
strengthen my opinion, as expressed in an article in the
Cutancous Fournal, of August, 1886, that it is undoubtedly
of a contagious nature. In December of last year I was
asked to see a boy, four years of age, who had “a large
sore under his eye and a number of warts upon the face.”
The history given was that three months previously the
mother had been a nurse in a children’s asylum in this
city, where the child lived with her. One of the inmates,
a little girl, hd “ warts” upon her face, and the mother
cautioned her boy not to play with this child, as he “ might
catch them.” Despite this warning, the young people
were frequently found together, as is often the case in
true love, and one day they were discovered kissing. After
this the mother always said to her son: “ Now you will
get the warts.” -And he did. Before they left the insti-
tution, two months previous to my seeing the patient, the
mollusca had begun to appear. ‘The first one noticed was
that under the eye, which had now become much inflamed
and ulcerated, and measured at least a centimetre in its
long diameter. Beneath this, and extending toward the
nose, were four smaller tumors; two were on the lower
lid, one upon the upper, one at the outer canthus of the
August 3, 1889]
THE MEDICAL RECORD.
117
eye, One upon the ear, and one upon the chin. All were
upon the same side of the face as the original lesion, and
had appeared at varying intervals, but mostly since the
large mollusc began to suppurate. ‘The lesion which
had last appeared was upon the opposite brow. ‘The
growths were all removed at one sitting by scraping out
with Vidal’s sharp scoop. A second operation became
necessary upon the large tumor beneath the eye, which
began to grow again, but after the stick of nitrate of silver
was applied to the bleeding base it was permanently
cured. No scars resulted, and no reappearance of the
affection took place. |
I visited the institution to find and examine the girl in
question. She had left, but I was permitted to visit the
wards with the house-physician, and discovered six patients
with small molluscum tumors upon the face. The house-
physician told me that when he had entered the institu-
tion only one child had shown these growths, that the
others had since developed, and that he had not looked
upon them as contagious, and had instituted no treatment.
Another instance pointing to contagion was seen on April
22d of this year.
M. J , aged ten years, presented herself with six-
teen mollusca upon the face. One inflamed and suppu-
Tating nodule upon the chin, the size of a white bean, was
recognized as the original lesion, and the story told was
that, three months before, the patient sat in school next to
a girl whose face was covered with similar “ warts.” The
girl had been dismissed from school on this account,
and I could not trace her. Shortly after this the first
mollusc appeared upon our patient’s chin, and the rest are
of recent growth. One by the side of the nose had be-
come horny at the summit, elongated, narrow, and pre-
sented much the appearance of the filiform wart occasion-
ally seen upon the eyelids. A little girl, of about the
same age, who accompanied this patient, and who lived
in the same house with her, had, in fact, one of those fili-
form warts growing from the under eyelid, which was half
a centimetre long, as big round asa pin, and very horny at
the free extremity. The base looked much like the mol-
luscum when cut out. It is possible that the filiform wart
occasionally originates in a small molluscum tumor.
When excised and examined the papille are found not
to be involved as in other forms of warty growth, but to
be made up of epithelial and connective-tissue elements,
resembling more the fibrous mollusc. Furthermore, they
are almost exclusively found upon the eyelids, breasts,
‘and neck, regions often the seat of molluscum tumors.
There is one point I wish to make in relation to the
etiology of molluscum contagiosum. If it depended upon
any other cause than contagion, as some authors maintain,
why should cases cease to appear in an institution after
all the lesions had once been removed from the skin of
the various children affected ?
I think the fact that new lesions continue to appear
upon a child’s face so long as the older lesions are allowed
to remain, especially if they be suppurating or inflamed,
and that the child continues wholly free from any newly
developed growths from the moment these lesions are
destroyed, goes far toward proving the disease to be auto-
inoculable as well as transmissible to others.
Inoculation of Molluscum.—Within the past month I
have removed a molluscum contagiosum growth from the
side of the fourth finger of a physician of this city, who,
as ophthalmic surgeon to one of our large orphan asy-
lums, where molluscum contagiosum is epidemic, has of
late removed many such growths from the faces of his
little patients, fifty or more of whom have had the dis-
ease. The doctor had made the diagnosis in his own
case, believing he had contracted it in this way, and came
to me knowing it to be a question in which I was inter-
ested. What can this be but a case of inoculation ?
Sometimes. the mollusc tumor attains such a size and
takes on such an unusual appearance as to make the
diagnosis obscure. ‘Twe weeks ago I removed such a
growth from a little girl’s cheek, which was as large as a
cherry, deeply embedded in the skin, covered with thin
pinkish skin, and having a minute central opening through
which sebaceous-like material could be pressed. When
scooped out, a hole was left in the cheek which would
admit the end of the thumb.
I have notes of several instances where one only of
several brothers and sisters has shown the growths, the
history being that this particular child had a playmate or
intimate similarly affected, with whom the other children
did not associate to the same extent or not at all.
Dermatitis from Oil.—I have had a number of cases
of follicular dermatitis of the hands, arms, and thighs, in
machinists and those whose work brings them into con-
tact with paraffine, fish, and other oils. The lesions are
papular, pustular, and furuncular for the most part (in
one case the furuncular element predominated), and oc-
cur upor the exposed parts, such as the hands, arms, and
also the region of the knees and thighs of -those who work
in machine-shops, wire and silk factories, etc.
Very much the same variety of dermatitis is occasion-
ally produced by benzole, chrysarobin, and similar drugs.
The papular and pustular lesions on the arms and legs
(mostly the inner surfaces of both limbs) might be called
“oil acne.” It develops only on the parts which come in
contact with the oil, or with the clothing which has be-
come saturated by it. In one case, in which the lesions
were principally boil-like, occurring in an employee of a
wire factory where fish-oil was used, peculiar concentric
annular rings of erythema appeared about the furuncles
on the hands and arms.
Since the summits are often dark-colored from the ac
cumulated oil and dirt, the lesions are spoken of by the
men in such factories as “ black boils.”
In some cases the inner surface of the forearms and
the region about the knees become rough, harsh, and
oo is rapid after the cause has been removed.
When the occupation cannot be changed I order repeated
washings with green soap, followed by bland ointments
and protective dressings. The oil-soaked clothing must
be discarded, and subsequent care and cleanliness exer.
cised.
Purpura.—Among the cases of purpura of which I
have notes, I find several interesting in the matter of dif-
ferential diagnosis. On May 9g, 1887, I saw a young girl
whose limbs and portions of the trunk were literally cov-
ered with purple spots, which close inspection showed to
be simply the result of flea-bites ( purpura pulicosa).
The lesion usually produced by the bite of the Pulex
irritans is an erythematous spot with a central point, but
so closely does it at times resemble a true purpura that
the error has been made of so regarding it, and an epi-
demic of ‘‘ purpura” has been reported which turned out
to be one of flea-bites only.
On January 11th I saw a four-year-old boy, S. S——,
whose whole body was covered with purple dots the
size of a pin’s head and who had a “ black eye.” Ec-
chymosis of the eyelids was accomplished by a hemor-
rhage into the sclerotic, all due to the violence of cough-
ing in pertussis. ‘These hemorrhagic lesions disappeared
in due time as the cough grew better, a few new purpuric
spots appearing now and then as the case progressed.
On April 23d the child began coughing violently again,
after an apparent cure had been effected, and the pur-
pura again made its appearance, and the tissues about the
eye showed the same ecchymosis. In about three weeks’
time the child was well again, the spots having in the
meanwhile disappeared.
Favus.—Favus is much more prevalent in New York
than is generally supposed. It is confined for the most
part, as yet, to those who have brought it with them from
the old world. Russian, Polish, Hungarian, and other
boys, who have the disease in its most active and danger-
ous form, are tu be found in our down-town public
schools playing with other children out of school, ex-
changing hats with comrades, and exercising no care
118
THE MEDICAL RECORD.
[August 3, 1889
in the use of combs and brushes, hence it is fair to pre-
sume the time will soon come when more American-born
children will become affected. It is sometimes surprising
to note how long the germs will remain active after the dis-
ease has appeared to be cured. I have repeatedly seen
adults with a great portion of the scalp permanently bald,
as aresult of the ravages of favus contracted in childhood,
who have shown evidences of renewed activity of the
favus after having for a number of years considered them-
selves entirely well. It is very difficult to induce patients
with favus to stay under treatment long enough to effect
a permanent cure. As soon as the scalp appears well
they are satisfied and neglect treatment, and if in an in-
stitution insist upon leaving.
The parents, too, have such a high appreciation of the
advantages offered by our public-school system that they
will not keep their children at home even when most
strongly urged to do so. Itis self-evident that the schools
should exclude children with such a contagious disease
and one so difficult to cure.
The following history illustrates how readily at times
the disease may be transmitted to those in close contact
with a favus patient, as from a mother to her child, a
patient to a nurse, etc.:
M.S was transferred from Bellevue Emergency
Hospital to Charity Hospital, with her child, on November
1, 1886. She gave a history of favus of fifteen years’
standing. On admission the disease involved the entire
scalp, and favus cups were well developed. Her baby
first showed signs of the disease about November 14th;
three spots appearing on the head, and one on the arm.
About one week later the nurse, Miss W , and a ward
helper were attacked, three spots appearing on the forearm
of the nurse, and one on the arm of the helper (who is now
said to have his scalp involved). A few days later spots
developed on the arm and head of another baby, which
were suspected by the house physician of being the same
affection. On the wrist of Miss W , the nurse, pus-
tules appeared three or four days after the onset, and
these were followed by well-developed favus cups. She
has been treated by pure carbolic acid, collodion with
hydrarg. bichlor. (gr. 1, to 3 j.), and subsequently with
ung. hydrarg. ammoniat. When I first visited her, on
December 16th, the lesions were still present upon the
arm of the nurse, but they soon disappeared after friction
with the tincture of green soap, then applying ammoni-
ated mercury, 3j. to lanolin 3 j., and, after a few days,
painting the part with four grains of bichloride in an ounce
of collodion. To effect a cure in favus of the scalp,
the hairs must be epilated from the whole diseased area
while parasiticides are being employed.
Leprosy.—The case of leprosy which I presented at
the County Medical Society in February, 1888, to show
the beneficial effects of surgical treatment, has continued
to improve ever since; the face being to-day quite free
from leprous nodules or tubercles. The ulnar nerve
has decreased to about one-half the size it then had, and
the infiltrations upon the thighs and trunk have in a great
measure disappeared. ‘lhe anesthesia of the hands has
improved to such a degree that the slightest stick or pinch
is now felt, and the patient can use his hands much better
than formerly. ‘This is especially noticeable in opening
doors, buttoning his clothes, etc.
These favorable results have been brought about by
the almost constant employment of large doses of chaul-
moogra oil. Beginning with ten-drop doses in capsule
three times daily, the patient has gradually increased
the dose until at times he has taken as many as ten cap-
sules, or one hundred drops at a dose, three times a day,
making three hundred drops as a daily dose. This is a
larger dose than I have known any patient to stand. In
Paris last year I saw a leper who had taken as high as two
hundred and ten drops daily for a short time.
Besides chaulmoogra oil internally, our patient has
used chrysarobin and pyrogallol externally in ten per
cent. ointment at times, but not with sufficient persistence
to materially affect the general condition or to have much
share in the improvement.
Dermatitis and Eczema from New Flannel.—Last
winter I was asked to see seven babies in the Infant
Ward of Charity Hospital, who had simultaneously de-
veloped an eruption of the skin. They were all found to be
similarly affected with a maculo-papular eruption over the
face, neck, arms, and hands, while about the buttocks and
folds of the groin either intertrigo, dermatitis, or eczema,
and sometimes all three varieties of lesion, were present.
Examination and inquiry elicited the fact that all of these
children had been wearing undergarments and skirts made
of new red flannel which had not been washed. I took
pieces of this flannel and tested them for arsenic and
coraline, but finding neither of these poisonous substances
present, concluded that the eruption was induced by the
irritant nature of the new flannel alone upon the delicate
skin of the infants, having frequently seen this effect of
new flannel upon the coarser skin of adults, where it is
capable by long contact of exciting an eczema.
Verruca on Vermilion Border of Lips.—Since this con-
dition is one rarely observed, and as Dr. Elliot presented
a case at the last meeting of the Dermatological Society,
being the only one he had ever seen, I am led to report
three cases which have come under my observation during
the past year.
One young girl, eleven years of age, was seen on April
13th. She had sixty warts on one hand, thirty-three on
the other, twenty-nine small ones on the face, and seven
upon the vermilion border of the upper lip, the largest
one being situated upon the mucous membrane of the in-
ner surface of the lip, quite within the mouth.
The parent wart was upon the end of the index-finger
of the left hand, and had existed for two years. At the
present time it is fissured and moist. ‘The warts have ex-
isted upon the face and lips for about a year.
On December 2d of last year I saw a young boy who
had upon the mucous border of the lip three small warts
arranged like a chain of beads. He had had a large
“ seed ”-wart upon the hand for about two years.
The third case was in the person of a little girl, who
came to the Northwestern Dispensary on November 5,
1888. She had twenty-three warts upon the hands, two
upon the arms, and one upon the vermilion border of the
upper lip. ‘They were all removed with the sharp spoon.
It will be noted in all of these cases that warts of long
standing were present upon the hands, and in each case
there was a large wart (usually the first one noticed by
the patient), which had reached the condition known
among children as a ‘*‘ seedwart.” In my experience, when
this parent wart, as we may call it, is once thoroughly re-
moved, other new warts cease to appear, especially when
all warts present upon the body are radically cured at
the same time. This is also true of molluscum contagi-
osum, as already stated, and appears to me to give much
weight to the popular opinion that warts are contagious.
I have already reported, and, so far as I am aware, have
been the first to call attention to it, that molluscum con- -
tagiosum may occur upon the vermilion border of the lips.
A wood-cut accompanying my article in the Cutaneous and
Venereal Journal, August, 1886, shows the location of
several molluscs in this region.
VISCUM FLAVESCENS, AN OxyToxic.—Dr. Daniel Gray,
before the Ogeechie Medical Association of Alabama,
demonstrated that a tincture prepared from the leaves of
viscum flavescens (Pursh.) is an oxytoxic of great value.
A number of cases in which this effect was obtained were
cited, in two of which, at least, it exhibited all the good
properties of ergot. His first attention was called to this
use of the mistletoe, by the fact that it is employed by the
stock-breeders to secure the expulsion of retained secun-
dines in cows. He further declared that the activity of
the growth appeared to depend upon the tree to whicn it
was parasitic, the best medicinal mistletoe being that
found on the persimmon.— Medical Age.
August 3, 1889] _
ON THE RELATION BETWEEN THE DISEASES
OF THE TEETH AND EARS.'
By ROBERT BARCLAY, A.M., M.D.,
FORMERLY ASSISTANT AURAL SURGEON TO THR NEW YORK EYK AND RAR IN-
FIRMARY, NEW: YORK . CONSULTING AURAL SURGEON TO THE CITY HOSFITAL
AND ST. MARYS HOSPITAL, ST. LOUIS, MO.
MR. PRESIDENT AND GENTLEMEN: If, in your prac-
tice, you recognize the presence and influence of reflected
oral irritation as a leading factor in the predisposition,
production, and continuance of aural symptoms and dis-
eases of the ear, and forthwith get nd of it, if possible,
you will find success more promptly attend your thera-
peutic efforts, and a recurrence of the aural phenomena
less frequent. Among the principal conditions giving
rise to oral irritation may be found cutting, crowding,
shedding, and caries of the teeth, gingivitis, hyperostosis,
pyorrhcea alveolaris, periostitis (pericementitis), tartar,
hypertrophy of the gums, catarrhal inflammation of the
buccal mucous membrane, vulcanized red rubber and ill-
fitting plates and dentures, numerous amalgam fillings,
and unskilful dentistry.
The following illustrative cases are worthy of your con-
sideration :
Case I.—A German clergyman, aged thirty-seven years,
consulted me for slight deafness, tinnitus, and occasional
pain of the right ear, which is worse on “ taking cold.”
Treatment availed little until after the removal of a super-
numerary nght upper wisdom tooth which was hidden
beneath the gum, when he soon recovered.
Case II.—A clerk, eighteen years of age, applied for
relief of intermittent otorrhoea and attendant symptoms
of left ear, of fifteen years’ duration. Cure was effected
in less than four weeks; and no recurrence took place
until nearly nine months afterward, when the lower wis-
dom tooth of corresponding side was found in eruption.
The discharge persisted until this was fully cut, when it
ceased.
Case ITI.—A clerk, nineteen years of age, applied for
treatment of otorrhcea and attendant symptoms of left
ear, of about eleven years’ duration. Within five weeks
he was cured of this, and had no recurrence until one
year afterward, when former symptoms and otorrhea re-
turned. The lower wisdom tooth of this side was cutting,
and otorrhcea would not cease until this was fully cut.
Case IV.—An Englishman, thirty-four years of age, a
conductor, consulted me for otorrhoea and attendant
symptoms of left ear, of about twenty months’ duration.
‘There were many carious spots in the teeth and the left
lower second molar tooth was very carious. After three
months’ treatment, the otorrhcea had almost ceased, when
he placed himself under a dentist’s care. The dental op-
erations aggravated the otitis and the discharge grew worse.
Treatment of the ear was steadily persisted in until after
the teeth had been put in good order. Improvement in
the aural trouble began immediately after the dental treat-
ment was suspended, and the patient was «lismissed shortly
afterward.
Case V.—A young lady, about eighteen years of age,
consulted me for deafness, slight discomfort, and tinnitus
of the right ear, which she had first discovered on awaken-
ing in the morning ten days before. There was cerumen
in both ears, impacted in the nght. Both upper wisdom
teeth were carious.
Case VI.—A lady, twenty-five years of age, a teacher,
came for treatment of deafness of left ear, which had be-
gun about one year before, but which had grown much
worse of late. A sensation of sound sometimes persisted
after the sound had ceased. She had confused hearing
when several people were speaking simultaneously.
Deafness was very marked. ‘The drum-head appeared
paler than normal. For some time she had been cutting
both left wisdom teeth. When the right lower one was
1 Read before the Medico-Chirurgical Scciety of St. Louis, Mo.,
June 25, 1889.
THE MEDICAL RECORD.
ì to the vertex.
119
cut later, the right ear began to be affected, but treatment
checked further aural trouble.
Case VII.—A drug clerk, eighteen years of age, con-
sulted me for intermittent left earache of several months’
duration. ‘This was worse at night. He had chronic
nasopharyngitis. There were no particular physical signs
nor subjective symptoms of an otitis to account for the
intense earache. ‘The left upper second molar and both
left lower bicuspid teeth were carious. A slight Politzer
inflation and removal of the decayed teeth gave perma-
nent relief from earache within a few hours.
Case VIII.—A German, fifty-six years of age, a yard-
laborer, came to me for relief from profound deafness,
tinnitus, autophonous voice, and slight itching pain in his
ears, of five months’ standing. ‘Twice before this, at sev-
eral years intervals, he had had similar trouble, developed
suddenly after wetting his head and exposure to cold.
Impacted cerumen was found in both ears. Of his teeth,
seven from the upper, and eight from the lower jaw, are
missing. ‘There are carious: Both nght upper incisor, the
canine and both bicuspid; both left upper incisor, the
canine, and third molar; the right lower central incisor,
canine, and first bicuspid; and both left lower incisor,
the canine, second bicuspid, first and second molar teeth.
Case IX.—An Englishman, twenty-two years of age, a
blacksmith, came for relief of slight deafness, autopho-
nous voice, tinnitus aurium, vertigo, and weakness of sev-
eral weeks’ duration, on account of which he had been
compelled to quit work. Cerumen was found in both
ears. He was cutting his wisdom teeth.
Case X.—A Frenchman, forty-six years of age, a me-
chanic, came to me for relief from slight pain, tinnitus,
deafness, and autophonous voice, of three months’ dura-
tion. He was very deaf; and during mastication could
hear no ectogenetic noise. Cerumen was found in both
ears. Ofhis teeth, three are missing from each jaw. There
are carious (mere roots and shells only remaining of
these): The right upper second bicuspid, first and third
molar; the left upper first and third molar; the right
lower second bicuspid ; and the left first and third molar
teeth.
Case XI.—A carpenter, fifty years of age, born in Ire-
land, came to me for relief from severe deafness, auto-
phonous voice, and varying tinnitus aunum, with violent
ear-cough, of one month’s duration. Mastication some-
times caused odontalgia. There was a small nasal poly-
pus. Cerumen was found in both ears. Of his teeth,
there were carious : The right upper second bicuspid, first
and second molar; both left upper bicuspid, and three
molar teeth ; and the right lower first and second molar
teeth.
Case XII.—A flagman, fifty-seven years of age, born
in Ireland, sought relief from violent itching in his right
ear, with autophonous voice, tinnitus, and deafness of
both ears. Both drum-heads were somewhat retracted.
Both upper wisdom teeth decayed to mere shells.
Case XIII.—An Englishman, forty-two years of age,
a car-builder, came to me for relief of pains which radiated
from the ears in various directions, sometimes settling be
hind the eyeballs, as it were. ‘This, and deafness, with
autophonous voice, and tinnitus of both ears, had lasted
some years. ‘There were ingrowing hairs and cerumen in
both external auditory canals. Of his teeth, five in the
upper, and one in the lower jaw, were missing. ‘There
were carious: The right lower first molar, left upper
second molar, and left lower second bicuspid teeth. ‘The
crowns were worn off all the upper incisor and left upper
canine teeth ; the roots of the right upper second molar
and left upper first molar teeth are exposed ; the right
lower canine tooth is crowded out of the arch; and the
lower teeth are covered with tartar.
Case XIV.—A woman, thirty-eight years of age, em-
ployed in housework, consulted me for a “ dumb-aching,”
with “roaring and ticking,” and slight deafness of left ear,
and with pains shooting from the angle of the lower jaw
This had persisted for four weeks, and
120
THE MEDICAL RECORD.
[August 3, 1889
was aggravated by scrubbing a floor, or blowing the nose.
There was slight dulness of the drum-head and a few dirty
spots thereon, with slight myringeal congestion. ‘The left
upper second molar, and central and lateral incisor teeth
are very carious. There are cavities in the left lower
back teeth, and some on the right side also.
Case XV.—A clerk, twenty-four years of age, applied
for relief of symptoms of catarrhal otitis media, aggravated
of late, worse on the nght side. ‘The drum-heads showed
peculiar but characteristic trophic changes. Both lower
wisdom teeth, for two years, have been coming through
the gum, and causing discomfort. ‘The right one is com-
ing in directly forward, against the second molar tooth ;
the left, almost backward, along and in the jaw and gum,
and cannot get out. The right upper wisdom tooth is
through, the left one not yet through cutting.
Case XVI.—A school-girl, twelve years of age, came
to me with intermittent earache of both ears, of two
months’ duration. She said she had had a slight “ dis-
charge” from the left ear two months before, at which
time she had had much odontalgia also. The drum-heads
show no characteristic changes. She has five very carivus
teeth.
Case XVII.—A clerk, twenty-four years of age, applied
for relief from tinnitus and slight deafness of left ear, of
one week's duration. Cerumen filled the canal of the left
ear. There was one carious upper tooth on the left side.
Case XVIII.—A middle-aged woman, born in Ireland,
employed in housework, applied for relief from tinnitus
of the nght ear, worse at night, of two months’ duration.
She had occasional odontalgia. No marked changes of
the drum-head were found. Her nght upper teeth were
decayed to mere shells.
Case XIX.—A boy, aged eighteen months, was placed
under my care for abscess of the right ear, which had
been developing for some days, and had runtured the
preceding night. He had had an attack of tonsillitis one
week before. The right lateral incisor tooth had been cut
about that time. The left upper canine tooth was cut
five days, the right upper and both lower anterior molar
teeth eight days, and the right upper canine tooth about
sixteen days, after being first seen by me. ‘The otitis per-
sisted until after these teeth were fully cut, when it readily
passed away under treatment.
Case XX.—A clerk, thirty-two years of age, came to
me for relief of deafness and autophonous voice, of six
days’ duration. There was tinnitus of the right ear, and
numbness about the right auricle. He had had a similar
attack three years before. Cerumen was found in both
ears. He was wearing, when seen, a vulcanized red-rubber
dental plate carrying all the upper teeth, except the mo-
lars, which remain, covered with tartar. The six lower
molars are missing, and the right upper first molar tooth
is decayed to a mere shell.
In the Archives of Otology, New York, March, 1885, is
an article—whose title I have borrowed for my own—
written by Dr. Bruns, of New Orleans, La., containing a
report of an examination of fifty cases taken from the wards
of Charity Hospital “at random.” Of these there were
twenty-three whose “ ears” were not “ normal,” of whom
nineteen had “ hearing” that was not “good;” and al-
though the writer actually states that there were nineteen
cases in whom the “hearing” was more defective on “the
side on which the teeth were worse,” yet, nevertheless, he
draws the conclusion “ that those cases are exceptional in
which dental irritation gives rise to aural affections.”
Dr. Samuel Sexton, of New York, in THE MEDICAL
RECORD, June 1, 1889,’ discussing “dentition, caries of
the teeth, and some of the neuroses resulting therefrom,”
says that although the special-sense organs, the ear, nose,
and eye, connected with the teeth and with each other
through a complex nervous network, while in health
“ maintain an independent and separate existence, so to
1 The Care of the Teeth, from a Medical Practitioner's Stand-
Seas Read before the Practitioners’ Society, New York, May 3,
1880.
speak, their intimate sympathetic relationship scarcely
manifesting itself perceptibly,” yet, “ under certain condi-
tions of the system, however, these organs become strik-
ingly susceptible to disturbing influences, and so far as his
own experience goes, from no cause more frequently than
from dental irritation.” ‘The same writer, in his Prize
Essay, “ On the Affections of the Ear Arising from Dis-
eases of the Teeth,” American Journal of the Medical
Sciences, January, 1880, states that “on reviewing the
records of some 1,500 cases, he finds that the teeth are
more frequently the seat of disease than was at first sus-
pected, for of these 1,500 aural cases, perhaps one-third
owe their origin or. continuance, in a greater or less de-
gree, to diseases of the teeth.” And again, “that all of
the morbid conditions of the mouth which have been
herein described may exist without serious or recognizable
aural affection being developed, cannot be denied, but
progressive disease of the ears, often without the occur-
rence of pain, is, in his experience, more common when
these oral affections are present than when the mouth and
throat are in a healthy state.” Those who desire an in-
structive analysis of this subject will do well to consult
. those two essays.
Presuming that the gentlemen to whom these remarks
are addressed are of course familiar with the anatomy of
the nervous system and its connections between the mouth
and ear, I shall therefore spare you a detailed description
thereof, which may be found in any standard treatise on
anatomy.
Oral irritation reflected to the ear produces, first, a
change in the calibre of the blood-vessels, through vaso-
motor influence ; this induces hyperzmia, pruritus, abnor.
mal glandular activity, and congestion of the integument
of the canal, and also of the mucous membrane of the
tympanum. Organic changes result, and at the same time
there is established a predisposition to exacerbations of
the chronic process, and acute otitis may supervene.
Success by treatment based on local aural symptoms,
and operative on local aural conditions only, is delayed
and often impossible.
In cases, therefore, of obstructing accumulations,
seborrhoea, eczema, zoster, diffuse and circumscribed in-
flammations of the canal, inflammations of the tympanum,
earache—I may say in all cases having aural symptoms
or disease, the oral cavity, as well as the nares and other
parts of the upper respiratory tract, should be intelligently
examined for irritation or disease, and if either be found
there, it should at once be removed if possible. Should
your acquaintance with oral pathology be so limited as to
leave you in doubt as to the presence of oral irritation or
disease, you will do well to seek counsel in diagnosis from
a skilful dental surgeon. `
A SUMMER HEALTH-RESORT.
By WILLIAM H. DAKEMAN, M.D.,
LOS ANGELES, CAL.
PHYSICIANS in search of climatic aid have been led to
send their patients to the various summer places of note,
such as the Catskill and Adirondack Mountains of New
York ; the White Mountains of New Hampshire ; Berk-
shire, Mass.; Atlantic City and Long Branch, N. J.;
Aiken, S. C.; Asheville, N. C.; Denver, Col.; and nu-
merous other places at home, as well as the many re-
nowned places abroad.
After careful study of this climate, I will attempt to
show that we can add to the list a health-resort of su-
perior advantages, the Pacific slope of Southern Cal-
ifornia, and particularly as a summer resort. A visit to
this sunny land of a section of country lying along the
Pacific coast, situate between .latitude thirty-two and
thirty-five degrees north, and between longitude one hun-
dred and seventeen and one hundred and twenty degrees
west, and comprising a portion of each of the four coun-
ties of San Diego, Los Angeles, Ventura, and Santa
August 3, 1889]
THE MEDICAL RECORD.
I2I
Barbara, very favorably impresses the writer of the su-
perior natural sanitary advantages offered, as being an
almost perfect health-resort.
Much has been said and written, in reference to this
section of country, as being a very favorable winter resort.
But as a summer resort it is far superior. Both seasons,
however, have their own peculiar advantages, and as a
winter resort it has no equal. And Southern California
is rightly termed “the sunny land,” “the land of blue
sky,” “the paradise of the world.”
In speaking of this, I have reference to that slope of |
land along the coast, from the city of San Diego to
Santa Barbara, extending eastward for fifty miles from
the coast to what is known as the Sierra Madre Moun-
tains, including the fertile valleys and undulating foot-
hills and mountain spurs, until an elevation of 6,000 feet
is reached; and in which is contained the prosperous
cities of Los Angeles, San Diego, Pasadena, Santa Bar-
bara, Santa Ana, etc., and the seaside resorts of Santa
Monica, Long Beach, Coronada, and Catalina Island, at
which places bathing in the surf of the Pacific gives new
charm and zest to our wearied existence.
Let us carefully make note of the following tables, as
compiled from the United States Signal Service Reports
of the Los Angeles station.
Table showing Temperature (Fahrenheit), Humidity (per
cent.), and State of Weather for the Colder Six Months.
} ‘ i l a i i
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| Bs E pepo ie ae vi a €o R
1888-1889. |! 85 | 383 ws o: "Y a a Y gg
le |8 S698 82/2 È 8) BIB
- og os Y g $20 of E> = 2 be r
Is pe < = S lza a | Be y
November ..... 57.2 | 83.8 §8.1 74.1 15 8 7 ' none. | 7
December..... 55.2 | 78.8 55.6 71.0 18 6 7 |", 6
January...... 'gr.2!1 73.01 52.5 80.0. 19 6 6!“ Ag
February..... | 54-0 | 84.0 54.4 83.0 18 8 2/i% 1 3
March........ 55.0 81.0 56.0 7.0° 9g | 18 4 sg
Apnil......... 59.0 | 93.0 58.6 75.0) 12 13 5 "4
Total oseca. surr. dais ~ahekeu:. | dese | gr 59 31 eee | 30
Table showing Temperature (Fahrenheit), Humidity (per
cent.), and State of Weather for the Warmer Six Months.
|
s |e 888, $ |
| E og gog 5 = | wi ee Sa ad
f=, -V È 5 ae HE P z ~ ~ S
= so ā &“ v ~ vi s a i
1888, 1 32 3 Y © LIS. R > © 5 a
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a" £0 Jewo. g5 be a] ~~ $ Ea
3 | AA v E q ~ aE f bg. 3 db £
S rm ' 952i g Sia) 2:8
= << = O a O e g
May ......... 60.8 83.0 62.0 79.2) 5 18 8 nonc.. 12
une... ' 67.5 94.0 65.3 74.1 '° 17 | 432 1 e o
uly a...n... 67.9 95.0 68.1 75.6 ' 18 13 o si I
August....... 7.6 97.0 69.8 | 79.4! 23 8 ' o * I
September. 68.4 98.2 67.6 97.7 21 7 2 = o
October ...... 61.9 98.0 62.5 82.3 © 16 10 5 ae 3
Total casu eas ' EE 100 68 16 DONE.
From the above tables we learn that the temperature
for the warmer six months is a very few degrees higher
than for the colder six months; that during the heated
part of the day the mercury runs very little higher dur-
ing the summer than during the winter; that the mean
relative humidity is comparatively lower in summer than
in winter ; and we have more clear and fair days, and less
cloudy days, and no rainy days in summer, giving us
every day to be out of doors.
From the above tables we learn that during the warmer
six months we had, out of the 184 days, 100 clear days, 68
fair days, or 168 sunshine days, and only 16 cloudy days.
Of the 16 cloudy days, only on six different days did rain
fall; three light showers occurred in daytime, and three
light showers at night. During these six warmer months
we find that the highest temperature was only 98° F., and
from United States Signal Service Reports I find that it
reached this point but twice, once in the month of Sep-
tember, and once in the month of October. And on but
very few days did the temperature run up in the nineties.
Generally the temperature, during the hottest part of the
day, rarely reaches 95° F., and this always occurs between
the hours of ro A.M. and 2 P.M., after which there is a cool
breeze blowing from the ocean. The heat, therefore, is
at no time oppressive, but the weather is always comfort-
able, always cool in the shade; and as night approaches
it grows from ten to twenty degrees cooler, making it very
comfortable, and necessary at all times of the year to
sleep under blankets. As the nights are always cool, one
gets good, restful sleep, from which he awakes refreshed.
It is generally remarked that a person requires more sleep
in this climate than in a colder one—at least he is in-
clined to sleep more, and the consumptive rests in peace.
It is to be noticed that we have no foggy days. But at
certain times of the year, as night approaches, a fog blows
in from the ocean, and sometimes in the morning we have
a high fog, having the appearance of being cloudy. The
relative humidity falls as the temperature rises, thus re-
lieving us of that depressing feeling during the heated term.
Take any given day, the temperature at 7 A.M. being 70° F.,
the relative humidity is about eighty-five per cent. From
10 A.M. to I P.M., the hottest part of the day, when the
temperature may be 85° or go° F., the relative humidity
will be as low as fifty-five or sixty per cent.
From this we learn why the heat is never oppressive, and
why sunstrokes never occur, and why one does not sweat
away in perspiration, and seek the ice-cooler for comfort.
From the above table it will be seen that there are only
four of the six warmer months where the average tem-
perature reaches only 67° F. And we also learn that the
mean temperature for the six warmer months, for the
past ten years, has been at the average standard of only
67° F. The months of May and October are of about the
same temperature, or several degrees cooler, averaging
about 62° F. for the past ten years.
Here, in the six warmer months, we find comfort and
peace from oppressive heat in a balmy climate. The
clearness and purity of the atmosphere is remarkably re-
freshing and invigorating. ‘There are no windy, nor wet,
nor damp, nor foggy days, which gives us every dav to be
out in the open air, inhaling a pure aseptic: atmosphere.
Dr. Bodington, of Warwickshire, forty years ago, said:
“To live in, and breathe freely, the open air, without
being deterred by wind or weather, is one important and
essential remedy in arresting the progress of phthisis.”
Regarding the attractiveness of the scenery, those who
have travelled much and visited this section of country
are at once captivated with its grandeur and beauty, and
generally concur in the opinion that there is no place so
charming. It abounds in majestic mountain heights and
cliffs, and romantic cafions and ravines, and fertile valleys
of exquisite beauty, and rippling streams finding their way
from the mountains to the great Pacific. Los Angeles,
from its central position, can boast of many attractive
drives over good roads to local places of interest, over
rounding bluffs and beautiful valleys to points command-
ing views of billowy hills and distant amphitheatre of
mountains, of most beautiful scenery, and a charming foot-
hill drive to the ocean.
Los Angeles is a beautiful, thriving city, of about
eighty thousand inhabitants. ‘The principal streets are
paved with asphalt or bituminous rock, and are kept clean
by being swept every night. An outfall sewer to the ocean
is soon to be constructed.
The resident portion of the city contains some of the
most beautiful homes in America. They are surrounded
by large green lawns, laid out with exquisite taste and
beauty, and contain a variety of evergreen trees and palms,
and semitropical plants and flowers of all descriptions.
There is a beautiful park in the heart of the city, and
several other parks are being laid out and decorated in
an elaborate manner.
The city contains numerous finely constructed private
hotels for the accommodation of the tourist and invalid,
built in the resident portion of the city, away from the
noise of the business portion of the city.
© Seventeen miles westward from Los Angeles is the sea-
122
THE MEDICAL RECORD.
[August 3, 1889
‘side resort, Santa Monica, where surf-bathing in the warm
coast stream is most enjoyable, and can be indulged in
every month in the year. Twenty miles southward is the
seaside resort, Long Beach, and five miles from this, west-
ward, is the port of San Pedro, where a steamer awaits
the tourist for an ocean voyage of thirty miles, to Cata-
lina Island, which place is a rapidly growing, popular
summer resort. Good hotels with good accommodation
will be found at each of these places, open to tourists
during the summer months.
About one hundred miles southward from Los Angeles
is Coronada Beach, with its renowned Hotel del Corona-
da of 750 rooms, beautifully situated, with grounds laid
out with exquisite taste and beauty, and wide, magnificent
views of mountain, ocean, and bay scenery, and whose surf-
bathing is most pleasant and enjoyable, and where the
sunny days pass away almost like a dream.
Regarding the healthfulness of this section of Southern
California, statistics prove it to be the most healthful spot
in America. From the Board of Health reports of the
prevailing diseases, we learn that cholera infantum is an
almost unknown disease among the little ones, which in
our eastern cities carries away thousands upon thousands
during the summer months. Dharrhcea and dysentery,
which also swell the death-list up in the tens of thousands,
are indeed of very rare occurrence, and the fear of the
death of the babe, from these diseases, by those mothers
who have lived East, is a thing of the past with them.
As there is no stagnant water, nor damp soil for the de-
composition of vegetable matter for the development of
malaria, intermittent and remittent fevers are equally as
rare.
The purity of the water, which is derived from the
mountains, which is free from contamination of sewerage
_ and decomposed animal or vegetable matter, gives us al-
most perfect immunity from the more common zymotic
diseases. When, however, such diseases do occur they
usually run a mild course.
The even state of the temperature, with no days of op-
pressive heat; the purity of the atmosphere, with a low
relative humidity ; and every day to be out of doors, makes
this section of country a most admirable one for consump-
tives. A patient with phthisis should come here in due
time and remain at least two or three years, when in all
probability, with due care, the progress of the disease
will be arrested. Many such persons I see daily. The
same may be said of those who are afflicted with diseases
of the kidneys.
Having a climate here which is conducive to sleep, and
which acts as a sedative to the nervous system to the
many who are afflicted with nervous trouble, the result of
overwork, or from other causes, for them no better place
can be found on the face of the globe.
A case of pneumonia, which recently occurred in my
practice, I here desire to report, as it will give evidence
of the mildness and aseptic condition of the atmosphere,
and show how such a fatal disease as pneumonia can
be successfully treated in this climate. The patient, a
young man, twenty-two years of age, had been working
on street paving. On the night of May 2d he had the
initial chill and pain on his right side below the nipple.
He was very anxious to keep at his work, and did so until
the 8th instant, when, almost exhausted and greatly emaci-
ated, he consulted me for shortness of breath and sore-
ness of the right side of his chest. On examination I
found there was consolidation of the whole of the nght
lung. He never kept his bed, but passed most of the day
out in the open air, sitting in the park, as he lived only
one block away, and walked to my office every day, a
distance of three blocks. He gradually recovered, and in
the course of four weeks he went to work again as well
and strong a man as ever.
DESTRUCTION OF AN ANATOMICAL MuSEuM.—In Ma-
drid, recently, fire destroyed the greater part of the Mu-
seum of Anatomy attached to the University.
CLIMATIC TREATMENT OF CONSUMPTION.
By H. D. NILES, M.D.,
SALT LAKE CITY, UTAH.
THE pretty general acceptance of the germ-theory of
Koch, and the encouraging progress made in climato-
therapeutics during the past few years have given a new
and strong impetus to the study of the treatment of
phthisis. And when an effective germicide, which may be
safely and easily applied to pulmonary cavities'shall have
been discovered, and each factor of a climate shall be
capable of mathematical computation, and its therapeutical
effect accurately determined, it 1s believed we will be pro-
vided with formidable weapons with which to cope with
this much-dreaded disease.
--If this much has not yet been accomplished, enough has
been done to show some of the errors of the past and to
promise a more hopeful treatment for the future.
The great majority of the medical profession, even those
who are not quite prepared to believe in the bacillar ongin
of phthisis, or who do not fully accept the remarkably
favorable clinical evidence from the high-altitude resorts,
are agreed on the following points: 1. The importance of
local treatment has been underestimated in the past. 2.
Preventive treatment has not received the attention it de-
serves. 3. In the general treatment too much reliance
has been placed on drugs.
While fully appreciating the usefulness of proper medi-
cinal treatment, hygienic surroundings, correct habits, and
especially appropriate exercises, the object of the present
paper is mainly to show how nearly a well-chosen climate
may meet these recently modified views of treatment, and
to make suggestions on the selection and adaptation of a
climate to'cases of lung disease.
The writer believes the following conclusions hold
good at the present time :
1. More effective than any available medicinal applica-
tion is the continuous inhalation of the nearest aseptic
and the most absorptive air possible, of even temperature,
free from irritating impurities, sufficiently rarefied to dis-
tend and reach every part of the lung and gradually
produce increased chest capacity.
2. In the treatment directed to the general improve-
ment of the phthisical patient proper climatic surround-
ings are first in importance. A place should be selected
where the air is pure, light, bright, bracing, tonic—even
exhilarating—and of even temperature, where the greatest
inducements, as well as opportunities, are offered for out-
door life amid new and attractive scenes.
3. A place possessing precisely the opposite of those
climatic conditions most favorable to the production of
phthisis is the one to be chosen for the residence of those
in whom there exists an inherited or acquired predisposi-
tion to this disease.
Prevention of Phthisis.—The advisability of early seek-
ing a proper climate by those who are predisposed to con-
sumption needs only to be mentioned here. Nor is any
argument needed to prove that as low, moist, warm places
are most favorable to the development of phthisis, a resi-
dence. in a high, dry, cool place should be advised where
such a tendency exists. As this class of prospective in-
valids more fully appreciate their increased risk in unfav-
orable surroundings they will be more willing, in spite of
business or social interests, to take every precaution, and
as the physician’s knowledge of climato-therapeutics be-
comes more precise he will be more positive in his counsel,
and the preventive treatment of phthisis will be as popular
in practice as it is now in theory.
Local Effete of High-altitude Climate.—The nearest
approach to that air which has been described as the best
local application available for diseased lungs is found only
in high, dry places. For it is here that the atmosphere 1s
the nearest aseptic, and possessed of the greatest absorp-
tive properties. Its coolness, equability, purity, freedom
from dust, fog, vapors, and smoke depending upon other
August 3, 1889]
THE MEDICAL RECORD.
123
conditions, which also exist in favorably located high-alti-
tude places.
Until an easier and more effective method of introduc-
ing an efficient germicide into the lungs is found than that
by pulmonary injections or gaseous enemata, or inhalations
of medicated vapors, sprays, or air, it is believed that as
much or more good may be accomplished by placing the.
patient where the lungs are continuously bathed in an
air possessing naturally precisely the same qualities (if not
in quite the same proportions) that we would artificially
produce.
The aseptic and absorptive properties of the atmos-
phere peculiar to dryness, coolness, and altitude are too
well known to need explanation here. The following
tables, however, may serve to give an approximate idea of
the markedly different degrees of strength of these quali-
ties in different locations. Table A shows the number of
bacteria in ten cubic metres of air, taken as nearly as pos-
sible at the same time in June, 1883, at the respective
places, by Professor Miquel.
Table A.
At an elevation of from 2,000 to 4,000 metres....... None
On the Lake of Thun, 560 metres................2- 8
Near the Hotel Bellevue at Thun.................. 25
In a room of Hotel Bellevue...................0005 600
In the Park of Montsouris (near Paris)............. 7,600
In Paris itself (Rue de Rivoli).............ccccccce 55,000
In Table B, Dr. Denison’s method of computing the
vapor transpiration of the same person in the different
places, varying 1n coolness and dryness, is used.
Jacksonville, Colorado Springs, and Salt Lake City are
compared in this way in the case of a man who, we will
assume, breathes 500 cubic feet of air in twenty-four
hours, dew-point of expired air being considered 94° F.,
Glaisher’s estimate of weight of vapor at saturation of air
of given temperature being adopted.
Table. B.
| Colorado Jackson-
Salt Lake. Springs. ville.
Mean temperature .............. sees 9.5° 47? 70?
Grains of vapor in saturated air per
cubic foot at given temperature...... 4.0 3.69 8.01
Mean relative humidity............ ... | 0.44 0.56% 0.754
Cubic feet of air breathed in twenty-
four hours ......sossoeseseessoscsooee i §00 500 500
Grains of vapor inhaled................ 880 1,033 3,020
Grains of vapor exhaled, with dew-point'
sp ar iP ccc ceaceuhetewen a eataaiay IPEA ' 8,345 8,345 8,345
Vapor exhaled more than inhaled...... eer 465 7,312 5.325
* Only a record for a short period obtainable.
Grains.
Excess of moisture exhaled in Salt Lake City over Jackson- '
ville
bag edie wed Ce wae Oe UGS Wien Cae teas sree a a wien aeeowe 140
Excess of moisture exhaled in Salt Lake City over Colorado
SPINS cos siectcde weaver ae es eeie ew Geesew iad .. 153
Excess of moisture exhaled in Colorado Springs over Jackson-
ville ............ E E E E E E ETE 1,987
It is only fair to add that the increased respiratory activ-
ity induced by the rarefied air and greater amount of ex-
ercise usually taken in high, dry places would make the
difference in transpiration still greater. Denison estimates
that one breathes about twenty per cent. more air in Den-
ver than in Jacksonville with the same amount of ex-
ercise.
The investigations of Dr. Denison and Professor Mi-
quel not only prove conclusively the existence of re-
markable aseptic and absorptive qualities of certain airs,
but they pretty clearly indicate the climatic conditions
most favorable for the development of these qualities.
This knowledge, combined with that of the attested value
of antiseptics and absorbents in the treatment of wounds
generally, and that afforded by the researches of Koch,
lead us to believe that in air possessing these qualities we
may have a most valuable local application for diseased
lungs. Regarding this air as a local application to an in-
flamed discharging surface, characterized by the presence
of a specific germ, it should be remembered that the other !
climatic factors have an important bearing on the remedial
effect of such an application.
1. Equability acts the negative part of preventing the
irritation liable to ensue from sudden changes in the tem-
perature of the application, and thus overbalancing the
good effects of dryness.
2. Rarefaction of the air, by its effect on the vaso-motor
system, tends to relieve any passive congestion of the
lungs. By increasing the depth and number of the respi-
rations it not only mechanically distends the weakened and
diseased portions of the lungs, but brings them into con-
tact with a greater amount of dry aseptic air. The sec-
ondary effect of this regular and continuous expansion is
to permanently increase the chest capacity.
3. The greatest number of bright, cloudless days gives
the “greatest opportunity for out-door life and exercise,
with a resulting augmentation in the amount of dry aseptic
air inspired.
4. Wind- and sand-storms render the air irritating, and
the respirations shallow, depressed, and irregular. ‘Their
absence has a negative value similar to equability.
5. Cold enhances the aseptic and stimulating qualities
of dry air.
Effect of Climate on General Condition of Patients.—
The climatic conditions described as the most conducive
to the improvement of the general health are also to be
found only in the high altitudes. Dryness, brightness, and
rarefaction of the air and abundance of sunshine belong
to all very high places. From among these a location
should be selected where the remaining desirable qualities
are four.d.
It is difficult for one who has never experienced the
effects produced by coming from a low to a very high
place, A undead the wonderful exhilaration that follows
breathing this dry rarefied air. ‘Those in health feel and
enjoy the powerful tonic, almost intoxicating, effect, but
not to the marked degree that the invalid does. It seems
to supply a necessity in his case. Nor are the effects
limited to a temporary stimulation, to be followed by a
corresponding depression. Very soon his appetite is
better, his digestion improves, the feeling of lassitude dis-
appears, exercise becomes a pleasure, and he is able to
thoroughly enjoy the out-door life to which he is invited
by new scenes, sunny skies, and a bracing air. With the
increased exercise there is a more rapid gain in weight
and strength.
These are the usual effects in appropriate cases, the
improvement being modified by, as well as modifying, the
local part of the trouble.
While all observers are agreed that these are the ordin-
ary results to be expected in appropria‘e cases, there are
differences of opinion as to just how they are produced.
Undoubtedly the strength of th- circulation and the
greater determination of blood to the periphery induced
by the lessened atmospheric pressure favor greater func-
tional activity of all the internal organs by relieving local
passive congestions. The heart’s action, which may at
first be accelerated, is always stronger, and the respirations,
at first more rapid, become deeper. Hence there is a
more perfect oxygenation of the blood. (It is possible
also that this attenuated air yields up its oxygen more
readily than the denser air of low places.) With all of
the internal organs relieved of venous engorgement, and
the surface and lungs supplied with blood in a larger
quantity, the conditions are most favorable for healthful
activity of the organs engaged in digestion and assimila-
tion, and the improvement of the general nutnition, as
well as for the repair of the local damage to the lungs.
The increased muscular and nervous energy, and the
better work done by the excretory organs may also be
attributed to a purer and more generous supply of blood.
The abundance of sunshine characteristic of high-alti-
tude places, aside from permitting and encouraging much-
to-be-desired out-door life, has a direct salutary effect
upon the health and spirits of the invalid.
If the theory thus briefly outlined be the one accepted,
124
THE MEDICAL RECORD.
[August 3, 1889
and the stimulus of the lessened atmospheric pressure
upon the vaso-motor system be accredited with the chain
of good results that ensue, it is evident that the two most
important points upon which the physician should satisfy
himself in each case before recommending a change are :
Is the heart capable of promptly responding and readily
adapting itself to an increased rarefaction of the air? . If
so, what elevation would be safe as well as efficient ?
It should be remembered that an adaptability of the
heart to a very high altitude may usually be acquired by
gradually increasing the elevation, and an altitude entirely
unadvisable, and even hazardous, at first, may become in
time the one most desirable. In the past there has been
a tendency on the part of physicians to advise or permit
their patients to seek an altitude altogether too high to
commence with. Experience has taught that elevations
of three thousand feet to six thousand feet should include
nearly all cases, with the greatest number in places of
less than five thousand feet above the sea-level. Un-
doubtedly, if more caution was exercised in this regard,
and greater care shown in selecting places as free as pos-
sible from sand- and wind-storms and sudden changes in
the temperature, the tabulated clinical reports of the
treatment of phthisis in high-altitude resorts would read
even more favorably than they now do. ‘The prevalence
of these storms, and the marked variability of the temper-
ature, so common in many high-altitude resorts, are always
objectionable features, and many times are insurmount-
able obstacles to a residence in an otherwise healthful
climate.
They lessen the number of days suitable for open-air
pursuits, and even indoors no amount of precautions
are sufficient to perfectly guard against their ill effects.
It would therefore appear that the requisites of a cli-
mate for pulmonary invalids are :
Altitude (3,500 feet to 6,000 feet).
Dryness (greatest possible).
Equability.
Greatest number of sunshiny days.
Greatest possible freedom from sand- and wind-storms.
Comparative coolness.
Possessing all of these attributes, there are still other
factors which need only to be mentioned here, but which
should have no light weight in influencing our estimation
of a health-resort, viz., the sanitary surroundings, the hotel
accommodations, the completeness of the change, and its
attractiveness. If a city is selected, it should be one
where the streets are wide, the houses far apart, and
where the invalid need be deprived of none of his accus-
tomed luxuries, comforts, and conveniences.
Selecting a Climate.—We have thus briefly presented
our idea of the best climatic treatment for phthisis, and of
the method by which a high-altitude climate produces its
beneficial effects, and have indicated the most important
attributes which should characterize such a climate.
While altitude should vary according to the individual re-
quirements and adaptability of each case, the other factors
mentioned are desirable in all cases.
The so-called “ ideal climates,” or climatic specifics for
phthisis, do not exist. Not only that, but it is certain that
in the most favored localities (climatically) consumption
may occur as the result of bad hygienic surroundings,
mode of living, habits, etc. A residence in none provides
immunity from this dreaded malady, or promises a certain
cure for all cases. Neither is it possible to find with
each different altitude suitable for different cases a per-
fect combination of all the other climatic factors most de-
sirable. We must choose that place which, being the
proper altitude, most nearly fills the other requirements.
For example, wind, dust, and variability belong, to a
greater or less extent, to almost all very high places; yet
among places of equal altitude there is a marked differ-
ence in these respects well worth our consideration in es-
umating the comparative merits of a resort.
A critical study of each climate and of each case will
enable us to more perfectly adapt the one to the other,
-and we may then confidently expect better results than
by the plan so much in vogue at present of recom-
mending a favorite resort in all cases, simply on account
of its popularity. In deciding upon a given climate it
is believed that reliable statistical data should rank first,
clinical observations second, and the opinions and im-
pressions of those who may be prejudiced advocates of a
certain resort last in importance in influencing our con-
clusions.
Contra-indications.—The contra-indications to the em-
ployment of a high-altitude residence are based on the
inability of the patient to bear and respond to the stimulus
of the rarefied air to the vaso-motor and respiratory
systems.
The success of this treatment depends upon the patient
having some general recuperative power, a sufficient
amount of healthy lung-tissue, and a heart in which
degenerative changes have not started. Large amount
of lung structure involved, extensive pleuritic adhesions,
fatty or parenchymatous degeneration of the heart would
be contraindications; while the age, constitution, and
temperament of the patient, amount of emaciation, fever,
etc., would guide us in estimating the vital powers.
Too often the change is attempted as a dernier ressort.
The fatal issue is sometimes hastened in those cases
known to be hopeless which are sent to the altitudes for
relief.
A clear comprehension of the rationale of the high-alti-
tude treatment, accuracy in diagnosis, sound judgment
in estimating the general and local recuperative powers
in each individual case are worth more than any fixed
rules that shall have a general application. But in all
cases of phthisis that are remediable or curable by any
treatment, it is believed, unless there be positive contra-
indications, that a residence in a well-chosen high altitude
is to be advised. ,
In Regara to Salt-water Bathing.—Many strumous pa-
tients have derived much benefit from residence near the
sea and salt-water bathing; and the medical profession
have long recognized the value of this plan of treatment
in such cases. Its success in strumous lung troubles has
doubtless given the coast much of its reputation as a resort
for the phthisical. ‘The majority of cases of caseous
phthisis, chronic bronchitis of children, and almost all
scrofulous diseases of the respiratory tract are unques-
tionably favorably influenced by sea-air and sea-water,
notwithstanding the bad climatic surroundings in other
respects. But is it not reasonable to hope for a more
certain and a greater improvement where to this treatment
is added all of the advantages of a high-altitude resort.
Impressed with this idea the wnter has been engaged for
some time in collecting notes of appropriate cases at
The Great Salt Lake, Utah, where such a combination
apparently exists. These notes, when complete, will be
submitted to the profession.
COLORLESS STOOLS IN UNJAUNDICED PERSONS.—From
a study of this subject Dr. Walker concludes: 1. That
the form of hydrobilirubin, the coloring matter of the
fæces, depended on the mutual reaction of the bile and
pancreatic fluid, under the influences met with in the in-
testinal tract. 2. That in disease a deficiency of pancre-
atic fluid would, equally with a deficiency of bile, cause
the pathological condition of colorless or clay-colored
stools. 3. That as, according to the most recent physi-
ological researches, that portion only of the colored con-
stituents of the bile which had been converted into hydro-
bilirubin was excreted in the fæces, while the unchanged
bilirubin, and biliverdin were absorbed, ıt followed that if
hydrobilirubin could not be produced without the aid of
the pancreas, that organ must have an important rôle in
regulating what proportion of the bile entering the intes-
tines should be absorbed and what thrown off in the fæces.
— The British Medical Journal.
August 3, 1889]
——---_.
Glinical Department.
CASTOR-OIL AS A MENSTRUUM FOR COCAINE.
By S. MITCHELL, Jr., M.D.,
HORNELLSVILLE, N. Y.
THE use of cocaine dissolved in castor-oil may not be to
many such a novel method of employing this valuable
agent as it was to me. I do not remember, however, to
have heard of its previous use, and the idea only occurred
to me in the dire extremity when seemingly I had ex-
hausted all the remedies that were at all applicable, and
my patient was “nothing better.”
I trust the publication of the following details of the
case wherein I first employed the above remedy may be
of interest and perhaps profit to others.
Mr. H—, aged fifty, whom I was treating for chronic
aural catarrh, was suddenly attacked with herpes zoster,
covering the whole left side of the head from the tem-
poral ridge to the occiput. Nearly the first vesicle to
form was in the conjunctiva of the upper lid of the left
eye. It was attended with much pain, great congestion
of the whole palpebral and ocular conjunctiva, contrac-
tion of the pupil, and sluggishness of the iris. Atropine
and cocaine were employed during the whole course of
the disease, and the eye thus kept quite comfortable,
until the disappearance of the Wsicles from the head.
As they healed, leaving deep and painful cicatrices, the
one in the conjunctiva healed also, leaving a hard cica-
trix that at once assisted in forming an ulcer in the lower
margin of the cornea, as large as a kernel of wheat, that
steadily grew deeper and more painful, despite all reme-
dies employed. At the end of a week there was well-
marked chemosis, together- with deep-seated and constant
pain. At this juncture it occurred to me to try a drop of
castor-oil in the eye, if possible by its use to mitigate the
ternble rasping the hard cicatrix was inflicting upon the
cornea; then the happy idea suggested itself to combine
cocaine with the oil. A five per cent. solution was made,
dissolving the cocaine in the oil by means of gentle heat.
A few drops of this were instilled into the eye, with almost
magical effect. Pain was at once greatly mitigated, the
chemosis disappeared, the cornea cleared up, the ulcer
began to heal, and my patient grew happy and smiling.
All other remedies were discontinued, recovery being rapid
and complete.
A CASE OF INTESTINAL OBSTRUCTION.
By DEWITT C. RODENHURST, M.D.,
PHILADELPHIA, N. Y.
On May 26th I saw Wiliam R , aged two and a
half, who was vomiting and had had no movement of
the bowels for two days. I gave calomel and bicarbonate
of soda as a cathartic, and bismuth and oxalate of cerium
for the vomiting, but without result. On the following day
the symptoms were the same. I ordered ten grains of calo-
mel, which controlled the vomiting, and then gave an
enema with an eighteen-inch rectal tube, and am positive
that the tube went sixteen inches into the bowel, as I was
able to trace it through the abdominal wall. With this en-
ema came quite a quantity of greenish mucus. I re-
peated the enema in four hours with the same result, and
I now became convinced that there was intestinal obstruc-
tion. The next morning Dr. Abell, of Antwerp, saw the
case with me, and confirmed my diagnosis. We then put
the child on ten-drop doses of tincture of opium, per rec-
tum, every four hours, giving at the same time about one
ounce each of beef-extract and milk, and once in about
twelve hours giving the large enema with the rectal tube.
There was no vomiting this day. The same treatment
THE MEDICAL RECORD.
125
was continued for two days, and condition remained about
the same.
On May 3oth the child began to show signs of failure,
and on the following day Dr. Willis E. Ford, of Utica, N.
Y., was called, with an idea of surgical interference, as it
had become evident that the child must die without.
Dr. Ford brought with him a Bergeon apparatus for
gaseous enema, and proposed inflating the intestines with
carbolized, sulphuretted hydrogen gas, after the method
introduced by Dr. N. Senn, of Milwaukee, Wis.
The gas-bag of the Bergeon apparatus holds five gal-
lons. It was filled, the child being well under chloroform,
and the gas was gradually pumped into the intestine, the
anus being firmly held to keep it from escaping. The
large intestine soon being inflated, the gas began to pass
the ileo-cæcal valve, and in a brief space of time there
was an audible sound, as of something giving way.
We suggested that the obstrution, which without doubt
was intussusception, was removed, the anus was let go,
and following the escape of the gas there came feces of
such a character as to assure us the obstruction was re-
moved.
The child was kept under the influence of morphine
for forty-eight hours, and then given a large dose of cas-
tor-oil, after which followed a natural stool. From May
28th till the operation the temperature of the child
ranged from normal to 100}° F.; the pulse ranged from
go to 120. There was no vomiting after the ten-grain
dose of calomel was given till the 3oth, and then the
vomited material was only what the child had been
allowed to take. ‘There was never any tenderness or
bloating of the abdomen. There was no tumor to be felt.
During all the time the child, when not asleep, would
ask for drink, answer questions, notice playthings, and in
no way seemed sick except that he wanted to lie in bed
and would take no nourishment. Before his sickness his
habits had been the same, except that he had developed
the idea of climbing. This, I believe, is the first time this
operation has been performed in New York State, as I
can find no record of it before.
A YOUNG LIVING FCETUS.
Dr. T. T. Krrx, of Pittsburg, Pa., writes: “ I had a case
similar to Dr. J. L. Nascher’s, reported in THE MEDICAL
RECORD of June 15th. My patient, Mrs. C , aborted
October 15, 1888. Shemenstruated November 15, 1888.
I was called hurriedly on May 2d, and found a head pre-
senting. The next pain brought a small living foetus, with
closed eyes, no hair, finger- or toe-nails. Ina few seconds
it gasped and cried. ‘The nurse wrapped it in cotton and
fed it on sweetened water. Allowing one week after the
menses began, the child was five months and ten days old.
It was born before 5 P.M., and lived till after 3 p.m. the
next day—over twenty-two hours.”
A QUESTION OF IMMENSE IMPORTANCE.—The General
Medical Council of Great Britain seems to be a body of
great importance, or at least so considers itself. Among
other mighty subjects engaging its attention, at a recent
meeting, was that of precedence as between its president
and those of the Colleges of Physicians and of Surgeons,
respectively. The question had arisen lately in connection
with a work in which they were jointly engaged. The
Council appointed a deputation to wait upon the Lord
President of the Privy Council in reference to the matter,
but the result of their interview proved inconclusive. It
was therefore resolved that the President of the Council
be requested to frame, together with the solicitor to the
Council, a petition to the Queen to request Her Majesty
to determine the order of precedence of the President of
the Medical Council and the heads of the other bodies
concerned in the administration of the medical acts.
126
THE MEDICAL RECORD.
[August 3, 1889
THE MEDICAL RECORD:
A Weekly Fournal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., EDITOR.
PUBLISHED BY
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
New York, August 3, 1889.
THE FATHER AND THE RACE.
A CONTROVERSY has been going on in Z he Forum re-
garding the relative importance of woman in influencing
the development and character of children and of the
race. Professor Lester Ward, reasoning from various zoo-
logical data, concludes that woman is the race and that
man is only a necessary adjuvant, who performs the duties
of impregnating the ovum and supporting the progeny.
All moral, intellectual progress comes through the woman.
Hence it is inferred that the most essential duty of mod-
ern civilization is to promote the moral and intellectual
welfare and progress of the mothers.
This chivalric view is directly antagonized by Mr. Grant
Allen, who, by a like appeal to zoology and embryology
and the facts of heredity, tries to prove that woman is
the appanage and man the chief factor of existence.
Woman, he says, 1s simply or mainly set apart for pur-
poses of perpetuating the race. The duties of maternity
make too severe a strain upon ber energies to enable her
to compete with man in those labors which advance
knowledge and improve the condition of mankind.
We think there are very few who will not agree in
the main with Mr. Allen’s argument. Without discussing
it now, however, we wish to bring to our readers’ atten-
tion an interesting contribution to one phase of this sub-
ject, in the shape of a monograph on the influence of
the father upon the development of the fœtus, by Dr.
Félice La Torre.’
The general tenor of Dr. Torre’s work is to show that
a decided preponderance of influence upon the child is
exercised by the father. ‘There is, he says, no single
thing which so influences the health and development of
the foetus as the constitutional condition of the father.
To have children strong and well, it is necessary that the
father be sound in health; the mother may be an in-
valid or not. Quoting Boinnet, he adds, “I have
shown by my tables of family histories that the axiom,
Pater est quem morbi filiorum demonstrant, has more of
certainty than the adage, Pater est guem nuptia demon-
strant.” Dr. Torre’s concluding sentence is “ Talis
pater, talis filius.”
Dr. Torre’s views are supported by a record of one
hundred cases, which he analyzes and tabulates.
1 Des conditions qui favorisent ou entravent le développement du
foetus. Influence du père. Recherche clinique, par le Dr, F. La
Torre. Paris: Octave Doin, 1888.
While his deductions are not absolutely conclusive,
they appear to show that if, when a marriage is contracted,
the father is weak in body or suffering from a constitu-
tional ailment, there is less chance of the children being
vigorous than if the mother were in such condition.
While Dr. Torre’s investigations cover chiefly the sut-
ject of the influence of the father upon the physical con-
dition of the child, they supplement in a measure the
studies of De Candolle, who showed that distinctive
traits are more often transmitted by fathers than mothers ;
more particularly the higher intellectual faculties.
CHEMICAL STRUCTURE AND PHYSIOLOGICAL THERA-
PEUTICS.
THERE is no field of medical activity at present more
interesting and fruitful than that which concerns itself
with the application of new chemical compounds to
therapeutics. The work here is not purely an empirical
testing of miscellaneous drugs, but is conducted, in a con-
siderable measure, on carefully laid-out plans based upon
chemical and physiological knowledge.
Dr. Lauder Brunton has recently delivered a series of
lectures upon the relationship between chemical struct-
ure and physiological action, in which he has shown the
guiding principles adogged or to be adopted in the search
for new remedies.
Dr. Brunton has gone over a very wide field, for he
passes in review a good many elementary facts of chem-
istry as preliminary to the consideration of his subject
proper. We cannot attempt, therefore, to give any sys-
tematic summary of his lectures, but only to refer to
some of the more interesting points that he brings out.
The causes of disease are first considered. ‘The lect-
urer dwells at some length upon microbes, microbic
ferments, ptomaines, and leucomaines. He shows that
microbes often cause morbid phenomena, not by their
direct action but by certain ferments which they produce,
or through the poisons known as ptomaines.
The fact that ptomaines are present in decaying meat
would lead one to suppose that poisoning from this
source would not be infrequent. Its comparative rarity
is thought to be due to the fact that mixed bacillary pro-
ducts are often very poisonous, while pure single cultures
are not. ‘This would explain the especially poisonous
character of meat, in which if diseased there may be the
products both of a pathogenic and a putrefactive bacillus.
Dr. Brunton is inclined to accept the views of Roux
and Yersin, that the diphtheritic poison belongs to the
ferments and can, therefore, act even after the microbe
which produces it is killed.
After giving a short history of the ptomaines, the lect-
urer says that a number of them belong to the compound
ammonias. ‘The most common of the ptomaines, viz.,
choline, neurine, and muscarine, belong to this class; and
they all have one common property, namely, that of stim-
ulating glandular action and involuntary muscle fibres ;
their action is antagonized by atropine, and it is suggested
that this drug be used in poisoning from tainted meat
and fish.
One prolific source of disease is microbic action and
chemical decomposition in the intestine. In the treat-
ment of disease from this cause there are three indica-
tions — to eliminate by purgatives, to antagonize by
August 3, 1889]
antiseptics, and to starve out the bacteria by changes of
diet.
The search for intestinal disinfectants has so far not
been very successful. Brunton quotes Pellicani as saying
that substances containing a diphenyl nucleus are less
poisonous and more antiseptic than those containing a
single phenyl nucleus. The use of sulphates with phenol
makes the latter less poisonous, while the sulphonic com-
pounds, hke aseptol, and the compound of beta-naphthol
and salicylic acid, known as betol, are suggested as likely
to be very efficient. In the matter of starving out bac-
teria, the lecturer commends the plan of stopping milk
altogether in infantile diarrhoea, and he discountenances
farinaceous foods in typhoid fever.
Following up the subject of microbes and disease, the
treatment of phthisis by antiseptics is considered. With-
out laying great stress on this subject, he speaks favor-
ably of the principle of gaseous injections, and recom-
mends the use of helenine, and of phenyl acetic and
phenyl propionic acids, because of their specially destruc-
tive influence upon the micro-organism. :
When microbic action takes place in the blood and
tissues, as in anthrax, tetanus, rabies, diphtheria, and
ceffain other infectious diseases, we cannot expect to
reach the trouble by antiseptics.. In such cases purga-
tion, diuresis, and washing out the system with copious
draughts of water ought to be resorted to.
Dr. Brunton discusses in an interesting way the subject
of preventive inoculations, in which he thoroughly believes.
He cites the work of Pasteur for rabies and anthrax,
that of Chantemann and Vidal for typhoid fever, that of
Roux and Chamberlain for septiczemia, and that of Roux
and Yersin for diphtheria.
Dr. Brunton discusses the relation of chemical structure
to antiseptic power, and also to analgesic and antipyretic
action. The subject is too much involved in chemical
details to enable us to present it here. We quote, how-
ever, his final words with regard to the prospects and
dangers of analgesics :
“Asthe ways in which methyl may be combined with
aromatic bodies are almost numberless, we may expect
before long a great increase in the number of analgesics,
and not improbably some new ones may far surpass in
their power to relieve pain anything that we as yet pos-
sess. Before passing from this subject, however, I must
indicate a possible source of danger from the continued
employment of such analgesics.
“ We know that the continuous employment of narcotics,
such as morphine or chloral, is apt to grow into a habit,
and the consequences may be very deleterious to the
mental functions. A similar habit, we know, may be es
tablished by the use of cocaine, and it is possible that
something similar may occur in the case of other anal-
gesics. But there is another possibility which I wish to
indicate in addition to this, namely, that just as the brain
. may become deteriorated by the use of chloral or mor-
phine, so the cord may possibly be injured by the use of an-
algesics. I have already mentioned that Dr. Cash and I
observed in frogs symptoms resembling those of dissem-
inated sclerosis, or of locomotor ataxy in man, and Bat-
ten and Bokenham have noticed that antipyrin may pro-
duce in frogs a condition like that of spastic paralysis.
Cash and I tried to produce symptoms of permanent dis-
THE MEDICAL RECORD.
cians.
127
ease of the spinal cord in frogs by keeping up the poison-
ing for some time. We were unsuccessful in the attempt,
as the symptoms always passed off when the poison was
eliminated, but still the conditions in our experiment were
very different from those which would occur from the
prolonged use of analgesics by a patient, inasmuch as the
treatment of the latter might continue for weeks, months,
or years, whereas in our experiment time could be counted
by days.”
MITHRADATISM.
MEDICAL writers have for some time been conscious that
medical literature needed a new word to express the ar-
tificial production of immunity against disease. When
small-pox was the only infection which could be avoided
by preparing the system against it, the term vaccinate and
vaccination answered very well. But we cannot say that
we “vaccinate” against rabies, or anthrax, or, in other
words, we have no general equivalent for that verb.
We believe that it is Professor E. Ray Lankester who
has come forward in this emergency and proposed the
term “ mithradate” and “ mithradatism.” This word is
taken from the name of the Phrygian King Mithradates,
who lived about 100 B.C., and who is credited with hav-
ing so thoroughly saturated his system with poisons that
he was proof against any of them.
Accepting Professor Lankester’s suggestion, we could
speak of Pasteur as mithradating patients bitten by rabid
dogs, or mithradating sheep against anthrax; and we
could speak of the unsuccessful attempts of Ferran to
mithradate against cholera, and of Freire’s firm belief in
the mithradating power of his yellow-fever cultures. The
name of the process would be “ mithradatism ;” and the
name of the thing, corresponding with “ vaccine,” would
be “ mithradatine.”
We submit Professor Lankester’s new word to the suf-
frages of our readers, only regretting that he could not
have found some ancient and toxibund Pltrygian who had
a little more euphonious name.
Rews of the Geek.
Tue Lecar Ricut To DISCIPLINE Puysicians.—Under
this title the Sun gives a review of a case which has
recently much occupied the attention of English physi-
The plaintiff was a physician named Allbutt. The
defendant was the General Council of Medical Education
and Registration of the United Kingdom of Great Britain
and Ireland. The Council is a public corporation em-
powered by law to keep a register of qualified medical
practitioners, and to cause it to be printed and sold, so
that the public may be correctly informed what physicians
are and are not on the list. Only those doctors who are
duly registered are entitled to sue for their charges, or to
give certain medical certificates provided for by law. The
council is expressly authorized to erase from the register
the name of any physician who shall be convicted of any
crime, or who shall, after due inquiry, be adjudged by the
council “ to have been guilty of infamous conduct in any
professional respect.” Such erasure, however, does not
absolutely prevent the doctor whose name is erased from
practising medicine. He is debarred from collecting his
bills by suit, and from giving medical certificates under
128
THE MEDICAL RECORD.
[August 3, 1889
the statute ; but he may still be employed by patients, or
called in consultation by other physicians. The name of
Dr. Allbutt was on the register, and was erased by the
General Council upon the ground that he had been guilty
of infamous conduct as a professional man in causing to
be published and sold a certain book, the publication and
sale of which was detrimental to public morals. The
plaintiff asked the court for a writ of mandamus com-
manding the Council to restore his name to the register,
and also sought to recover damages against the Council
for libel, because in its published minutes the fact of the
erasure and the reason therefor had been stated. The
case thus presented two questions: First, whether a
physician whose name has been stricken off a list of medi-
cal practitioners by the corporation authorized to keep
such list can compel that body to restore his name, when
it was removed for a cause and in the manner prescribed
by law ; and, secondly, whether it is libellous to publish a
statement that the name has been erased, together with
the reason for such erasure. The Court of Appeal has
answered both questions in the negative. In this con-
nection, a Massachusetts case of somewhat similar charac-
ter is cited. Dr. Ira Barrows was expelled from the
Massachusetts Medical Society for “ gross immorality,”
in having broken a promise to Dr. Benoni Carpenter, to
whom he had sold his practice at Pawtucket, for a large
sum. ‘The promise appears to have been an assurance
that he would not resume practice in the same locality ;
but he returned to Pawtucket, and entered upon profes-
sional work there again in the course of a year. An
article relating to his expulsion was published in the
Boston Medical and Surgica! Fournal by Luther V. Bell,
and the doctor thereupon sued Bell for libel. Chief
Justice Shaw held that the suit could not be maintained.
MEDICINE AND THE StTaGE.—In Mr. Henry Irving’s
speech at the festival dinner to Sir Morell Mackenzie, of
the Golden Squfare Hospital for Diseases of the Throat,
he said that “ there had always been a deep sympathy be-
tween actors and doctors, but he did not know why, unless
the doctors regarded the players as a little mad. Actors
were on the free list of the doctor’s skill.”
THE EFFECT OF CONTINENCE ON ADULTS.—Dr. Brown-
Séquard says: “ It is known that well-organized men, es-
pecially from twenty to thirty-five years of age, who remain
absolutely free from sexual intercourse or any other causes
of expenditure of seminal fluid, are in a state of excite-
ment, giving them a great, although abnormal, physical
and mental activity.”
BROWN-S£QUARD’S ‘TESTICULAR INJECTION. — Dr.
Brown-Séquard gives, in Zhe Lancet, the following account
of the technique of his injections: “I have made use, in
subcutaneous injections, of a liquid containing a small
quantity of water mixed with the three following parts :
First, blood of the testicular veins ; secondly, semen ; and,
thirdly, juice extracted from a testicle crushed immediately
after it has been taken from a dog or a guinea-pig. Wish- -
ing in all the injections made on myself to obtain the
maximum of effects, I have employed as little water as I
could. To the three kinds of substances I have just
named, I added distilled water in a quantity which never
exceeded three or four times their volume. The crushing
was always done after the addition of water. When fil-
tered through a paper filter, the liquid was of a reddish
hue and rather opaque, while it was almost perfectly clear
and transparent when Pasteur’s filter was employed. For
each injection I have used nearly one cubic centimetre of
the filtered liquid. The animals employed were a strong,
and, according to all appearances, perfectly healthy dog
(from two to three years of age), and a number of very
young or adult guinea-pigs. ‘The experiments, so far, do
not allow of a positive conclusion as regards the relative
power of the liquid obtained from a dog and that drawn
from guinea-pigs. All I can assert is that the two kinds
of animals have given a liquid endowed with very great
power. I have hitherto made ten subcutaneous injec-
tions of such a liquid—two in my left arm, all the others
in my lower limbs—from May 15th to June 4th last.
The first five injections were made on three succeeding
days with a liquid obtained from a dog. In all the sub-
sequent injections, made on May 24th, 29th, and 3oth,
and June 4th, the liquid used came from guinea-pigs.
When I employed liquids which had passed through
Pasteur’s filter, the pains and other bad effects were
somewhat less than when a paper filter was used.”
GERMAN PHYSICIANS ADOPT A CODE OF ETHICS.—On
June the 24th the seventeenth Congress of German Phy-
sicians met at Brunswick, and passed the following resolu-
tions: “x1. Every kind of public laudation, whether it
proceeds from the physician in question himself or from
others, and continued advertising in public papers are to
be reprobated. 2. The designation ‘specialist,’ for puff-
ing purposes, is to be reprobated. 3. The public offering
of medical assistance gratis, underbidding in concluding
contracts with sick societies and the like, offering advan-
tages of any kind to a third person in order to procure
practice, are inadmissible. The designations ‘ Klinik ’ and
‘Poliklinik’ (hospital) belong exclusively to institutions
which serve the purposes of instruction in connection with
universities. 4. The ordering and recommending secret
remedies are inadmissible. 5. Any attempt of any kind
on the part of a physician to intrude upon the practice of
another is dishonorable, especially in the case of one who
has acted as substitute or in consultation. A practitioner
must by no means undertake the treatment of the case
without the express assent of the previous physician. A
specialist called in for a definite part of the treatment
must strictly confine himself to that. 6. No physician is
at liberty to make disparaging remarks to others about
another physician.”
THE PENNSYLVANIA STATE MEDICAL SOCIETY has
postponed its annual meeting until next year.
ABOLISHING THE SCOTTISH MEDICAL FACULTIES.—A
Member of Parliament has introduced a resolution to
abolish the Faculties of Medicine in the Scottish Univer-
sities.
FLAGS TO ANNOUNCE CONFINEMENTS.—French medical
journals state that a flag will be displayed at the Medical
Department of the University of Paris whenever a con-
finement is in progress in the Obstetrical Ward. The
color of the flag will indicate the kind of confinement: a
blue flag indicating that the confinement is a simple one,
a yellow flag that the labor is difficult, and a green flag
that an operation is necessary.
August 3, 1889]
His Royat Hicuness the Duke of. Bavaria, M.D., has
just done his one thousandth cataract operation. We
should like to know his per cent. of failures.
SIR ANDREW CLARK recently gave a reception to Dr.
Tholozan, physician to the Shah of Persia.
THE AMERICAN RHINOLOGICAL ASSOCIATION will hold
its Seventh Annual Meeting at Chicago, Angust 28th,
29th, and 30th. The Committee on the Examinations of
the Inmates of Insane Asylums will make their report on
“ The Relations of Rhinal Inflammations to Mind Affec-
tions ” at this session.
Dr. DEWoLF has resigned as Health Officer of Chi-
cago, after thirteen years of most efficient service.
THE DEATH OF Dr. CHARLES ELaM, a distinguished
London physician and writer, is announced. Dr. Elam
was in his sixty-fifth year.
TRUSTEEING DRUNKARDS.—The German Medical Con-
gress has recommended that drunkenness be recognized
as a reason for placing a person under trustees.
THE daily papers announce the following : Tozoni, the
sculptor, has finished an excellent bust of the late Dr.
John Swinburne, the philanthropist.
Dr. Grissom ACQUITTED.—The trial of Dr. Eugene
Grissom, Superintendent of the Asylum for the Insane
near Raleigh, N. C., before the Beard of Directors, has
been concluded. ‘The charges were preferred by Dr. Lion
H. Rogers, Assistant Physician, and John W. Thompson,
Steward, and were of gross immorality, cruelty, and mis-
appropriation of property of the asylum. ‘The investiga-
tion consumed four weeks, and Dr. Grissom was acquitted
on every charge, the vote being 6 to 2, except as to the
charge of immorality, and on that it was 5 to 3. The
sensation of the trial was the introduction by Grissom of
a compromising letter written by Dr. Rogers to Miss
May Mendenhall, a former female attendant.
ALONZO CLARK SCHOLARSHIP.—By the will of the late
Alonzo Clark, M.D., LL.D., it was placed in the . power
of the Faculty of the New York College of Physicians and
Surgeons to bestow a scholarship, with an income of about
nine hundred dollars a year, for the purpose of promoting
the discovery of new facts in medical science. This has
been bestowed, for three years from October 1, 1887,
upon T. Mitchell Prudden, M.D., of New York City.
THE AMERICAN ASSOCIATION OF OBSTETRICIANS AND
GYNECOLOGISTS will hold its next annual meeting at the
Burnett House, Cincinnati, O., on Tuesday, Wednesday,
and Thursday, September 17, 18, and 19, 1889. No for-
mal invitations will be issued to non-members, but the
Association extends an invitation to all members of the
profession who may feel interested in this branch of medi-
cal work to attend the meeting and participate in the
proceedings. The papers and discussions will embrace
subjects pertaining to obstetrics, gynecology, and abdom-
inal surgery.
Dr. Lewis A. Sayre has recently been elected an honor-
ary member of the St. Petersburg Medical Society, one of
the largest and most important of the Russian societies.
Dr. Sayre returned a few weeks ago from his trip to the Hot
Springs of North Carolinay much improved in health.
-THE MEDICAL RECORD.
EXECUTION BY ELECTRICITY.—A London cable de-
spatch says: The investigation in New York in the case
of the murderer Kemmler, as to whether or not electricity
can be relied upon to cause a prompt and painless death,
is being watched with considerable interest on this side of
the water. A correspondent of the Pal! Mall Gazette
writes to that paper to say that, whatever doubt exists in
America, there is hardly room here to question the cer-
tainty of the results of electricity scientifically applied.
Killing, he says, by electricity, has been reduced to abso-
lute scientific certainty by the experiments of Dr. B. W.
Richardson in his model abattoir at Croydon.
CHLOROFORM.—Some time ago the Hyderabad Com-
mission of India made a report extremely favorable to the
use of chloroform as an anesthetic. There having been
some criticism made.upon this, the Nizam of Hyderabad
has telegraphed to Zhe Lancet offering to place the sum
of $5,000 at the disposal of Zhe Lancet for the purpose
of sending commissioners to India to investigate the
matter. The Nizam shows his faith in the anesthetic for
his Indian subjects.
Dr. Joun B. RosBerts has been elected Professor of
Surgery in the Woman’s Medical College of Philadelphia,
to succeed Dr. W. W. Keen, resigned.
Dr. CHARLES B. NANCREDE, of Philadelphia, has just
been elected Professor of Surgery in the University of
Michigan, Ann Arbor.
Bo.ocna, following the initiative of Milan, opened, on
June 30th, an Instituto Anti-rabbico, or institution for the
treatment of rabies on the Pasteur method. ‘The King,
the Prime Minister, and the various civic and scientific
bodies, as well as the townsfolk of Bologna, contributed
the requisite funds. Every considerable Italian city will
soon, it is anticipated, be provided with an institution of
the kind.
THE AMERICAN PUBLIC HEALTH ASSOCIATION will hold
its Seventeenth Annual Meeting at Brooklyn, N. Y., on
October 22, 23, 24, and 25, 1889. The Executive Com-
mittee have selected the following topics for consideration
at said meeting: 1. The Causes and Prevention of In-
fant Mortality. 2. Railway Sanitation. (a) Heating and
ventilation of railway passenger coaches. (4) Water-sup-
ply, water-closets, etc. (c) Carrying passengers with
communicable diseases. 3. Steamship Sanitation. 4.
Methods of Scientific Cooking. 5. Yellow Fever. (a)
The unprotected avenues through which yellow fever is
liable to be brought into the United States. (4) The
sanitary requirements necessary to render a town or city
proof against an epidemic of yellow fever. (c) The
course to be taken by local health authorities upon the
outbreak of yellow fever. 6. The Prevention and Re-
striction of Tuberculosis in Man. 7. Methods of Pre-
vention of Diphtheria, with Results of such Methods. 8.
How far should Health Authorities be Permitted to Apply
Known Preventive Measures for the Control of Diphtheria.
g. Compulsory Vaccination. 10. Sanitation of Asylums,
Prisons, Jails, and other Eleemosynary Institutions. Pa-
pers upon miscellaneous sanitary subjects not included
in the above list will be received by the Executive Com-
mittee, subject to the requirements of the by-laws. ‘The
secretary is Dr. Irving A. Watson, of Concord, N. H.
130
i rr a eS ee
Society Reports,
AMERICAN OPHTHALMOLOGICAL SOCIETY.
Twenty-fifth Annual Meeting, held at the Pequot House,
New London, Conn., July 17 and 18, 1889.
First Day, WEDNESDAY, JULY 17TH—MORNING SESSION.
THE Society was called to order by the President, Dr.
WıLLiaM F. Norris, of Philadelphia.
Dr. CHARLES STEDMAN BULL, of New York, read the
first paper, entitled
AN ANALYSIS OF NINETY CASES OF SIMPLE CHRONIC GLAU-
COMA, WITH SPECIAL REFERENCE TO THE EFFECTS OF IRI-
DECTOMY UPON THE ACUITY OF VISION AND THE VISUAL
FIELD. i ü
Detailed histories of the ninety cases,weft presented, and
the following conclusions formulated :
In endeavoring to draw some rational conclusions from
the study of ninety cases, it seems wise to begin with a
quotation from Priestly Smith, to whom ophthalmologists
owe so much of their knowledge of the pathogeny and
pathology of glaucoma.
1. In considering the expediency of an operation in
chronic glaucoma, he says: “In every case of chronic
glaucoma, the responsibility of advising an operation is a
heavy one and should on no account be undertaken with-
out a full explanation to the patient or his friends of the
almost positive certainty of blindness on the one hand
and of the uncertainties which beset the operation on the
other. Having regard to the age of the patient, the im-
possibility of great benefit, and the possibility of a painful
and accelerated progress, the prudent surgeon will only
operate on the express desire of the patient to receive the
only possible chance of benefit, however small it may be.”
Armed with the preceding precaution, it seems to be our
duty to operate in cases of chronic progressive glaucoma,
and the earlier the better.
2. If the disease in a given case seems to be stationary
and is still in the primary stage, and if it be possible to
test the vision and the visual field at short intervals, de-
lay in operating is permissible, but a weak solution of es-
erine or pilocarpine should be used daily, merely as an aid
in controlling the course of the disease. The examina-
tion of these patients should be at short intervals, and
should invariably include tests for visual acuity and the
careful examination of the visual field.
3. If the disease exists in both eyes but with useful
vision in both eyes, the eye in which the disease is the
more advanced should be operated on without delay ;
and the surgeon will be guided in his treatment of the
fellow-eye by the result of the operation on the first eye.
4. To insure the best result, the incision should be
made well in the sclerotic with a narrow cataract-knife or
a broad lance-knife, and the entire ins, from one end of
the incision to the other, should be carefully torn or ex-
cised from its insertion.
5. The most carefully performed indectomy by skilful
hands is sometimes followed by rapid loss of what sight
still remains ; sometimes partial, but, unfortunately, some-
times total.
6. A successful result is, in the majority of cases, more
likely to follow the operation if it is performed early in
the course of the disease, but the maintenance of the ex-
isting degree of vision even in these cases is not invariable.
7. Asregards the question of symmetry, it is probable
that in the large majority of cases,‘ probably as much as
eighty per cent., the disease is sooner or later present in
both eyes, and a careful study of the cases seems to estab-
lish the fact that there can be no specific interval of time
which insures the second eye against an attack.
8. If the patient is old and feeble and one eye is still
free from disease for a year or more after the other eye
has become affected, it may be considered prudent to
THE MEDICAL RECORD.
[August 3 3, 1889
eh ee 6 oe eet Se
er a ae er ee
avoid an operation on the affected eye, as it is probable
that the unaffected eye may remain free during the re-
mainder of the patient's life.
g. The condition of the field of vision is no constant
guide either in forming a prognosis as to the progress of
the disease or in deciding as to the time of operation.
10. The acuity cf vision bears no constant relation to
either the success or failure of the operation.
11. The anterior chamber is usually shallow, is occa-
sionally entirely absent, but is often apparently normal
in depth. The condition of the chamber gives no reliable
hint as to the state of the vision or the visual field, nor any
indication as to prognosis.
12. The appearance and motility of the iris appear to
have some bearing upon the prognosis, though perhaps
not to the extent believed by Nettleship. The latter
states that in the cases in which the iris reacts rapidly to
eserine the operation proves successful. ‘This has not al-
ways been the experience of the reporter, but in the ma-
jority of the cases in which eserine caused rapid contrac-
tion.of the pupil the visual acuity was fairly good and the
field was not seriously limited.
13. The depth of the excavation in and the color of the
optic disk seem to have no close connection with the de-
fective vision or with the limitation of the visual field, nor
do they offer any constant guide as to prognosis or to the
effect of an operation upon the progress of the disease.
14. The condition of the intra-ocular tension is a very
uncertain guide in deciding the time for operating. It
may be normal, or increased, or even diminished. It does
not even seem to bear any constant relation to the degree
of visual acuity or to the state of the visual field. ‘Ihe
steady maintenance of the increased tension, however,
without any diminution, almost invariably indicates the
necessity for an immediate operation, and this necessity
is especially indicated if the tension is continually on the
increase.
15. The health and age of the patient exert a decided
influence upon the effect of the operation. Any marked
evidence of senility is distinctly unfavorable to operation.
DISCUSSION.
Dr. H. Knapp, of New York: During the past nine-
teen years I have operated on six hundred and seventy
cases of glaucoma, two hundred and twenty-six of which
were cases of chronic glaucoma. I think that the prog-
nosis may be a little more favorable than has been indi-
cated by Dr. Bull. I have had four cases in which ma-
lignant disease followed operation for chronic glaucoma.
I do not agree with the author as to the advisability of the
continued use of pilocarpine or eserine in those chronic
cases where operation seems doubtful. 1 advise its use
when there are recurrent symptoms. In prognosis 1 am
guided a great deal by the condition of the ins. My
operations have been done with the lance-shaped knife.
I consider it of great importance to carefully reduce the
edges of the coloboma, not only by external pressure but
also by the use of the blunt probe. I am alsocareful not
to make the operation too peripheric. Peripheric wounds
are more liable to cystoid scars.
Dr. Emit GRUENING, of New York, read a paper en.
titled
IRIDECTOMY IN GLAUCOMA.
The speaker classified the different forms of glaucoma
under the following heads: 1, Acute inflammatory ; 2,
chronic inflammatory without visible degenerative changes
in the iris ; 3, chronic inflammatory glaucoma with visible
degenerative changes in the iris; 4, simple glaucoma; 5,
intermittent glaucoma ; and described cases illustrative of
these different varieties.
DISCUSSION.
Dr. S. O. RicHeEy, of Washington: I do not believe
simple chronic glaucoma to be entirely a local affection. I
think that it is a local expression of a cause to be looked
for in the nervous system. I habe used eserine with satis-
August 3, 1889]
faction in Mek early stages, but I support it by salani
applied to the cervical ganglia. In some cases this will
enable us to avoid operation.
Dr. SAMUEL THEOBALD, of Baltimore: I have met with
one case in which an attack of pronounced acute glau-
coma was cut short by the use of eserine.
Dr. C. S. Butt, of New York: Eserine is frequently
used in too strong solution. A solution of half a grain to
the ounce may cause iritis after a single instillation. I
never use a stronger solution than this. I often use one
as weak as one-tenth of a grain to the ounce.
Dr. B. ALEXANDER RANDALL, of Philadelphia: I can
confirm the remarks in regard to the value of weak solu-
tions. In one case of severe absolute glaucoma a solution
of one-eighth of a grain to the ounce was entirely successful
in relieving the pain. It has been used steadily for three
years with no recurrence of the severe symptoms, and
without the intervention of any inflammatory trouble.
Dr. S. D. Ristey, of Philadelphia: In experimenting
with weak solutions of eserine I have found that a distinct
effect was experienced from a solution as weak as one-
thirtieth of a grain to the ounce. If this was applied
three times a day, it would in two days cause distinct
browache. I have seen benefit from weak solutions where
stronger solutions failed to give relief.
Dr. Henry D. Noyes, of New York: One point to
which my attention was called many years ago is that in
certain instances of evident glaucoma, with a large amount
of refractive error, it has seemed that the aggravation of
the glaucomatous disease has been dependent upon the
accommodative strain. In operating I have gradually
withdrawn from the extremely peripheral place of. in-
cision. I prefer to come closer to the border of the cor-
nea than some do. This involves less risk and is easier
of performance.
Dr. SAMUEL THEOBALD, of Baltimore: My experi-
ence tends to convince me that astigmatism, and ‘particu-
larly astigmatism against the rule, is frequently the cause
of glaucoma.
Dr. ARTHUR MATHEWSON, of Brooklyn : In one case of
glaucoma in which indectomy had been done without
averting the progress of the disease, a large injection of
strychnia caused a decided improvement of vision, which
continued. I have used it in other cases with good
effect.
EMIL GRUENING, of New York, read a paper en-
titled
THE USE OF THE CURETTE IN ANTERIOR TRACHOMA.
The speaker, after referring to the various measures pro-
posed for the relief of this condition, described an op-
eration which he had employed in eleven eyes during the
past two years. A six per cent. solution of cocaine was
first instilled. ‘The surface of the cornea and the vessels
present were then scraped away with a gouge-shaped in-
strument, and the vessels followed well on to the conjunc-
tiva. The eye is then washed with boric-acid solution,
and warm compresses applied for four or five days. In
three cases new vessels formed, and the operation was re-
peated. The ultimate result in all the cases was highly
satisfactory. In old and protracted pannus this operation
may be recommended for its directness, simplicity, and
efficacy. 3
DISCUSSION.
Dr. S. B. St. Joun, of Hartford: I have used this op-
eration in one case with the highly gratifying result of
increasing the vision from 4, to yz%;. This has since
still further improved.
Dr. H. F. HANSELL, of Philadelphia, read a paper on
CORNEAL ABSCESS,
describing its symptoms and referring to the differential
diagnosis between it and ulcer. He protested against the
use of cocaine in abscess or other inflammatory conditions
of the cornea. A few drops of a strong solution will
often destroy the epithelium. Instillation of eserine, al-
j THE MEDICAL RECORD. 131
ternating atropine, was recommended. Operative inter-
ference should be limited to evacuation of the pus.
Dr. CHARLES J. Krep, of Newark, read a paper entitled
FURTHER OBSERVATIONS ON MALARIAL KERATITIS.
The author had called attention to this condition in a pa-
per read before the Society in 1880. He had seen one
hundred and twenty cases of the disease. In all there
had been paroxysms of malarial fever, and in ninety per
cent. the corneal inflammation followed a few days after
a paroxysm. In twenty-five per cent. the patients had
suffered from similar trouble in previous attacks of ma-
laria. The inflammation of the cornea occurred in the
form of serpiginous ulceration, with narrow prolongations.
The trouble began as a line of small grayish elevations,
which soon broke down, forming a furrow of ulceration.
In mild cases the duration is two or three weeks, while in
severe cases it may last several months. ‘There is a
marked tendency to recurrence in subsequent attacks of
malarial fever. In a few cases he had seen a similar
affection in non-malanial individuals. The treatment con-
sists In remedies directed to the general condition, and, in
mild cases, with warm fomentation. In severe cases a
one or two per cent. solution of nitrate of silver, applied
directly to the furrows after the use of cocaine, answers
well. In some very severe cases the actual cautery was
employed. This arrested the progress of the disease and
stopped the pain, provided the malarial trouble had pre-
viously been cured.
DISCUSSION.
Dr. Henry D. Noyes, of New York: During the
past fifteen or twenty years I have met with cases of su-
perficial keratitis due to malaria. It is rare to find the
deeper tissues invaded. I am led to suspect a malarial
origin in cases where there is exaggerated tenderness of
the supra- orbital nerve and distinct anesthesia of the
surface of the cornea. ‘The form of ulcerative keratitis
which has been described I regard as of mycotic ongin
and have cured it by scraping thoroughly the lines of
infiltration.
Dr. T. Y. SUTPHEN, of Newark: I have seen cases
similar to those described by Dr. Kipp in patients suf-
fering with malaria, and where there has been no distinct
chill ; the individuals have resided in malarious districts.
Dr. JOHN GREEN, of St. Louis: I have seen many
cases in which malarial feyer was followed by superficial
keratitis, or keratitis modified by neglect or improper
treatment. Ihave not met with the form described by
Dr. Kipp.
Dr. Emit GRUENING, of New York: I have seen this
form of ulcerative keratitis but I have associated it with
the teeth. These patients have had tartar on the teeth,
and have been in the habit of moistening the lids with
saliva. I think, therefore, that the source of infection is in
the mouth.
Dr. SAMUEL THEOBALD, Of Baltimore: I have also
seen for many years this keratitis associated with malarial
trouble. ‘These cases do not always show ulceration of
the cornea. I have, in a general way, regarded this con-
dition as analogous to herpes zoster. I have once or
twice seen iritis associated with the keratitis following
malaria. In one case of malaria I have seen this keratitis
with herpes zoster of the temple.
Dr. J. A. Lippincott, of Pittsburg, read a paper
entitled
IRRIGATION OF THE ANTERIOR CHAMBER,
This procedure is useful for the removal of débris in
cataract-extraction and of clotted or liquid blood. In
order to accomplish this successfully it is necessary to
have an apparatus which can be readily made and kept
aseptic ; which will always be ready for use ; which can
be easily handled and the movement controlled with one
hand ; whose ejecting force is capable of being easily reg-
ulated ; and which 1 is free from the liability of forcing air-
132
THE MEDICAL RECORD.
[August 3, 1889
bubbles into the anterior chamber. As fulfilling these
requirements, he exhibited an apparatus consisting of a
small metal receptacle with which was connected a rub-
ber tube ending in a metal nozzle, the flow of liquid
being controlled by a short piston in a rubber handle
through which the rubber tube passed. The ejecting force
can be varied by elevating or lowering the receptecal.
Dr. E. Gruening, of New York, exhibited a small flask
devised by Von Graefe for the same purpose.
Dr. David Webster, of New York, exhibited two
specimens of ‘“sword-fish’s eyes.”
Dr. Henry D. Noyes, of New York, exhibited a
“ spectacle-frame ” in which the nose-piece of the eye-
glass was combined with the ordinary spectacle-frame.
Dr. Henry D. Noyes, of New York, read a paper
entitled
ENUCLEATION OF THE EYE IN PAN-OPHTHALMITIS.
There have been reported by various observers thirty or
forty deaths following enucleation, almost all from menin-
gitis. About one-half of the fatal cases have occurred
after enucleation during acute suppurative pan-ophthal-
mitis. At the New York Eye and Ear Infirmary there
have been no deaths from this cause, when no additional
operation in the orbit, such as the removal of tumors, etc.,
has been done. The number of enucleations, from 1868
to 1838, was 1,164; the number of eviscerations, 17.
Pan-ophthalmitis existed in fourteen per cent. of the cases.
It seems fair to conclude that while a small nsk to life is
incurred by enucleation of the eye, the supposed increased
risk by the existence of suppurative pan-ophthalmitis is
not so far justified by the facts as to bar its performance
in this condition.
Adjourned.
AFTERNOON SESSION.
Dr. H. Knapp, of New York, read a paper entitled
THE TREATMENT OF CARIES AND NECROSIS OF THE ORBIT.
The upper wall of the orbit is the most frequent seat
of disease, and here its consequences are most dangerous.
In every case of caries and necrosis of the orbit the con-
dition of the neighboring cavities, and especially the nose,
should be carefully investigated. Foci of suppuration
should be freely opened, the cavity thoroughly cleansed,
and drainage established. ‘This can be well accomplished
by small silver tubes provided with flanges. Rough bone
should be scraped away with a sharp spoon. Necrosed por-
tions of bone should be removed as soon as they become
loose, or when they can be detached without injury to ad-
jacent tissues. ‘The eyeball should be protectéd, and, if
there is insufficient closure of the lids, a plastic operation
should not be postponed until the cornea becomes ulcerated
from exposure.
Dr. H. W. Wiis, of Boston, read a paper entitled
- MULTIPLE CYSTS OF THE IRIS OCCURRING IN BOTH EYES.
The subject was a girl, nine years of age. In the right
eye there was a projection resembling a large cyst, ex-
tending from the upper margin of the pupil. A similar
growth projected from the temporal border. At the inner
part there were two small pedunculated growths. All
were of the color of the iris. In the left eye, two some-
what oval cysts filled the pupillary space. ‘Through the
square opening left in each pupil there was a little oblique
vision.
Dr. T. Y. SuTPHEN, of Newark, read a paper en-
titled
SARCOMA OF THE OPTIC NERVE.
The patient was ten years of age. the tumor involved
the left orbit and was of two years’ duration. It was of
a mushroom-shape and sprang from the optic nerve.
Its size was six by five and a quarter inches and two
inches thick. It was readily removed with curved scis-
sors. As much as possible of the nerve was removed.
‘this operation for opacity of the cornea.
Dr. George C. HARLAN, of Philadelphia, read a
paper entitled
EXTENSIVE VASCULAR GROWTH IN THE VITREOUS,
The patient, a woman fifty years of age, presented
herself, November 29, 1888, on account of disturbance
of vision. Examination of the right eye showed the fun-
dus to be slightly hazy, with small dull white spots
about the macula, the remains of old hemorrhages, but
no recent exudation. The disk was obscured by 4 qeli-
cate net-work of vessels. Otherwise there was no opac-
ity. There was no stroma. Up to March 2, 1889,
there had been several retinal hemorrhages, but there
had been no change in the vascular membrane.. Vision
had been reduced to 4$
Dr. O. F. Wapswortn, of Boston, read a paper en-
titled
EXTRACTION FROM THE VITREOUS OF PIECES OF STEEL
BY THE MAGNET.
The author described two cases in which the piece of.
steel was removed by passing an electro-magnet into the
vitreous through an opening in the sclera. In the sec-
ond case the operation was followed some weeks later
by a separation of the retina, beginning at a point oppo-
site that at which the puncture was made.
Dr. J. O. TANSLEY, of New York, read a paper en
titled
CORNEAL TRANSPLANTATION.
The speake: reported a case in which he had done
At the first
operation the opacity was not removed to its full depth,
and although the cornea cleared to a certain extent, the
result was not satisfactory. The operation was there-
fore repeated, but without any improvement in vision.
In both operations there was primary union of the graft,
and in neither was there any inflammatory reaction.
DISCUSSION.
Dr. L. WEBSTER Fox, of Philadelphia: I have per-
formed the same operation in a case of opacity of the
cornea when the patient could just distinguish light from
darkriess. The graft healed readily without inflamma-
tory reaction, and the patient obtained useful vision and
could almost count fingers.
` Dr. CHARLES A. Outiver, of Philadelphia, read a
paper entitled
AN ANALYSIS OF SOME OF THE OCULAR SYMPTOMS OB-
SERVED IN SO-CALLED GENERAI. PARKESIS. :
These observations were made on twenty well-marked
cases of general paralysis of the insane. The study was
limited to subjects in the so-called second stage of the
disease, where the psychical symptoms had become of
such a character as to necessitate control, and where
motor and sensory derangement had become more or
less manifest. Care was taken that each subject was
seemingly free from any extraneous general disease or
local disorder, and the entire study was limited to the
male sex, so as to escape any conflicting and complicat-
ing changes that might appear in connection with the
many diseases peculiar to the female sex. Thirty obser-
vations were made, resulting in the following summary :
1. The sensory changes herein described, which have
been limited to unequal optic-nerve degeneration, de-
crease of retinal circulation, with subnormal direct and
eccentric vision for both form and color, distinctly
show lowered sensory response.
2. The motor symptoms, consisting in unequal and
feeble movement of the irides, causing inequality and
irregularity of pupillary areas, the peculiar form of ataxic
nystagmus, the slight loss of ciliary tone, all express
want of proper muscle-action—true paresis.
3. The peculiarly local conditions shown in the fun-
dus, such as the pigment massings, the crescents of ab-
sorption, the disturbed and granular condition of the
August 3, 1889]
choroid, etc., all indicate wear and tear of an abused and
iritated organ.
4. Therefore these observations upon the ocular ap-
paratus, which were most probably made during the
second stage of the disease known as general paralysis of
the insane, show not only local changes, but distinctly
demonstrate that the series of sensory motor disturb-
ances found are but the peripheral expression of one of
the many indices of gradual loss’ of neural strength and
power in this disease.
Dr. George C. Harlan, of Philadelphia, reported a
case of “ Hysterical Blindness,” of ten years’ duration, in
a male, twenty-two years of age.
Dr. Samuel B. St. John, of Hartford, described a case
of “ Hemianopsia, with Peculiar Cerebral Symptoms.”
Dr. B. Alexander Randall read a paper on “Simple
Tests of the Ocular Muscle.”
Dr. T. Y. SuTPHEN, of Newark, N. J., read a paper
entitled
A CASE OF DOUBLE PURULENT CHOROIDITIS RESULTING
FROM MENINGITIS,
February 23, 1887, I was called in consultation to see
G. W. B+—, a robust farmer, thirty-nine years of age.
He had always been healthy, with the exception of an
occasional ‘bilious headache.” Never had had any
specific trouble. The history was that on February gth
he came in at noon, perspiring very freely ; that evening
he suffered with intense headache. The next morning
he was apparently well, but at breakfast had a violent
chill, with aching of the whole body. This was followed
by high fever. Leaving the breakfast-table was the last
that the man remembered for three months, From this
time the patient rolled and tossed in bed, without decided
delirium, but being in a stupid condition and easily re-
strained. Questions were answered only after frequent
repetition, and the replies ran into complete incoherence.
On the third day of the illnessthe body became quite
rigid, with the head thrown backward. On the fourth
day the left hand and forearm became swollen and the
right eye inflamed. The left eye became inflamed on
the tenth day. Later the left foot became swollen. The
swelling of the hand and foot lasted about a week and
then subsided. The fever then became less violent and
the general condition improved, but the mental slug-
gishness remained. There was no paralysis, no convul-
sion, no vomiting. At the end of the third week he had
a slight chill, and another after he was out of bed.
At present the man is apparently in good health. He
has lost none of his functions and the mind is perfectly
clear. When first seen by the writer the eyes were in
the following condition: No swelling of the lids ; mod-
erate pericorneal injection; cornea clear; anterior
chamber normal in depth; irides slightly discolored ;
pupils moderately dilated, with a yellowish reflex from
the anterior portion of the vitreous; there was no per-
ception of light, no tenderness on pressure, but a marked
lessening of the tension of the globe. Three days later
the anterior chamber in each eye was obliterated by
pressure from behind the lens ; the eyeballs being harder
than normal. One week later the anterior chamber was
again restored and tension had again fallen much below
the normal. From that time there was progressive
atrophy of both eyes, until now there is left only the
greatly shrunken globes, with, of course, absolute blind-
ness.
In this case there must have been an extension of the
intracranial inflammation along the sheath of the nerves
and not a forcing of the products of inflammation for-
ward, as sufficient pressure within the cranium to pro-
duce this must evidently have become apparent by more
or less paralysis.
The case is reported simply as a clinical contribution
to this somewhat rare and obscure trouble, which is cer-
tain to be met with in the course of practice.
Adjourned.
THE MEDICAL RECORD.
133
SEcoND Day, THURSDAY, JULY 18TH—MORNING
SESSION.
Dr. C. S. Butt, of New York, read a paper entitled
CONTRIBUTIONS TO THE SUBJECT OF TUMORS OF THE OR-
BIT AND NEIGHBORING CAVITIES.
Case I.—Was an adenoma.sarcoma of the lachrymal
gland. It was operated on two years ago. There has
been no return.
Case II.—Was one of abscess of the ethmoid cells,
frontal sinus, and orbit in a male, aged forty-six. It was
opened, washed out, and drained. There was perfect
healing.
Case III.—Tumor of the maxillary antrum, nasal
fossa, ethmoid cells, orbit, and cranial cavity. The eye
was enucleated and the maxillary antrum cleaned out.
A large opening was found through the orbit into the
anterior fossa of the skull, and through this the tumor ex-
tended. The evening following the operation the patient
became comatose, and died the next morning.
DISCUSSION,
Dr. H. Knapp, of New York: The report of thess
cases shows the necessity of early operation in all casee
of tumors of the orbit or near the orbit.
Dr. B. A. REEvE, of Canada: Ina number of these
cases of empyema of the frontal sinus I have found hy-
pertrophy of the middle turbinated bone. This is a point
of importance in etiology and prophylaxis.
Dr. C. S. BULL, of New York, read a paper entitled
CASE OF DOUBLE CHOKED DISK DUE TO INTRACRANIAL
TUMOR, WITH AUTOPSY.
The patient, a young married woman, twenty-three
years of age, was seen, June 30, 1888. In February,
1888, had miscarriage, and was quite ill for a couple of
weeks. There was dull headache at vertex. This be-
came more severe, During April there were occasional at-
tacks of diplopia. During May there was failing vision.
When examined, V = }$ in each eye. Accommodation was
normal, There was no peripheral limitation of the field
of vision, either for form or color. There was an irregu-
lar negative scotoma for all colors. There was marked
exudative neuro-retinitis, with hemorrhages in both eyes.
Urine proved normal on examination. The only symp-
toms of intracranial disease were the lesions of the
optic nerve and the headache at the vertex. The diag-
nosis was intracranial tumor at the base of the brain.
Vision rapidly failed, and by September 25th there was
no perception of light. The mental faculties gradually
became impaired. Right hemianæsthesia came on. The
patient died May 5, 1889. Autopsy showed a tumor in-
volving the corpora quadrigemina and extending to the
anterior crura of the cerebellum. The growth appeared
to be a glio-sarcoma.
Dr. O. F. Wadsworth, of Boston, reported a case of
‘*Torticollis,” cured by tenotomy of the external rectus.
Dr. MYLES STANDISH, of Boston, read a paper entitled
PARTIAL TENOTOMIES IN CASES OF NEURASTHENIA, WITH
INSUFFICIENCY OF THE OCULAR MUSCLES,
The author reported five cases in which he had per-
formed this operation on account of constant headache,
inability to use the eyes, and neurasthenic symptoms,
In all but one there was marked and prompt relief of the
local and general symptoms by the operation, Cases
requiring operation are comparatively rare.
Dr. Davip CoccIn, of Salem, read a paper entitled
NOTES ON SOME VAGARIES OF ACCOMMODATION,
One case was of hypermetropic astigmatism passing into
myopia. A case of recurrent spasm of accommodation
was also reported. The third case was one of temporary
anomaly of sight, occurring daily. In the morning could
see well, but in afternoon could not recognize objects
across the street. Double vision also occurred. The
disturbance is gradually disappearing.
on
134 THE
MEDICAL RECORD.
[August 3, 1889
Dr. E. E. Hott, of Portland, read a paper entitled
EFFECT UPON THE ACCOMMODATION OF A PATIENT'S EYE
CAUSED BY LOOKING INTO THE MIRROR SET OBLIQUELY
IN THE ROOM DURING OPHTHALMOSCOPIC EXAMINA-
TION.
Directing the patient to look with one eye into a mirror
set obliquely while the other was examined with the
ophthalmoscope, an element of ease was found in making
the examination and of comfort and steadiness on the
part of the patient never experienced before. The eye
fatigues quickly in looking at a single object. Looking
into the oblique mirror gives the impression of gazing
into the distance. A notable change in the pupil will
be observed when the patient is directed to look at an
object at the distance of the mirror, and when he is
directed to look at objects reflected from it.
Dr. O. F. WapswortTh, of Boston, read a paper entitled
PARALYSIS OF THE SPHINCTER IRIDIS.
A case was reported of paralysis of the sphincter iridis,
without affection of the accommodation, lasting several
months ard following the instillation of homatropine in
both eyes.
DISCUSSION,
Dr. SAMUEL THEOBALD, of Baltimore: In all such
cases it is important to exclude malingering. It would
be possible for the patient, by the use of a weak solution,
to keep up the mydriasis without affecting the accom-
modation.
Dr. SAMUEL D. Riıstey, of Philadelphia: Another
practical explanation of such cases is the use of a pipette
previously used for a solution of a mydriatic, for a solu-
tion which contains no mydriatic.
Dr. John Green, of St. Louis, presented a series of
geometrical constructions illustrating certain cases of
“ oblique pencils refracted at cylindrical and spherical
surfaces.”
Dr. John Green also read a paper on “Some of the
Stereoscopic Alterations evoked by Unequal Glasses
placed before the Two Eyes.”
Dr. SAMUEL THEOBALD, of Baltimore, read a paper
entitled
THE EMPLOYMENT OF OLEATE OF VERATRIA TO FACILI-
TATE THE DETERMINATION OF ERRORS OF REFRACTION.
A mydriatic affords valuable aid in myopia and in hy-
permetropia, but in astigmatism its use is not so satis-
factory. In astigmatism he had found great help from
the use of a ten per cent. oleate of veratria to'the temple
and forehead once a day for three or four days. This
seems to exert a quieting effect upon the ciliary mus-
cle, and especially of the radiating fibres, and lessens
the tendency to asymmetrical accommodation. The
following rule was formulated in regard to the correction
of astigmatism : When the astigmatism is according to
the rule, we need correct only that which is readily made
manifest. On the other hand, in astigmatism against
` the rule, we are warranted in correcting fully every part
of the defect which can be rendered manifest.
Dr. E. E. Hott, of Portland, read a paper entitled
THE INEFFICIENCY OF HYDROBROMATE OF HOMATROPINE
IN CONTROLLING THE ACCOMMODATION FOR THE PUR-
POSE OF FITTING GLASSES.
The experience of the writer was that this drug could
not be relied upon. He reported one case in which the
latent hypermetropia revealed by a three per cent. solu-
tion of hydrobromate of homatropine was just one-half
of that revealed by a one per cent. solution of atropia.
DISCUSSION,
Dr. EDWARD Jackson, of Philadelphia: I have found
homatropine entirely satisfactory when used properly.
The instillations must be repeated at short intervals, five
or ten minutes, and three or four instillations practised.
The effect rapidly passes off and the examination must
be made within one or two hours. I have followed the
use of homatropine by another mydriatic without altera-
tion in the result.
Dr. E. Jackson, then read a paper entitled
AMETROPIA AS DETERMINED UNDER COMPLETE MYDRI-
ASIS,
He had examined four .thousand eyes under complete
paralysis, and presented the following table of his results.
These were compared with results obtained by another
observer without mydriasis.
With mydriasis. Without mydriasis.
i Per cent. Per cent.
Compound hyperopic astigmatism, . 40 9}
Compound myopic astigmatism. ... 9 II
Simple hyperopic astigmatism...... 6 164
Simple myopic astigmatism....... 2 24
Mixed astigmatism. ............. 64 2
Hy peropin. oie anaeiosanieee ve ts 31 10
Myöpia gece ees: BC Oe erasers 4 94
EXMMEtlOpia isipin asai I$ 173
Dr. Jackson also presented a paper on “ Accuracy in
the Prescription of Prisms.”
Dr. U. S. Dennett, of New York, read a paper in
which he suggested a “ New Unit of Angular Measure-
ment for Prismatic Glasses.”
Dr. George C. Harlan, of Philadelphia, exhibited
“© Periscopic Cylindrical and Sphero.cylindrical Lenses.”
Dr. W. F. Mitrenporr, of New York, read a paper
entitled
A CASE OF AMBLYOPIA DUE TO CHLORAL HYDRATE.
The object was to put on record a case of toxic ambly-
opia due to chloral hydrate. The patient had for six
months been in the habit of taking forty to sixty grains
of the drug at night to induce sleep. Suspension of the
drug relieved the amblyopia.
EXECUTIVE SESSION.
OFFICERS FOR ENSUING YEAR.
President—Dr. Hasket Derby, Boston ; Vice-Prest-
dent—Dr. George C. Harlan, Philadelphia; Secretary
and Treasurer—Dr. Samuel B. St. John, Hartford ;
Corresponding Secretary—Dr, J. S. Prout, Brooklyn ;
Delegate to the Ex. Com. of the Congress of American
Physicians and Surgeons—Dr. John Green, St. Louis ;
Alternate—Dr. D. B. St. John Roosa, New York.
The following were elected to membership: Dr. Carl
Koller, New York; Dr. R. A. Reeve, Toronto, Canada ;
Dr. David Harrower, Jr., Worcester, Mass.; and Dr.
George E. de Schweinitz, Philadelphia.
The Society then adjourned, to meet at the Hotel
Kaaterskill, N. Y., the third Wednesday of July, 1890.
AMERICAN OTOLOGICAL SOCIETY.
Twenty-second Annual Meeting, held at the Pequot
House, New London, Conn., July 16, 1889.
Tue Society was called to order by the President, Dr.
J. S. Prout, of Brooklyn.
Dr. B, ALEXANDER RANDALL, of Philadelphia, read
the first paper, entitled
INFLAMMATION OF THE TYMPANIC ATTIC, AND PERFORATION
IN SHRAPNELL’S MEMBRANE,
The author reported twenty cases, fifteen of which had
been seen in the past six months, and urged that the con-
dition was not a rarity. It often coexists with one or
more perforations of the other parts of the drum head.
If sought and recognized early, it is a less tedious and
serious matter than these attic inflammations are generally
considered to be. He cited some one hundred and
twenty cases, reported by several observers among ten
thousand patients, and, while he had seen a still larger
August 3, 1889]
THE MEDICAL RECORD.
135
proportion, accepted this as the average. Passing over
the treatment as having been already thoroughly dis-
cussed, he turned to the question of causation, and cited
the views of Walb, that infection from without, through the
“foramen Ravinii ” was the starting-point. Contesting
this view as to any colotomatous opening in the flaccid
membrane as wholly negatived by modern embryologists,
he urged that the individual variations in the septum in
the attic predisposed some cases to localized inflamma-
tion, and led to perforation at this point; and that
these cases, neglected or recurrent, formed the group
from which the usual obstinate cases were derived. He
therefore advocated scrupulous search in all cases for dis-
ease in this locality, as promising to nip in the bud what
might later become disease notoriously difficult to con-
trol. The paper was illustrated by drawings and photo-
graphs of specimens,
DISCUSSION,
Dr. S. D. Ristey, of Philad@phia : I have frequently
seen perforations elsewhere associated with perforation
in Shrapnell’s membrane. The presence of perfora-
tions in other parts of the drum-membrane does not ex-
clude its presence in Shrapnell’s membrane.
Dr. J. O. Tansey, of New York: I have never met
with perforation of that part of the drum to which the
doctor refers, associated with perforation in other parts
of the drum. A singular thing is that we so rarely get
the perforation whistle.
Dr. S. O. Ricuey, of Washington: I do not think
that perforations of Shrapnell's membrane are so common
as has been stated. My experience with the absence of
perforation whistle corresponds with that of others. I
have had cases in which perforations in other parts of
the drum healed, but the perforation in Shrapnell’s mem-
brane persisted. In treating these cases, besides using
measures through the external auditory meatus, I have
employed injections through the catheter, consisting of
nitrate of silver, one part ; boric acid, ten parts; glyce-
rine, twenty parts ; and water, five hundred parts.
Dr. GorHAM Bacon, of New York: I have not ob-
served this condition so frequently as Dr. Randall. It
is often difficult to see these perforations. In treatment
I have generally used Blake's intra-tympanic syringe. By
persistent syringing and the use of astringents cicatriza-
tion 1s often produced. These cases are, however, very
tedious.
Dr. J. A. ANDREWS, of New York: In treating these
cases in which there is purulent inflammation of the attic,
with a large hole in Shrapnell’s membrane, after inject-
ing the cavity I suck out the fluid by means of this in-
strument, consisting of a delicate metal tube with a
curved extremity, to which is attached a rubber tube. I
use simply a boric-acid solution. After sucking out the
fluid I dry it with cotton wrapped ona probe. I then
blow in a fine cloud of boric acid.
Dr. HERMAN Knapp, of New York: There is a capi-
tal difference between perforations in the upper and
those of the lower part of the drum-membrane. Those
in the lower part may close in a few days, while in the
upper part they may continue for months or years. I
think this is due to difference in anatomical structure.
The lower portion is a specific tissue with little associa-
tion with periosteum, while the upper part is a duplica-
ture of periosteum and skin. When the latter part is
affected the process extends to the periosteum, leading
to caries and necrosis of the bone.
Dr. F. M. Witson, of Bridgeport, Conn., read a
paper entitled
THREE DEATHS FOLLOWING SUPPURATIVE OTITIS, WITH
TWO AUTOPSIES.
Cases in which death follows a first attack are so rare
that it was thought of value to report these cases. The
first patient was forty years old, who for two weeks be-
fore coming under observation had had pain in both
ears.- February 27, 1888, the pain in the left ear became
very intense. March 1st, he became partially uncon-
scious and remained so, with occasional convulsive
movements, until March 6th, when he died. The mas-
toid was drilled half an inch, but no pus found, No au-
topsy was made.
The second case, a male, aged twenty-three years,
was attacked with subacute otitits. March rıth, symp-
toms of meningitis appeared, with high temperature, and
he died March 27th, At the autopsy one-third of the
base of the cerebrum was involved in the purulent pro-
cess, which extended up under the frontal convolutions.
There was.about half an ounce of turbid fluid between
the dura mater and inner meninges. There was pus in
the labyrinth and in the tympanic cavity. `
The third case was that of a boy, aged ten years, who
was attacked with suppurative otitis September 5th, and
died about ten days later. At the autopsy the meninges
were found normal, but an abscess containing two
drachms of fluid was found in the cerebellum. .
Dr. Wilson also presented
A MASTOID DRILL,
provided with a guard which could be set at any desired
point, regulating the distance to which the drill entered.
The edges of the drill are sharp, so that the opening can
be enlarged horizontally to any desired extent.
DISCUSSION.
Dr. GORHAM Bacon, of New York: It seems to me
that in these cases where we do not find any collections
of pus in the mastoid cells we are justified in investigat-
ing the condition of the brain.
Dr. J. O. TANstey, of New York: I have had sev-
eral of these cases, and have without success sought for
some means by which we could differentiate between
those cases in which there was meningitis and those in
which there was abscess. In one case Dr. Seguin made
a diagnosis of abscess, based upon conjugate deviation
of the eyes. Subsequent autopsy showed the correct-
ness of this diagnosis. In another case I suspected
abscess. Dr. Weir opened the mastoid, but found ro
pus. We also explored the cerebrum, and two days
later the cerebellum, but found no pus ; the patient died
of suppurative meningitis,
Dr. S. D. Ristey, of Philadelphia: It seems to me
that in the differential diagnosis attention to the tem-
perature in connection with symptoms of pressure is of
great importance. In meningitis the temperature from
the outset will be higher than in abscess, and the symp-
toms of pressure come on later.
Dr. J. A. ANDREWS, of New York: In the past year
I have made a number of autopsies in cases of brain
abscess. Brain abscess inay continue for a considerable
time without any very positive symptoms, but where
there is meningitis or phlebitis, especially phlebitis, there
is usually a sudden rise of temperature, with chills
Dr. Oren D. Pomeroy, of New York: In a case of
brain abscess, secondary to tympanic disease, the only
marked symptom was a sudden rise of temperature, some-
times going up in half an hour from normal to 107° F.
Intelligence was unaffected until the last. The man
gradually improved, but died suddenly. The autopsy
showed a large abscegs of the brain covering the petrous
portion of the temporal bone.
Dr. ARTHUR MATHEWSON, of Brooklyn: It is often
difficult to make a diagnosis between abscess and men-
ingitis ; and, in fact, many are mixed cases. In menin-
gitis the pain is more marked than in abscess. In menin-
gitis there is more likely to be optic neuritis, while in
brain abscess I have noted a peculiar dark appearance
about the retinal veins.
Dr. SAMUEL THEOBALD, of Baltimore: The treatment
of the preliminary stage of these cases is important. It
seems to me that a great deal might be done to prevent
the occurrence of the conditions referred to. I have
136
THE MEDICAL RECORD.
[August 3, 1889
found benefit from local applications, especially atropia
and cocaine, and morphia and cocaine. If the bowels
were constipated I should use a calomel cathartic. If
there should be symptoms of cerebral implication I
should administer mercury in some form to secure its
constitutional effect.
Dr. E. FRIDENBERG, of New York: During the past
eighteen months I have made autopsies in two patients
dead from cerebral abscess, In one case suppuration
had lasted a year, but there had been no symptoms until
a week before death, except irritability of temper. There
was some odor, but very slight discharge from the ear.
A week before death the patient developed pain in the ear,
slight tenderness over the mastoid, followed by fever and
symptoms of brain-pressure. A smallabscess was found
in the temporo sphenoidal lobe. The roof of the tym-
panum was carious, and the meninges strongly adhe-
rent. |
In the second case the patient had had suppuration
for years. Two monthsbefore death headache occurred,
which was relieved by treatment. It recurred, with
fever. There was some pain on pressure over the mas-
toid process. The symptoms again disappeared under
treatment. Three weeks later he returned with similar
symptoms. The next morning vomiting occurred, and
that evening he died. An abscess containing two ounces
of pus was found in the temporo-sphenoidal lobe.
Dr. T. Y. SuTPHEN, of Newark: These cases of
brain trouble almost invariably follow the arrest of the
flow of pus. We should look upon these cases as in-
stances of local trouble and should treat the middle ear
by fomentations, and perhaps by poultices, to bring about
free discharge of pus.
Dr. R. A. Reeve, of Toronto, Canada: In one case
of death following acute suppurative otitis there was the
most profuse purulent discharge that I have ever seen,
and it continued from beginning to end.
Dr. B. ALEXANDER RANDALL, of Philadelphia: A
case of cerebral abscess occurred in my practice last
year in a boy, the subject of scrofulous disease of the
elbow and other joints. I found both ears discharging,
caries of the auditory meatus on both sides. On the left
all the mastoid tissues were involved. Under treatment
the right side rapidly improved, and on the left side there
was also improvement. The case was then transferred
to my surgical colleague, Six weeks later the ears were
still in good condition, but the patient was gradually
failing from the constitutional trouble. An hour before
death there was suddenly a discharge of at least two
ounces of fetid pus from the ear. There was no menin-
gitis, but a large abscess cavity was found in the spheno-
temporal lobe, one-half inch from the tympanum, and
connected with it by a sinus.
In cases where it is thought justifiable to perform ex-
ploratory trephining of the brain, an admirable and safe
point is one and one-fourth inch behind, and an equal
‘distance above, the upper posterior margin of the osseous
meatus. This avoids the major blood-vessels, and it
would be possible to reach the cerebellum through it.
Dr. E. E. Hort, of Portland, Me., reported a case of
COMPLETE CLOSURE OF BOTH EXTERNAL AUDITORY
CANALS BY BONE :
in a patient having good hearing pgwer, with a previous
history of chronic suppurative otitis media.
T. M , aged eighteen years, was seen in April,
1889, for an affection of the eye. It was incidentally
learned that he had had abscesses in both ears when
seven years old, and the ears discharged more or less for
six years, but stopped entirely five years since. Exami-
nation showed the canals of both ears of about half the
usual length, and occupied by a continuation of the skin
of the meatus, with no appearance of the membrana
tympani. There was complete closure of the canal by
what appeared to be bone by all the tests employed.
The hearing power for the voice was good. The stop-
watch was heard only when close to the ear, the tuning-
fork was heard about ninety seconds, both by bone and
aerial conduction. Kénig’s rod of thirty thousand vibra-
tions per second was heard by both ears. He heard
less distinctly when both ears were closed by pressure
on each tragus. Shutting the mouth and closing the
nostrils did not seem to affect the hearing power much,
if at all. Cases with closure of one meatus with the
skin of the canal continuous over the obstruction have
been observed, but the hearing power is very defective.
Cases in which there is a small opening between the
exostosis and the walls of the meatus are not uncom-
mon.
Dr. SAMUEL THEOBALD, of Baltimore: Four or five
years ago I reported a case very similar to the one de-
scribed, the newly formed membrane was, however,
nearer the orifice. The hearing power was good.
Dr. B. ALEXANDER RANDALL, of Philadelphia: I
have had one case in which one ear was obstructed by
a bony mass. There was no evidence of exostosis.
The hearing was, however, defective.
Dr. E. E. Hort, of Portland, Me., also reported a
case of
OTITIS MEDIA CATARRHALIS ACUTA, ACCOMPANIED WITH
FACIAL PARALYSIS AND IMPAIRMENT OF ACCOMMODA-
TION OF THE EYE OF THE AFFECTED SIDE. `
Judging from statistics one would be led to believe
that paralysis of the facial nerve in connection with acute
catarrhal inflammation of the middle ear was not a com-
mon complication. In many cases the pain having been
slight and having passed off, and the paralysis having
come on, the patient's attention is directed to this and
he seeks advice for the latter affection, and the cause of
the paralysis is recorded as “a cold” or “ rheumatic.”
FL , aged twenty-four years ; seen May 19,1889.
Seven days before took cold, and right ear began to pain
that night. This pain continaed three days, when it sub-
sided, and on the fourth day he was unable to use his
lips properly. Examination showed all the characteris-
tics of facial paralysis. Testing the eyes there was
found paralysis of accommodation of the right eye. This
the author knew to be a fact because he had previously
had the patient under his care and recorded the test of
his eyes, and also by the fact that since the improve-
ment of the paralysis of the face the paralysis of accom-
modation has disappeared.
Dr. S. O. RicueEy, of Washington, D. C., read a paper
entitled
THE PHYSIOLOGY OF THE INTRO-TYMPANIC MUSCLES.
The paper was the elaboration of a suggestion made
by the writer in the discussion of a paper read by him at
the Congress of American Physicians and Surgeons in
1888.
If the membranum tympanum in purpose protects
the aural tissues lying interior to it, these muscles, being
appendages to the membrane, are designed to assist
the purposes of the membrane, which they do in part,
by protecting it from injury by the impact upon it of
sound impulses violent enough to rupture an inflexible
membrane firmly attached and having such a plane as
to expose it to the fullest force of the concussions. The
membrani tympani fulfils one of these conditions ; it is
firmly attached. He quotes Toynbee and Henle as hav-
ing many years ago expressed a somewhat similar view as
to the action of the tympanic muscles, and states that he
can find no reference to this subject by later writers.
The shape and other peculiarities of the auditory mea-
tus, the elasticity and capacity for motion of the drum-
membrane and its oblique position with relation to the
meatus, the co-ordination between the palatal and the
intra-tympanic muscles, converting the tympanic cavity
into an air-cushion, all indicate a similar purpose on the
part of nature to guard the membrani tympani imme-
diately and the labyrinth mediably from violence.
August 3, 1889]
THE MEDICAL RECORD.
137
EVENING SESSION,
Dr. GorHam Bacon, of New York, exhibited photo-
graphs of the ear.
CYSTS OF THE AURICLE.
Of late a number of cases of so-called cysts of the
auricle have been reported. Not one of these, however,
seems to represent a genuine cystic tumor, such as is
found in other parts of the body. They all were situated
on the anterior surface of the pinna and were of rapid
development. They either were the results of trauma-
tism and contained a sanguinolent fluid, or they devel-
oped without known cause. Mild inflammatory symp-
toms were present in all. The dévelopment within two
or three weeks, in almost all cases, distinguishes them
clearly from the slow and absolutely non-inflammatory
development of true cystic tumors. All got well either
by spontaneous absorption or by incision. The speaker
had seen at least half a dozen of these cyst-like sub-peri-
chondrial swellings of the auricle. He considered them
to be mild cases of perichondritis, for these mild cases of
circumscribed perichondritis may, instead of getting well,
remain in this condition for a time and then develop into
the full picture of a diffuse perichondritis. He reported
such a case. l
Dr. Knapp also described a case of genuine cyst of
the auricle occurring in a girl nineteen years of age. The
growth was double the size of a large filbert, distinctly
cystic, and had developed without known cause and with-
out any inflammatory symptoms. The cyst was re-
moved by operation, without rupture, and was exhibited.
These tumors are not frequent in the auricle, but they
cannot be so rare as we might infer from otological lit-
erature.
Dr. WiLLiIaM H. CaRMALT, of New Haven, reported
a case of
EPITHELIOMA OF THE MIDDLE EAR,
The patient, a robust man, aged forty-seven, was first
seen in June, 1888, on account of a suppurating ear
(left), which had existed forty-two years and had followed
measles. The ear had given him no inconvenience, with
the exception of the discharge, until a few weeks before
he came under observation. He then began to have
pain in and around the ear, and the discharge was ex-
ceedingly offensive. The canal was blocked by a rag-
ged but firm excrescence, very sensitive to touch. There
was slight tenderness, but no swelling or pitting over the
mastoid. ‘The pain radiated through the side of the
head and interfered with sleeping. At the second visit
the left side of the face was completely paralyzed. The
` case was regarded as one of epithelioma of the skin of
the canal.
who thought the trouble might be a carious antrum. An
attempt was therefore made to open the antrum, but the
bone around it was so sclerosed that the cavity was prac-
tically obliterated. There was nothing of the nature of
an abscess in the mastoid. The incision was then pro-
longed through the soft parts, and into the external audi-
tory canals. What polypoid could be reached was re-
moved, and a drainage-tube inserted. ‘The mass removed
proved to be carcinomatous. In the course of a few
weeks the ear again became blocked up, and the skin
became involved. With the object of alleviating some
of the distressing accompaniments of the condition, an-
other attempt was made to clear it out. By chiselling
away the bone posteriorly, free access to the ear-cavity
was obtained, and the bone scraped apparently clean.
No auditory apparatus was seen, simply a mass of car-
cinomatous tissue. The cavity was washed with a solu-
tion of resorcin, and fora time the wound did well, but
subsequently the disease reappeared. The discharges be-
came again offensive, and the patient exhausted, and he
finally bled to death without the condition being detected,
probably from erosion of the lateral sinus. No autopsy
was permitted,
The patient was seen by another gentleman, |
Dr. B. ALEXANDER RANDALL, of Philadelphia, ex-
hibited a series of photographs, and made some remarks
on the use of photographs and of the lantern in teaching
otology.
Dr. Randall also reported five cases of
SUPERNUMERARY AURICLE,
four of the right ear, one of the left ear.
A PEA FOR NINETEEN YEARS IN THE AUDITORY CANAL,
Dr. T. Y. SUTPHEN, of Newark, exhibited a mummi-
fied pea which he had removed from the auditory canal
where it had lain for nineteen years. The patient had
been deaf in that ear since childhood. He heard the
watch at one inch. After removal of the foreign body
the hearing was almost normal.
Dr. B. ALEXANDER RANDALL made some remarks
upon the anatomy of the drum-membrane.
Dr. Huntincton Ricuarps, of New York, sent a
paper entitled
TWO NOTEWORTHY CASES OF TRAUMATIC RUPTURE OF
THE MEMBRANI TYMPANI.
Case I.—Seen May 7th. A woman, aged thirty, two
days before had received a box on the left ear. The
symptoms were vertigo, tinnitus, and marked deafness.
There had been no bleeding or other discharge. There
were some evidences of pre-existing tympanic catarrh, in
that the drum-membrane was somewhat depressed and
moderately atrophic. Save for pronounced congestion of
the manubrial vessels, and a narrow red line along the
border of the opening, it was not congested. The ex-
posed inner wall of the tympanum was likewise pallid,
secreting only sufficient mucus to give its surface a
glistening appearance. The patient was directed to let
the ear alone, and a small, lvose cotton obturator was
placed in the auditory meatus.
Case II.—A` woman, aged twenty-three, came un-
der observation May 22d. There was no discharge nor
bleeding. There was no congestion of the membrane
or of the tympanic wall. The patient had complained
of aural symptoms for several weeks. On May 2ist
she consulted a physician, who introduced a cotton-
covered probe. This made her so dizzy that she had to .
lie down immediately, and within two hours she dis-
covered that she was very deaf.
The treatment was negative, and up to May 31st no
change had occurred. The edges of the opening were
then stimulated with nitrate of silver solution, and a
small quantity of boric acid was insufflated. Examina-
tion made a few days later showed that the opening had
healed, with the exception of a small part. The patient
then passed from observation.
EXECUTIVE SESSION.
OFFICERS FOR ENSUING YEAR.
President—Dr. Oren D. Pomeroy, New York ; Vice-
President—Dr. Gorham Bacon, New York ; Secretary
and Treasurer—Dr. J. J. B. Vermyne, New Bedford,
Mass.; Member of Executive Committee of Congress of
American Physicians and Surgeons—Dr. W. H. Carmalt,
New Haven; A/ternate—Dr. F. B. Loring, Washington,
D. C.; Committee on Membership—Drs. Arthur Mathew-
son, Samuel Theobald, and S. D. Risley; Committee on
Publication—Drs. J. J. B. Vermyne, C. J. Blake, and J.
Orne Green. l
A committee consisting of Drs. S. C. Ayres and Will-
iam-W. Seely was appointed to prepare a minute on the
death of Honorary Member Dr. E. Williams, of Cincn -
nati. :
The following were elected to membership: Dr. Har-
lan P. Allen, Columbus, O.; Dr. Ralph W. Seiss, Phila-
delphia, Pa.; Dr. David Harrower, Jr., Worcester,
Mass.; Dr. Robert Barclay, St. Louis, Mo.; Dr. Neil P.
Hepburn, New York, N. Y.
The Society then adjourned.
TH E
Correspondence.
OBSERVATIONS AT THE CLINIC OF DR.
APOSTOLI IN PARIS.
To THE Eottror oF THE MepnicaL Recorp.
Sir: For about three months during the past winter I was
a constant visitor at the clinic of Dr. Apostoli, for the
purpose of observing his method of treating fibroid tumors
of the uterus, and noting the results.
Certainly no improvement in medicine has of late years
attracted more widespread attention, if we may judge by
the frequent references to it in the medical journals, the
reports of societies, and the brochures which appear in va-
rious parts of the world.
The clinic is so easy of access, and strangers are so
courteously received here, and given so many privileges,
that there are always quite a number present, generally
representing several nationalities, some just beginning
their professional life, others men of distinguished reputa-
tion.
They have the opportunity of making examinations,
following the cases as long as they choose, consulting the
records, and drawing their own conclusions.
Every observation is dictated by Apostoli in their pres-
ence and hearing, and is recorded by a clinical assistant.
An enormous number of observations have been col-
lected in this way embodying a mass of information, the
scientific value of which can be properly estimated only
by those who have watched the painstaking, conscientious
care lavished on the work.
The technique of the method has been described in de-
tail many times, most favorable results reported by inde-
pendent observers in widely separated countries, and
objections, theoretical and practical, fairly answered ; yet
many have not been able to decide upon the question of
its freedom from danger, the amount of pain caused, or
its efficacy.
At least it is beginning to be realized that no roval
- road to science has been discovered, and that a little
knowledge of gynecology and a little knowledge of elec-
tricity will only lead the experimenter out of the beaten
track to land him in a quagmire.
In the hands of the originator, the method produces
results which compare favorably with anything done in
the field of practical medicine, for if we can believe the
evidence of our senses and the statements of patients, by
it hemorrhages are controlled, pain due to congestion and
inflammation relieved, as well as symptoms due to pres-
sure upon neighboring organs, while the general health is
restored and the patients return to active life.
In some instances it 1s not an extravagant statement,
that the size of the tumor has been sufficiently reduced to
permit child-bearing, when otherwise it would have been
difficult or dangerous.
An observer, who follows the cases for a few months
only, may be deceived as to the diminution in size of these
tumors, and can only judge of the permanency of the re-
sults from cases which occasionally report after a long in-
terval of time has elapsed, but he can hardly be deceived
about the other symptoms mentioned above.
The amount of pain which the patient must endtre has
been variously estimated by different writers, being even
considered by some a serious objection to the method—
which is a mistake ; that is, if it be properly understood
and applied.
In different patients, and in the same patiert at differ-
ent times, tolerance or supportability varies greatly, but
the rule is not to apply a current of greater intensity than
the patient is able and willing to bear without urging.
‘This limit is generally reached, but in some cases the full
force of the battery causes scarcely any discomfort.
The period during which there is suffering is a portion
only of the five minutes allotted to the séance, as some
MEDICAL RECORD.
Avene 3 1889
time is Souisuined? in di increasing the stteristth of
the current.
The patient is required, absolutely, to repose an hour
after the application, during which she suffers rather from
a sense of nervous fatigue than from actual pain.
However, it is during this period that some do have
pains due to uterine colic, but they are seldom severe, ex-
cept in cases of complete intolerance, when vomiting also
supervenes. ‘This was observed in two patients only, and
had no serious results.
One, on the contrary, terminated most happily, the
result being a suppression of a hemorrhage which had
occurred daily for nine months. When the patient re-
turned to the clinic shé was scarcely recognizable for the
improvement which had taken place. In this case only
thirty milliampéres were given on three occasions, for less
than five minutes.
It is rare for a patient not to be able to walk to an
omnibus and ride home without inconvenience, when the
hour of repose 1s terminated.
No accidents have been witnessed at the clinic beyond
the breaking of a wire or some derangement of the bat-
tery, by which a painful shock was produced—accidents
which are avoidable, and consequently ought not to
happen.
To avoid the possibility of septic infection from cau-
terization of the endometrium, or from the slight wound
inflicted by the galvano-puncture, antiseptic precautions
are taken in all cases.
The application is preceded by an injection of dilute
creoline, which is continued twice daily by the patient.
Where galvano-punctures are made iodoform gauze is ap-
plied, but in spite of it, or on account of the negligence
of the patient, ulcers have resulted occasionally, which,
however, were not of a character or appearance to cause
uneasiness.
Many of the patients have been more or less incapaci-
tated for work by abdominal pain and soreness, much in-
creased by standing or walking, cecydynia and cystitis,
as well as by painful or prolonged menstruation or hem-
orrhages.
It is remarkable with what promptitude their condition
is sufficiently ameliorated to enable them to resume work
by which they gain a livelihood.
When hemorrhages have been suppressed, the gain in
general health, weight, and color is easily accounted for,
as the blood making processes continue in activity ; but in
non-hemorrhagic cases the same thing occurs, as for ex-
ample in the case of a married woman who, after four-
teen applications, went up in weight from 114 to 130
pounds, with proportional improvement in general health |
and spirits.
When menstruation has continued regular, it is not in-
terfered with by the treatment, which is begun immedi-
ately after one epoch and continued to the next.
After the treatment is suspended, the improvement is
more fully realized, because the remaining abdominal
soreness continues to diminish, and the denutritive
changes which have begun in the tumor continue to go
on indefinitely.
There now takes place a deposit of fat in the abdo-
minal walls over the seat of the tumor, and the tumor
itself shows a tendency to become lobulated ; if subperi-
toneal it becomes even pedunculated to an extent which
brings it to the notice of the patient herself, who in one
instance declared that it had taken the shape of a gourd
with a crooked neck.
That great changes take place in the tumor in conse-
quence of the treatment, is shown in cases where the
sound cannot be introduced at all from the position into
which the cervix has been crowded.
Galvano-punctures are here resorted to, and after a
while there is a marked tendency of the parts to assume
a normal position, and the sound is now introduced with-
out difficulty.
The same thing is noticed in cases where the patient
THE
has to be placed in the genu-pectoral position for the
first few applications, after which the sound can be intro-
duced with the patient in the dorsal position.
It is difficult to estimate correctly the diminution
which a fibroid tumor has undergone, for the uterus rises
high in the abdomen after repose, and sinks into the pel-
vis after standing. ‘The apparent size vanes greatly with
the condition of the uterus as regards congestion, for if
this condition be relieved, the acute symptoms subside
and the tumor seems much smaller.
This lobulization, which is so evident upon palpation,
indicates. especially as it goes on increasing for a long.
time, nutritive changes which encourage one to hope
that the improvement will be permanent.
When the tumor is subperitoneal another termination
is sometimes observed (as with the treatment by ergot) ;
the mass is expelled into the uterine cavity or forms a
polypus. Eight cases of this kind have been reported by
Dr. La Torre, of Rome.
This is a fortunate termination, but as mere size bears
no relation to the amount of mischief caused, we may be
satisfied if in other cases the symptoms disappear and
there is no fear for the future.
It has been asked how the electric current can produce
denutntion of the tumor and increased nutrition else-
where.
‘The question assumes the existence of a specific denu-
tntive action, which it is not necessary to do, for all the
phenomena can be explained upon principles already es-
tablished by Onimus and others, who have shown the
beneficial influence of the continuous current upon con-
gestions, its stimulant effect upon the absorbents, and that
it promotes normal nutrition.
If we analyze the symptoms, they are bound to be large-
ly due to congestion and nervous irritation brought about
by an intolerance of the organ for the lesion, conditions
which are relieved long before the tumor itself could be
much influenced.
The congested uterine tissues offer less resistance to
the current than the tumor, hence they are the first to be
influenced by it.
The subsequent changes in the tumor may be traced to
the maintenance of a normal circulation, and the stimu-
lation of the absorbent and muscular systems of tbe parts.
A diseased endometrium often accompanies the tumor,
and isa potent factor in causing congestion. ‘The cauteri-
zation effected by the inter-uterine pole doubtless con-
tributes to a favorable result by curing this condition of
the endometrium.
It is probable that in other situations, where a lesion 1s
badly tolerated, the accompanying symptoms can be re-
lieved by the application of the continuous current—for
example, a localized tuberculous deposit in the lungs.
The writer has no doubt that skilful physicians are able
to do much for the relief of cases of fibroid tumors with
other means ; nevertheless, he is firmly convinced of the
safety and efficacy of Apostoli’s method, and would ad-
vise it under all circumstances.
More especially, he would insist that in the light of the
information we possess, no patient should be subjected
to a formidable operation until this method has been
tried and found wanting. Howarp Situ, M.D.
Paris, June 6, 1889.
ACCUMULATION OF BROMIDE OF POTASSIUM IN THE
Brain.—M. Doyon reports the case of a boy who died of
an intercurrent disease after from one to two drachms of
bromide daily for a year. Analysis showed the presence
of thirty grains of bromide in the brain and twelve grains
in the liver.
PILOCARPINE IN HysTEer1aA.—Dr. Vieira de Andrade,
writing in O Brazil-Medico, of May 8, 1889, reports a
case of aggravated hysterical convulsions, in a child aged
twelve, in which a complete cure was obtained within a
few days by the administration of pilocarpine.
MEDICAL
RECORD.
New Zustruments.
<< -- — —
AN EASILY QLEANED POCKET-CASE.
By S. OSCAR MEYERS, M.D.,
MOUNT VARNON, N. Y.
For the benefit of Dr. Bradshaw and others, who dislike
to cary a filthy, poison-saturated surgical pocket-case, I
offer the following suggestions :
Beauty must be sacrificed for utility and safety. ‘The
silver-clasped sealskin case, with its crimson silk, or
“violet velvet lining with the lamplight gloating o’er,”
may be a thing of beauty, but after a few weeks’ use it
must necessarily become saturated with septic germs. Its
material and make-up prevent cleansing and disinfecting.
For a simple, cheap, aseptic pocket-case, cut chamois-
skin like the diagram, fifteen inches long, five inches
wide, with two side-flaps, two and a quarter inches long.
Fold the section A B on B C, two and a quarter inches,
and stitch the two ends, thus forming a pocket for needles,
silk, etc.
The sections D E, F G, HI, are each two and a
quarter inches wide, and will hold four instruments each.
The dotted lines show where a piece of tape, one inch
wide, is stitched to form loops for the instruments. The
spaces C D, EF, G H, allow for folding, and are each
half an inch wide. When closed, J I folds on I H, to pre-
vent chafing, then on G F, then E D ; the side-flaps fold
over the ends, and the needle-pocket over all. ‘Two
A
|
|
aes
rubber bands slipped over the ends keep it closed.
Like any other case that is constantly carried in the
pocket, this one will soon become more or less saturated
with perspiration and effete matter from the body and
clothing. ‘To prevent this, it should be enclosed in a little
bag made of sheet rubber. ‘The superionty of this case
consists in the fact that it can easily be washed and disin-
fected. ‘The needle-pocket can be turned inside out ; the
whole case can he immersed in a solution of acid. carboli-
cum, acid. boracicum, or hydrar. bichloridi without injury,
and when dried will be thoroughly clean and aseptic.
Lastly, its cost is so little that the doctor can afford a
new one every time he collects a bill.
Army Rews.
Official List of Changes in the Stations and Duties of Cfi-
cers serving in the Meaical Department, United States
Army, from July 14 to July 20, 1889.
BRECHEMIN, Louis, Captain and Assistant Surgeon.
Ordered to Illinois National Guard, near Springfield, Ill.,
during remaining portion of Encampment. Par. 1, S. O.
159, A. G. O., July 12, 1889.
Batt, E. R., Lieutenant and Assistant Surgeon.
Leave of absence for fifteen days granted. Par. 3, S. O.
87, Department of the Missouri, July 9, 1889.
Burron, H. G., Captain and Assistant Surgeon. By
direction of the Secretary of War the extension of leave
of absence, on Surgeon’s certificate of disability, granted
in S. O. 22, January 26, 1889, is further extended two
months on account of sickness. Par. 1, S. O. 162, A.
G. O., July 16, 1889.
Ives, F. J., Assistant Surgeon, now at Fort Lyon, Cal.,
will proceed to Camp near Oklahoma City, I. T., and
report to the commanding officer for duty, relieving Cap-
tain W. C. Gorgas, Assistant Surgeon, who, when so re-
lieved, is authorized to avail himself of the leave of
absence grauted him in Par. 2, S. O. 84 c. s., Department
of the Missouri. Par. 1, S. O. 87, Department of the
Missouri, July 9, 1889.
GARDNER, WILLIAM H., Major and Surgeon. By di-
rection of the Secretary of War, detailed to attend the
Encampment of the National Guard of the District of
Columbia, at Fort Washington, Md., from July 22 to 29,
1889, for the purpose of giving instructions to the medical
officers and hospital corps in their respective duties. Par.
1,5. O. 164, A. G. O., July 18, 1889.
STEINMETZ, WILLIAM R., Captain and Assistant Sur-
geon, now at Baltimore, Md., on leave of absence on
account of disability, by direction of the Secretary of War,
will report in person to the commanding officer of the
Watertown Arsenal, Mass., for duty at that station, reliev-
ing Lieutenant-Colonel James C. McKee, Surgeon. Par.
3, S. O. 166, A. G. O., July 20, 1889.
McKeEFE, Lieutenant-Colonel. On being relieved at the
Watertown Arsenal, will repair to Philadelphia, Pa., and
assume the duties of attending surgeon and examiner of
recruits in that city. Par. 3, S. O. 166, A. G. O., July 20,
1889.
ROBINSON, SAMUEL Q., Captain and Assistant Surgeon,
Fort Hamilton, N. Y. H. Leave of absence for two weeks
granted. Par. 11, S. O. 165, Headquarters Division of
the Atlantic, July 22, 1889.
Batt, R. R., Lieutenant and Assistant Surgeon. Leave
of absence granted in S. O. 87, Department of the Mis-
souri, July oth, is extended five days. Par. 1, S. O. 167,
A. G. O., July 22, 1889.
EwING, CHARLES B., Assistant Surgeon. Promoted, in
accordance with the act of June 23, 1874, to be Assistant
Surgeon with the rank of Captain, after five years’ service.
July 5, 1889.
BALL, ROBERT R., First Lieutenant and Assistant Sur-
geon. ‘The extension ‘of leave of absence granted in S.
O. 167, July 22, 1889, is further extended ten davs. Par.
23, S. O. 169, A. G. O., Washington, July 24, 1889.
By direction of the President, the State of. Arkansas,
embracing Little Rock Barracks, is transferred to the De-
partment of the Missouri. General Orders No. 66, Head-
quarters of the Army, A. G. O., July 19, 1889.
THE MEDICAL RECORD.
[August 3, 1889
MNedical Items.
ConTaGcious DISEASES—WEEKLY STATEMENT. — Re-
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending July 27, 1889:
Cases. | Deaths.
ATTN DOVER saaat akr ahaha A jembueinw eae a o o
POOR OTET oeae a A OS Ea aN aa 29 Ic
OME COCO Ce on AT T PETEAR Secs oe eee ne Need 45 6
Cerebro-spinal meningitis.........cccecsccsecccnce 3 3
OOO fad v nad E E E E TA bee keeles 8 Eee 53 6
SPUN. 5S 5 oto ns bade Sake ae ab etadied dda swale’ | 97 27
a ie TTT is Cater shee rbcseccuss. ORs o o
COE. OVET aas a pede ab on a a n E a a a oe | o o
ma isos bb chose: O EE EES ENR | fe) | o
GERMAN PHYSICIANS AND THE PARIS EXPOSITION.—
At a meeting of a Berlin society of retired medical men,
not long since, a resolution was adopted calling upon
German physicians to keep away from the Medical Con-
gress to be held in Paris this summer. The members of
this society were very promptly rebuked by the Berliner
klinische Wochenschrift for their action, and the journal
urged the active members to take a part in the meetings,
and to show that they did not allow political feeling to
interfere with scientific progress. Some hot-headed
Frenchmen were incensed when it was decided to hold
the next International Congress in Berlin, but we believe
they have since come to look at the matter in a calmer
spirit, and it is hoped that the French representation at
Berlin will be fully up to the average of that at previous
congresses.
A New METHOD OF TREATING FRACTURED PATELLA.—
At a recent meeting of the Clinical Society of London,
Mr. Mayo Robson showed a patient (a young woman)
on whom he had operated by a novel method to secure
bony union in a case of fracture of the patella. The
skin over and around the joint was cleansed and rendered
aseptic and the joint then aspirated. Drawing the skin
well up over the upper fragment, a long steel pin was
passed through the limb from one side to the other, just
above the upper border of the patella. The limb being
similarly transfixed just below the patella, gentle traction
on the pins brought the fragments into apposition. Anti-
septic dressing was applied, and left undisturbed for
three weeks; when it was removed there was no sign of
irritation and the temperature had never been above nor-
mal. As the fragments seemed well united the needles
were withdrawn, a plaster-of-Paris splint applied, and the
patient allowed to go home. Mr. Robson observed that
the only precaution necessary was to draw up the skin
over the upper fragment in order to avoid undue traction
upon it when the fragments were approximated. If there
was much effusion in the joint it would be desirable to
aspirate.
SHORT-HAND FOR MEDICAL STUDENTS.—At a recent
meeting of the General Medical Council of England, Sir
Dyce Duckworth proposed to include short-hand among
the subjects of the preliminary examination for intending
students of medicine. His motion was, however, promptly
voted down. Short-hand is doubtless a very useful ac-
complishment, but it can hardly be regarded as a neces-
sary prerequisite to a sound medical education.
AN OLD ANATOMICAL WorK.—It is reported that there
has been discovered in the Royal Library of Berlin a “ Latin
Manual of Anatomy,” in manuscript, which was written
in the year 1304. Its author was Henri de Mondeville,
surgeon to Philip the Handsome of France, and teacher
of Anatomy and Surgery at Montpellier and Paris. ‘The
value of the manuscript lies in the fact that hitherto we
have possessed hardly any knowledge whatever of the state
of anatomy at the period in question.
The Medical Record
A Weekly Fournal of Medicine and Surgery
Vol. 36, No. 6
NEw YORK,
Original Articles,
TREATMENT OF INJURIES TO THE HEAD.’
By DUDLEY P. ALLEN, M.D.,
VISITING SURGEON TO LAKE SIDE HOSPITAL; VISITING SURGEON TO CHARITY
HOSPITAL ; CONSULTING SURGEON TO ST. ALEXIS HOSPITAL, CLEVELAND, O.
ANY surgeon familiar with injuries of the head is ac-
quainted with the difficulties which are met in diagnosti-
cating the exact seat of injury, and its extent. ‘The
differentiation between concussion and compression,
though much discussed, has been most unsatisfactory.
There is great uncertainty, too, in prognosis. Some cases
of severe injury result in recovery, while in other cases of
apparently slight injury death occurs speedily. There
are still other cases which do well for a time, and then
die suddenly and unexpectedly.
It is not the purpose of this paper to discuss cases of
severe injury where there are external wounds, together
with a fracture and evident depression of the skull. In
these there is no doubt of the necessity of surgical inter-
ference. I shall rather of cases where the diagnosis
is doubtful, and consider what plan is to be pursued under
such conditions.
As a basis for these considerations, I will state six
cases of injury which have recently come under my care.
The first will be stated somewhat at length, in order to
show the method pursued in treatment and operation.
On September 10, 1888, Mrs. W——., aged thirty-nine,
in vigorous health, while standing in a car door was
thrown violently backward, by the sudden starting of the
train, and struck her head upon the metal arm of a seat.
When I sawthe patient for the first time, on November
2d, she could not- definitely locate the point ‘struck, but
placed it at about the median border of the left parietal
bone, close to its posterior margin.
Patient was helped out of the car, and walked a short
distance, but soon became dizzy, and was compelled to lie
down. ‘The same night, some hours later, she aided in
caring for others injured in the same wreck, and the next
day took a railroad ride of several hours. During the
four weeks following there was much headache, but the
patient was up and about. About October roth the pain
increased, and dizziness, which had previously existed,
became more marked, so that patient staggered some
in walking. From this time patient remained in bed
until November 2d, when she was brought to Cleve-
land, about eighty miles, and entered Charity Hospital
under my care. At this time the pain in the head was
intense, and patient said she felt as though a nail were
pressing upon her brain at the point where she received
the injury. This pain was so severe that she threw her
head somewhat backward, and seemed to want to bore
the occiput into the pillow. Had a constant sensation of
falling backward ; slept poorly; was greatly depressed in
spirits and very nervous; had previously vomited oc-
casionally, but not recently ; but the vomiting may have
been due simply to gastric disturbances.
Patient was placed upon iodide and bromide of po-
tassium, and later bichloride of mercury was added to
these, and they were continued about five weeks, but with
out any noticeable change.
On November 30th a consultation was held at which
_—_
1 Read before the Ohio State Medical Society, May 23, 1889.
AUGUST 10, 1889
Whole No. 979
Drs. H. K. Cushing, W. J. Scott, Frank Weed, B. L.
Millikin, Henry S. Upson, and myself were present, and
the same gentlemen met again, December 7th. Dr. Mil-
likin made repeated examinations of the eyes, and Dr.
Upson of the various nervous phenomena.
The following are extracts from their examinations :
Dr. B. L. Millikin's Report.—“ Examination of the
eyes, November 3, 1888. O. D. v=§; O. S. v=.
Movement of the eyeballs in all directions normal. Pu-
pils normal in size and reaction. The objective field for
white shows undoubtedly some peripheral narrowing in
both eyes. Eyes very sensitive to light ever since the
injury.
‘The ophthalmoscope shows in O. D. borders of disk
shghtly hazy, disk and retina somewhat injected, choroi-
dal crescent to outer side of disk, arteries slightly dimin-
ished in calibre, veins greatly distended and very tortuous
all over fundus of the eye, from the borders of disk clear
out to the periphery all the veins being involved. O. S.
shows disk slightly injected, a little haziness of borders,
broad choroidal crescent outward, arteries normal in size
or a little diminished in calibre, and veins likewise greatly
distended and tortuous over entire fundus.
“ January 2, 1889.—Fundus of eyes has changed but
little since last examination. Perhaps calibre of veins
slightly diminished. No haziness of borders of disk of
O. D. The pupil of O. S. is now larger than O. D., but
both react readily to light and to accommodation. Vision
in both eyes normal.” :
Dr. Henry S. Upson s Report.—“ Examination of Mrs.
W , November 3, 1888. On palpation of head there
is a tender spot just to left of median line, in the poste-
rior part of the parietal regian. ‘There is no paralysis of
eye-muscles, nor deviation of face nor tongue. Patient
stands somewhat unsteadily; but there is no loss of
power in either arms or legs; grip is the same on both
sides ; sensation is acute all over the body, as well to
painful as to tactile impressions. ‘The triceps, wrist,
and knee reflexes are equal on the two sides, well
marked, but not exaggerated ; there is no ankle clonus.
The visual memory is perfectly good; patient can read
very well, can recall faces, scenes, and colors as well as
before the accident ; there is no hemiopia.
“ November 16th.—Patient has noticed a weakness of
the right side, and has had sharp pains in the right toe
and foot. On examination the grip seems distinctly
weaker on the right side, and the muscles of the nght
foot act less energetically, possibly as a result of the pain
in that region. ‘There is no change in the reflexes.
“ December 6th.—Patient’s condition practically un-
changed. Still intense pain at point of injury, and ten-
derness to pressure. No paralysis nor anesthesia. Pain
in right foot better since last examination. Has had
some pain in the left foot. Is still rather unsteady when
she stands.”
To summarize the case. It appeared that an injury to
the skull had been followed by severe headaches, eon-
tinued for three months, and that pain and tenderness at
the point injured were intense. There was also marked
dizziness. Examination of the eyes showed sensitiveness to
light and very marked congestion and tortuosity of the
veins, indicating perhaps increased intercranial pressure.
Examination of the nervous apparatus showed no focal
symptoms referable to the cerebrum, unless it were a slight
weakness of the right side, which, however, was not posi-
tive. There was also pain in the fourth toe of nght foot,
142
THE MEDICAL RECORD.
[August 10, 1889
later becoming general in ball of foot. This was so severe
that patient stepped on foot with difficulty. There were
neither chills nor fever accompanying sicknes¢
In spite of appropriate medication and surroundings,
patient grew worse rather than better. On this account,
and from the fact that the blow upon the head was just
posterior to the leg-centre of the left side, and that this
was accompanied by severe pain in the right foot, and
that the marked tortuosity of the retinal vessels indicated
increased intercranial pressure, it was decided by the gen-
tlemen in council to trephine at the point of greatest ten-
derness and pain.
On December 13th the operation was performed in the
presence of the consulting physicians and several others.
On the previous day the bowels were thoroughly cleared by
ol. ricini; the head was shaved and disinfected, and
wrapped in a towel wet in bichloride of mercury. A
hypodermic injection of morphine, one-fourth grain,.was
administered and the patient was etherized. A flap, three
inches wide at base and four inches antero posteriorly, was
made down to the periosteum. ‘The base of the flap was
toward the occiput. ‘The periosteum was divided by a
crucial incision and the bone exposed. The skull was
opened by a Horsley trephine one inch and three-quarters
in diameter. The trephine was made for me by Gemrig,
of Philadelphia.
Since the skull was of unequal thickness and about five-
sixteenths of an inch thick at one side, it became impossible
to complete the operation with the trephine, since by so
doing the brain would have been seriously lacerated at
one side before the skull was divided at the other. It
was thus necessary to divide the remaining bone with a
small chisel. In doing this the inner table of the skull
split off, the slivered part remaining attached to the but-
ton of bone and slanting out under the periphery of the
trephined opening. ‘Thus the button was removed with
much difficulty, but this was finally accomplished without
lacerating the brain or its membranes. ‘The button of
bone removed was found to be uninjured. The dura ma-
ter bulged quite markedly into the opening and fluctuated
slightly. This was divided through about two-thirds of
its periphery at about an eighth of an inch distance from
edge of bone. The pia mater was somewhat congested
at the central portion, and lifted from the surface of the
brain by an increase of the clear cerebro-spinal fluid.
This fluid was evacuated, neither clot nor inflammatory
exudation was found, nor was there any depression of the
inner table of the skull. ‘Ihe dura mater was then united
by a continuous suture of very fine catgut ; the bone, which
after its removal had been kept wrapped in an antiseptic
towel, and under water at a temperature of 100° F., was
returned to its place, the dura mater was drawn together
over it by a fine catgut suture, a drainage-tube was placed
under the flap up to the opening in the skull, and the scalp
was united and dressed antiseptically. ‘The patient re-
covered from the anzesthetic rapidly, having endured the
operation well, and soon regained consciousness. ‘The
dressings soon became quite moist with the escape of
cerebro-spinal fluid. A day anda half after the opera-
tion the temperature had marked 101.3° F. and the pulse
100. Ice-bags were applied, and after this it was impos-
sible to tell whether the moisture of the dressings was due
to the escaping cerebro-spinal fluid or to the moisture
from the ice-bags.
On December 17th, four days after the operation, the
dressings were opened, sutures and drainage-tube re-
moved, and the wound found in perfect condition. From
thistime the progress of case was most satisfactory, and
on December 28th patient sat up for first time. The
union of the wound was by first intention throughout, and
without a single drop of discharge.
On January 6th patient walked down hospital stairs, a
long and difficult flight, and on January 18th went to her
home. Since that time her progress toward recovery has
been continuous.
After the patient’s return home the left pupil was con-
siderably more dilated than the nght. On April 18th her
husband writes: “ ‘The left pupil is dilated some at times,
though not near so much as a few weeks ago. Within a
week past I have seen more improvement than in any
three or four previous. I think the trouble in the back
of the head is entirely relieved. ‘There is still some fron-
tal headache when she exercises too much, and the eyes
are weak so she cannot read very much.” I now present
you the lady operated upon to examine for yourselves.
She seems perfectly well.
This case is one of six that have recently come under
our notice, in which severe blows upon the head had been
received. In none of them was there evidence of injury
to the skull externally.
Case II. I saw about five weeks after the receipt of
his injury. During the last four weeks the patient had
had convulsions, and latterly high fever, and was coma-
tose. I trephined. There was no depression externally,
but a small piece from the internal table of the upper
margin of the left parietal bone penetrated the membrane
of the brain, and in the substance of the brain was an ab-
scess containing about two ounces of pus. The case ter-
minated fatally about one week later, the case being well-
nigh hopeless at the time of operation. The clinical
evidence of the case would have dictated an operation on
the third day following the accident.
Case III.—Was of a man struck upon the vertex of
the cranium by a shaft, but not rendered senseless. He
continued at work for about ten days. I saw the patient
five weeks after receipt of injury. He was then comatose,
and had impaired motion of nght side. Patient died one
week later. The brain was removed before I had an op-
portunity to examine it, but was said to show no lesions
which could be seen macroscopically. I examined the
skull carefully, and it appeared normal in all respects.
Case IV.—Was of a man who fell from a second-story
window. Was unconscious for a few moments, after
which time he walked upstairs. ‘There was considerable
nosebleed, and a fracture apparent of the nasal bones.
During night of injury was delirious for a few hours, but
later suffered little pain, and was about the house after
nine days, and three weeks from date of injury went to
work regularly. During succeeding eight weeks patient
was twice delirious and unconscious, but between these
attacks he worked. About ten weeks from the time of
injury patient was brought to hospital, when I saw him
for the first time. He was then unconscious, and had
stertorous breathing. It was 11 P.M., and I operated at
once, since condition admitted of no delay. ‘I'rephined
frontal bone of right side just above frontal sinus. The
skull was cracked vertically at this point. No depression
of inner table could be found. ‘The membranes were in-
jected, but no collection of pus was’ discovered, either
externally or by puncturing substance of brain deeply
with a scalpel. Patient’s condition did not improve, and
he died thirty-six hours after operation. ‘The autopsy
showed a diffuse meningitis, with a small amount of pus
under the pia mater. A small piece of bone just to the
right of the crista galli was fractured and depressed out-
wardly.
Case V.—Was of a man injured by falling from a car
about fifteen years ago, and stnking on head just over
right eye. Was in hospital a short time. Remained well
until November, 1885, when he began to be drowsy and
lose his memory. On December 8, 1886, had his first
epileptiform seizure, after which he became unusually
stupid. Case seemed hopeless without an operation, and
on January 8th I was asked to operate, which I did at the
seat of old injury. A trephine one inch in diameter was
used. Nothing abnormal was found. Button of bone
was not returned. Wound healed by first intention.
Patient got up from operation slowly. ‘Three months
later had two convulsions. Did not walk without
crutches for a year. At this time resumed trade of a
watchmaker, and did his work all right, but was forgetful.
Later had attacks of weakness, and two years from time
August 10, 1889]
of operation patient died. At autopsy the opening made
by the trephine was about half-closed by bone, and fully
covered by periosteum.
The inner table of the skull was normal. Effusion
Into the pia mater was quite marked over whole surface
of brain. At many places it was stained red. Brain
substance and medulla appeared normal. The microscope
showed serous and bloody effusion into the pia mater very
marked, with congestion of the meninges.
Case VI.—Was of a man who three years before, and
again three months later, received severe blows on right
side of head. He recovered rapidly in the first instance,
going to work in a few days, and in the latter on the
same day asthe injury. Since this time has occasional
clonic spasms which are slight. Worked most of the
time until about five months ago, since which time he has
been unable to do so. Recently has grown much worse.
Spasms and convulsions are more frequent. Is very slow
and uncertain in all motions and mental processes.
Walks with great difficulty, and during last week seems
to have a tendency to fall backward. A possibly slight
dragging of left foot. No other distinct focal symptoms
discovered, by most careful examination. Opthalmo-
scopic examination, by Dr. Millikin, showed marked optic
neuntis of both eyes, with considerable swelling of the
disks and several small hemorrhages. Pupillary reactions
normal. Vision of right eye, y; and of left, $.
During the week that patient was in hospital his con-
dition grew rapidly worse. Convulsions were more fre-
quent and more prolonged. It became evident that any-
thing which was done must be done at once. ‘The
history of a blow upon the right side, and the slight drag-
ging of the left foot, determined the operation over the
leg-centre on the right side. Two buttons of bone were
removed by a three-quarter inch trephine, and the open-
ing was elongated antero-posteriorly by a rongeur. ‘The
pulse at the beginning of the operation was 160, and
there was considerable cyanosis. ‘The membranes bulged
strongly into opening, and were congested. ‘The con-
volutions were much flattened and anemic. ‘The finger
was carried an inch outward from the opening in the
skull in all directions, but nothing abnormal could be felt.
A scalpel carried one and one-half inch into the sub-
stance of the brain gave no information. The dura
mater was united with great difficulty, owing to the great
bulging of brain. Patient died about thirty-six hours
after operation. At the autopsy a grayish mass one and
one-half inch in diameter was found, four inches posterior
to gabella of nose and two and one-half inches to right of
median line, and just anterior to the point touched by
the finger in operating. Under microscope this pre-
sented the appearance of a glioma.
It may not be unprofitable, in closing this paper, to
point out certain features peculiar to each of the cases
mentioned.
Case I. was reported at length to show the difficulties
incident to the diagnosis of a case of head injury, and
also the great care requisite for operation.
It is very remarkable, too, that a button of bone one
inch and three-quarters in diameter should be removed
from the skull for nearly half an hour, be replaced,
and grow firmly into its place, without any unfavorable
symptom of any sort. It is such results as these which
decrease one’s fears in operations upon the brain..
Case II. is one which might probably have been saved
by an early operation. ‘There was a convulsion on the
third day following the injury, and other symptoms indi-
cating the necessity of immediate interference. ‘The ac-
companying specimen shows a crack in the external.
table of the skull, and the depressed spicula of bone
from the internal table.
Cases III. and IV. are illustrations of the fact that ap-
parently slight injury to the skull, not so severe as to
prevent the patient’s working, may after a few weeks re
sult fatally.
The accompanying button of bone, taken from one of
THE MEDICAL RECORD.
143
these cases, illustrates how the skull may be cracked, and
still no depression of bone occur.
Case V. suggests that injuries may result in epilepsy.
That this is true seems now to be a fact well established,
as illustrated by the relief secured in certain cases of
epilepsy by trephining.
Case VI. suggests that cerebral tumors may result
from injury. Whether thisis so or not can only be es-
tablished by numerous observations, The importance of
quiet after injuries to the head is very great. It is not
improbable that Cases III. and IV. might have recovered
had they remained quiet after being injured.
A good deal might be said about methods of operating
and instruments. Of the necessity of strict antisepsis
there can, I think, be no question. By no other method
could one expect to remove and again replace portions
of the skull, and have them grow in place successfully.
As to instruments, the large ‘ Horsley” trephine
which I show you here, one and three-quarters inch
in diameter, has the advantage that it opens a large field
for work, and that the single piece of bone thus removed
can be replaced more easily than several smaller pieces.
It is, however, a very unsatisfactory instrument to use, for
several reasons. If the skull were flat ‘and of uniform
thickness, there would be little difficulty. ‘This, unfort-
unately, is not the case, and as a result the trephine cuts
through the skull at one point, and is liable to wound
the brain before the skull is divided elsewhere. If an
attempt be made to avoid this by tipping the trephine, it
binds so closely in the cut that it is impossible to turn it.
This might be remedied to a certain extent by making
the trephine conical, and the cutting grooves on the pe-
riphery of the trephine deeper and slanting, as in the small
trephine I show you here. It has been suggested to me
that a trephine might be constructed, consisting of a seg-
ment of a circle, so that this might be used to cut at any
portion desired.
I have operated with quite a variety of trephines, and
find the conical instrument, with deeply grooved sides,
by far the most convenient. Several openings can be
made with this if required, and the opening enlarged to
any extent desired by the rongeurs which I show you
here. I have used a chisel in working on the skull, but
a serious objection to itis that it is liable to splinter the
inner table.
The question of diagnosis of cerebral lesions is an ex-
tremely complicated one, and it is not within the province
of this paper to consider it. Though it must be impos-
sible to determine the exact character of many injuries,
much can be done by a careful observation of symptoms,
together with observation of the retina, for indications of
intracranial pressure, of the seat of the blow upon the
skull, and the possible manifestation of focal symptoms.
In these observations the surgeon may receive valuable
assistance from the oculist and neurologist.
In each of the operations mentioned ether was used,
and was wholly satisfactory as an anesthetic.
In conclusion, I would insist upon the fact that in-
juries to the head, though apparently slight, may be of
serious import, and that fatal results may be averted by
prolonged quiet.
I would also state my belief that, in skilful hands
and with modern methods, the dangers of operations
upon the cranium have been greatly diminished, and that
. timely interference will save many cases of injury to the
skull which have formerly been left to nature, and re-
sulted fatally. :
MULTIPLE BIRTHS IN NIcE.—According to statistics
published by Dr. Berlin in the Nice Médical, the propor-
tion of twin-births in Nice to the whole number of births
is 1 to 75.54, and of triple births 1 to 5,575. In France the
proportion of twin-births to the whole number is 1 to ror,
and of triple births 1 to about 10,000. Dublin surpasses
Nice, however, the proportion for twin-births there being
I to 57.
ww
CHLORATE, WITH REPORT OF A CASE.
By CHARLES H. CHETWOOD, M.D.,
NEW YORK.
EXPERIMENTS testing the physiological effects of cocaine
upon the lower animals have shown that different ani-
mals of the same species vary greatly in their power of
resisting its toxic influence, and that the toxic symptoms
produced often differ in their nature, being convulsions,
sometimes tetanic, more often epileptiform, and at times
paralysis, coma, and death, not preceded by convulsions.
And so it will be noticed, in the use of a moderate
amount, as an anesthetic on the human subject, while in
the majority of instances no ill effects may be experienced,
yet occasionally we meet with cases which show a marked
susceptibility to its influence, exhibited by symptoms
sometimes mild, and less often violent.
It is not infrequent after the injection of a small
quantity of cocaine under the skin, or local application to
some mucous membrane, for a patient to become garru-
lous and somewhat excited, or show other mild symptoms
of general excitement.
These milder symptoms are of various qualities, being
sometimes diffefent degrees of mental excitement, or,
when more of a depressing nature, slowing of the circu-
lation, general pallor, nausea, and fainting. They have
no direct relation with the amount of cocaine used;
they sometimes occur where the quantity is small, and in
other cases where it is larger do not appear.
The case I am about to report is one which occurred
during my service as House Surgeon in Bellevue Hos-
pital, and merits some notice on account of the peculiar
and rather violent symptoms produced.
The patient was about twenty-five years of age, and
was afflicted with a stricture of’ the anterior urethra
which it was deemed advisable to cut. About a drachm
of a four per cent. solution was thrown into his urethra,
and shortly afterward another drachm, most of the first
having escaped ; so that, in all, not much over one drachm
remained in contact with the urethral mucous membrane.
An examination by the bulbous bougies had previously
been made, hence a possible dissolution in the continuity
of the mucous membrane, and a consequent greater ab-
sorption, should be taken into account.
Within three minutes after the introduction of the co-
caine the patient seemed to be unnaturally nervous and
excited, his pupils showed marked dilatation, and the lids
being retracted gave him a very wild appearance. His
excitement greatly increased, he soon became unruly, so
that it took several men to hold him down, against whom .
he fought wildly and vociferated loudly. His actions re-
sembled what is seen in an attack of acute mania.
Outside of the maniacal symptoms the cocaine mani-
fested its effect in another form, which was an interesting
feature, and consisted in tetanic, or tonic, spasms of the
muscles, as varying from epilepuform, which is more often
met with as a result of cocaine.
At the onset of the attack the patient was on a table,
and though he fought and resisted, it could be noticed
that both arms were markedly drawn up and the muscles
rigid. ‘There was also spasm of the muscles of the
thorax, which was apparent from the impaired respiratory
movements. In getting upon his feet and attempting to
move, he walked “stiff-legged,” and the spasms became
more acute when he tried to use his muscles; in fact,
without assistance he would have fallen down. During
the attack the pulse was rather slow, and there was a gen-
eral pallor of the external surface.
_ He was given a hypodermic of whiskey and eight min-
ims of Magendie, and in a few minutes’ time became more
quiet, and submitted to being put to bed. Within a
quarter of an hour the whole attack had passed off, the
pupils became normal, the spasms had ceased, and all
that remained was a feeling of dizziness, and a vague recol-
THE MEDICAL
RECORD. [August 10, 1889
lection of having made a disturbance, without any vivid
remembrance of what had occurred.
Other cases, partaking of one or the other of the charac-
ters of this one, have undoubtedly been met. ‘letanic con-
vulsions do occur, although they are usually epileptiform.
Whether one is the effect of the cocaine on the spina]
cord, and the other on the cerebral cortex, I am not pre-
pared to discuss. Professor Mosso, of Turin, in experi-
menting on animals, after cutting the spinal cord high up,
still induced violent tetanic convulsions by the use of the
drug, and it was invariably the rule, after death follow-
ing the occurrence of epileptiform convulsions, to find ex-
tensive anemia of the cortex cerebri.
Many cases of epileptic convulsions have lately been
reported following the use of cocaine as an anesthetic,
and one or two have terminated fatally. Sajous Annual,
of this year, mentions a number of cases, notably one re-
ported by H. C. Simes, of Philadelphia, where the con-
vulsions were excessively violent, and resulted in death
twenty minutes from the onset.
I witnessed a case in Bellevue Hospital which might
have terminated fatally but for the active and immediate
measures employed.’
Besides these cases of epilepsy, grave conditions are oc-
casionally met, in the use of cocaine, in which convulsions
do not appear. As an example of this I quote a case of
almost instantaneous death, preceded by collapse and not
by convulsions, and probably referable to cocaine, recorded
by W. T. Belfield, of Chicago.” Abadie ° gives an ac-
count of a patient who died in a somewhat similar man-
ner, following the application of cocaine to the eye, death
being preceded by coma and paralysis, and not by con-
vulsions. `
In summing up the various untoward symptoms which
may follow the use of this drug, we find that we have
mental excitement of different degrees, generally ushered
in by headache, dizziness, and dilatation of pupils; morc
or less cardiac depression ; it may be only slight irregular-
ity of the pulse, but has amounted to total collapse ; and
dependent upon the cardiac depression cyanosis, difficult
respiration, general pallor, fainting; reflex phenomena,
such as nausea, vomiting, colic, evacuation of bowels ;
and then the more violent symptoms which occur: con-
vulsions, epileptiform and tetanic, producing often only a
transient commotion, but which have been so severe as to
result fatally ; and finally, paralysis, coma, and death, not
preceded by convulsions.
The pupils generally become dilated after the adminis-
tration of cocaine, and do not necessarily imply the onset
ot more alarming symptoms.
Notwithstanding the frequency of cases combining one
or more of the above symptoms, which have occurred
and have been reported, the progress, of late, in the use
of cocaine as an anesthetic, has been very marked, not
to mention its numerous internal indications.
However, many of those who have had recourse to its
use, and who have come in contact with cases which have
evinced evil symptoms, are constrained to acknowledge
something of the same kind of fear of this drug that a
person is apt to feel toward a dog by whom they have
once been bitten. Some have ceased to employ it en-
tirely.
While it cannot be denied, from the present report of
cases, that cocaine has acquired a dangerous reputation,
yet it is possible that amid the enthusiasm with which
it was first received, and has since been used, many lack-
ing an adequate knowledge of its different effects, which
experience alone could render, by being unwary of lesser
tokens, have been unprepared to ward off the more violent
and dangerous symptoms, which a resort to immediate
measures might have prevented.
It is scarcely necessary to mention that the administra-
tion of the other anzesthetics in common use is not de-
1 Case spoken of by Dr. Keyes, Sajous’ Annual for 1889.
2 Journal of the American Medical Association, 1887.
3 Recueil d’'Ophthalmologie, October, 1888,
August 10, 1889]
THE MEDICAL RECORD.
145
void of nsk, and they too, undoubtedly, in their early
career, had their “chapter of accidents.” It is only
through long experience and a careful study that we are
now enabled to give them fearlessly; and by having at-
tained a knowledge of the complications which are liable
to be met, are prepared to combat them when they arise ;
so that, at the present day, cases of disaster are compara-
tively rare. Their administration is entrusted to a special
assistant, who continually keeps watch over the patient’s
general condition. Of course, as cocaine is only used lo-
cally its employment can hardly be compared to that of
the general anzesthetics. But these facts are intended to
suggest that a proper knowledge of its untoward effects, a
careful watch for bad symptoms whenever it be used, to-
gether with future experience, are the means through
which we will learn to more clearly understand this drug.
If it be always used with stimulants, and such antidotes
as morphia, strychnia, and nitrite of amyl near by, and
someone at hand other than the operator to take alarm
in case of emergency, there certainly will be less risk in
its employment. |
In regard to the strength of the solution to be em-
ployed, except in special cases a four or five per cent. is
most commonly used where the surface to be anzesthe-
tized is large, and where it is of small area a few drops
of a ten per cent. solution.
Those who have had much experience in its use report
severe symptoms following the weak, as well as the stronger,
solutions in quantities relatively small. ‘There exists, there -
fore, a great difference in individuals in their power of
resisting its toxic influence.
A weak power of resistance may be acquired by an ha-
bitual or constant use of cocaine, and this I believe to be
the explanation (if it be ascribed to cocaine) of Dr. Belfield’s
case, which has been mentioned, and upon whom, it will
‘be seen, subsequent to an internal urethrotomy, two
drachms of a four per cent. solution were used prior to
each introduction of the sound, producing, possibly, a
chronic hyperzmia of the kidneys, which eventually be-
came overloaded ; and of the case in La Medicina Prac-
fica, December 15, 1888 (Dr. Lettier), violent symptoms
were aroused by a four per cent. solution of cocaine in
the bladder, the patient being in the habit of injecting,
himself, an ounce or more of a similar solution into
his bladder every day ; and of other cases, where there is
a sudden appearance of toxic symptoms in those who have
for some time previous resorted to the use of cocaine.
In order to obtain the best local anzesthetic effect of
cocaine, it is well to wait ten minutes after its introduc-
tion, during which time any tendency to constitutional
symptoms may be detected.
In operations where it is practicable, the application of
a ligature above will retard its entrance to the general
circulation, and enforce its local influence.
The value to the surgeon of such a local anzesthetic as
cocaine has proved to be, can hardly be estimated ; and
it is to be hoped that time and experience will help us to
ao its usefulness, as well as overcome its present de-
ects.
46 East THIRTIETH STREET.
WHERE ARE THE ALLOPATHS?—An act has recently
been passed by the Legislature of Tennessee to regulate
the practice of medicine and surgery. According to this
act, one of the requisites for the practitioner is the posses-
sion of a diploma from “a legally chartered allopathic,
homeeopathic, or eclectic medical college.” The act also
creates a board of medical examiners, and provides that
“ the three schools of medicine, viz., Allopath, Homceo-
path, and Eclectic shall be represented on said board.”
‘There may be some “allopaths” in Tennessee, and if
there are, they are doubtless entitled to a representation ;
but it seems hardly fair to exclude altogether the regular
practitioners of the State from the board of examiners, or
not to recognize the diplomas of regular medical schools.
is checked.
A CLINICAL NOTE ON THE USE OF CREO-
SOTE IN PHTHISIS.'
By JAMES E. NEWCOMB, M.D.,
ASSISTANT PHYSICIAN ROOSEVELT HOSPITAL OUT-PATIENT DEPARTMENT.
My experience concerns sixteen cases treated at the
above-named institution, and twoin private practice. For
various reasons the latter two cannot be considered as
bearing on the efficacy of the treatment. Of these 16
cases, I1 presented consolidation, 2 cavities, and 3 both,
t.c., consolidation at one apex and a cavity at the other—
advanced cases. Of the 16 there were 8 of each sex.
The average age was twenty-five, the youngest thirteen
and the oldest forty-six. ‘The average duration of treat-
ment was 78 days, the shortest 4o and the longest 141
days. The average duration of the disease, as ascertained
by the symptomatic history given on application for treat-
ment, was 28 weeks, the longest 72 and the shortest 2
weeks. In one case the patient felt perfectly well till the
occasion of his taking cold, when he immediately applied
for treatment and was found to have commencing con-
solidation at the left apex. Another patient had had
lung trouble several years, and this too is not of the above
number. ‘The average is reckoned on 14 cases. In 5
cases there was a family history of phthisis. In 8 the
temperature was normal ; in all the others more or less
pyrexia. Night-sweats were present in rr. There was a
history of distinct loss of weight in 12. In 12 there was
hemoptysis. In all, if the cough was at all severe, a sim-
ple cough medicine was used of antimony, ammonium
muriate, and small doses of morphine in differing com-
binations. Creosote was given only by the mouth. The
formula I have followed was as follows :
B. Creosote,
Tinet. CRAPSICL. 64.04.i.0 eae wecaeeas sais ai 3 iij.?
> Mucilag. acacie je. scicsredase ereksi Z ss,
WAalel icc S E T nE aa ad § iv
M. S.: Dose, one teaspoonful well diluted in water after meals,
In 11 there was unconditionally no gastro-enteric dis-
turbance from the remedy.
` Cough lessened in 8, cured in 2, unaffected in 3 = 13.
Fever é si 06 ti I, ce és 3 = $.
Sweating 66 66 5, te 6. I, 66 66 4 = 10.
Weight lost ‘* 4, gained 4, = “8 = 16.
To summarize : seven cases were apparently not in the
least improved, 7 were distinctly benefited, and 2 I re-
gard as cured. At the time of their last examination
there was not the least sign or symptom of any active pro-
cess going on in the lung. They felt as well as ever.
Were able to do their usual work. One had been under
observation fourteen weeks, and the other twenty weeks.
In collating these cases I have decided, in every doubt-
ful point, against rather than for creosote. I am well
aware that these observations are defective as regards the
influence upon the bacilli. When they were begun it was
with no intention of presenting them in this public man-
ner, and examinations of the sputa were not made. I feel
conscientious, however, about the diagnosis, and I am
bound to say that creosote has done more in my hands
than any other remedy I have ever used. Of all the cases
of phthisis I had seen, up to the time of beginning creo-
sete, in a hospital experience of eighteen months and out
patient service of four years, I had never seen but one case
cured on the usual treatment of tonics, cough-mixtures,
and cod-liver oil. .
Concerning the rationale of the action of creosote, I be-
lieve that it is a direct antiseptic and disinfectant. I do not
know whether it is a specific against the bacillus. I think
not. I believe, however, that it is not irrational to expect
that such an one may be found. I think, too, that the
sclerotic change which results on the arrest of tubercular
invasion is not so much the specific effect of creosete as
nature’s process, set up when the virulence of the poison
1 Extract from a paper read before the Hospital Graduates’ Club,
April 18, 1889.
2 If under twenty years of age, 3).
146
THE MEDICAL RECORD.
[August 10, 1889
CASE OF COMPOUND TRIPLE DISLOCATION
OF THE LEFT ASTRAGALUS, WITH COM-
MINUTED FRACTURE—RECOVERY, WITH
A USEFUL FOOT.
By WILLIAM A. GOTT, M.D.,
VIROQUA, WIS.
THE case under the above caption presented so many
interesting and, I may add, instructive features during the
time it remained under my immediate supervision—a pe-
riod of over three months—that I have thought it worthy
of being placed on record in the columns of THE MEDI-
CAL RECORD.
In order that a definite idea may be formed of its prog-
ress from first to last, it will be necessary to enter some-
what into detail. It is my purpose to do so in as concise
a manner as will suffice to give a clear understanding of
the main points the case presented during the time it re-
mained under treatment.
It will suffice, for the present, to say that from the
time the patient received his injury to that in which the
safety of the foot was an assured fact, grave and appar-
ently insurmountable difficulties beset the progress of the
case, and so far compromised the integrity of the limb, to
say nothing of the life of the patient, as to call for the
consideration of the question of amputation.
Surgical authorities, without exception, agree in the
opinion that dislocations and fractures of this bone, sim-
ple and compound, are not only of rare occurrence com-
pared to other less severe injuries of the bony structures,
but of great severity as well in the majority, if not in all,
of the cases, and consequently of the gravest import, im-
perilling oftentimes the integrity of the limb, and per-
haps the life of the patient also; and, no doubt, those of
the profession who have been privileged to have under
observation a case of the kind will confirm their state-
ments in these particulars. Judging from my experience
in the case to be described further on—the only one that
has come under my observation and care during the
course of a general practice of over thirty years, three
years of which time were spent in the capacity of a medi-
cal officer during our late Civil War—-I can truly say that,
so far as difficulty and, it may be added, uncertainty of
accurate diagnosis is concerned, no other class of bony
injuries will bear comparison. ‘The reason for this is ob-
vious. As is well known, intense inflammation and enor-
mous tumefaction invariably attend these injuries, of a
more pronounced character than the same conditions met
with in lesser injuries of the ankle-joint, as a severe sprain,
or a fracture of both bones of the leg in that vicinity ;
and these same conditions, in an aggravated degree, so ob-
scure for a while the normal contour of the joint and foot
as to render a differential diagnosis a matter of difficulty,
and oftentimes of impossibility. What has been the ex-
perience of eminent surgical authorities, both at home and
abroad, in regard to these injuries, has likewise been the
experience of surgeons of lesser note, as found recorded
in the current surgical literature of the day. ‘There is,
perhaps, no class of injuries to which the human frame is
liable in the pursuit of the various dailv avocations of life,
which the medical man is called to treat, that require the
exercise of more sound judgment, acute discrimination,
and prudent caution ; and, certainly, no other in which
he is more liable to err by reason of too hasty a diagno-
sis, because of the conditions already spoken of, and,
moreover, in which his professional reputation in the esti-
mation of both the patient and his sympathizing friends,
especially when an opinion, which subsequent develop-
ments prove to have been erroneous, has been too hastily
given, is more at stake than in the one under consideration
in this paper. In the case soon to be detailed the force
of some of the above statements is well shown, as will be
seen, and will doubtless serve the purpose of making the
medical man who may be summoned to treat an injury
of this character more than usually guarded in his opin-
ion until such time aS later developments point out con
clusively his line of conduct.
CasrE.—On the morning of June 15, 1886, I was
called to visit C. B , residing several miles in the
country, twenty-two years of age, of spare, but wiry build,
and a constitution somewhat impaired by reason of al-
coholic excesses. Was informed that in the early evening
of the previous day his team, which he was driving on the
highway near his place of residence, took fright, became ~
unmanageable, and ran away. In his efforts to control
the thoroughly frightened animals he was thrown out of
his wagon upon the whiffletrees in such a position as to
fasten with avice-like grip his left ankle between the evener
and whiffletree on the right side, and in this position, with
his body prone between the wheels, he was dragged at a
high rate of speed the distance of several rods along the
highway and through the dense brush into which the mad-
dened animals finally plunged, and in which they became
so entangled that their farther progress was out of the
question. As soon as his team came to a stand-still his
foot was released and he fell to the ground. When he had
recovered from the shock of the accident he was assisted
to his home by a couple of travellers who happened along
at the time. After resting awhile he proceeded to make
an examination of the injured part in order to “size up,”
as he expressed it, if possible, the nature and extent of
his injury, and, having detected a “bunch” on the an-
terior aspect of the ankle-joint, he very naturally came to
the conclusion that it had become displaced and that con-
sequently its reduction should be attempted without delay
and before the swelling, already forming rapidly, became
any greater. A resolute fellow naturally, he directed his
attendants to make extension and counterextension, and
another to make pressure on the “bunch” alluded to;
these efforts were continued for two or three minutes when
“a loud snap” was heard and the bunch found to have:
disappeared ; consequently all thought that reduction of
the joint had been effected and that, so far, all was well.
After listening attentively to the above statement of
the patient, I proceeded to make as thorough an examina-
tion of the part.as it was possible to do without the aid
of an anesthetic, which, unfortunately, was not at hand.
Sixteen hours had elapsed since the receipt of the injury.
I found the lower third of the leg, the ankle, and foot
enormously swollen, tense, and tender, and on the an-
terior aspect of the joint a strip of excoriated integument
of adull white color and mottled appearance, three inches
in length and an inch in width, and which appeared to
have been deprived of its vitality by reason of the undue
pressure to which it had been subjected between the op-
posing bodies alluded to. Unable, after long-continued
manipulation, to detect the usual signs of a fracture or
dislocation, and owing to the excessive swelling of the
parts by which the natural contour of the joint was for
the most part obscured, I felt at a loss to determine the
real nature of the injury—whether a luxation, fractures of
one or more of the larger tarsal bones, or both combined,
had been received; yet at the same time, in view of the
peculiar circumstances under which the injury had taken
place, together with the general appearance of the limb,
its uniform and excessively swollen condition, far in
excess of that usually seen in severe sprains of the same
joint, I felt convinced that the ankle-joint had sustained
an injury of the gravest character, the final outcome of
which the future alone would disclose.
The patient, on being informed of my rather gloomy
view of his case, was not disposed to accept it as conclu-
sive; on the other hand, he strenuously insisted that his
ankle-joint had been displaced, and properly replaced by
the efforts of his friends. Here, then, was an instance
in which physician and patient could not agree; and
while the one was in a measure non-committal for the
time being, by virtue of the inherent difficulties attending
the case, and consequently guarded in his utterances as to
prognosis—as a medical man is in duty bound to be who
has any regard for his professional reputation and at the
August 10, 1889]
- THE MEDICAL RECORD.
147
same time takes into consideration the contingency of a
suit for alleged malpractice because, perhaps, of an ex-
pressed opinion in an unguarded moment and under the
stress of persistent solicitations on the part of both the
-patient and his sympathizing friends—the other was posi-
tive and emphatic in his opinion, ignoring probabilities as
unworthy of consideration and, therefore, needless to be
entertained. In his view of the matter the patient was
both right and wrong, as will appear later on.
Notwithstanding the fact of the apparent difference in
opinion between physician and patient, I obtained his con-
sent to place the limb in a fracture-box for better se-
curity, improvised from such materials as happened to be
within reach, and for the speedy abatement of the inflam-
matory action that had taken place and was still in prog-
ress to employ cold water irrigation until such time as I
was able to visit him again. On the fifth day following I
again visited the patient, to find him in good spirits, with
little or no pain and a marked improvement in the local
Symptoms under the employment of the cold-water irri-
gations directed on the occasion of my first visit; so much
so, in fact, that gentle manipulation was no longer neces-
sary. The strip of integument previously mentioned
had become gangrenous, dry, and shrivelled, while a line
of demarcation had formed on all of its attached sides,
along which the dead and living parts touched; be-
neath the central portion of this strip, but obscuring it
from view, was felt what appeared to the touch a
rounded, smoothly convex surface, and slightly movable
from side to side-under firm pressure. It now appeared
evident that this was the astragalo-scaphoid articulating
surface, and that the astragalus had sustained a fracture
through its neck, with its fragment so displaced as to pre-
sent the articulating surface just mentioned directly up-
ward and transversely. In this view, it will be seen fur-
ther on that I was grievously mistaken. In justice to
myself, however, I will say that had the patient at this
visit consented to a thorough examination of the ankle, as
he was urged to do, involving necessarily an enlargement
of the existing wound, the real nature of the injury
would have been speedily disclosed and the proper oper-
ative measures instituted, without, as was the case, the
long, not to say dangerous delay, before anything of a
radical nature was attempted. To this, however, he
stubbornly refused to give consent, for reasons already
stated. At this juncture of affairs I was half-inclined to
retire from the further supervision of the case, for reasons
that will appear manifest to those who have been placed
under similar circumstances, yet at the same time it must
be confessed that I was anxious to keep it under observa-
tion on account of its ranty, comparatively speaking, as
well as its peculiar nature, involving a large and important
joint. At this visit I induced the patient to consent to
the application of a plaster-of-Paris cast to his limb, in
order to secure absolute rest to the joint.
Without entering into more extended and, perhaps,
unnecessary details, it will suffice to say that during the
interval in which this dressing remained in st#u—a
period of sixteen days—a rapid decline of the local
symptoms took place; the tenderness and tumefaction of
the parts so far subsided as to permit the patient to go
about oa crutches and avail himself of out-of-door exer-
cise without much inconvenience. The patient was
finally induced to submit to an operation, and for that
purpose came to this place on July sth. On that day
the plaster cast was removed, preparatory to the op-
eration on the day following. On its removal the tu-
mefaction was found to have quite disappeared, the long,
narrow wound remaining after the separation of the gan-
grenous integument cicatrized at either extremity, and
its central portion presenting a healthy granulating sur-
face, from the bottom of which the rounded head of the
astragalo-scaphoid articulating surface protruded, and still
somewhat movable from side to side.
On the morning of the sixth of the month named
above, twenty-one days after the receipt of the injury,
after the parts had been made aseptic and the patient
placed under the influence of chloroform, the operation
was made, in which I was ably assisted by Dr. A. B.
Bickford, of California, temporarily on a visit to relatives,
and Mr. Frank Morley, a student of medicine in my
office. ‘The original wound was enlarged at either ex-
tremity for a short distance, and by a vertical incision
parallel with the flexor tendons ; after which the index-
finger was introduced into the wound for the purpose of
exploration. I soon found that the neck of the astragalus
was intact, and that the entire bone had been dislocated
in such a way as to have abandoned all of the articulating
surfaces to which it is applied, tibia, fibula, calcaneum,
and scaphoides; in other words, its scaphoid articulating
surface looked directly upward and transversely, or nearly
so, its superior or trochlear surface backward, and its in-
ferior surface forward. As far as could be determined by
the exploring finger, the bone, as it lay in its abnormal
position, was thought to be intact, at the same time that
the finger could not be made to reach to the bottom of
the cavity for want of space. The bone was still firmly
held in its anomalous position by its ligamentous attach-
ments, which required division before its extraction could
be effected. After its removal, examination showed that it
had sustained a comminuted fracture—its entire poste-
rior surface having been literally ground off, so to speak,
by the force applied, including, of course, the groove
which transmits the tendon of the flexor longus pollicis,
with nearly one-half of the posterior articular facet on its
inferior surface and of the trochlear surface as well.
After the removal of the bone a number of small frag-
‘ments were removed with the forceps, and the débris re-
maining at the bottom of the deep cavity washed out with
carbolized water, the wound duly drained, dusted with
iodoform, and lightly dressed with antiseptic cotton, the
open method of treating such a wound being deemed pref-
erable to that in which sutures, adhesive strips, and band-
ages are employed, and the limb firmly secured in the
bracketed wire splint represented in Ashhurst’s “ Inter-
national Encyclopedia of Surgery,” vol. iv.
Without entering into the details of the case as it pro-
gressed from day to day, it will be sufficient to say that
for a few days its aspect was everything that could be de-
sired. On the sixth day, however, a change for the worse
took place. A high grade of inflammatory action of the
remaining structures of the joint supervened, attended
with the usual accompaniments of inflammatory action,
and progressed with such rapidity and intensity that within
twenty-four hours from the time of its approach the in-
ferior half of the limb was as greatly and uniformly swollen
as at the time I first saw the case; and, as may
be supposed, severe constitutional symptoms added to its
gravity. These symptoms continued with varying intensity
for nearly three weeks before any well-marked signs of
amelioration in either were observed ; and, it 1s proper to
add, so far compromised the safety of the patient as to
call up for consideration the question and propriety of
amputation of the limb as a last resort, as already stated.,
Fortunately, however, for the patient, and in spite of his.
oft-repeated clamorings for release from his suffering by
the sacrifice of his limb, the more alarming features of
the case gradually gave place to other more favorable
features under the judicious use of quinine, morphia, and,
especially, cold-water irrigation, for the space of nearly
three weeks. From this time the case went on gradually
toward ultimate recovery. After the deep wound had
healed, with but a trifling amount of suppuration from
first to last, as soon as the state of the parts admitted,
systematic passive motion was employed at frequent in-
tervals, and continued until flexion and extension were
almost, if not quite, as good as in the sound foot—a grat-
ifying result to both patient and physician, surely ; and, I
may add, altogether unexpected from the first. He was
finally discharged from under my care in the latter part of
September following, three and one-half months from the
time his injury was received.
Lf
148
rigation employed in the case. In my opinion, it proved
to be the most effective weapon for good that could have
been employed, and I am well convinced that by no other
method could the severe local symptoms have been so
successfully combated as proved to be the case in this in-
stance. By its unreiitting use for days and days the deep
wound was kept clean and aseptic, the local heat and pain
within endurable limits, and the tumefaction at rest; in
short, as the patient expressed it, it conduced more to
his comfort than all other treatment combined.
A few words in regard to the condition of the foot
something over a year from the time of his discharge from
under my care, before concluding. At this time he in-
formed me that, with the exception of a slight limp, walking
is attended with no difficulty, and with little or no fatigue,
even when a long distance has been covered ; and that,
as far as he can determine, his left foot, for all practical
purposes, was as good as his right.
ON A VISIT TO BIRMINGHAM AND TO MR.
LAWSON TAIT.’
By J. MILNE CHAPMAN, M.D., M.R.C.S.,
MEDICAL ATTENDANT TO THE NORTHERN INFIRMARY, INVERNESS, SCOTLAND,
As I had the advantage during February of seeing Mr.
Tait at work for a fortnight, and of enjoying frequent op-
portunities of personal communication with him, I have
thought that an account of the time so spent might be of
interest to the members of our society, and might not per-
haps be without profit.
In the first place I may warm those who, like myself,
may be anxious to see Tait at work, that it is no very easy
matter to do so, at least it does not appear to be, though
I am quite sure that he will specially welcome any one
coming to him from the North of Scotland, where he him-
self first saw ordinary medical practice. He is a Scotch-
man heart and soul, and delighted to talk to me of his
experience while acting as /ocum tenens and assistant to
Dr. Soutar of Golspie. He receives very numerous ap-
plications from practitioners anxious to see him operate,
but as the bulk of his work is private, and is undertaken
in ordinary sized bed-rooms, it is impossible for him to
gratify them all. ‘The story is told of one of our transat-
lantic cousins who, on one occasion, presented himself in
Mr. Tait’s consulting room about mid-day, and after
greeting him and expressing his pleasure at meeting him,
introduced himself and stated that he had just arrived
that morning in Liverpool, was on his way to London, and
had stopped on the way to see him operate. He had only
an hour or two, but would like to see him do one or two
sections. This, of course, is an extreme case, but the appli-
cations were so numerous, not only to see one operation,
but to be allowed to see twenty, thirty, forty, or one hun-
dred cases, that Mr. Tait felt compelled to institute a
system of pupilage which is now in operation.
ceives four post-graduate pupils for periods of six months
at a fee of one hundred guineas. For this they are privi-
leged to see all operations in the same way that I was,
and which I shall presently describe, and also, two at a
time, they attend with him when he sees his hospital out-
patients on Mondays and Thursdays. ‘This seems a heavy
fee for such advantages, but there is no doubt that it is a
good speculation for his pupils, and he has many more
applications than he can comply with. Those who have
already passed through the system and are now at work,
in America and elsewhere, have succeeded in speedily estab-
lishing for themselves positions and practices which they
might not so readily have obtained otherwise. America
1S an enormous country, and possesses numerous large
| Part of a paper read before the Inverness Scotland Medical So-
ciety, March, 188g.
He re-
[August 10, 1889
cities, and, therefore, openings for such specialists as are
thus trained.
On my first presenting myself to Mr. Tait on the day
of my arrival in Birmingham, he took me to his secretary’s
room, and instructed her to send me word of when op-
erations were to take place, and I was told there was to
be one that afternoon at 2.30. At that nour I according-
ly returned to the house and was shown into a small
drawing-room in the hospital wing, where I was presently
joined by his pupils. After waiting a little, a nurse
opened the door, and we all trooped upstairs into a small,
ordinary bed-room with white painted wooden floor and
strips of carpet. Resting with its lower end against the
window sill, was a narrow operating table with the patient
already anesthetized. Mr. Tait, in shirt sleeves and hold-
ing a small knife between his lips, was standing by the
patient’s side. No greetings were interchanged even by
look, nor was a word spoken. One of the pupils rapidly
washed his hands and took up his position opposite as
assistant. This post, however, is almost purely a sinecure,
as Mr. ‘Tait does practically everything himself. The
making of the abdominal incision was the work of less
than sixty seconds, and what particularly struck me was
the way in which he handled his knife. Never in all my
experience have I seen anyone make a knife cut like he
does. ‘The instrument is a narrow-bladed short scalpel,
and he lays it down so that the whole length of the blade
cuts. ‘The effect is like that of cutting butter with a good
table-knife. You hardly notice any motion, but the tissues
separate in front of the knife and the incision is made,
clean down in many instances to the peritoneum. One
or two touches at most make the wound even from end
to end, and then he picks up the peritoneum in two pairs
of pressure-forceps and cuts straight down between them,
the assistant meanwhile holding one of the two pairs; these
are then removed, he runs his knife up and down the
peritoneum and the abdomen is open, actually in a shorter
time than it has taken me to read this description, and
with a neatness and dexterity which I fear no words of
mine can fully convey. The case I speak of was one of
fibroid tumor, in size about that of a four months’ preg-
nancy. Mr. Tait rapidly enlarged the incision up and
down by putting the tissues on the strain with two fingers
in the abdomen and running his knife inside the abdomen
edge upward, the whole wall splitting with as much ap-
parent ease as the leaves of a book before a good paper-
cutter. He inserted his hand behind the tumor and
worked about for a time. As there was nothing to see of
the operation at this time I turned my attention on the
operator's face. It is a curious face, as those who have
seen it will readily admit, long and large featured in every
respect, except the mouth, which is unusually small with
thin, firmly compressed lips. A heavy band of hair—which
is long and black and glossy—hung down over the fore-
head and eye, but what then impressed me was the rigid
concentrated attention expressed on every line and feature.
The eyes were turned upward to the corner of the win-
dow, but were very evidently looking at nothing. Pres-
ently he said “ Trocar,” and a long curved one being
handed to him, he took it in his right hand and pulled
the point back till it was within the cannula, and slipped
the instrument down in front of the left hand, which was
still within the abdomen. Having settled its position, he
held it secure with his fingers on the cannula shield, and
having with the thumb slid the trocar forward, he pushed
the instrument still deeper, and on withdrawing the
trocar, there gushed out about a pint of thick offensive
pus. He then said that there was the same condition on
the other side and asked for the aspirator, but meanwhile
continued to work away at the sac from which the pus
had come, and presently brought it to the surface, a hugely
dilated Fallopian tube of the right side. He tied the
pedicle in the Staffordshire knot and removed it. He
then went to work on the other side, but the sac burst,
and he simply squeezed the pus out, fished the sac to the
surface, and ligatured straight away. He then brought a
August 10, 1889]
third mass up from behind the uterus—oval, and as large
as a breakfast-roll, which turned out to be a dermoid cyst
of the nght ovary. The pedicle of this was secured in the
same way. At the time he gave this third mass not a
moment’s consideration, but laid it aside, proceeding to
wash out the abdomen, using three large pailfuls—about
the size of stable buckets—of warm water, running through
an ovariotomy tube and trocar. During the process of
washing out he moved the contents of the pelvis and the
intestines freely about with the left hand to secure their
being thoroughly cleansed. Looking at the uterus, he
determined that it contained a fibroma, and impressed by
the amount of mess that was about, he resolved at once to
remove it. As his method of doing this is fully detailed in
his writings, I shall not enter info a discussion of the pro-
cess ; suffice it to say that the neatness and dexterity he dis-
played forced the conviction on me that I was witnessing
the performance of a real professor of the surgical art,
and thrilled me with a sensation which a lover of music,
who had never heard other than second- or third-rate per-
formances would feel, were he suddenly to hear the
strains of a Paganini.
But to complete the history of the case under consider-
ation. It was found that an adhesion which had existed
between the rectum and the tumor on the left side was
persistently oozing. There was no room for ligature,
and Mr. Tait first tried pressure with a sponge. As this
failed to stop the oozing he rubbed the surface over with
a piece of solid perchloride of iron, and as even this did
not completely succeed he made a watery solution of the
perchloride and applied it with a sponge. He then dried
out the abdomen with sponges, inserted a drainage-tube,
and stitched up the wound. ‘The whole operation took
fifty minutes, an unusually long time for Mr. Tait to
take over any operation.
Here I would say a word as to a use of the drainage-
tube which is but imperfectly understood, and that is its
good effect in stopping bleeding from torn adhesions.
Blood effused into the abdominal cavity shows little
tendency to coagulate save in a very fitful and fragment-
ary way, probably from its admixture with peritoneal
fluid. If, therefore, there is oozing from torn adhesions
into a completely closed abdomen the blood does not
coagulate fully, its presence sets up free secretion of peri-
toneal fluid, which reacts and leads to further bleeding
and still more defective coagulation; while, on the other
hand, if a drainage tube is employed and the pelvic
cavity kept dry by frequent withdrawal of blood and
serum, oozing will soon cease.
The operation in question having been completed we—
that is, the pupils and myself—silently left the room and
soon left the house. Next moming I got a postal card
saying that there would be two operations at the Private
Hospital at 9,30 A.M., and one at the Woman’s Hospital,
Sparkhill, at 2.30 P.M. ‘The first was a doubtful case of
distention of the gall-bladder. In less than five minutes
Mr. Tait had opened the abdomen over the region of the
gall-bladder, established the diagnosis of malignant dis-
ease of the transverse colon or omentum, and closed the
wound. I learned afterward that the patient left the hos-
pital in a week, none the worse. Of course, had the case
turned out to be one of gall-stones she would have been
relieved of her trouble there and then. In the afternoon
I saw an ordinary case of removal of the uterine append-
ages. I shall not stop to discuss this class of cases ;
the one that I saw on this occasion was certainly an in-
stance where the operation was perfectly justifiable, judg-
ing from the condition of the parts removed. When the
operation began I took out my watch to time it. Having
carefully looked at it I put it in my pocket and turned to
the operating-table, when, to my surprise, I saw that the
abdomen had been opened and Mr. Tait was fishing with
two fingers of the left hand (which was all the incision
would admit) for the diseased organs. On getting thesq
between his fingers he slipped down a pair of forceps,
seized them, and in this way brought them to the surface,
THE MEDICAL RECORD.
149
at the same time pressing down the abdominal incision
and walls with the back of his hand and holding the
ovary and tube between his fingers. He then passed the
ligature through the pedicle, ran the loop over the append-
ages, arranged the Staffordshire knot, pulled each end
firmly, tied a single knot, and then fastened a pair of
catch-forceps on each of the threads, wound the thread
three or four times round the handle of the forceps, and
selzing a pair in each hand he let go the ovary. and firmly
pulled the knot tight. ‘This method of securing the knot
he carried out without the slightest assistance and while
he held the parts to be removed in his own hand. I de-
scribe it thus in detail in the hope that I may convey to
you some idea of the marvellous dexterity of the man.
The other side was similarly dealt with, and the operation
was completed in ten minutes.
Mr. Tait only spoke once during that time. Just when
the patient was laid on the table, the Sister who was
giving the anesthetic put out her hand to lift the arm on
the table. Tait tapped her on the shoulder and said,
“ Attend to your own business.” This is quite charac-
teristic of the man. He has everything reduced to a per-
fect system, and everything goes on with just such steady
regularity and apparent simplicity as do the manceuvres
of a well-drilled regiment of soldiers. Trespassers, how-
ever, even be their fault as slight as the one I have just
mentioned, are at once rebuked, just as the soldier would
be who ventured on any irregularity during parade.
Among the other cases I saw operated on were a sim-
ple ovariotomy, which was completed in five minutes,
neither sponge nor fingers having been placed within the
abdominal cavity, and the incision being not more than
one and three-quarters inch long; a difficult ovariotomy ;
removal of tubes containing pus; removal of one ovary
and tube glued together and adherent to the back of the
uterus and floor of the pelvis, the other ovary having
been removed five years previously. In passing I may
remark that Mr. Tait has ceased to remove single ovaries
(except for cystic disease), as his experience is that for
inflammatory mischief a second operation always becomes
necessary sooner or later. I was also present at a hyste-
rectomy and at an exploration of the kidney. In this
latter case I saw illustrated the value of pressure in
checking hemorrhage. The wound was of course a very
deep one, the pelvis of the kidney being opened into,
and the bleeding was very free, much freer than mere
oozing, but, to reach the bleeding-pomts would have in-
volved enlarging the incision very much. The wound
was packed full with dry sponges, and these were firmly
held down by the hand for two or three minutes. On
taking them out the bleeding was markedly diminished
but had not ceased, so the packing was repeated and
again repeated, when it was found that the wound re-
mained dry. A drainage-tube was inserted, and the
stitches were tied with a running-loop knot, with long ends
so that they might be undone if required. Instructions
were left that should hemorrhage occur a solution of
perchloride of iron was first to be injected through the
drainage-tube, and that should this not succeed in check-
ing it, the knotsin the stitches were to be slipped, the
clots cleaned out, sponges wrung out of perchloride of
iron inserted and firmly packed in. The sponges that
were used were simply wrung out of plain water.
I have since learned that all the patients I saw oper-
ated upon made prompt and good recoveries.
One thing I saw Mr. Tait do which I certainly have no
intention of imitating him in. He used two of the fingers
of his left hand as a sort of Sims speculum, and, kneeling
by the bedside with the window facing him—the field of
operation therefore completely in the dark—he freely
curetted the uterus without in any way fixing it. He then
inserted a short Ferguson speculum, and through this
passed into the uterus a thermo-cautery. No doubt the
cervix had been previously fully dilated, and probably the
end in view was satisfactorily accomplished, but I hardly
think the somewhat free-and-easy method I have described
150
THE MEDICAL RECORD.
[August 10, 1889
will commend itself to the profession at large. Though
Tait may manage to dispense with the ordinary aids of
speculum, light, and vulsella, the general run of us, I think,
had better continue to perform our curettings in a more
wrthodox fashion.
{ was disappointed in not being able to see Mr. Tait
perform the operation which bears his name for restora-
tion of the sphincter and perinzum, as the written de-
scriptions of it are not very easy to follow. I talked it
over with his assistants, and they told me that he only
takes five or ten minutes to do it.
It may have struck you that I have alluded to two opera-
tions which went no further than exploration, one of the
liver and one of the kidney. And here I would say a word
in regard to Mr. Tait’s position on the subject of explora-
tory or confirmatory operations, for, in respect to this
more than to almost any other question, he has been very
greatly misrepresented, and I shall, as far as possible,
make use of his own words. We have all heard him
spoken of as a man who “would put his hand into a
woman’s abdomen with as little compunction or reflection
as he would put it into his trousers pocket ;” and also we
have heard him quoted as saying, when in doubt as to
diagnosis, “ open the abdomen and find out ;” or, even still
more grotesquely, he has been accused of not being able
to make a diagnosis in the ordinary fashion, but of open-
ing the abdomen and taking a look in when there is a com-
plaint of anything inside, and of doing this in as much a
routine fashion as one opens the mouth and looks in
where there is a complaint regarding the throat. Let me
quote his own words:
“ I have long since thrown the uncertainty of diagnosis,
as an impediment to the adoption of proper treatment, to
the winds, and when I find my patient in danger of death
from conditions within the abdomen which do not seem
to be clearly of a malignant character, but a correct diag-
nosis of which is impossible, I open the abdomen and at
once make the diagnosis certain and successful treat-
ment possible.”
This was written in 1876, and further he says that he
does “ the same things when the conditions were such that
the patient’s life was a misery by reason of suffering which
could not be relieved, or at least had not been relieved in
any other manner. ‘The result has been an enormous ad-
vance in abdominal surgery, obtained only after a severe
struggle with the authority of the elders who asserted that
the abdomen was aregion into which the writs of ordinary
surgical laws should not run.”
As a defence of exploration I would further quote from
Mr. Tait’s writings : “ This principle of exploration is noth-
ing new. In fact, the way it is sometimes used, or rather
abused, is almost horrible. I once saw a surgeon, who is
now a baronet, remove a breast with a tumor in it, and
after the whole thing was over he took the tumor in his
hands and drew his knife across it and out rushed a lot of
pus— laudable pus.’ He had made his exploration after
the treatment had been completed. If he had explored
first, his diagnosis would have been completed before his
blunder had been made, and the radical operation and
‘treatment would have been rendered wholly unnecessary.
I have similarly seen a limb amputated for a sequestrum
opening into the knee-joint which a preliminary explora-
tion would have shown to have been capable of removal |
without amputation, and the limb would have been saved.
Crowds of illustrations of this kind of practice could be
given, showing in the first place that complete accuracy of
diagnosis is no more possible in the breast than it is in the
abdomen ; that exploration is a sound principle when there
is doubt, and that many ghastly blunders would be saved
if the practice were extended.into general surgery. Ab-
solute accuracy of diagnosis in the abdomen is very far
from being possible ; only the ignorant assert that it is, and
only fools wait for it.”
More than any man, or, I might almost say, single-
handed, Mr. Tait has established this principle of explo-
ration in doubtful cases of abdominal disease when life is
threatened. He has been the better able to do so from
his extraordinary success as an operator. But what one
man has done another may do, and I can quite well fore-
see that before long it will be considered as bad practice
to allow such cases to die without operative interference
as it would now be to leave a man blind from cataract
without giving him the chance of again enjoying the bless-
ings of sight, for fear that an inflammatory attack might
necessitate removal of the whole eye.
Another charge that is freely made against Lawson
Tait is that he does not tell the truth. The statements
he had to make regarding his work in the earlier years of
his practice were so startling and novel that they were not
at first accepted as true. Time—the righter of all wrongs
—has proved by results that the facts and theories then
advanced can, and have, stood the test of experience,
and though Mr. Tait’s theories and deductions are not
very generally accepted as correct, the impression caused
by their startling enunciation still finds expression in the
charge of untruthfulness I have just mentioned. Now, it
is absolutely impossible for Mr. ‘Tait to tell lies regarding
his operations or his results. Of the four pupils who
watch every operation, each keeps an accurate note-book
for his own reference and use, in which he details every-
thing that happens both in Mr. Tait’s hospital and private
work. This has gone on for years; Mr. Tait’s results
are published down to February 2d of this year, yet they
have never been questioned by any of those who, had
there been occasion and justification, could have done so
successfully. Nay, I may say more, that I have met eight
or ten of Mr. Tait’s past pupils and not one of them
doubts a word he ever said. ‘They have seen what others
have not seen. They have had personal opportunities of
detecting any such tendency to perversion of the truth, but
one and all they have expressed their unbounded admira-
tion for the man and for the surgeon.
I had myself good opportunities of forming an estimate
of the character of the man. We spent together from
Saturday to Monday at Malvern, as guests of an old Scotch
practitioner there, and many were the topics that we dis-
cussed. I do not wish to make this anything of the style
of the modern society journal, so I shall not enter into the
private life of the man, I shall only say that I found, as I
was fully prepared to find from a perusal of his writings,
that he is a man of master intellect, that the range of his
knowledge is wide and far-reaching, that the accuracy of his
knowledge of details is surprising, that his tastes are re-
fined and cultivated to an extraordinary degree, and that
his capacity for the enjoyment of recreation, amusement,
and the good things of this world generally is unlimited.
As to the type of his mind, I would say that it is essen-
tially mathematical ang scientific, and I would ask you is
it not your experience that those possessed of minds of
such a type are naturally and instinctively, as well as
habitually and by training, rigid sticklers for the truth.
Before concluding I would briefly touch upon three out-
standing departments of Mr. Tait’s life-work. Already I
have referred to what he has done in establishing the
principle of exploration as applied to the abdomen. One
outcome of his work in this direction has been his demon-
stration of the fact that very many of the cases where
masses are felt at the sides of* the uterus, and which
are called peri- or para-metritis, and are-treated as such,
are really cases of occlusion and distention of the Fallo-
pian tubes with fluid of various kinds, or of chronic in- `
flammatory adhesion of tube, broad ligament, and ovary.
There are also many cases in which the functional utility
of the organs is completely destroyed by disease, and in
which, further, the disease, such for instance as pyosalpinx,
constantly threatens the life of the patient. Mr. Tait has
demonstrated that cases such as these are quite amenable
to surgical treatment. What suffering he has relieved and
averted, what life he has saved and prolonged by these
;means passes my ability to conceive. '
His work, too, in elucidatinz the natural history of
uterine myomata, and in elaborating their surgical treat-
August 10, 1889]
ment, is to my mind of the greatest interest and impor-
tance. His papers on these subjects at present appearing
in the Birmingham Medical Journal will well repay care-
ful perusal, and ought to prove an effectual antidote to
the effects of the electrical mania which is at present ram-
pant. |
And, finally, there is what I consider the crowning
triumph of his life, the establishment of the principle of
immediate abdominal section in cases of ruptured tubal
pregnancy, by his magnificent results—two deaths in forty-
two cases of an accident which, without interference, is
uniformly fatal.
Clinical Department.
NEUROTIC OR HYSTERICAL FEVER.
By CLARENCE KING, M.D.,
MACHIAS, N. Y.
MARKED elevation of temperature in hysterical indi-
viduals, unassociated with any visible structural cause to
explain it, has received but little attention from medical
writers, and those who have mentioned the subject have
mostly done so to deny its existence. These either at-
tribute the fever to fraud ingêniously practised by the
patient or to an accompanying disease undiscovered by
the physician. ‘There are, however, in my opinion, a
sufficient number of cases recorded by various observers
to justify us in acknowledging this as one of the rare
manifestations of the neurotic temperament. Thus Mit-
chell, as quoted by Mills,’ has recorded a case of an
hysterical female, thirty-eight years of age, whose temper-
ature ranged from 95° in the morning to 100 or 100.5° F.
in the evening, and whose pulse was never less than 130
per minute, even when lying quietly in bed. This patient
was suffering from no pulmonary or visceral trouble, and
no cause could be assigned in explanation of the elevat-
ed temperature aside from the neurotic influences. De-
bove, according to the same author,’ cites a case of a
female, twenty-four years of age, in whom the ther-
mometer sometimes registered as high as 102° to 104° F.,
and in whom the mention of the sumnambulistic state
would raise the temperature from 1° to 2° F. Bressler’
has also called attention to cases of elevated temperature
lasting froma few hours to several weeks, which were
associated with an accelerated pulse, vomiting, perverted
appetite, and extreme sensitiveness of the abdomen.
The disease usually began with sensations of chilliness,
loss of appetite, constipation, furred tongue, and head
ache, the temperature early reaching a high degree and
remaining there, or being subject to sudden and marked
variations. The pulse was usually increased in frequency.
The disease was distinguished from peritonitis by the
fluctuating character of the abdominal pain, absence of
tympanites, ovarian tenderness, and aca of temner-
ature.
‘In this connection a case occurring in my practice may
be of interest to some of the readers of THE MEDICAL
RECORD.
Lovina C , female, marned, aged twenty-one, mother
of one child ; neurotictemperament marked, inherited from
father.
In June, 1888, I saw her professionally for the first
time and found her in the fifth month of pregnancy, lying
apparently unconscious in an hysterical attack. She had
not been troubled a great deal with nausea ; passed abun-
dance of urine ; bowels quite regular. Her friends told
me that she had always had these “fits,” but of late she
had been quite free from them. I took her temperature
twice and found it each time 100° F., her pulse being
about 97. I could discover nothing to account for the
fever. The following day she was around the house again.
1 Pepper's System of Medicine, vol. Ve,
3 Op. cit.
age 252.
R RECORD, 1888
THE MEDICAL RECORD.
I5I
Ten weeks after this I saw her again in one of her fits
and found her much the same as at my former visit ; tem-
perature, 102° F.; pulse, roo. I took her temperature
three times, twice under the tongue and once in the axilla,
ard sat where I could watch her while it was being taken.
Each time the thermometer registered nearly the same.
Again I could find no structural discase to explain the
fever. The next day her temperature was 99.5° F., and I
did not see her again, but her husband told me that after
having several of these fits she “ was all right again.”
October rst, I was called to attend her in her confine-
ment. Upon my arrival I found her in the first stage of
labor, again lying apparently unconscious in one of her
fits, the os dilated to the size of a nickel, pains occurring
about every twenty minutes and becoming more frequent
and severe. Whenever she had a pain she would rouse
up and groan, but after its subsidence would quickly sink
into her former unconscious state. As her pains became
more severe these fits were discontinued, and she was
finally delivered, after a natural though somewhat slow
labor, of an eight-pound male child. Imagine my sur-
prise at my next visit, ten hours afterward, to find my
patient with a temperature of 105° F., a pulse. -of 120, the
bowels only a little sensitive to pressure, and everything
else, so far as I could ascertain (and I made a thorough
investigation), perfectly normal to a puerperium. The
lochia was about normal in quantity and not fetid;
bowels and bladder empty; no lung trouble, and ab-
solutely nothing to explain the high temperature. She
had no chills; the womb was well contracted; the
breasts flaccid, and not tender or painful. For the next
four days her temperature ranged between 103.5° and
105° F. She slept well, took some nourishment, but still
had “ fits” at irregular intervals. While I was still look-
ing for evidences of phlebitis or other disease to explain
the fever, her temperature and pulse suddenly dropped to
about normal, and she made a fairly good convalescence.
Her milk came the night following the day that her fever
left her. Her friends told me that she had a similar
complication when her other child was born, which had
frightened the attending physician the same as it had me.
Three weeks after the birth of this child I saw the
mother again in another of her “fits,” and found her
temperature 104° F.; pulse, 120. No lung trouble or dis-
ease in any organ, that I could find. ‘This lasted two days,
and suddenly dropped to normal.
Six weeks from this time I was again called to see her
and again found a temperature above 104° F. and a pulse
correspondingly high. All the indication of disease I
could find at this time was a moderate diarrhoea. The
next day her temperature and pulse were nearly normal,
and her diarrhoea better. Since this time I have treated
her for pneumonia, during which her temperature was
only moderately elevated.
Here, then, are five observations in the same patient of
high temperature with nothing to explain it. It might be
urged that in each instance there was some positive dis-
ease present which I failed to detect; as, some may
claim after her confinement the fever was due to puer-
peral infection, and in the last observation to diarrhcea.
A temperature of 105° F. following childbirth is suspicious
of puerperal infection, but can we base a diagnosis of in-
fection on the fever alone? In this instance I was un-
easy about my patient and called in consultation another
physician, and he failed to find anything to suggest infec-
tion except the fever and pulse. Ten hours after partu-
rition is early for infection to give rise to a temperature
of 105° F., while we must admit that the excitement of
childbirth would be a potent factor in producing hys-
teria.
In the treatment of this case the therapeutic measures
employed were simple but efficient. Antifebrin was
given only during the high fever following her childbirth.
Hyoscyamus, valerian, bromides, tonics, etc., were pre-
scribed in each instance, and baths, out-door exercise,
and laxatives in the interim.
152
SCIRRHOUS CARCINOMA OF THE BLADDER,
WITH VESICO-RECTAL FISTULA.’
By THOMAS C, KENNEDY, M.D.,
SHELBYVILLE, IND.
‘THE case presented is óne of great interest, and is gener-
erally considered rare, probably on account of mistake in
diagnosis, as was first made in this case. If a post-mor-
tem examination had not been allowed, and it was posi-
tively refused when I first broached the subject to the
friends, the correctness of diagnosis would not have been
questioned, and the case would have passed for simple
chronic vesical catarrh.
I was called to see Mr. J. D. M——-, carpenter, aged sev-
enty-two, April 16, 1888. When I entered the room he
was sitting over a vessel trying to urinate. ‘There was
considerable vesical tenesmus and he was suffering great
pain. He complained that the passage of urine produced
a burning in the urethra, with a feeling of weight in the
perineum. He had a sharp lancinating pain in the supra-
pubic region and over the right kidney. There was a
constant desire to empty the bladder, which he attempted
to do about every fifteen minutes. Hehad had a chill every
day about 9 a.M. He was very restless the night before
I saw him, and passed a few drops of highly colored urine
four or five times an hour.
I introduced a soft-rubber catheter, and drew off two
ounces of residual urine. I prescribed morph. sulph.
(gr. 4), to be given every three hours until relieved ; also
gave pil. quin. sulph. (gr. iij.) every two hours, with di-
rections not to disturb the patient if asleep.
I remained with the patient about one hour ; at the end
of that time he was resting comfortably.
April 17th. ‘Rested very well until about midnight, hav-
ing been up seven times in six hours to empty his bladder.
At twelve o’clock (midnight) he took another pill of mor-
phia, but did not rest as well after midnight as he did
before. He urinated sixteen times between midnight and
6 A.M. ‘There was less pain in passing urine than there
had been. The bowels acted slightly this morning.
At 5 P.M. of same day I found the patient quite com-
fortable. He had a light chill that morning, but rested
well all day and slept about two hours in the afternoon.
He passed urine twelve times in eleven hours.
An examination of the urine was made, with the follow-
ing results: Sp. gr., 1.030, highly acid ; is negative as to
albumen and sugar, but shows an abundance of stringy
mucus. I ordered hot fomentations to be applied over
the region of the bladder, and also a hot hip-bath in the
evening ; morphine to be given to relieve pain, if nec-
essary. Lime-water was to be drunk, to neutralize the
acidity of the urine.
From this time the patient improved rapidly, pain was
diminished, and the desire to urinate decreased. By April
25th he was able to be up part of the day, and, the
weather being pleasant, he was permitted to be out in the
yard a few moments at atime. ‘This improvement con-
tinued until May 8th, when he was suddenly seized with
a sharp, shooting pain in the urethra and perineum. ‘The
bowels began to discharge at 4 a.m. He had very copious
evacuations for several hours, when the discharges became
thin and slimy.
The urine was very offensive, having a strong fecal
odor. I gave opium to control diarrhoea, without any
notable effect. About nine o’clock he was taken with a
chill, and had rigors for several hours. He complained of
an accumulation of gas in the bladder, and said it caused
great pain when passing through the urethra. The escape
of this gas could be heard distinctly at a distance of three
feet. A vesicu-rectal fistula was suspected, but this could
not be confirmed by a rectal examination.
The patient continued to go from bad to worse until,
upon May 13th, I began the use of “ lithiated hydrangea,”
' Read before the Mitchell District Medical Society, Seymour, Ind.,
December, 1888,
THE MEDICAL RECORD.
[August 10, 1889
and discontinued all other remedies except morphia in
one-eighth grain doses. He improved again until June
11th, when he walked across the street and talked to a
neighbor for an hour. He felt stronger, but did not
attempt to do any work. On June 26th he walked to the
post office, a distance of one-half mile, and stopped at my
office on his way home. He said he felt well, except that
he was “troubled by the blowing, before passing urine.”
On July 29th I was hurriedly summoned to see him;
the messenger saying that the old man was dying. Found
him in bed complaining of violent pains in the bladder.
Had a severe chill, followed with fever and delirium.
Temperature, 104° F.; respiration, 22; pulse, 98. With the
urine were passed small particles of faeces, and also shreds
of broken-down muscular tissue. He had cleaned up his
shop that day, and filed a saw. While he was still at
work, he was suddenly seized with a cramping pain in his
bowels and had to be taken to the house. From this time
he began to lose flesh, lost all appetite, and a diarrhoea
commenced that baffled all efforts made to check it. All
the former symptoms of pain, vesical tenesmus, frequency
of urination came up with renewed vigor and could not.
be controlled.
On August 14th Dr. Edward F. Wells was called in
consultation. Acting upon his suggestion, we washed out
the bladder with a weak solution of boric acid, from which
the patient received temporary benefit. ‘The patient con-
tinued to grow weaker, became emaciated, and on August
26th lapsed into a semi-comatose condition from which
he could not be aroused. On August 30th he died from
exhaustion.
About ten hours after death I held a post-mortem ex-
amination, being assisted by Dr. E. F. Wells. Drs. Mc-
Faddén, Green, and S. A. Kennedy were present. A
large tumor was found in the apex of the bladder, which
also involved the entire body down to the trigone. On
the posterior wall was an ulceration of a considerable
size. Almost in the centre of this ulcerated surface a fis-
tula of large calibre was found, connecting the bladder
with the rectum. Inflammatory adhesions bound the
bladder to the rectum, and there were also metastatic de-
posits found in the rectum and intestines. I sent a por-
tion of the tumor to Dr. E. R. Palmer, of Louisville, Ky.
After having made a careful microscopic examination, he
pronounced it to be a scirrhous carcinoma.
At no time during the progress of the disease was there
any hematuria, although Stein (“A Study of Tumors of the
Bladder,” page 36) says that “all tumors of the bladder
present, more or less, sooner or later, the triple symptoms,
hematuria, irritable bladder, and pain.”
- ———
a M e MM —
Progress of Medical Science. -
Eczema IN CHILDHOOD.—In writing upon the pathology
and therapy of infantile eczema Dr. Schieff says that the
study of the causes of the disease, and what many are
pleased to call predisposition to it, is better carried out in
the infant than in the adult. The author bases his paper
upon 1,017 skin cases treated in the Vienna Children’s
Hospital, out of which number 449 were instances of
eczema. Eczema capillitii gave 230; eczema faciei, 57 ;.
eczema universale, 30, etc. ‘The anatomical changes are
given as an enlargement and hyperzmia of the vessels of
the papillary body, a serous and cell exudation into this.
and the mucous layer. The papillz are in consequence
elongated and broadened, and so produce the nodule or
papule. In greater new formation of cells in the papille,
and more abundant effusion in the mucous layer and be-
tween it and the horny layer, by which the latter is raised
up, a bulla is formed. If in such a lesion the quantity of
exudation cells increases and becomes greater than the
serous fluid, a pustule is formed. In more intense inflam
mation the corium becomes involved. When the acute
eczema goes over into the chronic form we find the papule:
August 10, 1889]
THE MEDICAL RECORD.
153
often extremely enlarged, the vessels increased in calibre,
the epidermis and corium thickened, at times pigmenta-
tion, indications of increase in connective-tissue growth,
and disappearance of the panniculus adiposus. As re-
gards etiology, it is especially noticeable that eczema ap-
pears most frequently in the first and second years of life,
136 cases in the author’s table’ being put down for the
first year and 143 for the second. There are four reasons
why this is so: 1. The thinness of the epidermis. 2.
The superficial disposition of the papillary body and its
plexus of vessels. 3. The comparatively greater turges-
cence of the skin in the infant compared with the adult.
4. The habitual hypersecretion of the glands of the skin.
The epidermis being thinner, there is more rapid des-
quamation of the horny layer, and the papille and their
vascular net-work lie nearer the free surface and are only
protected from external irritating influences by a thinner
layer of horny tissue. The skin is thus much more readily
affected by irritants, and by reason of the delicacy of its
formation the latter much more quickly produce lesions
of the tissue than is the case in the skin of adults. The
glandular system of the skin being so active, and the prod-
uct of the glands being so disproportionately rich, we
have here one of the most fruitful sources of external in-
jury in the irritation set up by the fatty-acid-fermentation
products of the skin secretions. These and other disturb-
ing influences do not probably in themselves dispose the
child to eczema, but only influence its production in so
far as they affect the nutrition, blood-supply, functions,
and sensibility of the skin, or possibly in some cases exer-
cise some especial irritant action. Although among ex-
ternal causes we must place in the first rank an accumu-
lation and decomposition of the natural secretions of the
skin, especially in children at the breast, still the number
of sources of irritation is infinite. Among them must be
mentioned too frequent bathing and rubbing; too long-
continued baths ; maceration of the skin from sweat ; acid
and alkaline excretions left in contact with the skin; con-
tact with secretions from irritated and inflamed mucous
membranes; various physical and chemical agencies ; too
warm bed-clothing ; piercing the ears; scratching occa-
sioned by the burning and itching such as vermin, scabies,
and other conditions produce. When eczema has once
broken out, these conditions prolong and aggravate it and
cause it tospread. A mycotic origin of eczema has been
suggested, but cannot as yet be regarded as proved. It
is, however, highly probable, from the configuration, locali-
zation, and obstinacy to treatment, that parasitic eczema
does exist.—/ournal of Cutaneous and Genito-urinary
Diseases.
TWENTY-FIVE CaSES OF NEPHRECTOMY BY ABDOMINAL
SECTION.—At a meeting of the Medico-Chirurgical So-
ciety Mr. Knowsley Thornton read a paper, and accom-
panied it with a complete table of twenty-five cases, showing
age, sex, condition, disease, date of operation, situation of
incision, method of treating ureter, whether drained or not,
immediate result, and subsequent history to date. Eight
of the cases had already been brought before the Interna-
tional Medical Congress in Copenhagen, and these were
marked off from the seventeen unpublished cases in the
table, and but briefly, if at all, referred to in the context.
Of one of them, No. 6, which was reported a failure in 1884,
with pain in the bladder and the other kidney, a very
satisfactory subsequent history was now given, the patient
being in perfect health, married, and mother of a son.
There were twenty recoveries and five deaths in the series,
a result twenty per cent. better than that generally given
for all nephrectomies, including those by lumbar section.
This result was compared with that in ovariotomy eleven
years ago, the mortality being then much higher for this
comparatively simple operation. ‘Two of the fatal cases
were pointed to as not properly to be counted against ab-
dominal nephrectomy, one being a malignant tumor which
had perforated the right pleura, and the other having died
of hemiplegia, which was brought on by the anesthesia
rather than by the operation. The superiority of nephrec-
tomy over nephrotomy and drainage for the cure of
hydronephrosis was illustrated by six cases. Incision of
suppurating kidney as a preliminary to nephrectomy was
condemned. The author’s practice of pinning out the
ureter had led to no troubles, and was claimed as the chief
factor in success. The removal of suppurating kidneys
without any puncture during operation was strongly ad-
vocated whenever their size admitted it. The superiority
of Langenbuch’s incision was insisted upon. ‘The ques-
tion of drainage was fully discussed, and that of the dif-
ferential diagnosis in sarcoma of the capsule and of the
kidney touched upon. A question was raised as to the
varieties of tubercular (so-called scrofulous) kidney ; and
the paper concluded with a promise of records of lum-
bar and abdominal nephrotomies and nephrolithotomies,
in which the mortality was considerably lower than in
nephrectomy. Either figures or actual specimens were
shown of many of the cases. Mr. Clement Lucas claimed
that the lumbar operation was more successful than the
anterior method. He had operated on six cases without
a death, and considered this success due to careful selec-
tion of the cases. He insisted on the importance of
knowing the working power of the other kidney; the
quantity of urea excreted daily should be estimated, and
if it were less than half the normal amount, then the op-
eration must be a very serious one. His cases included
hydronephrosis, pyonephrosis, and calculous pyelitis; but
he had not operated for malignant disease of the kidney.
Twice he had explored the loin, but finding the lumbar
glands involved he had abandoned the operation. Czerny
taught that hydronephrosis was best dealt with by laying
open the cyst and stitching the wall to the skin: this was
absolutely wrong. ‘The cyst should'be removed, for in
hydronephrosis it was generally possible to estimate the
condition of the other kidney. He questioned whether
suppurating kidneys could be removed through the peri-
toneum with perfect safety, owing to the danger of foul-
ing the serous membrane. The ureter had never given
him any trouble; he simply ligatured it and dropped it
back. Mr. Thornton said that he did not hope to convert
Mr. Lucas to the anterior operation, though he congratu-
lated him on his successful cases. It must be remem-
bered that when a large number of cases were dealt with
then the mortality came in. In his first eleven cases all
recovered, but in the next fourteen he lost five cases,
giving a mortality in the twenty-five of twenty per cent. He
agreed that it was important to estimate the condition of
the other kidney, but thought that a little msk might be
run, even if it were not quite sound, because the labo
thrown upon it by a fellow-suppurating kidney would be
greater than that thrown upon it by the operation. He
had not met with any difficulty in preventing septic in-
jection of the peritoneum. He defended his mode of
dealing with the ureter.— The London Medical Recorder.
HYDRATE OF CHLORAL IN CHAPPED NIPPLE.—Mitro-
polsky, of Moscow, recommends chloral as an excellent
local means for fissured and excoriated nipples. The lat-
ter should be kept covered with compresses (soft linen)
soaked in a solution of half a drachm of chloral in three
ounces of water. The compresses should be changed
every two and a half or three hours. When a prolonged
application is necessary, it is advisable to use a weaker
lotion (half-drachm to six ounces). The solution leaves
a thin, whitish, firmly adherent film over the diseased sur-
face, which does not disappear by suckling. Pain and
tenderness are said to be strikingly relieved almost imme-
diately ; the lesions rapidly healing. The chloral com-
presses do not produce any bad effects on nurslings.— S?.
Louis Medical and Surgical Fournal.
ANOTHER ATTACK ON AMERICAN INDUSTRIES.—The
Austrian authorities recently made a raid on the drug-
stores in Vienna and confiscated all the “safe-cure” prep-
arations they could lay their hands on.
154
THE MEDICAL RECORD.
[August 10, 1889
THE MEDICAL RECORD:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., EDITOR.
PUBLISHED BY
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
New York, August ro, 1889.
NATIVE AMERICANS AND IMMUNITY FROM
PHTHISIS.
IN an interesting article on the subject of phthisis (Medi-
cal Age, June 25th), Dr. E. P. Hurd presents some facts
which show, as he thinks, a slowly acquired immunity
among native Americans against this disease. Dr. Hurd
has compiled the statistics of mortality in the city of New-
buryport for the past thirty years with the following result :
Population of American Parentage.
1858, one death from consumption in 378
1865 t ts sé 66 564
1870 t: 66 66 66 t 252
1875 66 66 66 6 66 300
1880 <4 ‘6 66 66 66 351
Population of Foreign Parentage.
1858, one death from consumption in 273
1865 ‘6 (Z 66 €t 46 150
1870 66 66 66 t6 66 6I
1875 te 66 «6 66 66 176
1880 *“ 2 «6 66 66 66 136
The yearly average among persons of American par-
entage is one death from consumption in 336. The
yearly average among persons of foreign parentage is one
death from consumption in 179.
“The lesson taught by these tables,” says Dr. Hurd,
“is that consumption is far more prevalent among for-
eigners than among natives ; as far as the latter are con-
cerned, there isa gradual decrease in the death-rate from
this disease.”
Dr. Snow, of Providence, R. I., has also computed
statistics which show the same thing. For example:
Population of American Parentage.
1875, one death from consumption in 415
1880 66 66 . 66, (Z) 66 435
Population of Foreign Parentage.
1875, one death from consumption in 288
188 ‘* “ i j ‘* 268
Dr. Hurd’s theory that the native American race is
securing some immunity against phthisis, while the bacillus
attacks especially the immigrants who are being sloughed
upon our shores, has a certain amount of attractiveness—
for the natives. He does not, however, take fully into
account the fact that the foreign population are, as a rule,
not so well housed or fed, and that they in general live
under much worse hygienic conditions. If the mortality-
rate from phthisis is increasing among them, it is largely
because of the well-known fact that we are getting a much
lower grade of immigrant than we used to receive.
BIRTH RETURNS.
ACCORDING to the New York Herald, Massachusetts has
a new Statute, which has just gone into effect, for secur-
ing a more perfect record of vital statistics. All doctors
are required to report births, and for each birth reported
the doctor gets a fee of twenty-five cents. No penalty 1s
fixed for failure to report. ‘This little fee is no great ob-
ject, yet it is proper as recognizing that the State has no
right to exact a gratuitous service from medical men—
which it does when it calls for a whole series of certifi-
cates that must be given under penalties for failure, as
with doctors in this city. The language of the Massa-
chusetts statute is odd. It requires the doctor to report
all births “ at which he is present.” Suppose the baby is
born before the doctor gets there ?
The New York County Medical Association has a
special committee for the purpose of considering this
matter of certificate-grievance, with the view of securing
as well more complete returns. A professional friend
solemnly assures us that half his life is spent in wnting
certificates for life insurance, schools, judges, societies,
and all kinds of health organizations. Great Britain and,
we think, Germany wisely throw the responsibility of re-
turning births upon the parents themselves. At all events,
the legal opinion is that the State has no power to impose
any service without providing a compensation.
A GOOD WORD FOR THE GYPSIES.
In the minds of most people a vagabond is a vagabond
and a tramp is a tramp, without distinction or difference,
except, possibly, that each individual seen is dirtier than
the preceding, in proportion as the season is further ad-
vanced, and the dust has accumulated in ever-increasing
thickness on his unwashed hide. This belief is well enough
founded concerning the common tramp, that strange by-
product of Anglo-Saxon civilization. But it is unjust to
class with him that other race of vagabonds, the gypsy
that comes no man knows whence, and that is not seem-
ingly a degenerated stock but has ever been as it is now,
a semi-heathen and a nomad race, living among and on,
yet not of, the Christian and civilized communities of
Europe and America. The gypsies are vagabonds, per-
haps, but they are not tramps in the common acceptation
of the term. They may be lacking in honesty, yet they
are not without honor ; they are proud of their lineage,
and they are clean in their persons and in their homes.
This last statement may strike some of our readers as
rather strange, yet it is corroborated by no less an author
ity than Mr. E. L. Wakeman, than. whom no one in this
country is better qualified to speak concerning the mode
of life and customs of this peculiar people. In an inter-
esting article in the 4anals of Hygiene for May, 1889,
Mr. Wakeman treats of gypsy hygiene, and shows that
many of our own race might well imitate these despised
people in their worship of cleanliness. He says that,
during a close study of the race in many lands, for more
than a quarter of a century, he has never known a physi-
cally unclean gypsy, the only exceptions being a few in-
August 10, 1889 |
dividuals in the towns of Southern Hungary and in Ha-
vana. ‘The gypsy camps are always pitched near a spring
or a stream, and the morning bath is as certain as the
morning itself. But the cleansing is not of the skin alone,
the undergarments are as constantly washed, and the
straw bedding is likewise daily spread out for a sunning
and airing.
But it is not in cleanliness alone that the gypsies com-
pare favorably with those of the higher races among whom
they live. ‘Their virtue is absolute. Concerning this Mr.
Wakeman says: “ While gypsies are without law, as we
know it, no people live who more rigorously follow, in
fact and to the ultimate of spirit, the highest and purest
code of physical and moral observance. They universally
revere the marriage relation. I say universally, and use
that word unqualifiedly. There isnot an exception. . .
Such a thing as disloyalty of wife to husband, or husband
to wife, after marriage, has yet to be recorded of gypsy
on the European or American continents.” Furthermore,
before marriage, there is not with them, either in theory
or in practice, one law for men and another for women,
but they regard chastity as essential a virtue in man as it
is in woman.
Physical and moral cleanliness are cardinal virtues in-
deed, and, whatever his other shortcomings may be, the
gypsy has in them good reason for his pride of race, and
we cannot blame him, when he sees those virtues so little
prized among his neighbors, for looking upon them as
inferior beings, and unworthy of association with the
Romany. '
MEDICAL MEN AND THE LAND-TAX THEORY.
THE columns of Tue MEDICAL Recor are hardly suit-
able for the discussion of economic problems, unless they
relate very closely to the welfare of medical men. We
cannot, however, refrain from referring to the fact that a
number of communications have lately been received
by us bearing upon the single-tax theory of Mr. Henry
George. Our correspondents are all devout believers in
single-tax and are, in particular, of the opinion that the
adoption of Mr. George’s views would vastly alleviate the
condition of medical men.
It is interesting to find that the new propaganda has
reached and affected so extensively medical men. In a
liberal profession it is proper that every valuable idea
should be received and discussed with candor. Perhaps
physicians will view the single-tax idea with especial favor
because, as one of our correspondents, Dr. David DeBeck,
writes us, it was a physician, Quesnay, Court Physician to
Louis XVI., who first proposed this “ impôt unique.”
So far as we can learn, economists generally are agreed
that land is the best thing to put taxes on, though it is a
little hard to see’ how we can raise our $700,000,000 of
local taxes on our $10,000,000,000 worth of land; or
abolish poverty by shifting a tax which forms but seven
per cent. of our total production.
We must take exception, also, to the view of one of our
correspondents, who thinks that by lessening rents the tene-
ment-house problem could be solved. ‘This is sheer non-
sense, as everyone who has observed the gregarious habits
of the working people know. They would rather live to-
gether in small and dirty houses than go to the suburbs
and live in some degree of isolation.
THE MEDICAL RECORD.
155
We cannot, however, undertake to introduce economic
controversies into these pages. We are inclined to think
that medical men, as a whole, will prefer to follow the in-
ductive work of Mr. Edward Atkinson to the brilliant
reasonings of doctrinaires.
THE INFLUENCE OF HYPNOTICS ON
OF DIGESTION.
THE PROCESS
PROFESSOR CRAMER has made a study of the process of
digestion as influenced by some of the hypnotics now
commonly employed. Chloral, paraldehyde, hydrate of
amylene, and sulphonal were tested relative to their influ-
ence on the saliva, the gastric juice, and pancreatic secre-
tion. Cramer employed the method of artificial digestion.
The results of his researches are published in the Zhera-
peutische Monaishefte. His conclusions are, briefly, as
follows :
1. The diastatic action of mixed saliva is not interfered
with by the drugs referred to. 2. The capacity to digest
fibrin is not reduced by weak solutions of chloral, paralde-
hyde, amylene hydrate, and sulphonal. But in a more
concentrated form (1 to 20) the three first-named sub-
stances retard this action unmistakably. On account of
the insufficient solubility of sulphonal, reliable results were
not obtained with it. 3. The functions of the pancreatic
juice were markedly influenced by chloral and paralde-
hyde, less so by hydrate of amylene, and not at all by
sulphonal.
It follows, from these observations, what, indeed, many
physicians have already learned from their own experience,
that none of the hypnotics are to be indiscriminately dis-
pensed and, more particularly, that caution is necessary
where digestion is already impaired. .
Rews of the Week.
ACTINOMYCOSIS IN NEw York City.—The death of a
man in this city from actinomycosis of the liver was re-
cently reported. l
THE MEETING OF THE AMERICAN RHINOLOGICAL ASSO-
CIATION, which was announced for August 28th, has been
postponed until October 9, 10, and 11, 1889, at which
time it will be held at the Palmer House, Chicago.
Dr. Ciara Buiss Hinps, daughter of the late Dr. D. A.
Bliss, General Garfield’s physician, is practising in Washing-
ton, and is an active member of the Woman’s Anthropo-
logical Society of that city.
Dr. WEBER-LIEL, formerly of ,Jena, where he was at
one time Professor of Otology, and had to resign on ac-
count of ill health, has now recovered and has resumed
the practice of his specialty at Bonn.
‘THE LEHIGH VALLEY MEDICAL ASSOCIATION will hold
its Ninth Annual Meeting at Glen Summit, Pa., on Friday,
August 26th.
INSANITY IN Russia.—An official report recently made
to the Russian Government states that insanity is increas-
ing very rapidly in that country. ‘The majority of those
affected belong to the middle and upper classes, and the
years immediately succeeding puberty are those in which
the disease declares itself in the greater number of cases.
156
THE MEDICAL RECORD.
[August 10, 1889
THE RESIGNATION OF Dr. Day.—The following com-
munication was sent to Dr. Day after the acceptance of
his resignation as Sanitary Superintendent :
NEw YoRK, July 30, 1889.
Dr. WALTER De F. Day:
Dear Sir—The Board of Health directs me to inform
you that it has this day, with great reluctance, accepted
your resignation of the office of Sanitary Superintendent,
which you have long filled to the entire satisfaction of the
public and of this Department, and with great honor to
yourself. '
The Board desires me to officially express to you its
high appreciation of your valuable services as the Chief
Executive Officer of this Department, of your ability and
integrity, and of your uniform kindness and courtesy in
all your official relations. The Board regrets that your
health obliges you to dissolve your connection with this
Department, and thereby deprives it of the services of an
officer who has its entire confidence.
Very respectfully, and by order of the Board,
(Signed) EMMONS CLARK, Secretary.
Dr. W. A. Ewrnc has been appointed Sanitary Super-
intendent of the Board of Health in place of Dr. Day.
Dr. Ewing is well and favorably known to many physi-
cians of this city as a talented and hard-working prac-
titioner, and there is every reason to believe that his
administration of this department will not suffer in com-
parison with that of his predecessor, difficult as the task
may be for one who has to follow Dr. Day.
THE Nova Scotia MzpicaL Society held its annual
meeting in Halifax on July 3d and 4th. The attendance
was fairly large. ‘The President, Dr. Campbell, delivered
an address upon “ Medical Legislation in Nova Scotia. ”
The following papers were read the first day : “ The Prog-
ress of Medicine,” by Dr. J. C. De Witt; “ Pneumonia,”
by Dr. Buckley; “An Epidemic of Typhoid Fever at
Truro,” by Dr. W. S. Muir; “The Latest Methods of
Treating Wounds,” by Dr. Reid; “ Surgical Dressings,”
by Dr. John Stewart; “ Keloid,” by Dr. Parker ; “ The
Importance of Early Operations in Cancer,” by Dr. Far-
rell; and “ Report of a Case of Cancer of the Breast,” by
Dr. Muir. On the second day of the meeting Dr. Page
presented a communication on “ The Frequency of For-
ceps Application ;” Dr. Fox, one on “ Puerperal Eclamp-
sia ;” Dr. N. E. McKay, on “ Hare Lip ;” Dr. Stoddard, on
“ The Disposal of Sewerage ;” Dr. Morrow, on “ The Use
and Function of Medical Journals,” and Dr. W. B. Moore,
on “ The Therapeutic Value of Glycerine.” Dr. W. B.
Moore, of Kentville, was elected President, and Dr. W.
S. Muir, of Truro, Secretary, for the ensuing year.
THE MEDICAL Society OF WEST VirGcinia.—The an-
nual meeting of this Society was held at White Sulphur
Springs, on July 17, 18, and 19, 1889. The address of
welcome was delivered by Dr. T. R. Evans, of Charleston,
and then the President, Dr. L. D. Wilson, of Wheeling,
read the annual address. He referred in the opening to
the creation, during a special session of the Legislature,
of a State Board of Health, and then passed on to a con-
sideration of the advances in medical science during re-
cent years. Dr. D. Mayer read a paper on the value of
Crockett Spring, Montgomery County, Va. The water in
this spring is 70° in the coldest weather. The essayist
recommended the water for rheumatism, gout, and dis-
eases of that nature. Dr. L. B. Edwards, of Richmond,
spoke upon the advantages of State Medical Examining
Boards. Dr. Hoopman, of Baltimore, then read a paper
on the “ Pathology of Fever.” Dr. Upshur, of Richmond,
read a paper on “ Reflex Bladder Troubles,” which was
discussed by Drs. Hunter, McGuire, Richardson, and
others. A communication, entitled ‘‘ Two Laparotomies,
with Comments,” was presented by Dr. J. E. Michael, and
one on the “Care of our Females from Birth to Matu-
rity,” by Dr. J. D. Myers, of Huntington. The speaker
had a rather poor opinion of the physical powers of women
of the present day, saying that one hundred years ago one
woman could do the work of six in our day. Children,
he said, should be made to sleep in the dark. A child
who has always slept in the dark will not be always look-
ing under the bed for the burglar, nor will she jump on a
chair if she see a mouse or rat. He condemned high-
heeled shoes, and said that no girl should marry before she
is twenty years old. The following officers for the ensuing
year were elected: President, Dr. S. H. Austin, of Lew-
isburg ; 1st Vice-President, Dr. T. R. Evans; 2d Vice-
President, Dr. J. D. Mayer, of Charleston ; 3d Vice-Pres-
ident, Dr. Moss, of Cabell County. Dr. Fullerton, of
Charleston, the present incumbent, was re-elected Secre-
tary. Dr. Campbell, of Wheeling, was re-elected Treas-
urer. Board of Censors—Drs. McDonald, Enslow, Put-
ney, Fraval, Rupert, Hughait, and Wagner. The next
meeting of the Society will be held in Wheeling. ‘The
number of members is now nearly two hundred.
Jonn Howarp Prize.—The Russian Government
offers a prize of $400 and a gold medal for the best essay
on “ John Howard in the History of Prison Reform,” in
memory of the British philanthropist, who died at
Kherson, in South Russia, in 1790, after doing much to-
ward the improvement of the prisons in Russia. The
prize is open to general competition, but the essays must
be written either in Russian or in French. ‘They are
to be sent to St. Petersburg, when they will be judged
by a select committee during the convocation of the
fourth International Prison Congress, which takes place
next year during the centenary of John Howard. There
is ample room for prison reform in that free and enlight-
ened country.
AN ALL-EMBRACING SPECIALIST —A physician in an
Iowa town, who is given to advertising, has on one of his
display cards, printed on the same sheet with the butch-
ers, soap-makers, and confectioners, the following : “ Prac-
tice limited (except among former patrons) to Surgery,
Diseases of Women, Diseases of Respiratory, Alimen-
tary, and Genito-urinary Organs. The Eye, Ear, and
Skin. A general Office and Consultation Practice.”
“LE JOURNAL DES MALADIES CUTANEES ET SYPHILI-
TIQUES ” is the title of a new dermatological journal which
has appeared in Paris. ‘The editor-in-chief is Dr. Henn
Fournier. ‘The journal is to appear twice in each month.
THE MIssissipPp! VALLEY MEDICAL ASSOCIATION will
hold its next meeting at Evansville, Ind., September roth,
rith, and 12th.
August 10, 1889]
Dr. Epwarp J. TURNER died of nephritis at his home
in Walton, Conn., on July 26th. Dr. ‘Turner was born in
Bath, Me., in 1822. He was known as the founder of
the inebriate asylum, and his whole professional life was
passed in controversies upon the subject of inebriety as a
disease. After twenty years of labor, against great oppo-
sition, he finally succeeded in founding the Inebriate
Asylum at Binghamton, the first ever built. Since that
time over seventy asylums have been established in differ-
ent parts of the world. The Binghamton asylum was
afterward changed to an insane asylum, and at the time
of his death Dr. Turner was endeavoring to have it
changed again to its original purpose, and was also en-
gaged in trying to establish an asylum for female inebri-
ates. While not the originator of the idea of inebriety as
a disease, he was one of the earliest upholders of this
view, and was the first to urge the treatment of inebriety
In asylums.
Dr. A. E. Jones, of Cincinnati, was murdered on July
25th by his colored coachman, the object being appar-
ently robbery. Dr. Jones was a well-known physician,
and a prominent citizen of Cincinnati, having been for
several years a member of the Common Council. During
the war he was appointed provost-marshal, and was
always greatly interested in military affairs, being at the
time of his death Surgeon-General of the Ohio National
Guard.
THE Eyes oF SCHOOL-CHILDREN.—Dr. T. F. Bliss, of
Springfield, O., recently made an examination, at the re-
quest of the School Board, of the eyes of the children
attending the public schools of that city. The number of
pupils examined was 3,707, of which 378 had some defect
of vision, or some disease of the eye, or both, divided as
follows: Granular ophthalmia, 13 ; chronic conjunctivitis,
14; inflammation of lids, 8 ; strabismus, or cross-eye, 37 ;
low vision not improved by test-glasses and less than one-
fourth normal, 24. In the remainder there was defective
vision which was improved by test-glasses.
A LIBRARY THREE THOUSAND FIVE HUNDRED YEARS
O.p.—At the annual meeting of the Philological Society
of Great Britain, held on July 1st, a paper by Professor
Sayce was read on the recent discoveries in the palace of
Amenophis III. From the tablets and inscriptions there
found we learn that in the fifteenth century before our
era—a century before the Exodus—active literary inter-
course was going on throughout the civilized world of
Western Asia, between Babylon and Egypt and the smaller
states of Palestine, of Syria, of Mesopotamia, and even of
Eastern Kappadokia. And this intercourse was carried
on by means of the Babylonian language, and the com-
plicated Babylonian script. This implies that all over the
civilized East there were libraries and schools where the
Babylonian language and literature were taught and
learned. Babylonian appeared to have been as much
the language of diplomacy and cultivated society as
French has become in modern times, with the difference
that, whereas it does not take long to learn to read French,
the cuneiform syllabary required years of hard labor and
attention before it could be acquired. We can now un-
derstand the meaning of the name of the Canaanitish city
which stood near Hebron, and which seems to have been
one of the most important of the towns of Southern
THE MEDICAL RECORD.
157
Palestine. Kirjath-Sepher, or “ Book-town,” must have
been the seat of a famous library, consisting mainly, if not
altogether, as the Tel el-Amarna tablets inform us, of clay
tablets inscribed with cuneiform characters. As the city
also bore the name of Debir, or “Sanctuary,” we may
conclude that the tablets were stored in its chief temple,
like the libraries of Assyria and Babylonia. It may be
that they are still lying under the soil, awaiting the day
when the spade of the excavator shall restore them to the
light. ‘The literary influence of Babylonia in the age be-
fore the Israelitish conquest of Palestine explains the
occurrence of the names of Babylonian deities among the
inhabitants of the West. Moses died on the summit of
Mount Nebo, which received its name from the Babylonian
god of literature, to whom the great temple of Borsippa
was dedicated; and Sinai itself, the mountain “ of Sin,”
testifies to a worship of the Babylonian Moon-god, Sin,
amid the solitudes of the desert. Moloch or Malik, was
a Babylonian divinity like Rimmon, the Air-god, after
whom more than one locality in Palestine was named, and
Anat, the wife of Anu, the Sky-god, gave her name to the
Palestinian Anah, as well as to Anathoth, the city of “ the
Anat-goddesses.” In a careful reading of the tablets
Canon Sayce came upon many ancient names and inci-
dents known up to the present only from their appearance
in the Bible. All these he carefully described, as well as
several references in the tablets to the Hittites.
MEETING OF THE AMERICAN MEDICAL ASSOCIATION.—
Dr. Vaughan, of Michigan, writes that he was reported as
saying that Koch did not believe the Eberth germ to be
the cause of typhoid fever, whereas he said that Koch did
not believe the Eberth germ to be demonstrated to be the
cause of typhoid fever. ‘The thyrotomy reported by Dr.
Ephraim Cutter was performed in 1866 instead of 1886.
It was Dr. Jenkins, and not Dr. Jaggard, who discussed
the paper on dioscorea villosa, or wild yam.
BEES AND RHEUMATISM.—A remedy for rheumatism,
that is said to be popular in France, consists in exposing
the patient to the stings of bees. The insects are applied
to the neighborhood of the affected part and the stings
are repeated until a cure results. In a memoir presented
to the Academy of Medicine of Paris, a report is given
of over one hundred cases of acute and chronic rheuma-
tism so treated with success. It required, however, an
average of nearly three hundred and fifty stings for each
case. Some patients might prefer the disease to the
remedy.
‘THE AUSTRIAN PHARMACOPIA.—The seventh edition
of the Austrian Pharmacopceia will soon be published.
It will not contain many alterations. ‘The proportion of
hydrocyanic acid in cherry-laurel water will be raised
from 0.6 to 1 per mil., and that of arsenic in Fowler's
solution will be reduced to 1 percent. Zittmann’s decoc-
tion will henceforth be called compound decoction of
sarsaparilla, and Dover’s powder will be known as pulvis
ipecacuanhz opiatus.
THE LENGTH OF THE MEDICAL STUDENTS’ COLLEGE
Course.—The German Medical Congress has resolved
that the obligatory period of medical study, including the
term of military service, should be fixed at not less than
five years.
Society Reports,
THE EIGHTH GERMAN CONGRESS OF IN-
TERNAL MEDICINE.
Held at Wiesbaden, April 15, 16, 17, and 18, 1889.
Upon the opening of the first session of the Congress
THE PRESIDENTS ADDRESS
was delivered by HERR VON LIEBERMEISTER, of Tiibingen.
The subject of the address was “ The Scope of Internal
Medicine.” ‘This was, he said, not a branch of medical
science, but medical science itself, the trunk from which
surgery, gynecology, ophthalmology, laryngology, and all
the other branches sprang. ‘The problems which the
specialists were called upon to solve were easy compared
to those which confronted the general practitioner, and in-
ternal medicine could advance only by dint of hard and
unremitting labor. But in addition to these purely med-
ical subjects, general medicine had also its public duties
to perform. It stood in the relation of a guardian to the
public in all things that had to do with health. It must
warn the people against the dangers which threaten them
in the neglect of hygienic rules, and it must also guard
them against the attacks of quackery. After a few well-
chosen words of greeting to his fellow-members, the
speaker declared the Congress open.
HERR SCHULTZE, of Bonn, delivered a eulogy upon
Professor Hugo Riihle, who had died on July 11, 1888,
aged sixty-four years. He was one of the earliest mem-
bers of the Congress, and had always been active in its
interests,
INTESTINAL OBSTRUCTION.
HERR LEICHTENSTERN, of Cologne, opened the discus-
sion with a brief reference to the history of this affection,
which was recognized by the earliest medical writers. ‘The
most important contributions to our knowledge of the
nature and treatment of the condition, however, date from
comparatively recent times. ‘The first employment of the
term “ileus ” was to designate disease of the ileum ; later
it came to be applied to intestinal obstruction accompanied
by stercoraceous vomiting; but now it is used to denote
intestinal occlusion simply, which may or may not present
vomiting of fecal matter as one of its symptoms. In-
testinal obstruction may be due to mechanical causes, or
it may arise from paralysis of the muscular coat; but in
the majority of cases both conditions are present. The
most frequent
CAUSE OF ILEUS
is peritonitis, and especially perityphlitis. It may also
follow injuries of the abdomen, the reduction of a hernia,
laparotomy, or even the removal of some mechanical ob-
struction. Here the obstruction is a paralytic one. Ex-
cessive meteorism may also occasion it by inducing a
paralysis of the muscular coat. The paralytic form may
also lead to mechanical obstruction by the formation ofa
sharp bend at either or both extremities of the paralyzed
portion.
The sudden occurrence of symptoms of intestinal oc-
clusion does not necessarily imply a sudden formation of
the obstruction. ‘There may be well-marked obstruction
which remains concealed because of the hypertrophy of
the portion of intestine above it. After a time, asa result
of inflammatory changes in the mucous membrane, or
from some other cause, the muscular coat becomes paretic ;
it is then unable to drive the contents of the intestine be-
yond the constriction, and the condition at last declares
itself by unmistakable signs.
In the
DIAGNOSIS OF ILEUS
we have first to ascertain the cause of the obstruction,
whether it lie in the intestine itself, in the peritoneum. or
in other of the abdominal organs ; secondly, the nature of
THE MEDICAL RECORD.
[August 10, 1889
the obstruction, whether it be from gall-stones, from fecal
impaction, from peritoneal bands, from paralysis of the
muscular coat, etc.; and finally, the seat of the obstruc-
tion. The signs pointing to occlusion of the small in-
testine are the sudden onset of the symptoms, copious
vomiting, contraction of the upper portion of the abdo-
men, and the presence of indican in the urine. When
the large intestine is the seat of the obstruction, the symp-
toms are more gradual in their onset and are less intense,
the abdomen is unevenly distended, and the portions of
the large intestine can be felt as distended masses, often
displaced as a result of this distention. The lower down
the seat of occlusion, the longer will have been the in-
terval between the appearance of the constipation and the
onset of the more acute symptoms.
THE SYMPTOMS OF ILEUS
are those directly due to the intestinal obstruction, such
as constipation, pain, and stercoraceous vomiting. ‘True
fecal matter is seldom vomited, and what is called fæces
is simply the contents of the small intestine having a
fecal odor. Other symptoms are general, and are due to
the absorption of the products of decomposition or to re-
flex causes. These are fever, delirium, collapse, etc.
HERR CuRSCHMAN, of Leipsic, continued the discus-
sion, taking for his subject the
TREATMENT OF INTESTINAL OBSTRUCTION.
The speaker said that every physician should have an out-
line of the treatment to be pursued always in his mind, as
the suddenness of the symptoms demanded prompt action,
with a clear idea of the end sought for and of the means
best adapted to that end. He uttered some words of
caution against a resort to laparotomy in all cases without
distinction. In some cases, indeed, the danger of an oper-
ation was not less than that of the ileus itself. When a
patient is not seen until collapse is imminent, if not act-
ually present, and when the physician is able to form
only the most vague idea of the nature and seat of the ob-
struction, the outlook of surgical treatment is in no degree
better than that of medical. On the other hand, the rule
to operate early is more easily formulated than carried
out. It is no light matter, for either physician or patient,
to consent to an operation at the very beginning of a
trouble which, as statistics prove, yields to internal treat-
ment alone in over one third of the cases. Nevertheless,
when it is possible early in the progress of the affection to
make a diagnosis of the seat and of the cause of the ob-
struction, it would certainly be wrong not to operate.
MEDICAL TREATMENT OF ILEUS.
The diet must be absolutely restricted, thirst being con-
trolled by cracked ice or small enemata of water. Pur-
gations should on no account be given, but opium is to
be used freely to restrain the peristaltic movements.
Washing out the stomach, as recommended by Kussmaul,
is useful, as it not only relieves the distention of this viscus,
but even tends to reduce the pressure in the intestine by
emptying it in a measure of its contents. Puncture of
the intestine with a hollow needle, in order to give exit to
the gas, is a measure often of great benefit. The speaker
was decidedly opposed to the use of fluid injections,
which he looked upon as dangerous, but favored gaseous
injections as recommended by von Ziemssen.
HERR JURGENSEN, of Tiibingen, agreed with the last
speaker as to the utility of puncture of the intestine for
the withdrawal of gas, but he did not regard with favor
the employment of gaseous enemata. They caused an
increase of the intra-abdominal pressure, and he had even
seen a fatal case of general emphysema and pneumo-tho
rax caused by the escape of gas from the rectum into the
retroperitoneal connective tissue.
HERR Rosensaca, of Breslau, referred to a sign of con-
siderable value furnished by the examination of the urine.
If the urine is boiled and then nitric acid added, grad-
ually a red color is developed, and on shaking the bub-
August 10, 1889]
bles assume a violet tint. ‘This reaction is not the same
as that of indican. It denotes the decomposition of al-
buminous bodies in the tissues, and not the presence of
products of intestinal decomposition. The persistence of
this reaction for more than two weeks is of very grave
prognostic import. ‘The speaker regarded puncture of
the intestine as a measure of great value.
HERR NOTHNAGEL, of Vienna, dwelt upon the ques-
tion of intussusception, which he did not regard as a
very frequent cause of intestinal obstruction.
HERR VON ZIEMSSEN, of Munich, had never seen any
evil effects follow the injection of air, yet he thought it
should be done with care. From his personal exnerience
in an attack of ileus, he had come to regard the administra-
tion of drugs by the stomach as useless, and had found them
effective only when given hypodermatically or by the rectum.
He was in favor of perforation of the intestine with a hollow
needle, and had often seen great relief from this measure.
HERR FÜRBRINGER, Of Berlin, said that in the Fried-
richshain Hospital thirteen per cent. of the cases of ileus
recovered without operation. The results of medical
treatment are not bad enough, and those of surgical treat-
ment not good enough, to justify a resort to operative
measures in all cases. He thought opium was the best
drug in most cases. He was in favor of puncture of the
intestine, yet at the autopsies of cases so treated he had
occasionally seen evidences of peritonitis caused thereby.
He had seen one case of rupture of the intestine follow-
ing puncture.
HERR HOFFMANN, of Leipsic, had had some unpleasant
experiences after puncture of the intestine. He was
greatly in favor of laparotomy, an operation in itself with-
out much danger, and one which was becoming every day
more and more safe.
HERR SCHEDE, of Hamburg, thought that the future of
surgical measures depended greatly upon the advances
made in diagnosis of the seat and character of the ob-
struction. The danger of operation was due rather to the
previous critical condition of the patient. If a certain
diagnosis could be made in acute cases, he would resort
at once to surgical measures, but otherwise he would try,
first, medical means. At the first indication of heart fail-
ure, however, he would operate.
HERR FLOTHMANN, of Ems, reported four cases suc-
cessfully treated by operation.
HERR BAUMLER, of Freiburg, favored the use of opium
in all cases, even though surgeons claimed that it often
caused an apparent improvement, and thus operative treat-
ment was postponed and much valuable time was lost.
He believed in surgical measures only in cases of very
acute strangulation. He had had success with internal
treatment in even the most severe cases.
HERR LeEuBE, of Würzburg, said the question divided it-
self into twv, viz., when may the surgeon operate, and
when must the surgeon operate.
ate in cases in which all medical resources, such as opium,
washing out the stomach, and purgatives (in the general
condemnation of which he did not join) had been tried in
rapid succession without success. The surgeon must
operate upon the first indication of a failing pulse.
HERR IMMERMANN, Of Basle, read a paper on
THE FUNCTIONS OF THE STOMACH IN PULMONARY PHTHISIS.
He had made a series of investigations on fifty-four
phthisical patients to determine the digestive power of the
stomach, and had found digestion to be normal in
all cases, very little disturbance being present even in
febrile cases. He concluded, therefore, that the anorexia,
so common in pulmonary phthisis, was nervous and wholly
independent of structural changes in the gastric mucous
membrane. The logical deduction from this was that
forced feeding in phthisis was a rational measure.
HERR PETERSEN, of Copenhagen, read a paper on
THE HIPPOCRATIC METHOD
of following nature and aiding her in the cure of disease.
He thought this was too much neglected in these days,
THE MEDICAL RECORD.
‘upon stricture.
The surgeon may oper-
159
and believed that truly practical medicine must work
along the lines of Hippocratism.
HERR FURBRINGER, Of Berlin, read a paper on
IMPOTENCE IN THE MALE,
referring especially to the nervous form. ‘The prognosis
is not very favorable, the speaker having = a cure
in only about one-third of his cases.
HERR DETTWEILER, of Falkenstein, exhibited
A POCKET SPITTOON FOR PHTHISICAL PATIENTS.
It consisted of a bottle with a funnel-shaped opening
which was closed, when not in use, by a screw-cap.
HERR KLEMPERER, of Berlin, read a paper on
DILATATION OF THE STOMACH, AND ITS TREATMENT.
The cases which he had studied were not consequent
In most of them there was hyperacidity
of the gastric secretions. In some there was good mus-
cular power in the walls of the stomach, in others the
motor strength was diminished. In the treatment of this
condition washing out the stomach held the first rank.
This was best done in the evening, and with the use of
but a small quantity of water. In regard to food, meat
should be forbidden, the chief reliance being placed on
the carbohydrates and fats, such as cream, sugar, bread,
and butter. Other remedies which he had found to be
of value were massage, electricity, creosote, and alcohol.
HERR HANAU, of Zürich, reported two cases of
SUCCESSFUL INOCULATION OF CANCER.
He used pieces of cancer taken from a white rat, which
he inserted into the scrotal tissue of two other rats. Two
months later one animal showed a general peritoneal car-
cinosis, and the other had carcinomatous nodules in the
scrotum. Histologically the inoculated cancer was the
same as that from which the inoculations were made.
HERR LAUENSTEIN, of Hamburg, read a paper on
STRICTURE OF THE PYLORUS.
His report was based upon the study of twenty cases—
eleven of carcinoma, seven of cicatrices following ulcer,
one of duodenal stricture (indistinguishable clinically from
pyloric stricture), and one of compression of the pylorus
from without by a large gall-stone. Tumors of the
pylorus, when the stomach is of moderate size, are found
in the epigastrium at the level of the eighth or ninth
costal cartilage. When the stomach is empty the tumor
lies a little more to the left, and moves over to the nght
when the stomach is full. When there is marked gastric
dilatation the movements of the tumor are more exten-
sive. Sometimes the tumor cannot be felt except when
the stomach is empty. Tumors following ulceration lie
somewhat deeper, as a rule, than cancer, and frequently
form adhesions with the mesocolon or transverse colon.
TREATMENT OF PYLORIC STENOSIS.
There are three operations which may be undertaken
for the relief of strictured pylorus, the choice of which
can be made only after the abdomen has been opened.
The first operation is the plastic one of Heineke and
Mikulicz, which is of service in cases of non-malignant
stenosis. ‘The second consists in the establishment of a
gastro-intestinal fistula, and is applicable to cases of can-
cer or of ulcerative stricture which cannot otherwise be
relieved. This operation can be performed in less than
an hour, and is less dangerous than resection of the
pylorus. The third operation is resection, and 1s occa-
sionally of service in cases of non-adherent cancer. The
operation is a tedious one, and apt to be dangerous to
the patient.
Herr Roser, of Hanau, presented a patient upon
whom he had performed
TOTAL EXTIRPATION OF THE LARYNX
on account of carcinoma. The hyoid bone was also re-
moved.
160
HERR FINKELNBURG, of Bonn, read a paper on
THE RELATION OF THE SOIL TO THE SPREAD OF TUBER-
CULOSIS.
A stagnant condition of the subsoil water would seem
possibly to favor the production of the disease.
HERR VON ZIEMSSEN presented a communication upon
the
MOVEMENTS OF THE HUMAN HEART,
in which he detailed the results of a series of observations
he had made upon the heart movements in a boy four-
teen years of age, in whom the organ was exposed after a
resection of the ribs.
HERR KREHL, of Leipsic, read a paper on the
VARIATIONS OF INTRA-CARDIAC AND ARTERIAL PRESSURE,
in which he described a series of experiments, on dogs,.
made by Frey and himself.
HERR EBSTEIN presented a paper on
THE NATURE OF GOUT.
He recognized two forms of the disease, according as the
process was primary in the articulations or in the kidneys.
Primary articular gout is essentially a chronic disease, in-
terrupted by acute exacerbations which are known as the
“ attacks.” The speaker did not believe that the deposits
occurred in consequence of inflammation, but he regarded
uric acid as a chemical poison which excited, not an in-
flammatory but a necrotic process. We may have very
serious gouty lesions, caused by the presence of uric acid
in the tissues, without having any deposits. In renal gout
there is a stagnation of uric acid, together with anatomical
or functional alterations in the kidney. But this is not
the cause of the deposits in the tissues, in the articular
form of the disease. In this form there is an excessive
production of uric acid in the medulla of the bones and
in the muscles, whence it passes into the lymphatics, and
thus gets into the blood, and is finally excreted by the
kidneys. But juices rich in uric acid pass with difficulty
through the lymphatics, and this is the true reason for the
deposits.
HERR PFEIFFER continued the discussion of the subject
with a paper on
THE TREATMENT OF GOUT.
In regard to diet, he said that he did not favor the ex-
clusjon of meat, as such a course might serve to increase
the gouty cachexia. The hydrocarbons give rise to the
formation of uric acid, and should be absolutely forbidden ;
alcohol in any shape should not be permitted. Exercise in
the open air should be taken as soon as possible, since rest
only prolongs the attack. The medical treatment should
consist in the administration of alkalies, preferably by means
of mineral waters, both externally and internally, at the
very beginning of an attack. During the height of the
attack, when the pain is severe, salicylic acid and dilute
hydrochloric acid are of the greatest service.
HERR KRAUSE, of Berlin, read a paper on
THE TREATMENT OF TUBERCULAR LARYNGITIS.
He advocated tracheotomy to secure rest to the organ,
and then scraping of the diseased parts, followed by local
application of iodoform or lactic acid.
HERR SCHEISSMANN, Of Berlin, said that he had seen
the best results with incisions, scarifications, scraping, and
the local use of lactic acid and menthol.
HERR DEenio read a paper on
THE VESICULAR MURMUR,
in which he maintained that this sound was produced by
vibrations transmitted to the residual air in the alveoli
from the column of inspired air.
Herr Bascu, of Vienna, read a paper on
CARDIAC DYSPNCA.
This form of dyspnoea, he said, is marked by three
symptoms, viz., shortness of „breath, diminution of the
THE MEDICAL RECORD.
[August 10, 1889
useful effect of respiration as regards hzematosis, and in-
creased volume of the lungs. ‘These last two conditions
had been shown experimentally, by the speaker, to result
from interference with the action of the left ventricle. ©
HERR FINKLER, of Bonn, related the history of an
epidemic of pneumonia, observed by him, in which he
found streptococcus pyogenes in every instance. He be-
lieved that the disease was due to the presence of this
microbe.
HERR STORCH, of Copenhagen, exhibited
A NEW FORM OF ASPIRATOR,
which consisted of an air-tight bottle filled with water.
The tube connected with the aspirator needle opened
into the upper part of the bottle, while from the lower
part the water was allowed to escape slowly. In this way
a vacuum was caused and a considerable aspirating force
was produced.
HERR MULLER, of Berne, read a paper on
THE TISSUE-CHANGES IN CARCINOMA.
He had found that in cancer there was a considerable
diminution in the quantity of urea excreted, and that
this was independent of any kidney trouble.
After some discussion on the papers read at this last
session,- the President declared the Congress of 1889
closed.
NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting, March 13, 1889.
WILLIAM P. NORTHRUP, M.D., PRESIDENT, IN THE
CHAIR.
REPORT OF THE COMMITTEE ON MICROSCOPY.
Drs. Ira vaN GIESON and Jonn S. ELY reported that
the tumor of the breast referred to the committee on
February 2oth, by Dr. L. H. Sayre, had the morphological
structure of fibro-carcinoma, or the scirrhous variety of
carcinoma.
Dr. Jonn S. ELY presented a specimen showing
PRIMARY CARCINOMA OF THE COMMON BILE-DUCT,
with the following remarks :
“ Primary tumors of the biliary passages outside the
liver, of whatever nature, are of great rarity. ‘Two or
three fibromata, a papillary myxoma, and sarcomatous in-
filtration of the wall of the gall-bladder have been de-
scribed, but by far the commonest form of tumor of these
parts is carcinoma.
“It is customary to consider separately carcinoma of
the gall-bladder and of the ducts. This distinction ap-
pears to me to be properly made, since the clinical his-
tory in the two cases is essentially different, carcinoma of
the biliary ducts being almost invariably accompanied by
intense jaundice, while carcinoma of the gall-bladder alone
never is.
“ There is a considerable number of cases of so-called
primary carcinoma of the gall-duct on record, but in most
of these the presence of nodules of cancer in adjacent
organs destroys the proof regarding the point of origin of
the new growth. I have succeeded in collecting seven
cases, however, in which there could be no question as to
the origin of the tumor in the gall-ducts, no other growth
of any kind occurring in any of these cases. ‘These cases
are reported by Durand-Fardel,’ Rosenstein,’ Schreiber,’
1 Durand-Fardel: Recherches anatomico-pathologiques sur la
Vésicule et les Canaux biliaires, Archives gén. de Méd., 1840, p. 167;
also, 1841, p. 418. l
2 Rosenstein, S.: Icterus durch Cancroid des Ductus choledochus
mit Albuminurie, Berl. klin. Wochenschr., i. (1864), No. 34, P. 336.
3 Schreiber, J.: Ueber das Vorkommen von Primãren Carcinomen
in den Gallenwegen, Berl. klin. Wochenschr., xiv. (1877), No. 31,
p- 446.
patients were men; two, women. Four were more than
sixty years of age ; two (Key, thirty-five, and Kraus, forty-
nine) were younger ; of one (Rosenstein) the age is not
given. In all cases except one (Durand-Fardel) symptoms
distirfctly reterable to the tumor were present, and they are
of great uniformity." ‘There was gradually developed
jaundice, which toward the last became very intense and
presented all the characteristics of jaundice due to obstruc-
tion. Pain was not a marked symptom, but is mentioned
as having been present in slight degree in four of the cases.
The duration of the symptoms appears to have been from
eight weeks to about eighteen months. ‘The tumor in all
cases was very small. In three it was situated at the
mouth of the common bile-duct; in four it was in the wall
of the hepatic duct. A more or less careful microscopical
examination, in most of the cases, confirmed the diagnosis
of carcinoma. In all the cases there was narrowing of
the lumen of the gall-duct at the site of the tumor, but
there was complete occlusion of it in only one, that of
Kraus, in which there was a large impacted gall-stone.
The biliary passages above the tumor were markedly
dilated in every case, and contained liquid variously de-
scribed as brownish, dirty gray, clear and slightly greenish,
_etc. The liver is stated to have been enlarged in four
cases, and not enlarged in one ; it was soft, owing to great
dilatation of the bile-ducts, in three cases; firm and hard
in two; in all except one (Durand-Fardel) it was deeply
stained with bile. The fact that five of the seven patients
died of some intercurrent disease a comparatively short
time after the onset of symptoms of obstructive jaundice
renders it probable that in these cases we have to do with
very early stages of what would later have become more
widely diffused growths involving neighboring organs. It
is consequently reasonable to suppose that many of the
diffused growths in the neighborhood of the gall-ducts
have their starting-point in the walls of the latter.
“Through the kindness of Dr. Hartley, in whose ward
the patient died, I am able to present to you this evening
a specimen of this very early stage of carcinoma of the
common gall-duct. The patient was a German, fifty-
three years of age, a tailor. He was admitted to Bellevue
Hospital on February 11, 1889, and gave the following
history. Four years previously, had an attack of jaundice
of short duration, from which he recovered. Present ill-
ness began four months before, when he began to be
again jaundiced, but this time instead of disappearing it
steadily increased in intensity. He complained of head-
ache, loss of flesh, pain and tenderness over the liver. No
vomiting, appetite good, bowels costive. Was confined to
bed four weeks prior to admission. Examination showed
patient to be intensely jaundiced. Tongue coated. Noth-
ing abnormal discovered, except decided enlargement of
the liver and distention of the gall-bladder, the outlines of
which could be distinctly appreciated by palpation. Urine
was Olive green, 1.012, acid; contained a trace of albumen
and a few granular casts. There was slight fever on ad-
mission (100.5° F.) and this continued, the temperature
ranging between g9° and 102° F. On February 16th he
was transferred to the surgical division, and five days later
Dr. Hartley performed the preliminary operation for
cholecystotomy. Thirty-six hours later parenchymatous
hemorrhage developed, which baffled all attempts to
check it, and on February 26th the patient died of exhaust-
ion.
“ Autopsy, eighteen hours after death. Dressings
soaked with blood and about an ounce and a half of blood
' Korezynski: Primär Carcinom im Ductus hepaticus. Review in
Virchow-Hirsch Jahresbericht, 1878, ii., p. 208.
2 Schtippel, O.: V. Ziemssen’s Handbuch, viii., 1 (1880), pp. 66-76.
3 Key: Fall af primar Kanceri gallgangarna. Review in Virchow-
Hirsch Jahresbericht, 1881, ii., p. 190.
4 Kraus, J.: Ein Fall von primären Krebs des Ductus choledochus
in Folge eines im letzteren cingekeilten Gallensteines, Prager med.
Wochenschr., ix. (1884), No. 49, p. 483.
$ Durand-Fardel’s patient was an old woman, eighty-one years of
age, who apparently died of senility, the tumor having given no symp-
toms whatever.
ee eee 8 ee ee
end of wound. No peritonitis.
“ Liver much enlarged, soft, olive green color; surface
shows occasional white spots and streaks, apparently di-
lated bile-ducts just under the capsule. Gall-bladder and
ducts very much dilated ; contain whitish liquid resembling
thin pus. At the mouth of the common duct there is a
small nodular tumor, completely surrounding the duct and
narrowing its lumen so that it is impervious to the liquid
contents of the duct. The tumor is thicker in the lower
and left walls of the duct, where there 1s a nodule measur-
ing rr mm. byg mm. The duct just above this nodule is
dilated to a smal] pouch.
“ There is no ulceration of the mucous membrane lin-
ing the duct. The cut surface of the tumor presents the
appearances of carcinoma. Surrounding organs appar-
ently not involved. Cut surface of liver shows markedly
dilated bile-ducts, the walls of which appear to be very
much thickened, and from which thin whitish liquid ex-
udes ; centres of lobules somewhat dark, peripheries light.
Softness of liver apparently due to the great dilatation of
the bile ducts.
“Pancreas somewhat hard, but no apparent lesion.
- Kidneys show lesions of chronic diffuse nephritis. Mes-
enteric glands enlarged, but no lesion evident. Stomach,
intestine, and rectum normal; spleen normal; brain ard
thoracic contents not examined.
“« Microscopical examination shows the tumor to be cylin-
drical-celled carcinoma ; the alveoli are very thick-walled.
Sections of the liver show pigmentation of the cells and
dilatation of the terminal bile-ducts, the walls of which,
and of the larger ducts, are much thickened and infiltrated
with small round-cells. The epithelium lining the bile-
ducts is, in most places, gone or breaking down. Many
of the bile-ducts are completely occluded by the products
of inflammation. There is also a little interstitial hepa-
titis, besides dilatation of the central vein and fatty de-
generation of the liver-cells. The pancreas shows the
lesions of interstitial pancreatitis, besides, in places, evi-
dence of recent inflammation; no-sign of carcinoma
discovered. Mesenteric glands show only ordinary hyper-
plasia. Kidneys show the characteristic changes of chronic
diffuse nephritis.
“ This case may, then, be epitomized as one of primary
carcinoma of the common bile-duct, causing obstruction
to the flow of bile, general dilatation of the biliary pas-
sages and gall-bladder, jaundice, and secondary inflamma-
tion of the bile-ducts. The other lesions found were
insignificant. l ,
“ It is hoped that in the discussion of this case some
light may be thrown upon the interesting question of the
etiology of primary carcinoma of the liver. Importance 1s
given to this subject, when it is appreciated that the liver
is fourth upon the list, as regards frequency, of the organs
affected with cancer. To be sure, the large majority of
these are secondary to new growths in other parts of the
body ; still, a considerable number of them cannot be
shown to be so, and we are compelled to suppose them
primary in the liver. À
“ The laws of evolution render it impossible to believe
that a highly differentiated cell can change into one of
entirely different character, and we are, therefore, com-
pelled to believe carcinomata to originate from epithelial
structures. In the liver two such epithelial structures are
present, the liver-cells and the epithelium lining the bile-
ducts. We must look to one or both of these, then, for
the source of primary carcinomata in the liver. Formerly
the liver-cell was thought to be to blame in nearly all
cases, but latterly the epithelium of the bile-ducts has
come to be looked upon as the more common source of
the neoplasm. This latter view is strengthened by our
knowledge of the development of the liver, if we believe,
with Cohnheim,’ in the origin of tumors from embryonic
1 Cohnheim: Vorlesungen ueber allgemeine Pathologie. 2 Aufl.
Leipzig, 1882, i., p. 723.
162 THE MEDICAL RECORD.
[August 10, 1889
cells arrested in development, for all the epithelial struct-
ures of the liver have a common source—the epithelium
of the embryonic bile-ducts. If we suppose some of these
cells to be hindered in their evolution and to remain for
a time inactive, later to take on an abnormal activity, we
have at least a plausible explanation of the origin of
primary carcinoma of the liver from the bile-ducts. ‘The
careful study of cases of primary cancer of the liver by
Naunyn,’ Waldeyer * and Weigert,’ has lent much weight
to this theory, almost amounting to proof. ‘The case pre-
sented this evening, as well as the seven collected from
the literature, seem to me to add evidence in favor of
this idea, since they prove indisputably that carcinoma
may originate from the gall-ducts outside the liver; and
if this is possible outside the liver, why not equally well
within it ?” |
Dr. Ira Van GIESON presented specimens illustrating
PRIMARY CARCINOMA OF THE COMMON GALL-DUCT, EN-
CROACHING ON THE PYLORUS AND LIVER.
“ The specimen was taken from a woman, fifty years of
age, who for twenty years had had fits of vomiting with in-
tense epigastric pain. She was in the hospital but three
weeks, and died deeply jaundiced, with symptoms of.
peritonitis.
“ At the autopsy the wall of the common bile-duct was
found to be uniformly thickened by a zone of rather dense
white tissue, which also involved slightly the surrounding
connective tissue, and a contiguous portion of the muscu-
losa of the duodenum and pylorus. The latter contained
in its musculosa a dense white nodule, 2 ctm. in diameter,
which was not directly connected with the thickened duct.
The thickened duct at its bifurcation into the hepatic
ducts measured about two centimetres. Each of the
hepatic ducts was about one and one-fourth centimetre
in diameter. The thickening disappeared as the common
duct entered the duodenum. Just before entering the
liver each hepatic duct was adherent to the organ by a
dense whitish zone growing into the liver. The enlarged
and somewhat thickened gall-bladder contained about
thirty variously sized, smooth, white-facetted gall-stones,
and was adherent to the liver. Just above the gall-blad-
der the right lobe contained a hard, white nodule, 3 ctm.
in diameter, not connected with the tubular mass sur-
rounding the common duct and its branches. The liver
also contained a number of rather small, scattered pus-
cavities, the result of a suppurative inflammation about
the gall-ducts. The intestines were loosely matted to-
gether and the abdominal cavity contained serum and
flocculi of fibrin. There was nothing noteworthy about
the other organs except that the kidneys were bile-
stained.
“ Microscopical Examination.—A large portion of the
mass surrounding the gall-duct and its branches was com-
posed of richly cellular connective tissue, in which were
rather large acini lined with cylindrical epithelium. ‘The
nodules in the pylorus and in the liver were similar in
structure. ‘The pancreas and its duct were normal.
“ Anatomical diagnosis was glandular carcinoma, pri-
mary in the gall-duct, and spreading thence to the liver
and pylorus.”
Dr. G. C. FREEBORN presented a specimen illustrating
CARCINOMA OF BILE-DUCT AND PANCREAS, WITH CYST OF
THE HEAD OF THE PANCREAS.
“The patient, a female, aged fifty-five, was admitted
into the New York Cancer Hospital in September, 1888.
Her history, taken from the records of the hospital, is as
follows: She has always taken alcohol in moderate quan-
tities and for the past three years has had considerable
pain in the gastric region and attacks of vomiting, espe-
1 Naunyn, B.: Ueber die Entwickelung der Leberkrebse, Reichert
u. DuBois-Raymond's Archiv, 1866, p. 717.
2 Waldeyer: Die Entwickelung der Carcinome, Virchow’'s Archiv,
lv. (1872), p. 67.
3 Weigert, C.: Ueber primires Lebercarcinom, Virchow's
Archiv, Ixvii. (1876), p. 500.
cially after eating. The heart-sounds were rapid, but no
murmur was detected over the apex; a soft blowing mur-
mur was detected over the pulmonary artery. At the
junction of the epigastric with the right hypogastric re-
gions, and at the lower part of the epigastric and umbili-
cal regions, there is a mass approximating the size of
an adult fist. This mass extends more below the umbil-
icus than above, and elevates the region about half an
inch above the surface. It is hard to the touch and
is immovable. Deep pressure causes no pain. The
pulse is 106° F. The tongue is reddened. The patient
is very anemic. ‘The stomach was washed out some
fifteen times and nə traces of hydrochloric acid were
found.
“On November 18th a diarrhoea set in which was
hard to control. From this time the patient grew weaker,
and died in the first week of January. ‘The clinical diag-
nosis of carcinoma of the stomach was made.
« Autopsy.—The right lung was normal ; the left was
cedematous and adherent at its apex. ‘The heart showed
some fatty degeneration of the muscle. The capsule of
the left kidney was adherent and the cortical substance
thickened ; the right kidney was small but presented no
marked lesions. The liver and spleen were normal.
“ There were a few scattered ulcers in the rectum and ©
descending colon. ‘The head of the pancreas was embed-
ded in a dense mass of tissue. The pyloric end of the
stomach, as well as the descending and transverse portions
of the duodenum, were adherent to this mass. Upon
cutting into the mass a cyst which occupied the head of
the pancreas was opened into, and found empty. In the
anterior wall of the cyst two openings were found, one of
which communicated with the ascending portion of the
duodenum, the other with the transverse portion. The
superior and anterior surface of the cyst was also ad-
herent to the abdominal wall. The cavity of the cyst was
irregular in shape and seemed to be limited to the head
of the pancreas. No trace of the common duct could be
found. The stomach was normal.
“ Microscopical Examination.—The tail of the pan-
creas was normal. The walls of the cyst, except the an-
terior, were found to be made up of carcinoma with a
small amount of pancreas tissue. The anterior wall
was found to be made up of intestinal tissue infiltrated
with a new growth of carcinoma.”
Dr. T. M. PRuDDEN said that it was well worth while
bringing these three specimens together, for, while cancer
of the liver with extensive involvement of the organ was
commonly enough met with at autopsies, it was very rare
to see a collection of cases, such as this, in which the
lesions were in such an early stage. He was glad that
Dr. Ely had stated his views concerning the origin of can-
cer of the liver, and his theory, if accepted, would simplify
` the question very much. It has been said that the presence
of cylindrical cells in carcinoma of the liver shows that the
tumor is from the gall-ducts, and if cylindrical cells are not
found that it is a tumor of the liver proper. ‘This ts not
correct, however, as the epithelium of the gall-duct is
not composed entirely of cylindrical cells. The specimen
presented by Dr. Freeborn would ordinarily be regarded as
one of primary cancer of the pancreas, but taken in con-
nection with the other specimens shown it could nghtly
be considered as occurring by extension from the bile-
duct.
Dr. Van GIESON thought that the specimen presented
by Dr. Freeborn was one of considerable importance, be-
cause it resembled other cystic forms of pancreatic dis-
ease, such as result from hemorrhagic pancreatitis. When
death has taken place in an early stage of hemorrhagic
pancreatitis we often find the lesion surrounded by zones
of pancreatic tissue. But when the disease has existed
for a longer period, it is found that the ascending perito-
nitis has resulted in the production of a wall incapsulat-
ing the pancreas. The tumor then becomes amenable to
surgical treatment, and successful cases of removal have
been reported by Gussenbauer and Thiersch.
August 10, 18869]
THE MEDICAL RECORD.
163
The intestines, matted together by the peritonitis and
forming a wall around the pancreas, are very likely to be
perforated, and sometimes the pancreas escapes in this
way from the newly formed capsule. Rokitansky has re-
ported such a case, and Chiari relates an instance in which
no less than fifteen apertures were found in the wall sur-
rounding the cyst.
Dr. GRAUER reported a case that he had seen in Wei-
gert’s laboratory, Frankfort, of primary cancer of the gall-
bladder, with secondary growths along the ducts and
extending into the liver. He noticed that the gall-bladder
was full of gall-stones, and Weigert told him that in his
experience these concretions were always present in cases
of primary cancer of the gall-bladder.
Dr. FREEBORN called attention to
A NEW LAMP FOR ILLUMINATING THE FIELD OF THE
MICROSCOPE,
devised by Dr. Koch. It consisted of an oil lamp with an
ordinary argand burner. Fitting over the chimney was a
sheet-iron shade in which were two apertures for the in-
sertion of solid glass rods. One of these rods was curved
so as to terminate beneath the stage of a microscope.
The light from the burner was conveyed along this rod,
and, after passing through a disk of blue glass to cut off the
yellow rays, furnished a brilliant illumination for the ex-
amination of objects by transmitted light. ‘The other rod
was shaped so as to throw a light above the object when
it was desired to examine it by direct illumination.
Dr. R. G. FREEMAN presented a specimen showing
MULTIPLE CAVITIES IN THE LIVER FROM POST-MORTEM
DECOMPOSITION. l
“'This specimen is from a Polish woman, aged thirty,
who died at Bellevue Hospital, when eight months preg-
nant, from rupture of the uterus. ‘The autopsy was made
by Dr. Prudden, through whose courtesy I am able to
present the specimen.
* Autopsy, November 11, 1888, thirty-nine hours after
death. Body fairly nourished ; decomposition advanced.
Liver full of small cavities, one to three millimetres in
diameter ; these cavities showed no special distribution
along vessels, nor were they more numerous in one part
of the organ than another; they were for the most part
elongated, closed cavities.
“ No cavities of this sort were found in the other or-
gans. The liver was preserved throughout in alcohol.
Microscopic examination showed the cavities to be sur-
rounded by no membrane, nor was there any cell-infiltra-
tion in the surrounding liver-tissue. ‘The edges of these
cavities were in some cases ragged, in others smooth;
some of the cavities contained a granular substance; in
the vicinity of the cavities, as a rule, the nuclei did not
stain. The bacteriological investigation was begun with
the Grour stain, but staining with the aqueous solution of
fuchsine gave much better results. Groups of large, stout
bacilli were found here and there, while between the
lobules throughout the liver occasional bacilli could be
seen. In places the hepatic artery was filled by a great
mass of these bacilli; many were also seen in the portal
veins.
“ Dr. Prudden tried to get cultures in gelatine from the
liver, but no growth of micro-organisms took place.
“ I have found no case similar to this reported. Through
the kindness of Dr. Delafield, however, I am able to re-
fer to two very similar cases observed by him, the material
of which I have worked over and compared with that of
Dr. Prudden’s case. ‘The first of these died of typhoid
fever with perforation and peritonitis.
“ Autopsy..—Body not well preserved. Liver showed
multiple cavities, which varied in size from microscopic
proportion to 3 mm. ‘The liver was hardened in Miiller’s
fluid.
“The second case died after several attacks of uncon-
sciousness, with cyanosis.
“« Autopsy in eight hours. Kidneys: Suppurative ne-
phritis; no bacilli found. Liver: Studded with small
whitish nodules, of the size of a pin’s head, in some of which
are cavities. The liver was hardened in Miiller’s fluid.
The microscopic examination of these two cases showed
practically the same condition as in Dr. Prudden’s case.
The white nodules mentioned in the second case were
areas of intense bacterial invasion, and in which the nuclei
did not stain. The same large stout bacilli were present
in great numbers.
“These cavities, then, since there is no evidence of
inflammatory change in the liver, are probably a post-
mortem change due to the introduction through the cir-
culation of putrefactive bacilli and the generation of gas
by them; it is interesting, however, to note that in one
case the autopsy was performed eight hours after death,
during the winter months. The possibility of bacterial
invasion during the preservation in Miiller’s fluid was ob-
viated in the last case, where the liver was put directly in
alcohol. ‘This case has been thought worthy of presenta-
tion to the Society because the condition of the organ
simulates a lesion.”
Dr. PRUDDEN said that cultures from this case were
attempted on gelatine only. Nothing grew, but possibly
better success might have attended trials in other media.
Dr. Witi1aM P. NORTHRUP presented some specimens
showing
MILIARY GUMMATA OF THE LUNGS, LIVER, SPLEEN, KIDNEYS,
AND LYMPHATICS IN A CHILD NINE MONTHS OF AGE.
A male child, aged nine months, was returned to the New
York Foundling Asylum from the Out-door Department,
suffering from moderate conjunctivitis, and, in addition,
“ seemed sick ;” it had a temperature of 102}° F., and
slight increase in rapidity of respiration. It died thirty-
six hours after entrance. ‘There was no eruption, and no
diagnosis was made.
Autopsy, fourteen hours after death. Brain: Normal.
Pharynx and larynx: Catarrhal inflammation, with mod-
erate swelling of the mucous membrane, and superficial
ulcers at the base of the tongue and between the arytenoid
cartilages. Lungs: Bronchial and tracheal glands enlarged
and cheesy. ‘There were no adhesions. On the surface of
the lungs were three to five miliary bodies like tubercles.
On section four to six pea-sized cavities, with thick walls
and with branching processes, were found. No hepatiza-
tion. Heart: Normal. Liver: ‘Thickly studded with
round, opaque yellow bodies two to five millimetres in
diameter. These on section showed a granular centre
surrounded by a pellucid zone. ‘There were a few bile-
stained points in the centre, obviously the openings of
gall-ducts. ‘The whole organ was the seat of exten-
sive fatty infiltration. ‘The cceliac lymph-nodules were
markedly enlarged and mostly cheesy. Spleen: Firm,
dark, moderately enlarged ; ten to twelve miliary, opaque
white bodies were found on the surface and on section.
Stomach: Normal. Intestines: Contents, bile-stained
mucus.
Microscopic examination showed the nodules to be
164
characteristic gummata of the lungs, liver, spleen, and
kidneys, and of the lymphatics at the root of the lungs
and at the cceliac axis.
CANCER OF THE UTERUS, WITH INVOLVEMENT OF THE OVA-
RIES.
Dr. H. J. BOLDT presented two cancerous uteri, ob-
tained by vaginal hysterectomy. In the first case the
patient had suffered from hemorrhages only a short time ;
in the second case, however, the disease had existed,
judging from the symptoms, fully six months, and the
cancer involved the body of the uterus. In this case the
Interesting feature was that the ovaries were simulta-
neously involved. ‘This possibility existing in cases in
which the body is diseased showed the importance of al-
ways removing the appendages, although formerly it had
not been the speaker’s habit to do so unless it could be
done without trouble. The lesson learned in this in-
stance, however, would lead him always to follow this pro-
cedure in the future.
Dr. Boldt presented a third specimen, showing a
SARCOMA OF THE OVARY,
removed on the previous day.
ent were menorrhagia and pain on the affected side.
A fourth specimen was one of
OVARIAN CYSTOMA,
with beginning malignant changes in the thickened wall of
the tumor near its origin. It had existed over two years
and had attained a large size. It showed the importance
of operating early in all cases of ovarian tumor. All the
patients from whom these specimens were removed were
doing well.
Dr. R. H. Sayre presented a knee-joint, removed by
amputation, showing lesions of
ACUTE OSTEOMYELITIS FOLLOWING TUBERCULAR ARTHRITIS
OF LONG STANDING.
The patient had had knee-joint disease for five years, the
trouble coming on after an attack of measles. Last July
he was seen by Dr. Sayre, and his knee was at that time
flexed and swollen. Abscesses formed and were opened.
The patient went to the country, contrary to advice, with-
out having proper protection for his knee, and when he
returned there was more marked trouble in the knee, and
he had a high temperature and other constitutional symp-
tons. ‘The leg was amputated in the upper third of the
thigh. The medullary canal was scraped out sufficientl y,
as it was supposed, but the patient now has a return of
the high temperature, and there is evident extension of
the disease in the bone.
Dr. FRANK GRAUER presented some specimens re-
moved at autopsy from the body of a young man, showing
MALIGNANT ENDOCARDITIS
affecting the mitral, aortic, and tricuspid valves. There
were infarctions in the spleen and small miliary abscesses
in the kidneys and liver. In the left lateral ventricle of
the brain a large hemorrhage had occurred which had ex-
tended both anteriorly and posteriorly. ‘Throughout the
brain there were also small extravasations and abscesses.
Cultures made from the lesions in the kidney showed the
presence of a micro-organism supposed to be a streptococ-
cus. In the small intestine, in the neighborhood of the
ileo-czecal valve, were found small nodules thought to be
tubercles, and a little above this point was another col-
lection of tubercles. ‘These were the only tubercles found
anywhere in the body.
Dr. Grauer also presented a specimen showing
TYPHOID ULCERATION OF THE INTESTINE.
The Society then went into executive session.
‘THE SOLUBILITY OF QUININE is said to be greatly in-
creased by the addition of a little antipyrine.
THE MEDICAL RECORD.
The main symptoms pres-.
[August 10, 1889
Correspondence.
OVERCROWDING AND THE
SINGLE TAX.
To THe EDITOR or THe MepnicaL Recorp.
Sir: In THE Recorp, for June 22d, on page 700, is an
item stating that a Western physician recently read a
paper in which he showed that overcrowding in the pro-
fession would be prevented were the single tax on land
values, as advocated by Henry George, in operation.
As the connection between the land-value tax and over-
crowding in the ranks of the medical profession may not
seem at all obvious to those whose only knowledge of the
theories of Henry George is that obtained through the
distorting medium of the daily press, and as any plan for
making the struggle for existence more bearable should be
received with attention by those to whom it is addressed,
and especially by the more recent additions to the ranks,
it may not be out of place for one of the many physicians
who are earnestly laboring to bring about a realization of
Henry George’s plans, to try to show where the connec-
tion lies.
When we contemplate human society from the economic
point of view, we find that the struggle for existence cen-
tres around the strife for the material things with which
we gratify our necessities and desires, and which collec-
ively we call wealth. Now, nature yields wealth to one
thing only, and that is labor. But labor alone is power-
less. It must have a field of operation ; it must have the
raw material to work upon; it must have opportunity.
And the opportunity for labor is land.
No matter what particular kind of wealth a man may
produce, directly, or indirectly, he must go for his materials
to the great, and in the last resource the only, storehouse,
the earth. (Here let me say, parenthetically, that physi-
cians are, economically speaking, non-productive laborers.
They belong in the same category as lawyers, actors,
preachers, ballet-dancers, and the like, and are paid out
of the wealth of the community, unlike productive labor-
ers, whose wages consist of the fruits of their labor.)
But, if we allow land—the passive factor in ‘the pro-
duction of wealth—to become the absolute property of
some, and there always a minority of the population
(for in all countries, this included, the land is in the hands
of the few, while the great mass is landless), it must neces-
sarily follow that, as natural opportunities to labor are
fenced in, those who are so unfortunate as to have been
born outside the fence will be willing to pay to the owners
of the fences a goodly price to be allowed inside. This
premium, which is given in exchange, not for anything that
the landholder has in his turn produced by labor, but
simply for being granted the privilege of employing one’s
self on God-given opportunities, is called rent. And be
it here noted, please, that in economics the term “rent”
applies only to natural opportunities, and never to houses,
or to anything made by the hand of man.
While population is sparse the monopolization by the
few of the rightful heritage of all produces but little
effect. But as soon as all the land is “ owned” (which
by no means implies that it is used) then trouble begins.
The increasing pressure of population continually in-
creases the premium which the landless have to pay for
access to natural opportunities for labor, and thus the
landlords are enabled to appropriate a continually in-
creasing share of the products of others’ labor without
further exertion than collecting the rent. And in coun-
tries like our own, where not only the land is fenced in,
but the ocean is fenced out by a tanff wall, so that men
are forbidden, unless they pay a fine, to make the most
profitable exchange of the wealth they have produced, of
course the impoverishment of the many to the enriching
of the few goes on at accelerated speed.
(I have not got to the doctor yet, but I am gradually
PROFESSIONAL
' approaching him, and promise to produce him shortly.)
August 10, 1889]
Well, the increasing pressure of the landless against the
parchment fences, called title-deeds, forces men to look
about them for employment less directly connected with
land than the one they have been accustomed to. It
drives men from the country to the cities, in the hope
that the infinite diversity of desires which is to be found
wherever there is a large population may afford employ-
ment. Hence the phenomenon at present complained of
wherever land is made private pronerty, of the congestion
of population in large cities.
It explains perfectly what our State assessors have re-
ported, namely, the enormous increase in the land values
of towns and cities, and the falling off in the value of
farm lands. ‘This is due simply to the fluctuation of
population. For land value, represented in ground rent,
is determined solely by demand, created by density of
population.
As men become removed further and further from the
means of actually producing wealth, they naturally seek for
the means of obtaining wealth from those who have pro-
duced it. I have said that, economically speaking, profes-
sional men are classed as unproductive workers. ‘The
community needs them, and willingly sets aside a certain
portion of its wealth for their maintenance. Hence, as
an (apparently) easy way of making a living, men crowd
not only into the medical, but into nearly all professions,
especially into those where the element of success is not
so much actual knowing as the art of making people
think you know.
The farmer’s son, who sees his father and mother slav-
ing from moming to night with an unpayable mortgage on
the farm as his prospective inheritance, and then notes that
the country doctor apparently does little else than drive
about behind a pair of fast trotters, and in addition that
he wears a lung-tailed broadcloth coat every day of the
week, does not, I know, reason in this way when he de-
cides to go to the nearest town that has a medical college
to become a doctor. But though they are not Ais rea-
sons, yet they are fhe reasons. He is but the puppet
irresistibly controlled by the laws of economics. He is
but following the law that impels men to seek to gratify
their desires with the least exertion ; a law, of which it
has been said that it is to political economy what the law
of gravitation is to mechanics. I follow it, you fol-
low it, we all follow it. Not because we are lazy, but
because it is a natural law. We follow it for the same
reason that a brook runs down hill, not up—because we
must.
Well, now, my medical brother, who is perhaps wonder-
ing how a living is to be made by giving advice free to
pauperized patients at a dispensary, you may ask, how is
the single tax, the land-value tax, going to remedy mat-
ters? Pray listen, and think it well over in the solitude
of your office hours, for the matter interests you.
Clearly the way to relieve the overcrowding in our pro-
fession, in all professions, and in the ranks of labor gen-
erally, is to undo the conditions which have caused the
overcrowding, and which we have just traced.
Throw open natural opportunities. ‘Tear down the
fences that keep men from the element which is life itself
—the land. And the way to do it, the practical way, the
feasible way, the just way, the on/y way, is not by seizing
the land and redistributing it, but by exacting from those
who now or at any time may occupy it, the full ground
rental value, and take nothing else. Take for the uses of
the community only the value with which it, in its com-
munal function, has endowed the soil, and to which it is
therefore nghtfully entitled, and cease confiscating, as is
now the custom, the hard-earned wealth of the toilers. Put
the tax on monopoly, and take it from labor. Where the
full ground-rent is absorbed by the community in the
form of a tax, what man could afford to hold land idle
that another man might want to use? He would either
have to use it himself, by farming on it, mining on it,
building a house or factory on it, or putting it to any other
useful purpose for which it was fitted, in order to get the
THE MEDICAL RECORD.
165
amount of the tax out of it plus a profit, or he would
have to stand aside and let the man who would work it
occupy it.
In this way all natural opportunities would be forced
into the freest, fullest use, and no man would be idle, un-
less he chose to be; the rent that each man paid would
but represent the equal rights of all others to what he is
monopolizing ; and the earth, given as the heritage of God
to all his children, and not to afavored few, would return
to the people once more.
The spectacles that now meet our eye—of freezing in
the midst of unused fuel, of starving in the midst of
stores of food, of wretchedness generally while all the
means for relieving it are spread by the prodigal hand of
nature on every side—would no longer disgrace our
boasted civilization.
To you, my recent graduate, thrown so lately from
your Alma Mater into an unappreciative world, the prob-
lem of overcrowding in the profession will most press-
ingly present itself.
Think it over, as you haply truage up and down foul
tenement-house stairs, the emissary of some health board,
ladling out diarrhoea mixtures to sickly infants who are
being crowded off this fertile earth every year by the
thousand, and yet, who are born with rights to life not in-
ferior to those of the richest landlord’s child in the city.
Ask yourself, why all this herding together of human be-
ings? why all this poverty, hunger, and dirt? Don’t, in
your plenitude of knowledge, be hasty in your judgment
and say it is because the people are lazy, drunken, and
vicious. I think you would be the same were you con-
demned to such surroundings. I am quite sure I would
be
Go back to your office and wait, day in day out, for
the patient that does not appear. Why is it that you have
such a hard time to get along? Are you too, perhaps,
lazy, drunken, and vicious? Is it not rather because those
who now demand your services are debarred by unjust
social conditions from producing the wealth wherewith
to pay you? For that you are needed in the world there
is no doubt, else you would not be sent under the guise of
charity to relieve the sick poor. Try, my friend, to bring
about juster social conditions, conditions that will not
condemn thousands of men to stand in enforced idleness
in one of the most sparsely settled of countries, like our
own ; and so by raising others you too will nse. If we
would relieve our own overcrowded profession we must
begin not with ourselves, but by helping those still more
crowded and overburdened to emerge into conditions of
freedom, into a better, purer, and nobler life.
WALTER MENDELSON, M.D.
Naw York.
THE SINGLE-TAX THEORY AND THE |
DOCTOR.
To THR Epvitor or THe Mapicat RECORD:
Sir: I see in your valuable journal of June 22d a refer-
ence to the article on “ Overcrowding in the Medical
Profession,” by Dr. Cornick, of Mascoutah, Ill., which
appeared in the Journal of the American Medical Associa-
tion some weeks ago.
That article was of most striking merit, and I only re-
gret (for the sake of our profession) that you were unable
to give any extended abstract or summary in your widely
circulated journal.
As members of the most liberal profession, I feel that
it is our duty to take careful note of the progress of the
“new political economy,” and of the vast changes in our
social structure of which it is unquestionably the pre-
cursor. ‘The proposition to leave, unhampered by restric-
tive taxation, all the products of our industrial forces in
the possession of those who practically create them, and
to meet the common needs by drawing for public revenue
upon those values which are solely the result of a com-
munity’s growth and common industry, viz., land values,
166 THE MEDICAL RECORD.
should receive, if nothing more, at least our cold intellect-
ual assent, as a mere fiscal method that is perfectly
simple, absolutely exact, conducive to political purity in
assessment and collection, most equitable, and with none
of the objectionable features in the present method.
To me its advantages are vastly greater and more far-
reaching. ‘This single-tax, in its death-blow to speculative
land-holding, would really give our industrial forces easy
and continuous access to those natural opportunities from
which all wealth must primarily be produced.
The greatly augmented production that would ensue,
not being drained away in economic rent (ground-rent),
would necessarily follow such laws of distribution as
would elevate our industrial classes to a plane of proper
remuneration, steady employment, and, as a consequence,
ample comfort. Dr. Cornick very clearly shows how the
proper share of this increased wealth-production would
rest finally with the watchers over the health of the com-
munity. ‘This is our selfish interest in this reform—the
increase of our incomes.
The destruction of speculative land-holding would have
two tendencies (apparently at first sight diverse, but really
analogous). In our cities it crowds our poorer classes
into tenements, while abundant building-sites are held out
of use on every hand. In preventing this, the reform will
settle that evil problem, “the tenement-house question.”
Only physicians can realize the resulting benefits to health
and happiness, the lowered mortality, the improved mo-
rality, the lessened temptations to intemperance and vice,
that would result from a gradual transfer of our tenement
populations to smaller family-homes of their own. In our
rural districts families are separated and isolated, while
vast tracts of unused land lie between them. Their lives
are thus narrowed, hampered, and restricted, while they
are deprived of many of the advantages of our advancing
civilization that might readily be theirs. In destroying
speculative land-holding, rural population would tend to
at least healthful density ; and social pleasures and neigh-
borly co-operation (which make up more than half of life)
would begin to brighten the dull tedium of isolated coun-
try-life. |
These are a few of the social improvements that we
may accurately and absolutely predict; and it is the ap-
peal that these make to the better, unselfish sides of our
natures that should most attract us.
You speak of “ Henry George’s land-tax theories,” and
as a physician I wish to protest. I am too proud of my
profession to neglect the opportunity of claiming for it
the initiative in the greatest movement of modern times.
‘To the famous Quesnay, the Court Physician to Louis
XVI., and the intimate friend and adviser of the great
minister ‘Turgot, belongs the honor of having first pro-
posed an “impôt unique.”
Yours fraternally,
Davip DEBEck, M.D.,
elssistant to Chair of Ophthalmology, Medical College
ef Ohio; Librarian Cincinnati Singletax Club,
MEDICAL NOTES IN THE NORTHWEST.
To THe EDITOR oF THe Menica RECORD.
Sir: It is supposed by many physicians in the East
that the profession in the West has not kept up with the
rapid material development of that section. Doubtless
this is true with reference to certain parts of the country,
but it cannot apply to the Northwest. In some respects
they are in advance of many of the Eastern States. ‘This
is particularly true with reference to medical legislation
and examination. Minnesota has an excellent and strin-
gent law for regulatıng the practice of medicine. This
law is embodied in eight sections, the two most important
being as follows :
“Sec. 3. All persons hereafter commencing the prac-
tice of medicine and surgery, in any of its branches in
this State, shall apply to said board for a license so to do,
[August 10, 1889
and such applicant, at the time and place designated by
said board, or at the regular meeting of said board, shall
submit to an examination in the following branches, to
wit: Anatomy, Physiology, Chemistry, Histology, Ma-
teria Medica, Therapeutics, Preventive Medicines, Prac-
tice of Medicine, Surgery, Obstetrics, Diseases of Women
and Children, Diseases of the Nervous System, Diseases
of the Eye and Ear, Medical Jurisprudence, and such
other branches as the board may deem advisable, and
present evidence of having attended three courses of lect-
ures of at least six months each ; said board shall cause
such examination to be both scientifc and practical, but
of sufficient severity to test the candidate’s fitness to prac-
tise medicine and surgery. When desired, said examina-
tion may be conducted in the presence of the dean of
any medical school or the president of any medical soci-
ety of this State. After examination, said board shall
grant a license to such applicant to practise medicine and
surgery in the State of Minnesota; which said license
can only be granted by the consent of not less than seven
members of said board, and which said license shall be
signed by the president and secrétary of said board, and
attested by the seal thereof. The fee of such examina-
tion shall be the sum of ten dollars, and shall be paid by
the applicant to the treasurer of said board, to be ap-
plied by said board toward defraying the expenses
thereof; and such board may refuse or revoke a license
for unprofessional, dishonorable, or immoral conduct. -
In all cases of refusal or revocation the applicant may
appeal to appointing power of said board.
“Sec. 6. Any person practising medicine or surgery
within this State without first having obtained the license
herein provided for, or contrary to the provisions of this
act, shall be deemed guilty of a misdemeanor, and upon
conviction shall be fined not less than fifty nor more
than one hundred dollars, or by imprisonment in the
county jail not less than ten nor more than ninety days,
or,both fines andimpnsonment. Any person shall be re-
garded as practising within the meaning of this act who
shall append the letters ‘M.D.’ or ‘M.B.’ to his or her
name, for a fee prescribe, direct, or recommend for the
use of any person any drug or medicine, or other agency
for the treatment, care, or relief of any wound, fracture, or
bodily injury, infirmity, or disease ; provided, however,
this act shall not apply to dentists. Justices of the peace
and the respective municipal courts shall have jurisdic-
tion over violations of the provisions of this act. It shall
be the duty of the respective county attorneys to prose-
cute violations of this act.”
The examinations for license to practise are conducted
with great impartiality, the applicants being known to the
examiners only by the numbers on their papers. Any ap-
plicant for examination, who is a graduate of over five
years’ standing before making application, is considered an
“old practitioner,” while an applicant who is a graduate
of less than five years is considered a “recent graduate.”
The latter class are required to attain a rather higher per-
centage in order to pass than the former. If the Board
is somewhat uncertain about passing a candidate, a sup-
plementary oral examination may be given upon those
subjects in which the applicant has failed to pass an en-
tirely satisfactory examination. Any applicant failing to
pass the examination may present himself at any subse-
quent regular meeting of the Board and receive another
examination. ‘The Examining Board consists of nine mem-
bers, two of which must be homceopathic physicians. No
member of any college or university having a medical de-
partment is eligible to serve upon this Board. ‘The actual
operation of the Minnesota law has been exceedingly good.
Since July 1, 1887, when the law first went into effect,
123 candidates have come up for examination, of whom
79 have passed. This law is a great step toward the sup-
pression of quackery. ‘The Secretary of the Board tells
me that within the past three months 9 quacks have been
driven from the State, 17 compelled to stop practice, and
20 to come up for examination. It is needless to say that
August IO, 1889]
THE MEDICAL RECORD.
167
there has been much opposition to this law, which has re-
sulted in several legal contests, but its constitutionality has
been upheld by five different decisions of the courts.
Montana passed a similar law last winter. In Wisconsin
and Kansas the Minnesota law was killed by a small ma-
jority. Iowa, Missouri, West Virginia, and Dakota have
the Illinois law in force. This law requires a diploma
the recognition of which is based on the will of the Board,
or an examination of those not possessing such a diploma.
Several small medical colleges in St. Paul and Minneapo-
lis have recently consolidated into the medical department
of the University of Minnesota. ‘This institution requires
a preliminary examination and a three years’ graded course,
so that the change has been a
good one for higher medical
education.
There seems to be a strong
tendency toward specialism in
the West. It is a question
whether a halt will not have to
be called soon in this direction.
The lucrative returns and regu-
lar hours of some noted spe-
cialists have tempted many to
abandon general practice. Af-
ter all, however, the legitimate
field of many specialties is com-
paratively narrow, in spite of
the ever present “reflex,” and
if they become overcrowded, the art and reputation of
medicine must suffer. ‘The tone of the profession in St.
New Instruments.
RETINOSCOPE, PUPILLOMETER, AND STRA-
BISMOMETER COMBINED.
By JOHN E. WEEKS, M.D.,
NEW YORK.
A Lonpon maker of optical instruments has introduced
to the medical profession an instrument combining a
retinoscope and pupillometer in the compact form repre-
sented in Fig. 2. Desiring to have a strabismometer
always conveniently at hand, I have copied the frame
Fic. 1.—Open.
of the London instrument and caused an instrument to
be made combining a retinoscope, pupillometer, and stra-
Paul is exceedingly high, as anyone can testify who has | bismometer in the same compass.
had the pleasure of meeting many of its members.
HENRY DwiGuT CHaPIN, M.D.
ST. PAUL, MINN., July 24. 1889.
THE CAUSE OF RICKETS.
To Tue EDITOR or THe MEDICAL RECORD.
Str: Some months ago, in a letter which you thought
worthy of publication, I made the suggestion that the at-
tention of the profession might well be directed to the
consideration of the frequency and the cause of rickets as
it occurs in the United States.
It is with great regret that I find there is a tendency,
if I may judge by the paper contributed by Dr. Irving
Snow, of Buffalo, on this subject, that more trouble is
taken to explain the views of others than to give the
simple results of actual personal observation of the dis-
ease as met with in practice. What we require is a care-
ful clinical report of the facts of each case, without any
theory as to causation, for there is no theory that satisfies
all conditions. ‘There is no evidence in England that
want of proper food is a cause of rickets, for we find the
disease quite common among the well-to-do classes in this
country.
It is absolutely necessary for anyone who undertakes
to investigate the question of causation to start with a
perfectly free mind and to trust to nothing but actual ob-
servation. |
There is but little to be gained by stating the opinions
of the past in regard to this matter, for the most singular
and irreconcilable differences exist.
|
The retinoscope consists of a plane perforated mirror
with a diameter of 40 mm. ‘This I consider to be the
best form of mirror for retinoscopy, as the illumination
obtained is very good and the range through which it can
| be satisfactorily used is greater than with the concave
mirror. ‘The pupillometer consists, as represented in
Fig. 2, of a perforated metal disk. The perforations
are sixteen in number, with diameters ranging from one
to ten millimetres. This disk is fastened securely to the
back of the instrument.
at ear
m st
|
i" |
| i |
~ i | i it HN
EA i i jii | |
ce |
Fic. 2.—Closed.
The movement of any given point on the surface of
the globe of the eye is about a central point, more or less
fixed, and the excursion of a point on the cornea which
serves to measure the degree of deviation in a squinting
eye 1s, in the vast majority of cases, on a horizontal plane,
If we could obtain, | and is virtually the movement of a point through the arc
in the first place, some accurate idea of the frequency of | of a circle whose radius is about 13.2 mm. in the adult
rickets in the different parts of the United States, it
would be most interesting and valuable, and I venture to
hope that you will use your influence in obtaining such a
report. I am, obediently yours,
ROBERT LEE.
Lonpon, June 24, 1859.
CHANGE OF NAME.— The name ot the Annales Médico-
chirurgicales, of Paris, has been lengthened to the Annales
de Therapeutique Médico-chirurgicales. We wish our es-
|
|
|
|
teemed contemporary a long and prosperous existence `
under its new title.
eye.
Because of the existing conditions above mentioned,
ophthalmologists recognize the desirability of measuring
the amount of strabismus in degrees. -~ This cannot be
accomplished by the strabismometer of Lawrence or the
binocular instrument of Galezowski, as these instruments
are designed for linear measurement, being marked in
lines or millimetres not representing the tangential meas-
urement of angles. ‘The measurement of squint in de-
grees of a circle is made by use of the arc of the perime-
ter, or by the ophthalmotropometer of Snellin ; but the
| use of these instruments requires more time than can
168
THE MEDICAL RECORD.
[August 10, 1889
usually be given for such a purpose. ‘To overcome this
difficulty I have devised a strabismometer which consists
of the arc of a circle with a radius of 14 mm., marked in
degrees, so combined with retinoscope and pupillometer
that the whole when closed corresponds in size to Figure
2, and can be carried in the vest-pocket.
As seen in Fig. 3, the strabismometer represents one
hundred and fifty degrees of the circumference of a
circle, and is marked as represented. When in position
the antero-posterior axis of the globe, passing through the
centre of the pupil, cuts the strabismometer at ninety
degrees ; the diameter of the circle of the strabismometer
at right angles with the point marked ninety minutes, if con-
tinued through the globe, would pass through the centre
of rotation of the globe, this centre being also the
centre of the circle of which the strabismometer forms a
part.
- DIRECTIONS FOR USING.
Place the strabismometer over the eye to be measured
so that its upper surface falls a very little below the hori-
zontal plane of the centre of the pupil, the antero-
posterior axis of the globe passing through the centre of
the pupil, cutting the arc of the strabismometer at ninety
degrees, when the eye fixes a point on the median line
Fic. 3.—1. Centre of rotation. 2. Direction of optical axis when converged for
24 inches in front of eye. 3. Angle of deviation in a supposed case. 4. Stra-
bismometer in position. 7%. Temporal side. M. Nasal side.
and on the horizontal plane at about fourteen inches dis-
tance. This may be obtained by covering the eye that
usually fixes. After having obtained this position, remove
the covering from the eye that ordinarily fixes, cause it to
fix the point at fourteen inches, and, by following the
movement of the deviating eye by movement of the ob-
server's head, read off the degrees of squint from the
graduated arc (Fig. 3).
All measurements of strabismus are approximate. This
instrument, however, affords a strabismometer which gives
sufficiently accurate results and is easy of application.
The measurement of strabismus where the vision is ec-
centric can be best made by a binocular instrument,
which I shall probably soon present.
MONDEVILLE’s ANATOMY.—Dr. Pagel, of the Royal
Library of Berlin, announces that he has found there the
manuscript in Latin of a work on anatomy, written in
1304 by Henn de Mondeville, surgeon to Philip the
Handsome, of France.
Army and Havy Hews.
Official List of Changes in the Stations and Duties of Cfi-
cers serving in the Medical Department, United States
Army, from July 28, to August 3, 1889.
HarL, WILLIAM R., Captain and Assistant Surgeon.
Granted leave of absence for ten days. Par. 5. S. O. 80,
Headquarters Department of Dakota, July 27, 1889.
ROBINSON, SAMUEL Q., Captain and Assistant Surgeon.
The leave of absence by Par. 11, S. O. 165, from these
headquarters, is hereby extended ten days. Par. 8, S.
O. 172, Headquarters Division of the Atlantic, July 30,
1889. ,
BRECHEMIN, Louis, Captain and Assistant Surgeon.
By direction of the Secretary of War, so much of Par. 1,
S. O. 159, July 12, 1889, A. G. O., as directs him to re-
turn to his station at the close of the encampment of the
Illinois National Guard, is amended to direct him to re-
port in person, not later than August 20, 1889, at Fort
Robinson, Neb., for duty at that place. S. O. 174,
Headquarters of the Army, A. G. O., Washington, D. C.,
July 30, 1889.
SHaus, Louis M., Captain and Assistant Surgeon.
Is hereby granted leave of absence for twenty days, on
surgeon’s certificate of disability. Par. 2, S. O. 173,
Headquarters Division of the Atlantic, August 1, 1883.
Harris, H. S. T., First Lieutenant and Assistant Sur-
geon. By Par. 9, S. O. 176, A. G. O., August 1, 1889, the
leave of absence granted in S. O. 140, A. G. O., June 18,
is further extended two months.
Official List of Changes in the Medical Corps of the United
States Navy for the week ending August 3, 1889.
BryanT, P. H., Assistant Surgeon. Ordered to tem-
porary duty on iron-clads, Richmond, Va.
Detlical Items.
ContTacious DISEASES—WEEKLY STATEMENT. — Re
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending August 3, 1889:
| Cases. | Deaths.
Typhus fever foccess so elia wi wee nea a ea es | o o
Typhoid fever eos acc witis, duos wee cesta. corser 37 13
Scarlet fever. sese ieee we PEN Kaa werk en Re BERS 29 2
Cerebro-spinal meningitis.............. cc eee eeee 3 3
Measles sc ccdccia onene a rE eee Rk E e ee 31 I
Diphtheria si sie asins oo se we cde ecalee tees oe ieaS 74 22
Small-pPoxX sie aeri ese os n mei aiene iae e aa ea SS o o
Vellow fever nrneree eeka e a AN E Ea E | o | o
o o
Cholera -ocen onuar arni inae a a e Era e aaas |
For PLUGGING THE NARES TO CONTROL EPISTAXIS.—
Dr. Juan W. McCoy, of this city, sends a description of a
device for controlling nasal hemorrhage not susceptible
of control by the ordinary means. It consists of a flex-
ible tube provided at one end with a stopcock, and sur-
rounded at the other end by a bag of soft rubber. The
bag is long enough to reach back of the posterior nares,
while the other end projects from the anterior opening of
the nostril. In the part of the tube surrounded by, the
bag are several perforations through which water may be
forced. The tube is introduced and then the stopcock
is opened, and hot or cold water is forced into the bag
until the latter is well inflated so as to exert an even
pressure, and by its expansion at either projeeting end to
effectually plug the anterior and posterior nares. Now
the stopcock is closed, and the instrument may be left in
the nose as long as necessary. Inflation may be effected
by means of an ordinary Davidson syringe.
The Medical Record
AW eekly Journal of Medicine and Surgery
-o
Vol. 36, No. 7
Original Articles,
SOME RECENT SURGICAL CASES.
EIGHT CASES OF SUPRA-PUBIC CYSTOTOMY; ONE CASE
OF SIMULTANEOUS DELIGATION OF LEFT CAROTID AND
Lerr SUBCLAVIAN ARTERIES FOR AORTIC ANEURISM;
Two Cases oF DELIGATION OF EXTERNAL CAROTID
ARTERY—ONE DOUBLE, ONE SINGLE; THREE CASES
OF AMPUTATIONS; Four Cases OF EXCISION OF
KNEE.
By JOHN A. WYETH, M.D.,
PROFESSOR OF SURGERY AT THE NEW YORK POLYCLINIC.
SUPRA-PUBIC CysToToMy.— Of the 8 cases of cystotomy
herewith reported 3 were for removal of tumors; 2
were for the removal of calculi, and in one of these a
tumor of the prostate was also removed; 1 was for re-
moval of foreign body; 1 was for relief of chronic cysti-
tis; 1 was for cure of vesical fistula.
The operations occurred within a year from May, 1889.
All recovered. One case of cancer, greatly relieved and
improved by the removal of the mass, suffered a recur-
rence in the bladder and lymphatics of abdomen, and
died six months later.
The cases of stone and foreign body were cured. In
one case of stone an enlarged middle lobe of the pros-
tate was removed, enabling the patient to void his urine
without a catheter, which he had not been able to do for
many years. A third tumor case was relieved of the dis-
tressing bladder symptoms, and a fourth case, now under
treatment, will without doubt be cured.
The case of cystitis was discharged cured after drain-
age and irrigation through the wound for three weeks,
and the case of fistula was cured easily and promptly.
Case I. Supra-pubic Cystotomy— Tumor of Bladder—
Epithelioma— Recovery.—X ——, male, aged forty, United
States, unmarried. First seen July 7, 1888. Specific
urethritis twelve years ago, never entirely cured. Dis-
charge at times until two years back, when the stream
of water became smaller and smaller until complete re-
tention ensued. Sounds were employed. Seven months
since, marked hzematuria, with chills and high tempera-
tures. Pain in lower part of abdomen. Has alcohol
and tobacco habits. Syphilis excluded. Urine pale,acid,
albumen ten per cent. Patient’s condition not good, appe-
tite fair, bowels regular. No family history of interest.
July 18, 1888.—Ether. Supra-pubic cystotomy. On
entering the bladder I discovered a soft, spongy tumor,
mushroom in shape, the pedicle attached near the neck
of the bladder, the parasol-like expansion of the growth
filling about half of the cavity. It was friable, broke
down under the finger, bleeding considerably. It was
easily removed, the attachment gouged out with a sharp
spoon, bladder irrigated with ‘Thiersch’s solution, Trende-
lenberg’s T-rubber drainage-tube inserted, wound packed
with 1odoform gauze.
July 22d (fourth day).—Temperature normal, no ill
effects of operation. Patient improved as to comfort.
Bladder washed out with Thiersch’s solution through T-
tube every four hours since operation.
Eighth day, tube removed; ninth day, temperature
103° F.; tenth day, 104° F.
Sixteenth day, urine ceased to escape through wound.
By August 14th had healed entirely.
‘Into the bladder.
Sections under microscope showed mass to be carcino-
ma. Discharged August 15th, greatly improved. Neo-
plasm showed signs of recurrence in October, and patient
died in December, 1888, from sepsis and exhaustion.
Case II. Tumor of Bladder—Supra-pubic Cystotomy—
Recovery.—J. P. L , male, aged thirty-six, United
States. First seen July. 1888.
September, 1883, patient had renal colic, which left
him with frequent micturition and pains in left lumbar
region for eighteen months, when a second severe attack
ensued. Since then attacks have occurred at more fre-
quent intervals, lasting from a few hours to several days-
During the paroxysms urination very painful and urine
bloody.
Personal history good. Father died during paroxysm
of renal colic, about sixty-four years of age.
Patient in good condition. Urine pale, acid, 1.018 ;
trace of albumen, pus-cells, and epithelia. Seen in con-
sultation by Drs. Sands and Gerster. Operation advised.
Small elevation on floor of trigonum made out by cysto-
scopic examination.
July 2zoth.—Supra-pubic cystotomy. A small sessile
tumor, about three-quarters of an inch across its base,.
and elevated about a quarter of an inch above the:
floor of the bladder, was found occupying the left side-
of the trigonum vesicæ, half-way between the left ureter’s.
mouth and the urethral orifice. It was firm to the touch..
With the sharp spoon it was scraped out. Hemorrhage
arrested by hot Thiersch solution; T-shaped drainage-.
tube, iodoform gauze packing.
July 21st.—Patient comfortable ; temperature 100° F. ;.
bladder irrigated every three hours with Thiersch.
July 26th.—Tube removed ; temperature normal.
August 7th (eighteenth day).—Wound in bladder
closed.
August 15th.—Temperature 102° F., cause not known ;.
quinia sulph., gr. v., twice a day.
August 29th.—Discharged cured.
This patient is still under observation. His bladder
symptoms are relieved, but he has had three attacks of
intense renal pain in the last six months. ‘There is evi-
dently either tumor of the kidney or renal calculus. I
have advised exploration, and he has consented.
Case III. Supra-pubic Cystotomy for Tumor of the
Urethra and Bladder.—¥.G , female, aged twenty,
servant, first seen in 1888. Family history of no interest..
Patient complained of inability to pass water. On intro-
duction of catheter, which went in easily, bladder was.
emptied. Examination per vaginam revealed almost com-
plete occlusion of this canal by adhesion three inches.
from vulva; hymen present. Suspecting spasm of con-
strictor urethrze muscle, caused by the vaginal stricture, L
stretched the urethra and removed the vaginal obstruction-
The patient’s condition was not improved. Left without
catheterization the bladder would fill until it was greatly
distended and then overflow. With the cystoscope I
noticed what seemed to be a fold of the mucous mem-
brane of the bladder which was pouched above the in-
ternal urethral orifice.
March 26, 1889.—Supra-pubic cystotomy. A small.
polypus was found filling up the urethral opening and pro-
jecting shghtly into the bladder. With my little finger
this was pushed outward through the urethra, and ex-
tracted by the external meatus. It was attached by a.
long filamentous pedicle to the urethra, growing backward
As the urine accumulated, it was evi-
170
dently driven into the urethra, plugging it and causing
probably spasm of the constrictor muscle. The wound
in the wall of the bladder was closed at once with catgut
sutures, and the wound above this packed with iodoform
gauze. A soft catheter was fastened in the urethra and
bladder. The patient recovered without any unfavorable
symptoms. The wound in the bladder united well with-
out ever leaking. She still has some difficulty in expelling
the water, due, I believe, to weakness of the bladder-mus-
cle from chronic over-distention, but this will, without
doubt, be relieved by proper treatment.
Case IV. Supra-pubte Cystotomy for Vesical Calculus
and Tumor of the Prostate— Recovery.—M. B. M. ;
male, aged sixty-seven, United States, came under obser-
vation August 28, 1888. Gave history of stricture of
urethra of long duration. For seventeen years had drawn
urine by catheterization. Has had various attacks of
cystitis. Typhoid fever in 1885. Gives history of rheu-
m&tism and malaria. Excessive tobacco habit. Has
been treated for cystitis by vesical irrigation.
August 28th.—Condition fair; urine, 1.020, amber, alka-
line, pus-cells, triple phosphates, trace of albumen.
September 4, 1888.— Ether ; operation. Phosphatic cal-
culus, one inch and a quarter in longest measurement, re-
moved. An enlarged third lobe of the prostate projected
from the floor of the bladder in such a manner as to close
the urethral orifice. Removed with sharp spoon. T-
drainage-tube through wound, iodoform gauze. Patient
had no nse of temperature. On sixth day tube removed ;
on fifteenth day wound had closed.
October 1st.—Discharged cured. Could pass water
without catheter, although bladder power is much crippled
from long over-distention and disuse.
Case V. Supra-pubic Cystotomy for Vesical Calculus—
Recovery.—September 24, 1888; Abraham L , aged
forty-six, Russian. About three years ago patient began
to have frequent and painful micturition. These symp
toms gradually increased. No hematuria. Has had
hemorrhoids at intervals for twenty years. History
otherwise negative. General condition fair ; temperature,
98° F.; urine, 1.020, acid, albumen trace, oxalate lime
crystals, and phosphates. Exploration with sounds de-
monstrates presence of large calculus.
September 28th.—Operation. Ether.
stone removed, measuring 24 x 14 x # inches.
and iodoform gauze-dressing.
October 3d.—Temperature not over 100° F. since
operation.
October 7th.— Temperature 101.2° F. Examination of
wound shows a pustule on right side of bladder. This
was laid open; drainage-tube inserted. Urine very cloudy,
and incrustations forming on edges of wound. Has cough.
Oil of gaultheria, gtt. v., t.i.d., and lithiated potash given.
In this case a fistula persisted, which was scraped out and
finally closed, and patient discharged cured.
Case VI. Supra-pubic Cystotomy for Removal of For-
eign Body.—July 25, 1888. G. A. V , aged forty-one,
United States. ‘Ten years ago received fracture of last
dorsal and first lumbar vertebrz, and since that time has
had to use catheter to draw off his urine. A week ago,
while introducing a metal spiral catheter, broke off a piece
two inches long, which remained in the bladder. At my
office I removed a piece of this with a lithotrite, but fear-
ing laceration of urethra in any further attempt, advised
cystotomy.
August 3d.—Operation.
moved. T-drainage-tube.
August 8th.—No elevation of temperature.
moved.
August 17th.—Wound closed.
August 25th.—Discharged cured.
Case VII. Supra-pubte Cystotomy for Chronic Cystitis.
—N. U , male, aged forty, laborer. Came under ob-
servation in 1888. He gave a history of chronic cystitis,
lasting for more than one year. ‘The urine did not con-
tain pus gr epithelia in sufficient quantity to indicate
Flat, elliptical
T-tube
Ether. Catheter readily re-
Tube re-
THE MEDICAL RECORD.
[August 17, 1889
severe inflammation of this organ, and the patient was
ordered full diet, alkaline drinks, and tonics. After eight
weeks, no benefit having been obtained, it was determined
to explore the bladder, and the high operation was done
in December, 1888. No tumor was present, and the
lining membrane of the bladder was only slightly in-
jected. A drainage-tube was left in for three weeks,
then removed, and the wound closed promptly. The pa-
tient’s condition improved rapidly, and he was discharged
certainly relieved and probably cured.
Case VIII. Supra-pubic Cystotomy for Vesical Fistula
— Recovery—Cure.—lI. G , aged sixty-eight, male.
Was first seen September 2, 1888. He had been operated
upon in May, 1888, by the high method, and a large
stone removed. A fistula persisted, and on September
24th I cut into the bladder through the old cicatrix, dis-
sected out the indurated tissues, enlarged the opening in
the bladder by free incision, inserted a drainage-tube,
which was removed on ninth day. On twenty-sixth day
the wound was closed, and on November 7th patient dis- .
charged cured.
The Operation—The preparation of the patient should
be as for any ordinary laparotomy, for it is always best to
have the bowels cleared out. The pubes should be shaved
and a thorough disinfection made. After the anzesthesia
is established the sacrum should be placed on a block or
cushion high enough to give a decided tilt to the trunk,
thus causing the abdominal viscera to gravitate toward
the diaphragm. The bladder ‘should now be washed out
by injecting and evacuating through a soft catheter about
twelve ounces of warm boracic acid solution (gr. v.—x. to
3j.). This should be repeated several times, especially
when there has been a chronic cystitis. For lifting the
bladder, a Barnes dilator or rectal bag well lubricated is
introduced into the rectum and filled with from eight to
ten ounces of water. About twelve ounces of warm
boracic acid solution is thrown into the bladder. ‘To pre-
vent escape of this fluid, a string may be tied around the
penis or a plug placed in the female meatus.
A longitudinal incision is made, about three inches long,
directly over the symphysis pubis. The muscles being
separated, the operator comes down to the fat and loose
connective tissue which occupies the space between the
muscles and pubic bones and the bladder. In order to
expose more freely this space, with the dull scissors the
attachments of the muscles should be clipped for about
half an inch on either side and blunt retractors inserted.
Carrying the finger down closely in contact with the inner
surface of the pubic bones, the anterior wali of the dis-
tended bladder may be felt, and with the nail or handle
of the scalpel the areolar tissue may be lifted from the
wall of the organ. Should the peritoneum dip down
unusually low, it will also be carried up out of the way
by this dry dissection.
The bladder-wall is now in plain view. Should any
vessels be seen crossing the proposed line of incision,
they should be secured by passing a needle armed with
fine double catgut beneath them, tying and dividing be-
tween the ligatures.
On either side of the proposed incision a middle-
sized silk thread should be carried into the wall of the
bladder, to support this organ after it is emptied. It will
not matter if the needle perforates the wall. The thread
should be left as loops to be removed after the operation.
The incision through the anterior wall is made in the
median line by pushing a sharp knife through and cutting
upward from one-half to one inch. The fluid contents
immediately escape. ‘The incision should always be large
enough to admit the finger, and may be enlarged by dila-
tation or incision if necessary. All downward pressure
on the anterior wall of the bladder should be resisted by |
tension of the silk loops, in order to prevent a separation
of the bladder from the tissues in front of it. Foreign
bodies, calculi, etc., may be removed with the finger or
delicate forceps. When a neoplasm is to be removed, a
larger incision may be needed, and the size of the tumor
August 17, 1889]
will in part determine the shape of the incision. When
it becomes necessary to inspect the cavity of this organ,
or to apply the cautery, the wound may be enlarged by a
transverse incision just at the upper margin of the pubic
crest. When the large size of the neoplasm can be made
out beforehand, the transverse incision alone may be re-
quired. This incision should extend through all of the
tissues, separating the attachments of the muscles, but
division of the internal pillar of the inguinal canal and ring
should be avoided. I have not yet been compelled to use
this method, but it has been frequently done and no seri-
ous inconvenience from division of the muscles has, to my
knowledge, resulted. In removing tumors the sharp spoon
has so far been satisfactory in my work. The attached
portion should be scraped out, going well into the wall of
the bladder.
Papilloma and epithelioma are easily removed, but tu- |
mors resulting from prostatic hypertrophy offer consider-
able resistance. The scooped forceps used in tearing
away post-nasal polypi are well adapted to this operation.
When the neoplasm is malignant in character the cautery
should be applied to the attachment. The bladder should
now be irrigated and clots and débris thoroughly removed.
The question of immediate closure of the bladder by
suture, or of drainage by the T-tube, and subsequent clos-
ure by granulation, must depend upon several conditions.
Drainage is indicated: 1, When there has been severe
and long-continued cystitis; 2, when intra-vesical hemor-
rhage 1s considerable ; 3, when, from any cause, as thick-
ness of the abdominl walls and consequent depth of the
wound, disease of the walls of this organ, failing condi-
tion of the patient, etc., further operation may not be
called for.
Should closure be determined upon, proceed as follows :
Draw aside the edges of the wound down to the bladder
with wire retractors. By traction on the silk loops already
fastened into the bladder bring this organ as high up as
possible. With a fine curved needle, armed with a small-
sized catgut, insert the interrupted suture after the man-
ner of Lembert’s intestinal suture. The needle should
not be ¡made to penetrate the mucous membrane Lut be
passed about one-eighth of an inch through the muscular
substance, emerging just on the edge of the wound, then
carried across to the opposite side and into the blad-
der-wall in the same manner. The stitches should be
about one-eighth of an inch apart. By this suture the
outer surface of the bladder is turned in and held in ap-
position. ‘The superficial wound may be partly closed at
the angles, but over the line of sutures in the bladder iodo-
form and sublimate-gauze packing
should be used, and this part of
the incision treated by the open
method ; for should the bladder
leak the patient would be safe.
A soft catheter should be placed
through the urethra to keep the
urine constantly flowing away, or
it should be drawn off at frequent
intervals. An accumulation of
urine would endanger the line of
sutures. ‘The catheter should be
discontinued about the tenth or
twelfth day.
For drainage the T-tube is em-
ployed. ‘This should be of soft
rubber and about one-fourth of an
inch in its lumen. It is carried
into the bladder so that the cross- 4
piece is well into the cavity and a O ae
the wound packed snugly with (a -zi
iodoform gauze. After the pa- k
tient is put to bed the lateral po- Fic. 1. — Treudelenberg’s T-
sition should be maintained. A AE aan
long tube should now be connected with the T-tube, and
this fastened so that it will make traction on the bladder.
This longer tube leads over the side of the bed to a ves-
THE MEDICAL RECORD.
171
sel into which the urine trickles continuously. Every
two or three hours during the first forty-eight hours the
long tube should be disconnected and the bladder irngated
through the T-tube. by injecting four to six ounces of
warm boracic-acid solution. The irngations may be less
frequent after this and the tube removed from the fourth
to the tenth day. ‘The earlier the tube is removed after
the fourth day the better, for as soon as adhesions have
formed around the edges of the wound the danger of in-
filtration is avoided.
Supra-pubic cystotomy has at various times in the his-
tory of surgery been brought prominently before the pro-
fession, only to achieve a short-lived popularity and then
to be practically abandoned. It is safe to say that within
the last five years it has attained a prominence never be-
fore secured, and I think it is equally safe to assert that
from its present established position it will scarcely again
recede.
The greater perfection of surgical practice in our day,
the proper selection of cases, the preparation of the pa-
tient, etc., have combined to lower the death-rate after a
procedure once considered forinidable.
Conclusions.—1. For the removal of tumors there can be
no hesitation in preferring the high operation to perineal
cystotomy. By no other method can a safe and thorough
removal of a neoplasm be effected. 2. In vesical calculus,
without regard to size, the supra-pubic operation is pref-
erable in hypertrophy of the prostate, where this organ is
elongated and thickened, and has thus made the cavity of
the bladder more difficult of access. 3. In large calculus
—two inches in diameter and over—the high operation
should be chosen. 4. For stone in the female bladder it
should be invariably selected, when the calculus is too
large or too firm to be crushed and removed per urethram.
5. In male children perineal section for stone may be pre-
ferred, since the perineum is not deep, the organ quite
easy of access, and the after-treatment less troublesome.
6. In female children supra-pubic cystotomy should
be done when the calculus is more than one-half inch in
diameter. 7. For foreign bodies other than calculi, not
safely removable with the lithotrite, the same rules would
apply as for stone. 8. As between lithotrity and cystot-
omy I am of the opinion that when the urethra is normal,
the bladder not materially diseased (and therefore not in
great need of the rest which drainage after cystotomy se-
cures), the stone soft enough to be crushed, and not over
two inches in diameter, lithotnty should be done, a/ways
provided that the operator 1s well versed in the technique of
this operation. I do not know of a procedure requiring
greater skill, a more practised hand, and clearer head than
lithotrity. Given a tyro at both procedures, then by all
means the high operation, for here, if the lines are ad-
hered to, the end will be attained. 9. In drainage of the
bladder for chronic cystitis in women, when the drainage
is to be continued for many weeks and a urinal worn, the
vaginal operation is indicated. For temporary drainage
the high operation is best, since the wound closes sponta-
neously after the tube is removed. 10. In males I prefer
the high section for drainage, for the reason that a fistula
in the perineum offers more difficulty to close than one
through the abdominal wall above the pubes. 11. I con-
sider the chief objection to this operation to be the ten-
dency to establishment of a fistula in the track of the
wound. It is probable that this tendency will be greatly
lessened by an early removal of the tube, say on the third
or fourth day.
Case. Deligation of the Left Common Carotid and Left
Subclavian Arteries, for Aneurism of the Aorta— Death.—
O. P , aged forty-eight ; United States ; builder by oc-
cupation. Came under observation through the courtesy
of Professor R. C. M. Page, February 16, 1889. History
of syphilis commencing seventeen years before. Had
been treated only a few months after chancre appeared.
For a number of years patient had cough, with occasional
attacks of dyspnoea. Sixteen months ago these symp-
toms increased, and, accompanying them, has severe pains
172 THE
MEDICAL RECORD.
[August 17, 1889
referred to the anterior part of the chest about the heart.
Appetite good ; bowels regular.
February zoth.—Temperature, 101°; respiration, 28 ;
pulse, 132 ; systolic murmur loudest at right second inter-
space and travelling along arch of aorta; no expansion of
innominate or carotid arteries. Radial pulse at left wrist
weaker than right. Urine, 1.026; albumen, and numer-
ous hyaline and granular casts. Patient deeply cyanotic.
Moist rales over both lungs, loudest over right.
February 21st.—Oxygen gas, five minutes every half-
hour. ‘Temperature reached 104° F.; antifebrin. Diag-
nosis: Aneurism of transverse aorta ; compression of tra-
chea; chronic pneumonia. Operation advised as last
resort. ;
February 22d.—I tied the left common carotid and left
subclavian third division with large catgut; chloroform.
The operation, including the anesthesia, lasted thirty min-
utes; both incisions closed with catgut sutures. Patient
rallied well considering his bad condition.
February 23d, 6 p.m.— Temperature, 103.5° F.; breathes
laboriously, but evidently easier than before operation ;
pulse on nght side full, absent on left.
February 24th.—Temperature, 101.4° F.; respiration,
28 ; pulse, 120; symptoms of urzmic coma appeared ;
only five ounces of urine from 5 A.M. to 11 A.M. ; poultices
over kidney region ; hot-air bath. '
February 25th.—Died from renal and pulmonary
asphyxia at 3 P.M., seventy-two hours after operation.
Autopsy.—Right lung solidified in great part; large
syphilitic gummata scattered throughout—fibrinous pleu-
risy ; left lung about normal. Heart: Hypertrophy and
Fic. 2.—Showing Aneurism of Transverse Arch of Aorta.
dilatation of left ventricle ; aortic valves roughened ; arch
of aorta dilated. Commencing with the origin of the left
carotid, and extending beyond that of the left subclavian
artery, an aneurism was situated. It was spherical in
shape, about three inches in diameter, filled entirely with
firm, stratified clots, and pressed heavily on the trachea
and cesophagus from the seventh cervical to the second
dorsal vertebrae. ‘The chief direction of the tumor was
upward and backward. Kidneys small, cirrhotic, coarsely
granular surfaces, and adherent capsules. ‘The aneurism
was evidently due to syphilitic arteritis. Dr. Page had
employed iodide of potassium faithfully for several weeks
before I saw the patient, and although the consolidation
of the aneurism was well advanced, the symptoms of
dyspnoea increased. ‘The increasing dyspnoea was in`all
probability due to the progressive consolidation of the right
lung, an acute localized pneumonitis spreading from the
gummiatous patches.
The iodide of potassium did not favorably affect this
process. I based my hopes of benefit from the operation
upon the consolidation of the aneurism as a result of the
deligation of the two arteries coming off in connection
with the sac, thus damming the blood back upon the
aneurism, changing the direction of the current, with more
or less arrest of the circulation and consequent coagula-
tion.
That the distal ligature will effect the gradual forma-
tion of an organized clot in an aneurism not immediately
connected with the vessel tied, is now accepted.
In the American Journal of the Medical Sciences for
January, 1881, I published a case in which, for a large
aneurism of the ascending aorta, I tied the right carotid
and subclavian arteries with immediate and marked bene-
ficial effect. ‘The tumor had eroded one rib, and pre-
sented as a large swelling, with a wall so thin that rupture
seemed imminent, and through which the rush of blood
and aneurismal tremor were easily felt. The tumor di-
minished rapidly in size, and the patient was greatly im-
proved. She died of acute diarrhoea one year after the
operation. ‘The autopsy showed an aneurism springing
from the ascending aorta, about three inches in diameter,
filled with organized clot in its lateral and posterior portions.
On the upper anterior surface, which had cut through
the rib and sternum, the sac was thin, with a recent clot
filling a space not quite one inch in diameter. The
tumor was practically solidified, and had this patient not
returned to her dissipated habits (alcoholism) I do not
doubt her recovery would have been complete.
Case I. Deligation of both External Carotid Arteries
for Arrest of Hemorrhage from Tumor of the Naso-
pharynx.—Recovery.—W. M , aged sixteen ; April 17,
1889. In March, 1888, a tumor was removed, by means
of the Jarvis snare, from the vault of the pharynx. It
recurred, and was again in part removed by the galvano-
cautery loop on April 20, 1889.
During the night of April 27th, a severe hemorrhage
occurred from the tumor, and on the morning of the 28th
I tied both external carotid arteries between the lingual
and thyroid branches. ‘This operation was done prelim-
inary to an attempt at removal of the neoplasm, but as
the patient’s condition was so bad the latter procedure
was postponed.
On May 8th I split the soft palate, and with a key-
hole saw I removed a part of the horizontal processes of
both palate bones and the posterior portion of the vomer,
to which bones the tumor was attached. ‘This opening
gave a full view of the vault of the pharynx and the neo-
plasm. With a Volkmann spoon I rapidly scraped away
the attachment of the tumor from the vault of the
pharynx. Notwithstanding the ligatures to the arteries,
the hemorrhage was so alarming that I had to desist and
rapidly plug the cavity with sponges. ‘The patient is now
under treatment by his father, a physician in ‘Texas, who
is applying at intervals the galvano-cautery to the region
where the neoplasm was attached.
It has long been a matter of discussion among surgeons
whether ligature of both external carotids should be done
preliminary to removal of vascular tumors of the naso-
pharynx. :
In this case the benefit was very slight, as far as preven-
tion of bleeding was concerned, when I removed the
tumor ten days later; for by this time the collateral cir-
culation had been established to such an extent that I was
forced to desist, and to arrest the bleeding by packing
with sponges.
It isof interest to note how thoroughly tumors of the
vault can be seen by splitting the soft palate in the me-
dian line, and retracting the sides of this divided curtain.
It is my opinion that this method will prove of great
value when a preliminary tracheotomy is performed, and
the larynx protected by packing the lower pharynx with
sponges. Under such conditions the additional ligature
of both external carotids should depend upon the vascu-
larity and size of the neoplasm to be removed. ‘This
operation certainly renders the parts anzmic for several
hours after the vessels are tied. It is not of value after
August 17, 1889]
THE MEDICAL RECORD.
173
several days have elapsed, when the collateral circulation
is re-established.
Case II. Ligature of the Right External Carotid, in
removing an Epithelioma of Tongue.—This vessel was tied
preliminary to the extirpation of a number of infiltrated
glands of the submaxillary and upper carotid region on
the right side, and to removal of the right anterior portion
of the tongue and the floor of the mouth. ‘The patient
recovered promptly without accident. ‘The safety and
propriety of this operation is now, I believe, universally
accepted in surgery. I have tied this vessel about twelve
times, successfully in each case, while the list is swelled
now by many hundreds. Up to 1878, when I published
my American Medical Association Essay on the “ Carotid
Arteries,” in the whole history of surgery this vessel had
been tied less than one hundred times, and not a single
standard work on surgery of that day advised this opera-
tion in preference to deligation of the primitive carotid.
_ And yet forty-one per cent. died after this last opera-
tion, and only four and a half per cent. after ligature of
the external carotid.
AMPUTATIONS.—Of the amputations which have come
under my care, only three possess especial interest.
Case I.—L. J. L-—, aged forty-three, of Seattle,
Wash. Terr., came under my care in December, 1888,
with this history : While serving in Company B, Fifth New
York Cavalry, at the battle of the Wilderness, May 5,
1864, he received a minié-ball wound through the left
thigh, causing a comminuted fracture of the femur, about
Seven inches above the knee. He was taken to a field-
hospital, cold-water dressing applied, and three days later
Fic. 3.—Bone showing effort at Repair after Gunshot Fracture of Femur.
1 ] At
sequestrum with two pieces of lead buried in the bone. i
hauled in an ambulance about twenty miles to Fredericks-
burg, where a starch bandage was adjusted. ‘This was
removed later, extension made, union secured, and dis-
charged as cured, September, 1864. In 186ọ inflamma-
tion took place at the seat of injury, pus discharged, and
several pieces of bone came away.
The sinuses persisted from this on to 1887, when a se-
vere inflammation was established, and patient was com-
pelled to use crutches. The discharge of pus increased,
his health failed, and when I saw him, through the cour-
tesy of Dr. Leo, of New York, in December, 1888, he
was pale, emaciated, and evidently suffering from pro-
longed sepsis. There were six or eight sinuses openirg
out between the knee and trochanter, and the soft tissues
were infiltrated with pus. A piece of lead had escaped
through one of the openings a few days before. ‘The
uriné was normal. l
In consultation with Drs. Leo and Bryant, it was deter-
mined to explore the seat of injury and perform necrot-
omy or amputation, as the conditions might justify. I
did this January 8, 1889. The soft parts were wholly
undermined with sinuses running in all directions. The
bone was, for about seven inches in its length, incrusted
with a rough callus, with several large spines projecting.
Six inches above the joint a large sinus led into the bone,
and this was partially filled with a piece of dead bone.
This was evidently the point where the missile had cn-
tered, for two bits of lead were buried in the bone at this
point. Considering the bad condition of the bone, the
extensive infiltration of the thigh, and the patient’s ex-
hausted condition, I determined to remove the member,
and amputated above the middle of the femur. The pa-
tient made a good and rapid recovery, and returned to
his home.
The interesting feature of this case is the length of time
the pieces of lead remained in the bone before producing
ostitis. .
Case II.—M. B. , aged sixty-nine, residing in West-
ern New York; was seen in January, 1887. He had
been a healthy man up to three years ago, when he had
diabetes mellitus. ‘The sugar would disappear at inter-
vals and then recur. In August, 1888, gangrene of the
left foot was noticed, commencing in the great toe and
gradually involving the foot. When I saw him the line of
demarcation was not well established ; the entire foot was
swollen and œdematous, and the patient was evidently
failing. He had been in bed four months, and was help-
less. I amputated at the middle of the leg, using ether as
the anæsthetic. The arteries were calcareous, and in order
to hold them with the catgut ligatures I was compelled to
include some of the soft tissues with the vessels. With-
out this the ligatures would cut through. The patient
rallied from the ether, had suppression of urine, and died
from uræmia thirty-six hours after operation.
This case was no exception to the rule that any opera-
tive interference is dangerous in senile gangrene with dia-
betic urine. And yet we know that the risk of amputa-
tion is justifiable when death from sepsis is inevitable.
Case III.—G. S. A——; aged twenty-four; United
States; single ; stenographer. He had been operated upon
in Roosevelt Hospital for osteo-arthritis of the left knee,
for which exsection of the joint was done.
Osteo-myelitis of the tibia and femur was discovered
when I saw the patient, several weeks later, and for this I
amputated the thigh, just above the knee, on February 4,
1889. On cutting through tĦe bone I found the medulla
entirely destroyed, the canal containing a purulent fluid
which discharged itself as the femur was divided. The
shell of compact tissue was very thin, leaving the medul-
lary cavity about twice the usual size. As the patient’s
condition was too feeble to withstand the risk of a pro-
longed operation, as well as the increased danger of am-
putating nearer the hip, I rapidly scraped out the canal
up to the trochanter, irrigated it with 1 to 1,000 subli-
mate solution, and introduced a drainage-tube long
enough to extend from the trochanter out through the
flaps. This tube was not perforated, so that when the
nozzle of the irrigator was introduced the stream of sub-
limate solution passed entirely up through the tube and
flowed out by way of the medullary canal.
The tube was shortened one inch a week for five weeks,
and was entirely removed at the end of eight weeks. ‘The
patient recovered without any distress, and is entirely well,
with a long, healthy stump. ‘This is one more case in
proof of the great reparative power of bone, if only
healthy drainage is secured.
174 THE
Of the excisions, thé following four cases are here re-
ported.
EXCISION OF KNEE-JOINT.—CasE J.—W. A. R— ,
aged nineteen; United States; student; first seen in June,
1888. ‘Two years before this date he began to have pains
in the left knee, not severe in character, but enough to
annoy and constantly irritate and alarm him. Under the
advice of his physician he began the use of crutches, and
later a plaster-of-Paris dressing was applied at intervals.
The knee continued to enlarge, though it was not painful
unless he put his
foot to the ground
and brought the
weight of the body
upon it. When
seen by me, in June,
1888, he was in
about the condition
just described, and
hoping to save him
from an operation,
and with the advice
of Dr. V. P. Gib-
ney, a Thomas long
splint was applied.
This was faithfully
worn, but without
improvement. In February, 1889, the
pain was much increased, symptoms of
osteo-myelitis supervened, and I had
the lad sent to New York from his home
in Bristol, ‘Tenn.
On April 2d, under ether narcosis, I
excised the knee. The joint was de-
stroyed, and on sawing a section from
the head of the tibia I opened into an
abscess which occupied not only all of
the cancellous expansion of the head of
this bone, but the entire medullary canal
down to the ankle. I trephined into
the canal six inches from the upper
end, and again one inch above the
ankle, scraped out .all diseased tissue,
irrigated thoroughly, and inserted a
rubber tube in the canal, leaving one
end just below the level of the sawed
. surface above, while the other projected
FIG 4. 7 Drainage of through the trephine hole at the ankle.
putation for Osteo myelitis. The condyles of the femur were sawn
away, the bones fastened together with my steel fixation
drills, and the wound closed.
April 3d.—Doing well, slight oozing; temperature,
100.6—102.2° F. Given antipyretics and stimulants.
April 4th.—Temperature, 100.8-1o1° F. Received
antifebrin, gr. v., once, at 4,15 P.M.
_ April 5th.— Temperature, 99.2-101.8° F. Doing well.
One dose antifebrin, gr. v., at 6 P.M.
April 7th.—Temperature since April 5th, 99.2—100.4° F.
No antipyretics.
April 14th.—To-day temperature 98.6° F., all day, for
first time. Quinine stopped.
April 17th.— Doing well.
April 27th.—Dressed. Union perfect along line of
section ; all drains and drills removed from about knee-
joint. Perfect asepsis. Long drain extending down shaft
of tibia pulled out and shortened. No irritation of skin
about joint. Light gauze dressing applied.
May 4th.—Plaster splint put on, extending from hip to
ankle. Patient to be up.
May 17th.—Long tube removed from tibia.
condition improving.
May 2oth.—Plaster removed ; obliged to insert small
drain in tibia shaft. A light dressing applied, with poplar
splints. Patient up and about. Improving rapidly.
Case I.—F. B——, aged twenty-four, Italy, laborer,
seen first January 31,1889. Three years ago began to
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Patient’s
MEDICAL RECORD.
[August 17, 1889
have pain in right knee, which was soon followed by
swelling. For two years had used cane or crutches. Of
late has had fever daily. Present condition: Knee
swollen, synovial pouches very prominent, leg flexed on
thigh about forty-five degrees ; temperature, normal ; gen-
eral condition, fair.
February 5th.—Operation ; ether.
February 16th.—Complains of slight pain in knee ;
temperature ranged from 99° to 101° F. since operation ;
urine has to be drawn off occasionally by catheter.
February 21st.—Wound dressed first time and drills re-
moved ; healing nicely.
February 28th.— Dressing changed.
March 6th.—Dressing changed.
March 13th.—Dressing changed; about on crutches.
April 3d.—Discharged perfectly cured. :
Case II.—Amanda R , aged twenty-six; United
States; cook; first seen March 21, 1889. Family history
negative. Patient has had slight cough for five or six years ;
once had hemoptysis. Ten months ago developed sudden
painful swelling of left knee; integument reddened.
This lasted for three months, during which time there was
continuous fever. Leg became flexed on thigh, and was
never since extended. Present condition, fair; tempera-
ture, 98.6° F.; left knee, irregularly enlarged ; leg flexed
at ninety degrees on thigh; almost complete anchylosis ;
attempts at motion painful.
Diagnosts.—Subluxation and partial anchylosis from
rheumatoid arthnitis.
March 26th.—Operation ; ether.
March 27th.—Rested well; temperature, 99.6° to
100.6° F.
April 6th.— Temperature, 98.6° to 100.4° F.
April 22d.—Wound dressed first time ; union perfect ;
drills removed.
May 2d.—Wound again dressed.
May 16th.—Discharged perfectly cured.
Case III.—Mrs. T. O’R——, aged thirty-three ;
housewife; Ireland ; seen first, December 26th, with his-
tory of painful enlargement of left knee for more than
one year. She could not walk without crutches, and was
evidently suffering from chronic sepsis.
December 27th.—Excision of joint under ether narcosis.
Wound cleansed and surface freely dusted with iodoform:
December 30th.—Temperature, 102° F., controlled by
antifebrin, but would rise when effect of medicine wore
off. As sepsis was scarcely possible, iodoform poisoning
was suspected, and, on examination of the urine iodine
was found present.
January 4th.— Wound dressed.
January 13th.—Wound dressed.
January 21st.—Wound dressed ; drills removed.
March.— Patient moving about on crutches. Small
sinus on right anterior aspect of knee. In April this was
laid open, scraped, and healed quickly. Patient cured.
Résumé.—These cases, with others heretofore operated
upon, confirm the freedom from danger which this pro-
cedure enjoys. I have so far not lost a single case of
excision of the knee. Occasionally failure of the opera-
tion occurs as a result of recurrence of ostitis in the
bones at or near the lne of coaptation. The chief in-
terest is in the complete fixation, by means of the drills,
which gives perfect rest. ‘This, with the aseptic tech-
nique and dressings, permits the parts to remain undis-
turbed until union is secured.
In three of these cases the original dressing was
changed on the twenty-fourth, sixteenth, and twenty-
seventh days, respectively. In the other instance too
much iodoform necessitated a change on the eighth day.
In cases of extensive disease of the tibia or femur, where
the patient is greatly run down, amputation should be seri-
ously considered in place of exsection. Yet the safety of
exsection would justify an effort of saving the limb where
doubt may exist.
The operation which I prefer is as follows :
Under the strictest asepsis the leg is cleansed, the foot
August 17, 1889] .
THE MEDICAL RECORD.
175
elevated to empty the extremity of blood, and a rubber
tube tourniquet applied above the middle of the thigh.
With the leg straightened out, an incision is made
across the centre of the patella, and down on each side,
until the level of the posterior surface of the tibia is
reached. These points must be low in order to secure
free drainage. ‘The skin flaps or cuffs are now dissected
and rolled up uatil the upper one is turned back from two
to three inches, the lower about one and a half inch.
As the flaps are held well away by assistants, the operator
cuts down to the femur through the tissues, parallel with
the attached edge of the reflected flap, lifting everything
from the anterior aspect of the femur and its condyles, to-
gether with the patella, the attached fringes, ligamentum
patellz, and coronary ligaments, thus clearing in one
mass all the tissues which envelop the anterior three-
fourths of the joint.
By sharply bending the knee the crucial ligaments are
exposed and divided, the lateral ligaments cut away, and
the disarticulation effected. In stripping the attachments
of the ligamentum posticum Winslowii from the tibia and
femur, the operator should closely hug the bone and thus
avoid wounding the vessels. ‘This dissection should ex-
tend about three-fourths of an inch below the level of the
tibia and one and a half inch above the lowest surface
of the condyles. Determining now the amount of bone
necessary to be removed, a cloth retractor is applied so
as to protect the soft parts from bone detritus or injury,
and a slice thick enough to freshen the head of the tibia is
sawed away, as nearly as possible parallel with the normal
plane of the articular surfaces. Should the section expose
a focus of disease which dips down into the bone, this should
be cleared out with a scoop or Volkmann spoon, and final-
ly mopped with a strong bichloride solution (1 to 500).
The section through the end of the femur should now
be made. It follows that if the limb is to be straight in
the position of anchylosis the sawed surfaces of the two
bones must be parallel. I have found it of great value to
employ this method. By pulling on the foot the limb is
fully straightened, and the articular surface of the femur
separated from the sawed surface of the tibia. If the op-
erator will now start the saw into the femur, sighting by
the flat face of the tibia, the instrument will cut directlé
parallel with this. If by error the section of the tibia has
been slightly oblique, that of the femur will have a like
obliquity, and therefore the bones will fit snugly with the
extremity straight.
The next step is to dissect away with forceps and curved
blunt scissors all the diseased capsule. ‘This should be
done thoroughly, and even the bursz that communicate
with the joint should be cleaned out. If care is not taken,
a portion of the sac which extends up beneath the quad-
riceps tendon will not be removed. All bleeding points
should be tied with catgut and all hemorrhage stopped.
The bones are now brought in exact apposition, and while
so held the steel drills are introduced. I usually carry
two of these in from below upward, passing them through
the skin about two inches below the sawn surface of the
tibia, and directing them obliquely through the tibia into the
femur. When the end of the drill has reached the com-
pact substance of the femur, it is stopped, the handle
unshipped, and the drill left in position. ‘Three are used,
one on either side from below, and one directly down the
median line from above, entering the femur and passing
into the tibia (Fig. 3).
As the leg is now held steady, the edges of the wound
in the skin are sewed together with catgut, and two short
bone-drains inserted at the inferior angle. I no longer
use rubber drains, having had considerable trouble with
the sinuses that persist after their removal. If the absorb-
able bone-drain is not at hand, twists of catgut will suffice.
Aseptic dressings and layers of veneering as a splint are
applied under firm compression of a roller. Over all one
layer of starched crinoline bandage is placed. This dress-
ing is allowed to remain on for from two to three weeks,
and when changed the drills are pulled out.
SHAKEN MILK.
By JOHN C. MORGAN, M.D.,
PHILADELPHIA, PA.
EVERYWHERE this dietetic paradox confronts the physi-
cian, viz., that milk—cows’ milk—is the best possible rep-
resentative food; that it “‘ contains every element of nu-
trition,” hence, that it is ‘Ae typical diet for the sick of all
ages, as well as for the healthy; this on the one hand,
and on the other, that there are few articles from which
worse results may accrue to individuals, young and old.
“ Starving on cows’ milk” is a common phrase; and
“ milk is bilious,” or “ constipating,” or causes diarrhoea,
or headache, indigestion, etc.; and these often parry our
thrusts at malnutrition. “Acidity of cows’ milk,” the
massiveness of its curd contrasted with human milk, with
its fine flaky curd, evidencing faulty digestive processes ;
its deficiency in oil and sugar—all these are quoted, end-
lessly, to explain the paradox, and doubtless all are sig-
nificant ; but there are other important considerations
which are less considered, and these are, in my judgment,
largely as follows :
Firstly, human milk; drawn by the child, is a nascent
life-product. Cows’ milk, at its first emission, 1s equally
so. Secondly, both are living fluids, and their contained
cells are the site of vital metabolisms, all, doubtless, pro-
motive of assimilation and of digestion itself. Thirdly,
their oil globules and casein gran@les are sundered and
enveloped by their containing shells of albumen and the
watery menstruum.
Milk which has died, whether human or cows’ milk, has
ceased to be nascent, has ceased its living metabolic cell-
mutations, has become a mere physical or mechanical
admixture of bodies of unequal density and specific grav-
ity, whose particles separately mass themselves, and within
a few hours, if undisturbed, form crude strata, as cream,
heavy caseous milk, and whey; each, after longer inter-
vals, becoming very distinct, as is proved by the so-called
‘“‘ candles ” formed in the large test-tubes in use in con-
densed milk factories. Preservation on ice does but pro-
mote this change. Sterilizing processes, fer contra, inter-
fere with it, over and above the intended germ-destruction,
inasmuch as the high heat, with agitation, prevents rapid
separation. ‘The housewife recognizes the same principles
when preparing “ curds and whey,” or “slip,” with milk and
the pepsine-bearing rennet, choosing a cold and quict place
for the setting of her pan, her object being to obtain a
half-digested, massive, unruptured curd, with its transpar-
ent substratum of watery albumino-saline fluid, or whey.
Most stomachs can easily complete the digestive process
thus begun—for it is nothing else—and it rarely disagrees
with anyone. Should it do so, we may, by beating, or
shaking it, break up the curdy mass (with the aid of an
admixture of atmospheric air), thus reducing it to tke
finely comminuted flaky state so admired in “ mothers’
milk,” and intimately mingling it with the whey at our
option. Afterward, the process of curdling being com-
plete, these particles have but feeble tendency to reunite ;
are, indeed, until decay sets in, in excellent condition for
the full play of the digestive organs.
Cows’ milk, as received from the milkman, especially
in hot weather, has undergone an incipient change of like
nature. Chilled and quiescent during the night, the
evening’s milk is combined with that of the early morn-
ing, but both are carefully deprived of all remaining
“animal heat.” ‘The whole becomes as one by this treat- -
ment. ‘The motion of carriage opposes, but the tendency
to mechanical separation has already fairly set in. Re-
ceived now at our dwellings, and transferred to the re-
frigerator, this separation goes on rapidly, and indigesti-
bility progresses part passu.
To counteract this change, so far as may be, would
seem to be the dictate not only of science but as well of
common-sense. ‘Io prevent the gastric struggle with
curdy masses, one need but insure the comminution of
those masses, and thus invoke mutually repellent forces of
176
— =. paii dii Ss |S a a a ee,
the minute particles of oil, water, and casein. ‘The rapid
digestion of each and all of these in the gastric and pan.
creatic juices should now occur without the aid, ordi-
narily, of pepsin or pancreatin, artificially introduced.
Such is the theory I would propound, and I have
witnessed a number of cases of its practical and success-
ful application. One of these is a stout, florid gentleman,
- of about sixty years, who is subject to the usual disturb-
ances from drinking even the best quality of milk. ‘The
preparation now so popular under the name of “ milk-
shake,” at an extremely low temperature too, agrees with
him perfectly, and is readily and speedily digested.
Another case is that of a physician, fifty-two years of age,
convalescent from malarial fever, for whom I prescribed
a milk diet; but who met me with the fatiguing state-.
ment that it was always disastrous to him. Lime-water
did not better the matter. I now advised that it be vio-
lently agitated by shaking or beating, with a view to com-
minution of its massive elements—the oil and the casein
—and their thorough diffusion in the whole of the fluid
portion ; this preparation to be taken in small portions
until the teacupful was finished. This was duly accom-
plished by means of a conical tin cup, such as is used by
bar-tenders, being closely fitted over the tep of a glass
of milk, and the whole vigorously shaken for some time
just before drinking (in sips, as directed). The result
was really charming. His own report was: “ Here isa
man who never has daaed, in many years, to drink a glass
of milk, but who now takes it, in the new way, every day,
and 1s building up on it.”
The use of milk just drawn from the cow is also im-
portant for infants and weakly persons; but most people
can do admirably well, I opine, on “ shaken milk.”
Judging from my own experience, I think it is not too
much to predict that in the future the medical and other
attendants in typhoid cases, perhaps in infantile disorders
and in many others in which patients refuse everything in
the way of “ sick-diet,” and crave everything which they
must be denied—particularly as to those who “ cannot
take milk ”—will find the solution of the perplexing but
essential problem in providing, as an indispensable utensil,
the bar-room tin, and regularly using it, in the prepara-
tion of shaken milk.
A dilution of milk with one-tenth of water “ scalded,”
not boiled, and taken hot, or even ordinary hot milk, is a
noble stimulant (versus alcohol) in threatened collapse,
and in debility in general. If shaken, also, it must prove
invaluable in a wide range of low cases.
When a cold drink is more suitable, as in some febrile
conditions, cracked ice may be added to milk before shak-
ing; and lastly, when the taste is fastidious, strawberry
or other fruit-syrup, or any other approved ingredient may
also be introduced.
‘THE INTERNAL USE OF CHLOROFORM.—Dr. Henry
Shimer, of Mount Carroll, Ill., writes : ‘“‘ The letter of Dr.
Wallace, in THE Mepicat REcorp of July 2oth, recalls a
case that I had many years ago. I was called, in the
early evening, to see a large, muscular man, who was in
convulsions from alcohol. ‘The spasms were tonic, the
knees being drawn up to the chest and held there as rigid
and immovable as the roots of an overturned stump. I
learned that the man had had such attacks before, and
that chloroform only gave him relief. I accordingly gave
him six ounces by inhalation, with the effect of causing
intervals of relaxation, but the spasms frequently returned.
{ sent the bottle to be refilled about midnight. I was
then tired of watching with the patient, and began giving
him chloroform internally in teaspoonful doses every
fifteen or twenty minutes. After administering about six
doses I was able to leave my patient. The only remark
he made about it was after the first dose, ‘There, you
have played the devil with my mouth.’ ‘The next day he
was able to go out, though not yet entirely recovered from
his two weeks’ spree.”
THE MEDICAL RECORD.
[August 17, 1889
RESUME ON MATERNAL IMPRESSIONS.
By WILLIAM R. LOWMAN, M.D.,
LECTURER ON PHYSIOLOGY AND HYGIENK M. H.S.) SURGEON TO PRISON AND
ALMSHOUSE, BTC.; MEMBER OF COUNTY BOARD OF BXAMINERS, ETC.; ORANGE-
BURG, S. C.
UNDER this heading may be classed all those peculiar
freaks of nature connected with the genesis of species, all
abnormalities resulting from nervous, psychic, and he-
matic influences that affect the foetal subject while yet
in the bosom of its mother, and all anomalies of sperma-
togenesis. But, specifically, in this let us consider the de-
partures from “ primogeniture” in woman and see how
and why “this plastic ideal of the mother’s emotional im-
press can be made to subserve for the congenital welfare ot
the child in utero,” and see if sufficient demonstration can
be found to show the mother’s power for transmission of
mental impressions as in those that impart likeness of
physical configuration.
I. History.—Records are rich in stories showing the
effects of maternal impressions. The ancients fully be-
lieved in them, as we have attested by Baptista Porta,
Furnelius, and others. ‘The belief that psychical, mental,
and physical impress is implanted on the foetus has al-
ways found a responsive chord in writers of all ages,
not only from love of the mystic and wonderful that be-
longed to some, but also, we are forced to conclude after
careful study, from actual and positive knowledge of such
things by many of these authors. Of course, being of in-
ferior knowledge, the majority therefore were easily led
into erroneous conceptions often, but, with the light of
succeeding ages focalized and knowledge concentrated and
purified, we are compelled to give credence to the honest
and oftentimes abstruse (comparatively) dissertations of
Hippocrates and Fabius Quinctilius,’ even though they
assure, with seeming sincerity, that white parents begat
African-hued offspring perforce of the antenatal impres-
sion of pictures of some Hannibalian hero hanging in the
connubial chamber. Be this as it may, in sacred his-
tory” we have at least one well-attested case of the re-
sult of impression upon animals during heat in which
Jacob craftily outwitted his father in-law.
Were we to search medical literature from remote an-
tiquity, through all there would be a connected and un-
broken chain of records from the markéd Cain and curséd
Ham on through medizval folios, through Roman and
Grecian history, mythical and true, to this day; and we
would find numberless instances of strange freaks of nat-
ure and Minotaurean wonders attributed to sensonal and
psychical impressions. The greater number are not reli-
able, but still there is sufficient to be of positive value.
The tendency of the day is decidedly agnostic, and espe-
cially is this sceptical inclination manifested in regard to
everything that is immaterial, that is not tangible. A man
of science who meets a new fact simply arrests his judg-
ment until he can explain it. ‘The dogmatist takes refuge
in the intellectual indolence of denial. Every scientist
is naturally a materialist, but there are many who cannot
see beyond the limit of their narrow sphere and who will
not look beyond the tip of their Æsculapian proboscis, and
anything that cannot be dissected, vivisected, or subjected
to the microscope, kymograph, and balance is cast aside
as valueless and without foundation. Such are hot-house
plants developed in the labyrinths of laboratories, and,
when subjected to the light of practical truth, it matters
not how much sneering hauteur and enthusiasm they have
for their pseudo-scientific knowledge, the well-attested re-
sults of observation must and will drive their puny theo-
ries to the wall. Often, also, crazed by a desire emanat-
ing from a would-be authorship, they proclaim theories
completely at variance with facts for the sake of noto-
riety.
Many attempt to demonstrate the erroneous character
1 According to Ceelius of Rhodes, cited in De Morbis Cutaneis.
Dan’) Turner, London, 1716.
2 Book of Genesis, chapter xxx,
August 17, 1889]
of observation. confess myself to have been very scep-
tical in regard to the effect of maternal impressions until
facts compelled me to admit that a single well-observed
and carefully tested fact is sufficient to upset a dozen a
priori theories. Scepticism is the order of the day, and a
sceptical incredulity is considered an evidence of superior
wisdom. On anatomo-physiological principles the influ-
ence of maternal impressions in the production of mon-
strosities has been denied. The “coarse materialism” of
many has ignored the demonstrated fact that other psy-
chological impressions are admitted to produce other
physical effects. Our mental impress is left on the off-
spring. | |
II. Can we assign any cause outside of an unsatisfyirg
Kismet; or shall we, with the Moslem, exclaim: “ Allah is
good, Allah is great! What is to be will be—Kismet !”
Or can we, by a close study of spermatogenesis, receive
some light on this hitherto darkened subject? A good part
of work that has been recorded is chiefly based on observa-
tions on lower animals, in whose analogous genesis may
be reflected some light on the human phase of the prob.
lem. Our comprehension of the subject of heredity also
affords a ray. It is known that an impression is much
more easily received and transmitted to the offspring by
an animal—this is to be accounted for by lack of the rea-
soning inhibition by man. Heredity, well
studied, affords a guide to a partial explanation. Crim-
inals, according to latest researches, are born in a nascent
state, to be developed by opportunity, and if this be so
the converse must be true. ‘The law of heredity shows that
the mother, in most instances, stamps her individuality on
the offsprmg more frequently than does the father ; there-
fore an impression made on her, transmitted by nervous
force direct or through control of hzmatic supply of the
blastema, must be capable of a moulding influence. Is
this strange? Lockwood’ tells us that a human embryo
twenty-three days old is not larger than a common house-’
fly (yy of an inch). Would it not be an easy, yea, plausi-
ble thing that, an impression could affect this minute ob-
ject still in an unmoulded, unformed, and plastic state ?
We know that monstrosities are most frequently met with
among impressionable people ; that emotional disturb-
ance of the mother can and does affect the child in utero.
We know that the milk of an angry mother is liable to
sicken a child, and must not the utero-fcetal connection be
much more intimate? The embryo, prior to the begin-
ning of the third month, is much more easily affected than
later. This is consistent with embryological law. In
embryological experimentation in production of mon-
strosities by artificial methods, “an interference with de-
velopment at an early period produces a far greater mal-
formation than one at a later period.”* A philosophical
explanation of the results of these maternal impressions
would regard them as arrest of development, showing itself
in atrophy or hypertrophy of a given part.’ ‘Ihe impres-
sion may be sensorial or psychical, and may be of either a
sudden and vivid, or of a continuous nature. But how
do these impressions affect the child in utero? Is it
through herve-force regulating the flow of blood? Would
this be an explanation to this seemingly inexplicable ques-
tion? It is not so singular as it first seems that the trans-
mission of a transient impression need not necessarily
aff2ct the mother to a great extent, yet materially injure
the plastic, unformed embryo. There is no direct nervous
connection, so far as we know. Is there something per-
taining to this solution buried in nature’s mystic breast ; is
there some channel yet to be discovered through which
these influences find transmissal? ‘The experiments of
Dareste, Symkiewicz, and Fol in varnishing eggs in differ-
ent ways, irregularly heating them, subjecting them to the
motion of a railway car, produced different monstrosities ;
t Annual of Universal Medical Sciences, v., 1888, p. 417.
2 Dr. Spitzka, in Medical Classics, cited Professor Macalister, Brit-
ish Medcal Journal, April 25, 1885.
3 See an article appearing in the Chicago Medical Standard of
September, 1888.
THE MEDICAL RECORD.
177
yet, while many scientists, great minds, and embryologists
like Thomson, Geoffroy St. Hilaire, and Carpenter, and
physicians like Velpeau and Flint were firm believers in it,
a tangible cause has not yet been found. But, even
though an almost inexplicable phenomenon, the effect of
maternal impressions cannot be gainsaid by opponents.
And if such a thing is or has been attempted, to him who
does we would ask an explanation of a few acknowledged
facts, to wit: vital force, genesis, evolution, and heredity.
Dr. Archibald Dixon’ draws the following inferences
and facts in reference to cause and effect after impres-
sion :
a. That during embryonic existence certain parts may
be hindered or arrested in their development, while the
other organs not directly connected with them may con-
tinue their evolution and become fully developed.
6. That ectopia viscera of the abdomen, spina bifida,
cleft palate, hare-lip, webbed fingers and toes, etc., are
only evidence of arrested development of embryonic ab-
dominal, spinal, and maxillary processes, or, in the case
of webbed extremities, the continuation of the embryonic.
hand or foot of the second month.
c. That any agency causing arrest of development of
any portion of the fœtus must necessarily operate prior to
the evolution of the part.
d. That the cause of the arrested development may be:
local or general, as injuries to the mother’s abdomen, dis-
eases of the uterus or its membranes, hereditary trans-
mission of deformity. (We add positively sensorial and
psychic impressions made on the mother !)
e. That excessive development of parts of the fœtus
may obtain, resulting in nzvi, aneurisms by anastomosis,
supernumerary fingers and toes, etc.
f. That intra-uterine amputations are the result of am-
niotic bands or placental adhesions, fracture, or from:
constriction of a loop of the umbilical cord.
g. That amniotic bands or placental adhesions result
from inflammation of the uterus, decidua, or inflammatory
disease of the foetus. (How caused ?)
hk. That false membranes causing these amputations
may be afterward absorbed, as also the amputated ex-
tremity.
i. That so-called double monsters are the result of the
development of double cicatncula on the blastodermic
membrane of a single ovum.
j. That twins with a common chorion also result from
the development of a double cicatricula on the blastoder-
mic membrane of a single ovum.
k. That in either case there is always unity of sex.
J. That the nearness of the primitive traces to each
other determines whether the impregnation will result in
separate twins, or a double monster.
m. ‘That in twins with a single chorion, or anastomosis
of placental vessels, one foetus may become perfectly
formed while the other becomes monstrous.
n. That the development of the abnormality in such
cases depends on local anatomical causes and is governed
by fixed laws. (What are they ?)
o. That every known malformation in the human race
has its analogue in the lower animals, birds, fishes, and
reptiles.
p. That arrest of development at any of the stages of
embryonic life results, in part or in whole, in a permanent
embryo of the stage at which the arrest took place.
III. Dr. Spitzka’ classifies maternal impressions and
their ensuing deformed results thus: “ First, those in which
there is no resemblance between the deformity and the
impression to which it is attributed ; second, those in
which there is a superficial resemblance ; and, third, those
in which there is an almost photographic reproduction of
the mother’s impression in the markings of the child.”
The first class has been the one to which statistical]
methods have been applied chiefly. Profound grief, men-
tal or physical shocks acting on the mother, produce
1 The American ‘Practitioner and N ews, December 10, 1887,
2 Medical Classics, p. 35, 1888.
178
defects mentally and physically in the child. Dr. Spitzka
gives the statistics of Legrand du Saulle,’ in reference to
the ouvriers of Paris, of the defective children born in
1871, as “enfants du siège.” The French are known to
be exceedingly impressionable and emotional. Of 92
children born in Paris during the siege, 64 had mental or
physical anomalies, and the remaining 28 were weaklings,
21 imbecile or idiotic, and 8 showed moral obliquity or
emotional insanity. ‘The financial crises in Berlin ° (1875
and 1880) were followed by an increased number of idiots
born. Can we not see the effects of the civil war in our
country? Melancholy envelops many in its dark shades.
The voice of the Southern muse, which once sang so
sweetly, is it not hushed? ‘Truly has the bitterness of
Rama been upon us! Observers of large experience with
the illegitimate * say that the mental suffering of the dis-
graced mother reacts on them, arrests development, pro-
duces mental deficiency, or in after-years, even though
under the best moral care, that offspring oftentimes follows
the mother in a life of sin. The sins of the parents shall
be visited on the offspring, and this law of impression the
means of transmissal.
A second class, in which the resemblance is superficial
and the analogy is slight. A woman‘ 8 angling, her
playing child is finned, and the foetal impress is outline
of a fish on the sacro-lumbar region. Another," severely
excited, one month gone, forced to copulate by a drunken
husband, seven months later gave birth to a child, which
mow, though fifteer. years of age and possessed of com-
mon-sense, sometimes staggers and mouths his words as a
-drunken man. A lady,’ three months enceinte, while
scrubbing, was severely shocked by her husband, who
from behind suddenly flaunted a large swamp-owl in her
face ; five months later a child was born with sharp, aqui-
line nose, receding chin, and very large, prominent eyes.
The child, now a man, so resembles the swamp-cyclops
that he is known far and wide by the appellation of “ Owl-
eye C.” A timid, city-bred wife,’ while pregnant, was
called on to assist in disembowelling a hog. She was after-
ward delivered of a boy having a caudal appendix, “ which,
when he was in good health and flesh, would kink up,
swine-like.” ‘The wife of a physician ° discussed the pros
and cons of hermaphroditismus with her husband. He
also gave her some literature and illustrations on the sub-
ject. Eight months thereafter another incident occurred
in the Aésculapian household which added to its census.
The child had perfectly formed male genitalia, but just
where the caudal extremity of the monkey is attached
was a pretty fairly formed pudendency, but fortunately no
cul-de-sac. The embryologist Von Baer’s® sister carried
through hfe a red mark on the forehead, shaped exactly
like a flame.
of pregnancy, had had this flame constantly before her.
She had first seen it at a conflagration.
Under the third class a seemingly difficult phase is pre-
sented to us, yet we find many instances of almost exact
Teproduction of impression upon the foetus. Dr. Reeves,’
of Georgia, tells us of having been called in to see a
patient whose hand had been severely crushed in a sor-
ghum mill. After amputation, and before dressing, one of
the patient's sisters-in-law present was requested by him
to hold the stump. She was encrente at the time, and was
eight months from date delivered of a well-developed boy,
with the exception that the left hand in every particular re-
sembled the stump. Dr. L. L. K——” has reported a case
of “ mental influence of mother on foetus, exerted through
two successive pregnancies.” ‘The shock was produced
by a little daughter being severely burned by falling from
1 Revue scientifique: 1884.
3 Neurologisches Centralblatt, 1886, p. 449.
3 Mitchell, THE MEDICAL RECORD, July 16, 1887.
4 The wren, Medical Standard, September, 1888.
‘® Ibid. s Ibid. 7 Ibid., 1888. 8 Ibid.
? Dr. Spitzka, in Medical Classics, cited Dr. Swift,
Medical Journal, October 9, 1886, p. 407.
te Medical Briefs, fee cited by writer ig Lusus Naturz, Proc.
Med. Assoc., S. C., 18
11 American Journal Poi the Medical Sciences, 1857.
New York
THE MEDICAL RECORD.
Her mother, during the last three months
[August 17, 1889
a table upon a hot stove. The mother afterward gave
birth to a child with the appearance of being severely
burned, just like the little daughter, and it experienced like
agonies. ‘The child born in next labor was afflicted “in
exact similitude to that which had caused the emotional
reflex seal of the catastrophe.”
The “ two-headed nightingale,” well known in dime-
museums, was doubtless the result of a maternal impres-
sion.
Dr. B. R. Johnston ` reports a case in which a monster
was produced by a shock from the sight of the “ two-
headed nightingale.” ‘The patient was an X.-para.
Menses ceased in March. In November she was told she
was likely to have twins, whereupon she said she did “ not
care, so they were not Siamese.” Soon after cessation of
menstruation in March, she had visited the “ two-headed
nightingale,” and fainted at the sight. Forceps and ver-
sion were necessary at labor, occurring January 22d. ‘The
children were connected from neck to umbilicus. There
was a common cord and common umbilicus. The con-
necting link was sufficiently lax to permit them to lie
side by side.
Another well-known case is that of Ritta-Christina,
which lived eight months and eleven days.
Dr. Bechsinger,* of Para, Brazil, reported a case, doubt-
less due to an impression resulting from hypertrophy
at a point where there isa natural tendency in that
direction. An octoroon woman, in addition to a double
vagina, had three legs. ‘The third leg was attached to a
continuation of the processus coccygeus, such as is some.
times found to a lesser degree in Sumatran Malays. ‘The
patient, who is at this time in Paris, has, besides two well-
developed mamme, a third double mamma just above the
os pubis, and two vaginæ and vulve. Both vaginæ are
well supplied with nerves, and natural pleasurable sensation
is experienced in either. Sexual appetite is markedly de-
veloped. Having heard of a Frenchman who had two
penes, four testicles, and three legs, she removed to Paris,
France, to make his acquaintance.
The next’ is the case reported to your honorable
and distinguished body last year by the writer. ‘The
specimen is now in the hands of Dr. E. C. Spitzka, of
New York, who is making researches in this field. Of
the specimen, he wrote the following to the Medical
Classics: “ The case herein considered is probably the
most remarkable one in the history of maternal impres-
sions. I therefore hasten to present to the same
body of readers what is certainly an almost miraculous
occurrence.”
“Dr. W. R. Lowman, of Orangeburg, S. C., was
called to attend a colored woman, living at Edisto, who
presented the following history: About two months ad-
vanced in pregnancy, while passing througha copse of
woods, she suddenly came upon a buzzard who, having
caught a pig, had devoured the greater portion of its
head. She was greatly ‘shocked, mentally and bodily,
adds Dr. Lowman, and attacked with uneasy sensations
in the hypogastrium. Two weeks after, these culminated
in violent parturient throes. The doctor was called in at
this juncture and learned the above facts. He diagnosed
incipient miscarriage, which he succeeded in preventing.
As soon as the woman recovered from the immediately
threatening symptoms, she however discontinued the
treatment recommended. One month (twenty-eight days)
after this severe pains set in again, and the contents of
the uterus were expelled. Fortunately Dr. Lowman was
called in, and his careful examination led to the discovery
of a remarkable body, which on first sight struck the doc-
tor as resembling the body of a bird, about the size of a
robin, and lacking the head. Even the skin resembled
that of a plucked bird. ‘The umbilical cord was normally
attached, and the placenta, about two anda half centi-
1 British Medical Journal, 1885.
3 Annals of Gynecology, May, 1888.
3 Writer in Proc. Med. Assoc., S. C., 1888, and Dr. Spitzka in Medi-
cal Classics, December, 1888.
rd
_ logs were very similar to those of a vulture.
August 17, 1889 |
metres in diameter, also appeared normal. Dr. Lowman
adds that the feet presented aspread claw like appearance,
imitating a bird’s foot even to the ‘subsidiary posterior
digit with its long claw.’ ' - >
“This ‘amazir z freak ’ is in every respect a mal-develop-
ed human fœtus. The shape of the bones, where exposed ;
the minute character of the articulations ; the disposition
of the foetal membranes, all leave no doubt on this head.
As unquestionable as this fact is, it is equally indisputable
that the surface resemblance to a decapitated and plucked
bird is something startling, ‘The skin everywhere, except
at the points of the extremities, presents the ‘ goose-skin’
appearance. The little papille contain a darker spot,
whose exact nature an examination involving mutilation
of the specimen could alone reveal. The neck is long, bent
over, ventro-lateral, and its terminal tissues appear rounded
off smoothly. At one point is seen a loose vertebral
arch. From present appearances there must have bétn
some maceration, as the end of the femur is exposed
and the left leg is distorted upward; probably through
the expelling force of the uterus. The upper extremities
terminate at the distal humeral end, which is covered by
a membrane continuous with the subcutaneous tissues.
At one place the cutis is raised from the nght arm. The
disposition of the thighs and legs is marvellously bird-like,
particularly in the contour of the muscular masses. ‘The
feet are human feet, exhibiting a tendency to webbing of
the toes, of division beyond the metacarpo phalangal
line, and on the left foot, most remarkably, a claw,
set back as in the bird’s! ‘The dorsum is prolonged
into a caudal process, repeating the disposition of a
bird’s. I reserve a more detailed analysis till ] can ac-
company it by more exact delineations. [This will soon
appear in Medical Classics—W.R.L.] Provisionally, I
would say that this case fulfils one condition demanded
-= by Hunter and Darwin, and demanded in vain, i.¢., the
woman related her impression before the fœtus was de-
livered. Its explanation is therefore not an after-thought.
A most interesting speculation may be indulged in regard-
ing the unconscious psychological process and impression
which combined the impression of the bird, which had its
head, with the headless character of the pig. It may be
also questioned whether the—to a woman—familtar figure
of a plucked bird was superadded. The chest exactly
resembles a robin’s breast. Certainly, as a whole, the re-
semblance externally to a bird is so great that before the
days of comparative anatomy and embryology supersti-
tion would have undoubtedly found much food in this
specimen. Dr. Lowman’s case now offers to us a valua-
hle and unimpeachable permanent record of a maternal
1 opression.”
And what adds to the peculiar interest and value af
this case is the fact that in the next pregnancy of this
same woman a completely analogous incident occurred,
except that when the woman aborted (March) she was
further advanced. ‘The foetus must have been dead in
utero for two weeks or more before the mass was expelled.
Decomposition was considerably advanced, and the foetus
was crushed and macerated. Still, the fragments exam-
ined presented almost exactly the contourage of the first
result of the impression, and some parts, particularly the
feet, were in a much higher state of development. The
This speci-
men, although much decomposed, is still in a preservative
fluid in my office, and while it is inferior to the first as a
specimen, yet it is of great value since it shows the con-
secutive influence of the “emotional reflex seal.”
‘The last case to which I will refer is that of an amelus,
or limbless monster, reported by Dr. R. T. Cæsar, in the
British Medical Journal, March gth. He says: “ I have
in my possession a specimen, which was born at full term,
and consists of a head and trunk fully developed, but no
trace whatever of a limb, no appearance of intra-uterine
amputation having taken place ; no scapula or clavicles,
and no acetabula, simply a fully developed male trunk.
Fifteen months before the birth of this child I was sum-
THE MEDICAL RECORD.
a
moned one morning by a midwife to attend the mother in
her fourth confinement. On my arrival at the house I
found an arm born, and the nurse holding on to it with
all her strength, trying to bring the child into the world in
this way, and this she had been doing for some hours.
As may be imagined, the child was so firmly fixed in the
pelvis that I found it impossible to move it, even under
the influence of chloroform, nor could my friend, Dr.
Young ; so, in the end, we were obliged to eviscerate by
opening the thorax in the axilla, amputating the arm, and
delivering with forceps. ‘The child, of course, had been
dead some time. When all was over, and our backs
turned, the stupid nurse allowed the mother to see the
mutilated remains, which considerably shocked her.
Fifteen months after, she was delivered of the subject of
this note. How far we can call this a case of maternal
impression I will leave your readers to decide.”
IV. In view of all the facts adduced above, would it
not behoove us, in behalf of ourselves, in behalf of our
country, in behalf of the human race, to advise together
for means of treatment ? And there being nothing appli-
cable save prevention, should there not be some law to
enforce legal hygiene in this particular direction? Plato,
in the “Seventh Book of Laws,” after discussing how
easily impressions are stamped upon newly born infants,
says: “ Nay, more, if I were not afraid of appearing
ridiculous, I would say that a woman during her year of
pregnancy should of all women be most carefully tended,
and kept from violent or excessive pleasures and pains;
and, at that time, she should cultivate gentleness, benevo-
lence, and kindness.” It seems that medizval legislation
was in some instances more enlightened than that of
to-day. Our authorities “allow horrifying pictures of
museum freaks to be placarded all over town, thus risking
the production of numerous deformities.” While Bavaria `
banished “a maid with two heads” from her limits, “ lest
that by frequent looking upon her the imagination of
women with child, strongly moved, should make the like
impression in the infants” they bore in their wombs,
the Roman aristocrats’ recognized the law of maternal
impressions and considered their wives sacred during the
first months of pregnancy. It is certain that the mind is
more susceptible at this time to impressions. The
Romans therefore jealously guarded their wives against
external mal-impressions of a shocking character at such
times, and surrounded them during the whole period with
beautiful objects and agreeable sights and sounds. ‘The
result is well known. We have as their progeny a race
of high artistic development, which has given birth to
many like Michael Angelo and Patti. Nor could I better
conclude this rsum than again to say :? “Let us con-
sider these things, although they be seemingly unscientific,
before we enter our final zolle prosegui upon them. There
are many things and mysteries occult in nature’s breast,
of which we know not the modus operandi. The story of
Minotaur, his savage lusts and escapades, and final over-
throw by Theseus, is not, at least in theory, all a myth.
And although the progressing enlightenment of the mind
has already swept away, as was it a fate deserved, the be-
lief in ‘spooks,’ mesmerism, spiritualism, ‘ equivocal gen-
eration,’ zodspermes, the supernatural power of bezoar,
the exaggerated idea of the influence of the moon, and
many errors of like kind, yet this fate is not in store for
the influence of maternal impressions during gestation.
"Tis true—'tis no error—'tis no delusion. Magna est
veritas, et pravalebit.”
SUICIDE AND INSANITY.—A correspondent asks for in
formation as to the relation between insanity and suicide,
and whether the view held by some that a suicide must be
insane is generally accepted.
1 Lycosthenes, cited by Ambrose Paré, Johnson's translation, 1579,
cited by Dr. Spitzka, Medical Classics, 1888.
3 See Medical Briefs, 1888.
3 Peroration, Lusus Naturz, Proc. Med. Assoc., S. C., 1888.
1f0
THE MEDICAL RECORD.
[August 17, 1889
SOME POINTS IN THE TREATMENT OF
GONORRHEA.
By BRANSFORD LEWIS, M.D..
ST. LOUIS, MO.
In THE MepicaL Recor of July 2oth Dr. E. P. Rice
describes a method of treating gonorrhcea which has given
him much satisfaction.
In the first place, believing in the theory that gonor-
rhoea is due to a specific microbe, the gonococcus, he ad-
vises the antiseptic plan of treatment. In order to carry
this out, he inserts into the urethra, as far back as the
prostatic portion, a soft rubber catheter ; through this, by
means of a glass syringe which he attaches to the distal
end of the catheter, he injects two drachms of the follow-
ing emulsion: Ac. boric., 3ij.; glycerine, 3j.; and
hopes to see five or six treatments suffice to attain a cure.
There are some points in the above to which I would
beg leave to take exception.
In the first place, to deposit two drachms of any fluid
in the prostatic urethra would almost assuredly defeat
the primal object of the operator—that of spreading his
application over the portion of the urethra that is in-
flamed; for the muscular structures surrounding the
urethra are so arranged that, at the triangular ligament,
they divide the canal into two parts, the anterior and pos-
terior urethra. ‘That this division is real, physiological as
well as anatomical, and not merely arbitrary, and for the
sake of making finer but impractical distinctions, may be
demonstrated in various ways, one being the very fact
that, if we inject a quantity of water, say a quart, through
a catheter whose eye is just distal to the triangular liga-
ment, that same amount will return alongside the catheter
and escape at the meatus; whereas, if we place the eye
of the catheter just beyond (proximal to) this muscular
ring, and then inject, the fluid will not reappear at the
meatus, but will pass on into the bladder. Indeed this
is the mode of irrigating the posterior urethra originated
and practised by the recently deceased Ultzmann in
chronic posterior urethritis. So, therefore, the bulk of
the two drachms (aside from what has remained within
the catheter) used by Dr. Rice, probably exercises its
effect on the mucous membranes of the posterior urethra
and bladder, and all that reaches the inflamed area does
so by following in the track of the catheter as it is being
withdrawn.
It has been determined ' that the natural rate of prog-
ress of the gonococci, as they invade the tissues from the
meatus backward, is notably a slow one ; that, unless car-
ried back by some accident or instrumentation, they do
not reach the bulbo-membranous neighborhood until about
the third or fourth week of the disease ; and, furthermore,
that it is only a minority of the cases in which the pos-
terior urethra is involved at all, being preserved from this
by the musculo-membranous barrier before mentioned.
It will be readily conceded, of course, that to treat any
portion not involved in the inflammation is nothing short
of ‘‘meddlesome surgery,” aside from the risks, to which
it leads, of infecting innocent tissues. So that the corol-
lary of the above premises would lead us:
Ist. 'To refrain from passing our instrument to even the
deeper portion of the anterior urethra, in the early stages
of the affection ; and, |
2d. Never to pass it beyond the compressor urethrz
muscle, unless the posterior urethra be affected—which is
always shown by well-defined symptoms.
Another question comes up: Is glycerine the best
vehicle we can use in making our antiseptic emulsion ?
From its hygroscopic nature and rubefacient effect, is it
not likely to be irritating, rather than soothing, to the
raw and tender membrane? And again, in the presence
of water glycerine loses entirely its lubricous properties ;
with the first urination out it goes, and the medicament
1 Finger: Die Blennorrhoe der Sexualorgane, 1888,
with it, so that, until the next treatment, the membrane
is minus the beneficent influence of the antiseptic.
None of these objections applies to vaseline or lanolin.
They are perfectly bland and unirritating, giving rise, be-
cause of their presence, to absolutely no pain or irritatior,
but, on the contrary, mollifying that which already exists,
by keeping the inflamed surfaces from rubbing against
one another, and also, by the coating which they form,
preventing the scalding contact of the urine. Water has
little or no effect on them, so that they are persistent and
adhere to the canal-wall even after several urinations ;
this assures the continuous application of the remedy, as
well as of the protecting vehicle, and obviates frequent
repetition of the treatment.
Of the two, vaseline and lanolin, the latter, in my esti-
mation, is preferable. It is a far more elegant prepara- |
tiqn ; is more readily absorbable, carrying with it into the
subepithelial layers, the stronghold of the cocci, the
germicide with which it is charged; and lanolin is an-
tiseptic in itself.
As a means of introducing this preparation I have
been using an application as suggested by a Dr. Smith, of
England, a year or so ago. It is simply a hard-rubber
rectal ointment-applicator, modified by having a catheter-
end, four or five inches Jong, which may be inserted into
the urethra to any depth desired ; the screw-piston serv-
ing to express the ointment at the proper time.
Boric acid is doubtless an excellent remedy, it fulfils
two essential requirements: it is antiseptic and at the
same time unirritating. I have been in the habit of using
resorcin, three to four per cent., to which, in the later
and subacute stages, I add some antiseptic astringent,
such as the sulpho-carbolate of zinc.
With this plan as a basis, and the addition of hygienic
and rational adjuvants, results have been more encourag-
ing than with any other method with which I am con-
versant.
1006 OLIVE STREET.
Clinical Department,
INTESTINAL OBSTRUCTION OVERCOME BY
THE PASSAGE OF A RECTAL TUBE.
By PHILIP F. O'HANLON, M.D,
NEW YORK,
Havinc read in THE MEDICAL RECORD of August 3d
an article by Dr. DeWitt C. Rodenhurst, on intestinal
obstruction, I would like to relate my experience. Dur-
ing my service as House Surgeon of Gouverneur Hospital
a man about fifty years of age was admitted to the ward.
His abdomen was distended and filled with gas, he was
suffering most intense agony ; had had no movement from
his bowels for a week, was vomiting, and was unable to
sleep owing to pain. Intussusception was diagnosed, and
enemas of soap water and turpentine were given, the in-
jection being repeated five or six times with no result. A
gas stove was on the table, to which was attached an ordi-
nary rubber tube of about the diameter of the little finger.
I cut off thirty-six inches of this tube, vaselined it well,
put the nozzle of a syringe at the end of the tube, and .
passed the other end into the man’s rectum, distended the
rectum with water, and screwed the tube toward the sig-
moid flexure. But the tube would not advance, and then
I inserted one finger, then two, and gradually distended the
anus until I got my right hand within the rectum, grasping
the tube with my fingers, and after a screwing motion had
been continued for a few minutes suddenly the tube ad-
vanced and made onward movement until thirty inches
had passed. I was startled by one of the staff stating that
I had probably perforated the gut and gone into the peri-
toneal cavity ; at the same time I felt that so long as I had
gone so far I might as well finish what I intended doing,
nameiy, to overcome the intussusception. I pumpedabout
August 17, 1889]
four quarts of water through the tube, when suddenly a
puff of gas escaped per rectum, and the man’s abdomen
began to sink. With a cry of joy the poor fellow kissed
my hand and manifested his gratitude in other ways.
What happened in this case was this: The smaller intes-
tine had been pushed out of the larger one by the dis-
tention of the water that had passed through the tube,
thus allowing the escape of the small intestine from the
large.
cending and transverse portions of the colon, the man
being thin and having little fat on his abdomen. I did
this in three cases in the hospital, two of which were suc-
cessful ; the third case was diagnosed intussusception, and
failing, the visiting surgeon was notified, and after a care-
ful examination it was decided that laparotomy was the
patient’s only chance. The operation was performed by
Dr. H. M. Silver, and it was found that adhesive perito-
nitis was the cause of his trouble.
I wnite this because it has been said that the tube could
not be passed so far along the intestine, and i trust that
the report of these cases may be of use to those who doubt
the value of the method.
SATYRIASIS CAUSED BY VARICOCELE, AND
CEASING AFTER SUCCESSFUL OPERATION
FOR THE LATTER.
By GEORGE T. WELCH, M.D.,
KEYPORT, N. Je
In August, 1888, a young German, of a slender but lithe
and vigorous physique, consulted me in regard to an ag-
gravated eruption of tinea versicolor, from which I found
he suffered more agonies of mind than of body, the un-
pardonable error of diagnosing the disease as syphilis hav-
ing been committed by his previous medical advisers. A
cure speedily followed upon the use of proper epidermi-
cides, and I so won the patient’s confidence that he, with
much embarrassment, proceeded to divulge a far more
serious difficulty, and ventured to hope for relief from
this also. He informed me that he had had for four
years an inordinate passion for the opposite sex, which
had so tormented him that he had felt it incumbent upon
him to keep away from the presence of women, lest he
should commit some flagrant outrage, or at least betray
his emotions in some unguarded moment.
He had lascivious dreams, and like Rousseau he had
reveries in which the women of his acquaintance accorded
him the last honor of exalted pleasures.
silken dress would stir fancies in him too lawless for ex-
pression, and he would doubtless have given way. to an
erotic mania had he not had good sense at the bottom
of these mischievous desires. He had reasoned with
himself, and had come to the conclusion that some disease
prompted the morbid symptoms, and he had attributed
them to an enlargement of the left testicle, which he did
not understand.
He told me he had used cold douches to the genitalia,
had made frequent use of Turkish baths, light diet, ab-
stinence from liquors, avoidance of the sex and of stimu-
lating literature and pictures, but all to no purpose, and
shame had prevented him from consulting a physician in
regard to the matter. So cool an analysis of his own
symptoms precluded any suspicion of mental disease, and
there was no reason to suspect any phase of epilepsy.
I at once proceeded to examine the condition of the
testicle referred to, and found an enormous varicocele—the
largest I had ever seen. The enlarged veins hung below
the testicle, and I was informed that under the stimulus
of sexual desire the veins became even more extended
than I then saw them. Without promising relief from his
satyriasis, though I encouraged him to hope for it, I ad-
vised an operation for the cure of the varicocele, at once,
to which he willingly consented.
Having made his arrangements to retire from business
for a fortnight, I operated on him the following day. I
THE MEDICAL RECORD.
The tube was felt without any trouble in the as- |
The rustle of a:
181
separated the varicose veins from the vas deferens while
the patient was standing, and the veins, therefore, more
completely distended ; but warned by Mr. Jacobson’s dis-
astrous experience in a similar case, where gangrene fol
lowed upon ligating too many of the veins, I left a small
number of them undisturbed. The scrotum was then
transfixed behind the separated veins with a scalpel, and
the veins ligated with carbolized catgut ligature in two
places, an eighth of an inch apart. The ends of the liga-
tures were cut off, and the latter were thrust back into
the scrotum, a dressing of carbolized cotton completing
the operation. A good recovery was made, and I am
pleased to say the excessive sexual desire diminished from
that time on, to the intense satisfaction of the patient.
He resumed the social life he had longed for, without
any return of the morbid symptoms.
A CASE OF BLOODLESS LABOR.
Dr. B. J. WETHERBY, of Arlington, Kan., writes: “On
July 17, 1889, I was called to confine Mrs. C——,, aged
thirty. She had previously given birth to four healthy
children, the births being unattended by anything out of
the usual order. After about two hours of waiting and a
little assistance a healthy, well-nourished male child was
born. As soon as the cord ceased to pulsate I put two
ligatures around it, as I always do, and cut the cord between
them. In about ten minutes uterine contractions came
on and the placenta was expelled without any assistance
on my part. As I transferred the after-birth to the ves-
sel, I was surprised to find that my hand did not have a
single blood-stain upon it ; and upon further investigation
I found that not a single drop of blood had been lost
except that resulting from cutting the cord. ‘The patient
stated that after her previous confinements she had
suffered terribly from after-pains, but I hazarded the
assurance that in this case she would suffer little, if any.
When I saw her next day she told me she had had no after-
pains at all, and I found that no clots had been expelled.
The woman made a rapid recovery. Several physicians
have made the statement that an entirely bloodless labor
is impossible, therefore I report this case.
“There is some difference of opinion as to the proper
management of the third stage of labor, some advising
active expression of the placenta, while others advise
the expectant plan. The point of difference is principally
in regard to the method of separation of the placenta,
the advocates of the Credé method of expressing the
after-birth holding that separation begins at the edges,
while the opponents of the method claim that separation
is effected by the formation of a retro-placental hæma-
toma. If the latter theory is correct how was the placenta
separated in the case I have just recorded, when there
was no hematoma, retro-, intra-, or extra-placental ? I
have no theory to offer, but simply state the case as I
saw it. ‘The Credé method, properly performed, is good
enough for me.”
A CAUTIOUS BRITISHER.— In a paper on the change
of gray hair to black by the use of jaborandi, published
in the Therapeutic Gazette, Dr. Prentiss relates that a pre-
vious case reported by him had been commented upon by
one of the New York dailies, the result of which was an
avalanche of letters from people asking for information
and offering money for the recipe. One man in England
wrote, enclosing the half of a two-dollar bill, with the in-
formation that the other half would be sent at once upon
receipt of the formula.
TINCTURE OF IODINE INTERNALLY FOR Warts.—Dr.
Imossi, writing in the Bulletin Général de Thérapeutique
of June 15, 1889, recommends the employment internally
of tincture of iodine in the treatment of warts. He has
obtained excellent results in a number of cases with this
remedy, in doses of ten drops twice a day for adults.
182
THE MEDICAL RECORD:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., EDITOR.
PUBLISHED BY
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
New York, August 17, 1889.
PREVENTIVE INOCULATION AND THE
THEORY OF ITS ACTION.
OF all the questions that have been brought to the notice
of the medical world in recent years, none has been the
subject of more acrimonious discussion than that of
Pasteur’s alleged preventive inoculation for rabies. Yet
we venture to say that many, even of those who have
taken part in the discussion, have but a very hazy con-
ception of the theory upon which Pasteur bases his
methods. This theory was set forth in a very able and
interesting manner by M. Roux, in the Croonian Lecture
recently delivered before the Royal Society.
Preventive inoculations were first used, the speaker
said, for variola, but they had now been superseded by
vaccination. A more satisfactory method of preventive
inoculation had been furnished by the discovery of the
power of artificially attenuating (weakening) virus.
It was in studying “ chicken cholera ” that Pasteur first
obtained cultures of an attenuated virus. ‘The gradual
diminution in the virulence of the virus was found to be
due to the action of the oxygen of the air. If, instead of
making the cultivation in a bottle, where the renewal of
the air was possible, we were to make it in a closed tube
containing only a small quantity of air, the microbe
would soon consume all the oxygen, and would cease to
grow, for oxygen was a necessity of its development. In
a tube deprived of air it could not grow, but it remained
alive for a long time, as one could satisfy one’s self by
sowing in aërated bouillon the small culture formed in the
sealed tubes. After being thus preserved for a year it
gave cultures which were as active as a recent culture
from the blood of a fowl just dead of chicken cholera.
The diminution in virulence which took place in cultures
exposed to the air was therefore dependent on that expos-
ure, and not on the length of time the microbe was kept.
In applying this method to the virus of splenic fever a
difficulty arose. It was found that the spores formed dur-
ing the first hours of culture were able to resist the action
of the oxygen of the air. To prevent the bacilli from
producing spores, the virus must be cultivated at a tem-
perature, not of 35° C., as in the case of the virus of
chicken cholera, but at one of 42° to 43° C. Under
these conditions the bacilli developed, producing the
filaments, but no spores. By drawing off every day a
little of the culture from the bottle at 42° and placing it
in bouillon at 85° C., we had a series of cultures of grad-
THE MEDICAL RECORD.
[August 17, 1889
uated virulence, and furnished with spores capable of fix-
ing each of these special degrees of intensity. The pre-
ventive vaccination of sheep had reduced the mortality
from splenic fever to one per cent. If in nature we
came across one of those attenuated bacteria we had
learned to prepare, and which were so harmless as to be
incapable of killing even a mouse, it would clearly be
impossible for us to recognize in it a descendant of the
terrible dact/lus anthracis. To do so it would be nec-
essary to have watched it in its stages of gradval atten-
uation. But it was possible (unless the process of atten-
uation had been carried too far) to make the bacillus
reascend the steps of virulence. It was not capable of
killing even a mouse. But let us inoculate with it a
very young mouse, only one day old. ‘This young mouse
would be much more sensitive than an adult mouse, and
would die in a few days. In developing in this young
mouse the bacillus would recover a portion of its old fit-
ness for life in living surroundings. The blood of this
first mouse introduced into that of one a liitle older,
would cause its death, and thus proceeding step by step
from the youngest mouse to the oldest, it would gain
power to kill first old mice, then guinea-pigs, rabbits,
sheep, and, last of all, oxen.
M. Roux then referred to rouget, and to an extraordi-
nary point in connection with it, discovered by MM. Pas-
teur and Thuillier. By passing the virus through a num-
ber of rabbits in succession it could be rendered more
potent, but as the strength of the virus increased for the
rabbit it was diminished for the pig ; so much so that, after
a sufficient number of passages of the virus had been made
through the rabbit, it had become a vaccine for swine,
able to confer upon them exemption from the fatal form
of malady. With this example before us the question
arose, What would happen with certain human diseases
if we made them also pass through a great number of
different kinds of animals? Was not this very process
taking place in nature, and did it not give fresh support
to the idea that the vaccine of small-pox became modified
by its passage through the horse and the cow?
The lecturer then proceeded to discuss at some length
Pasteur’s work in regard to rabies. M. Pasteur, he said,
had demonstrated that the true seat of the virus was to be
found in the nervous system, and that by inoculating th2
virus directly into the nervous system the incubation pe-
riod could be shortened. If inoculation by trephining
(with antiseptic precautions) were performed upon a series
of rabbits from the spinal cord or medulla of an animal
just dead, and this process were continued with successive
animals, we found that the incubation period, at first
fourteen to eighteen days, gradually diminished. It be-
came shorter and shorter, until it finally went down to six
days. At that point it remained stationary, and the rabic
virus was said to be fixed, it having attained its maximum
virulence for that animal. The virus was attenuated by
gradually drying in pure warm air (at 25° C.) the spinal
cord from a rabbit which had served in a passage se-
ries of inoculations, and therefore contained “ fixed”
virus. At the end of fourteen days this spinal cord
was absolutely innocuous, after having passed down the
scale of gradually diminishing activity during the preced-
ing days. Having now obtained our material containing
the attenuated virus, if we each day injected subcutan-
August 17, 1889]
eously into a dog a portion of the attenuated cord, crushed
in water, beginning with the harmless fourteen days cord,
then going on day by day till we reached the cord at zero,
or, in other words, spinal cord unattenuated, spinal cord
which was deadly, the dog thus inoculated would not die.
He would even remain well if the most active rabic virus
were inoculated into his brain, though we knew that other-
wise intra-cranial jnoculation produced rabies without
fail. , The exempt condition had been obtained in one
fortnight. As rabies usually remained latent in a dog
which had been bitten for a period generally exceeding
one month, it was thought that it might be possible to
profit by the long exemption period to give exemption
from the malady before its manifestation. Experiments
on dogs showed that this could be done, and since then
the method had been applied to man. The circumstances
under which the latter step had been taken by M. Pasteur
were now a matter of history.
M. Roux then proceeded to speak of the poisonous
products manufactured by microbes, and the way in which
they could be utilized for protective vaccinations. By in-
troducing, little by little, into the bodies of animals those
chemical substances produced by pathogenic microbes
(¢.g., those of acute septiczemia), in such a manner as to
avoid causing speedy poisoning, but so as to gradually
accustom the animal to their presence, it became refrac-
tory not only to toxic doses which would have originally
caused death, but also even to the microbe itself. Be-
sides the chemical, we had also the physiological question
to deal with, as shown by the fact that, although the rab-
bit was by nature refractory ta “quarter evil,” yet, inocu
lated with the virus after having first had a lesion pro-
duced in its tissues, an anthrax tumor would soon appear,
and the animal might succumb. When an active virus
was injected into a refractory animal the microbes were
soon destroyed—chiefly by the phagocytes. Any satisfac-
tory explanation of the problem of immunity should com-
prise these facts, and be based upon the relative importance
of the action of the chemical products and the resistance
of the tissues. The lecturer remarked that the best ex-
planation was to consider immunity as the result of the
habituation of the cells to the poisons secreted by the
microbes.
THE DIETETIC TREATMENT OF GOUT.
AN interesting confirmation of the views expressed for
a long time by certain American physicians, notably Dr.
Wm. H. Draper, regarding the dietetic treatment of gout,
may be found in a paper recently read before the Congress
of Internal Medicine by Professor Pfeiffer.
No particularly new views are entertained on the sub-
ject of the pathology of this affection, and, indeed, nearly
all views are still to be reduced eventually to a question
of uric acid.
“ ‘The first indication,” he says, “in treatment (Medica
Press and Circular) should be the excretion of a proper.
amount of urea and uric acid in the urine, since the reten-
tion of this product soon produces a low cachectic condi-
tion of the system. After this, the administration of a salt
that will convert the insoluble substance into a soluble
substance allowing of rapid elimination, soon relieves the
pain and reduces the swelling. The first important step
is to correct the diet. This should consist largely of
THE MEDICAL RECORD.
183
‘albuminous matter, as beef, eggs, etc., as well as fat and
green vegetables; but fermented drinks, starch, and
sugar should be forbidden. The use of a meat diet is
very important, as the retention of the urea and uric
acid quickly produces a cachectic condition of the system
which must be early combated in the treatment ; but the
meat diet does more than supply this necessity, for the
salts of the meat, when taken into the system, have a sol-
vent influence that speedily raises the elimination of urea
and uric acid to even more than the normal quantity.
The same may be said of all proteid substances, and more
particularly of eggs. Sour milk and cheese should be
avoided, but fruit and salads are beneficial, as they alka-
lize the alimentary canal; while wine and beer have the
opposite effect, and should be strictly prohibited.
“The medicinal treatment should consist in the admin-
istration of some alkaline salt, and the carbon salts seem
to be the best, though phosphoric acid and boracic acid
have, in some cases, proved beneficial. Hydrochloric
acid and sulphuric acid are objectionable. All alkaline
and mineral waters should be given in small doses to be-
gin with, and gradually increased.”
Certain German mineral waters and baths are, of course,
very highly recommended.
The formal advocacy of a meat diet, however, shows
that physicians generally are breaking away from the can-
onical teachings of the English school.
It is not to be forgotten, however, that there are many
cases of gout, especially in very plethoric persons, in which
meat is not tolerated.
POST-MORTEM SWEATING. ®
THIS curious phenomenon is said to have been observed
occasionally in cases of sudden death in acute disease,
and is supposed to be due to the continuance of capillary
circulation for a brief period. But a case related by Dr.
J. A. Cones in Zhe Lancet of May 25, 1889, appears to
be unique in the length of time that had elapsed after
death before the transudation through the skin occurred.
The patient had albuminuria, without dropsy or ascites,
and ten days before his death was seized with uremic
coma, in which condition he remained to the end. Dur-
ing the last forty-eight hours of his life, and even at the
moment of his death, he was perspiring freely. ‘Ihe body
was washed and laid out on a bed, and four hours later
was placed in the bier. At this time nothing unusual
was noticed. But the following morning the sheets and
pillow on which the body lay were saturated with moisture,
and the skin was cold and wet. ‘This exudation con-
tinued for about eight hours, and then ceased.
The theory of a continued capillary circulation will not
suffice in explanation of this case, for there was no sweat-
ing immediately after death, and it did not begin until
several hours later. ‘The author suggests that it was the
result of compression of the sweat-glands and surround-
ing lymph-spaces taking place when rigor mortis began.
The man had been sweating profusely at the time of his
death, so that it would be not inapt to compare the sur-
face of his body to a large sponge which yielded its fluid
upon being squeezed. ‘That the man was actually dead
was shown by the fact of post-mortem discoloration, which
was well marked when the body was first seen on the
morning after death.
Rews of the Week.
ANOTHER ImpostToR.—A correspondent sends the fol-
lowing note of warning concerning a man who has already
victimized a number of charitably disposed persons in this
city : “A physician holding a diploma from Bellevue
Hospital Medical College, and bearing a paper signed by
a number of persons alleged to be physicians in Johns-
town, Pa., stating that he is a victim of the great disaster,
has been applying to graduates and professors of Belle-
vue College, and probably to other physicians, for aid
to establish himself in Troy, N. Y. He gives as reference
a gentleman of ‘Troy doing business as a brewer. A note
just received from the gentleman denies all knowledge of
the man. Evidently, we have to do with a fraud. Men-
dacity combined with mendicity is doubly criminal, be
cause besides the direct wrong it poisons the fountains of
sweet charity.”
THE FRENCH SURGICAL ConGRESS.—The fourth ses-
sion of the French Congress of Surgery will be held in
Paris, in the grand amphitheatre of the Ecole de Méde-
cine, on October 14 to 20, 1889. ‘The President of the
Congress is Baron Larrey. ‘The following are the subjects
announced for discussion: 1. The immediate and re-
mote results of operations for local tubercular troubles.
2. The surgical treatment of peritonitis. 3. The treat-
ment of aneurisms of the extremities. The remaining ses-
sions of the Congress will be occupied with the reading
of voluntary communications and the presentation of pa-
tients and apparatus. All communications relating to the
sciefitific business of the Congress should be addressed to
the Secretary General, M. Pozzi, No. 10 Place Vendôme,
Paris.
Dr. Mary E. HANCHETT died recently in Chittenango,
N. Y. She was graduated from the Albany Medical Col-
lege in 1848, and was one of the first women to receive
a degree of doctor of medicine in this country.
CONVICTION OF AN INSURANCE EXAMINER.—A_ physi-
cian in Belfast was recently sentenced to six months im-
prisonment for having passed as sound an applicant for
insurance who was suffering at the time with well-marked
cardiac disease and dropsy, and who died shortly after-
ward.
INJECTIONS OF ‘TESTICULAR JuIcE.—The Brown-Sé-
quard trouble has struck America, and seems to have at
once attained the proportions of an epidemic. ‘The daily
papers are filled with reports of testicular injections prac-
tised all over the country, and on old men in all stages of
decrepitude. The results in each case, if the despatches
are to be believed, are little short of miraculous. One of
our German exchanges, in commenting upon the rejuve-
nator, remarks that it furnishes additional proof of the
wisdom of retiring professors at the age of seventy.
Brown-Séquard is seventy-two years of age.
“ THE WESTERN MEDICAL AND SURGICAL REPORTER”
is the name of the latest born of medical journals in this
great country. The object of its creation is stated to be
to give the Western doctor and the Western medical school
a show. We, of the effete East, greet our Western brother
and wish him every success in his laudable undertaking.
THE MEDICAL RECORD.
[August 17, 1889
A SOCIETY OF HYGIENE AND Pusiic HEALTH has re-
cently been foundéd in Rome.
Dr. N. SENN has been proposed for honorary mem.
bership in the National Academy of Medicine of Mexico.
THE NEw JERSEY STATE VETERINARY MEDICAL ASSOCIA-
TION held its annual meeting in Hoboken on August gth.
Secretary of Agriculture Rusk, Mr. Philip, Chief Clerk of
the United States Bureau of Animal Industry, and Frank-
lyn Deyo, Secretary of the State Board of Agriculture,
were elected honorary members.
THE AMERICAN PuBLic HEALTH ASSOCIATION will hold
its seventeenth annual meeting in Brooklyn, on October 22
to 25,1889. The programme is a very extensive one, and
includes discussions on yellow fever, diphtheria, tubercu-
losis, compulsory vaccination, prison, railway, and steam-
ship sanitation, methods of scientific cooking, etc.
Mr. CLARK BELL, President of the Medico-Legal So-
ciety of this city, was entertained at a reception by the
President and Councilof the London Society for the
Study of Inebriety on July 26th, in the rooms of the Med-
ical Society of London. Several resolutions were passed
and speeches made complimentary to the Medico-Legal
Society and to its President.
Dr. PauL MEYER, Privatdocent of Strasburg, and for
a number of years assistant to v. Recklinghausen and
Kussmaul, died recently of endocarditis, at the age of
thirty-six years. He was known to many Americans, who
will be pained to learn of his early decease.
A COMPLETE SET OF THE ‘TRANSACTIONS OF THE CON
GRESS OF GERMAN NATURALISTS AND PHYSICIANS, said to
be the only copy in existence, came near being captured
by America. It was offered for sale, and was on the point
of being sold to an American, when a member of the
Society stepped in and purchased it at a high price.
Dr. Oscar C. DE WoLF has resigned his position as
Health Commissioner of Chicago, after a continuous ser-
vice of thirteen years. Dr. Wickersham has been ap-
pointed his successor.
THE AMERICAN ACADEMY OF MEDICINE will hold its
next annual meeting in Chicago, Ill., on September 17
and 18, 1889.
THe MepicaL Society oF VIRGINIA will hold its
twentieth annual meeting on September 3 and 4, 1889, at
Roanoke, under the presidency of Dr. E. W. Rowe.
SUICIDE OF PROFESSOR LORETA.— Professor Pietro Lo-
reta, of Bologna, by whose name the operations of resection
of the liver and digital divulsion of the orifices of the stom-
ach are known, killed himself with a razor on July rgth.
He had lately shown symptoms of melancholia, and had
several times suggested to his friends the desirability of
putting an end to the persecutions to which he believed he
was exposed, by taking his own hfe. Loreta was born
in Ravenna, and was fifty-eight years of age at the time
of his death. Last spring two tablets were erected in
Bologna commemorating the ‘“ Loreta operations,” and
the distinguished surgeon was the recipient of many
honors, at the time, from societies in Europe and America.
Until his mind became diseased he was always of a
happy and cheerful disposition.
August 17, 1889]
THE DECADENCE OF THE CIGARETTE.—The falling off
in the habit of cigarette smoking, at least in the street and
other public places, is becoming very noticeable, and
dealers also say that there has been of late a very great
decrease in the sale of cigarettes.
A DEATH AFTER THE ADMINISTRATION OF SULPHONAL.
—A case is reported by Dr. R. R. Petitt, in the Medical
News, in which death followed the exhibition of thirty
grains of sulphonal. The patient was a woman aged
twenty-eight, and the drug was given in two doses of
fifteen grains each, with an interval of an hour and a
quarter between them.
A REGISTRATION Law iN NorTH Caro.ina.—The
law relating to medical practice, recently passed in North
Carolina, requires that every person entitled to practise
medicine in that State shall register in the office of the
- Clerk of the Superior Court of his county, before January
1, 1890. The. first license under the new law was issued
to Dr. Thomas F. Wood, editor of the North Carolina
Medical Journal, of Wilmington.
THE AMERICAN SOCIETY OF MICROSCOPISTS will hold
its thirteenth annual meeting in Buffalo, on August 2oth.
THE MEDICAL JOURNAL TRUST.—This is the way the
funny rumor about a medical journal trust has affected
one of our esteemed contemporaries. Under the caption
of “An Infamous Scheme,” he writes: ‘On the eve of
going to press we are pained at a current report purport-
ing that a general move is on foot to form a mammoth
‘Medical Journal Trust ;’ whereby Meritorious Journals
may be crushed out of existence by a combination of
prominent proprietary and patent medicine houses. This
combination is said to be known as the ‘ American Medical
Press Association.’ This move, if not thwarted at once,
will aim directly at the complete annihilation of every
legitimate medical journal in the United States; their
places being filled by trade and patent medicine journals.
Let the physicians of this country keep a critical eye on
‘this hydra-headed monster. ‘The plan for destruction
seems to be to induce all advertisers to gradually with-
draw their patronage from the reliable medical journals,
and place them in the hands of trade and patent medicine
journals; thereby causing good journals to die out for want
of support. Unless this infamous trick is exposed, and
every physician does his duty, patent medicine humbugs will
drive to the wall the physicians of the whole country.
Let the physicians of the Southwest sit down on this das-
tardly scheme in no uncertain manner. Let the wolf in
sheep’s clothing be jugulated before it envelops with its
slimy embrace every legitimate interest of scientific
medicine.” We think the writer is somewhat needlessly
alarmed, for this alleged trust is, we opine, largely a creat-
ure of the imagination.
THE CONDITION OF THE MEDICAL PROFESSION IN GER-
MANY.—In an address to a German medical society Dr.
Hiillmann, of Halle, discusses the ever-interesting theme
of the state of the profession and the outlook for the fut-
ure, which in Germany is no more promising than it ap-
pears to be in this country. The main causes account-
ing for the unsatisfactory position in which medical men
find themselves are, he considers: (1) The increase in
the number of practitioners as compared with that cf the
population ; (2) the low remuneration offered by clubs,
THE MEDICAL RECORD.
185
and the competition for appointments which bring in but
little more than the pay of an artisan; and (3) the con-
tinued development of specialism. He goes on to show
that there has been a steady increase in the proportion of
practitioners to population—from 3.33 for each 10,000
in 1883 to 3.77 for each to,ooo in 1888. The remedies
he suggests are to limit the number of men entering the
profession, and also the number of specialists. He remarks
that at present the course for the medical student is shorter
than that for students of any other learned profession,
for only four years are obligatory ; while a lawyer has, in
addition to his three and a half years’ study at the uni-
versity, to spend an equal period in learning the practical
duties of his profession ; a pastor has, after his university
general studies, to spend two or three years as “‘ Candidat ;”
and a school-master must after his university course work
for a probationary year before he can obtain the grade of
assistant master. Considering the immense amount of
scientific knowledge that a medical man ought to acquire,
five years would, in his opinion, seem to be the very least
that ought to be enjoined, and if a knowledge of mentz]
diseases and hygiene is to be attained, a longer period will
be necessary.
ALBOLENE.—In an article in THE MEDICAL REcorp of
July 6th, page 23, referring to a paper on “ Menthol in
Laryngeal Phthisis,” by Dr. Charles H. Knight, it should
read that the drug was dissolved in fluid albolene, not
“ fluid cosmolene,” as printed.
Reviews and Rotices of Books,
PHTHISIE LARYNGFE. Par le Dr. A. GOUGENHEIM, Méde-
cin de Hôpital Lariboisiére et de la Clinique Laryn-
gologique de l’Hépital Lariboisiére, et PAUL TISSIER,
Interne des Hôpitaux de Paris. Paris: G. Masson.
1889.
Tuts work on laryngeal phthisis fills a gap in medical
literature, for such an exhaustive treatise on the subject
has not appeared in many years. ‘The author’s reputa.
tion is a guarantee in itself of the reliability of the work.
The book 1s illustrated with woodcuts, and several chromo-
lithographic plates.
Du LAVAGE DE LA VESSIE SANS SONDE. Par le DOCTEUR
J.-M. Lavaux, Ancien Interne des Hôpitaux de Paris,
Membre de la Société de Médecine Pratique. Paris :
G. Steinheil. 1888.
In this monograph Dr. Lavaux describes in detail his
method of washing out the bladder without the use of a
sound, indicates its uses, and especially its value in the
treatment of cystitis accompanied with much pain. A
number of cases are reported to show the range of ap-
plicability of the method.
GUIDE TO THERAPEUTICS AND MATERIA MEDICA. By
ROBERT FARQUHARSON, M.P., M.D. Edin. Fourth
American Edition. By Frank Woopsury, A.M., M.D.
I2mo, pp. 598. Philadelphia: Lea Brothers & Co.
1889.
Tuts work is probably the most complete and comprehen-
sive of its kind that can be found. ‘To the practical ther-
apeutist it is almost invaluable, giving as it does in th:
smallest possible compass the latest and best means in the
shape of drugs for the treatment of all classes of disease.
The talented American editor has made some very im-
portant additions which particularly adapt the handboox
to the wants of the American practitioner. As he aptly
styles it, it is “ a miniature dispensatory.”
186
ATLAS OF VENEREAL AND SKIN DISEASES. By PRINCE A.
Morrow, A.M., M.D., Clinical Professor of Venereal
Diseases ; formerly Clinical Lecturer on Dermatology
in the University of the City of New York ; Surgeon to
Charity Hospital, etc. New York: William Wood &
Co. 1889.
THe “Atlas of Venereal and Skin Diseases,” by Dr.
Prince A. Morrow, of which notices have appeared from
time to time, is now complete, and forms the most valu-
able and comprehensive addition to the literature of this
branch of medicine that has yet appeared in any lan-
guage. The illustrations are marvels of artistic excellence
and clinical accuracy, and altogether form a collection of
typical skin lesions the value of which to the student and
practitioner can scarcely be estimated. ‘The study of skin
diseases by mere text-books has always proved uninterest-
ing, simply for the reason that, no matter how accurate the
word-description may be, there is no lasting impression
made upon the mind of the learner, but rather a confused
notion of form, color, and general characters of an erup-
tion. ‘The picture of these diseases can never be com-
plete until it is actually presented to the eye as it appears
upon the patient, with form, color, general arrangement,
situation, and distribution, such as can be seen in our
large cliniques in skin diseases. Next in order is the
faithful and artistic presentation in plates, such as are
contained in the plates which make up this truly remark-
able collection. The illustrations of the different forms
of syphilis, extending as they do over the whole range of
this interesting and common disease, gives a range to the
study which is almost surprising. The typical forms of
other skin lesions are also admirable in their way, and
leave nothing to be desired in the presentation of the
salient points of study for the rarer as well as simpler forms.
Dr. Morrow, the painstaking author, has piaced every
student and practitioner under obligations to him by the
admirably practical manner in which he has described the
different lesions and brought out their clinical significance.
In fact, it would be difficult to understand how the work
could be improved or be made more valuable to that
large class of students and practitioners for which it is
intended.
AN ELEMENTARY TREATISE ON HUMAN ANATOMY. By
Joser Leipy, M.D., LL.D., Professor of Human and
Comparative Anatomy and "Zoology i in the University
of Pennsylvania, etc. Second edition. 8vo, pp. 933.
Philadelphia: J. B. Lippincott Co. 1889.
THis work, after having been published many years ago,
comes to us in its second edition. It may be said, as it
at present stands, to be anatomy simplified, and as far as
possible, made interesting. The author has very success-
fully endeavored to make the study of anatomy compara-
tively easy by the presentation of an easy nomenclature
and the avoidance of unnecessary names. The general
plan is schematic and dwells largely upon principles, avoid-
ing, as much as is consistent with scientific accuracy, the
use of more than one common name for each organ.
Many of the illustrations are original, and present in a
new aspect many an old picture of anatomical relations.
It cannot be said that this book is Boe more than it
pretends to be, and yet it is everything that can be ex.
pected in a broad, elaborate, and comprehensive elemen-
tary anatomy.
HANDBOOK FOR THE HOSPITAL CORPS OF THE UNITED
STATES ARMY AND STATE MILITARY Forces. By
CHARLES SMART, Major and Surgeon, United States
Army. Approved by the Surgeon-General of the Army.
New York : William Wood & Co. 18809.
‘THE title of this book gives to the civilian but a faint idea
of its scope and utility. It treats not only of the post
hospital and of the duties of the hospital authorities, but
of active service in the field, of the elements of anatomy
and physiology, of nursing, of the preparation of food, of
first aid to the injured, minor surgery, management of
THE MEDICAL RECORD.
[August 17, 1889
cases of poisoning, disinfection, hospital and camp hygiene,
etc. Indeed, it would be difficult to find any subject con-
nected with the duties of an army surgeon or hospital
steward which is not touched upon. Physicians and
nurses in civil life will find the book as useful to them as
it is to those for whose special benefit it was written. The
illustrations are numerous and helpful.
IMMUNITY THROUGH LeEucomMaAINES. By Eusesio GUELL
Bacica.Lupi. ‘Translated from the second French edi-
tion by R. F. Rafael, M.D. New York: J. H. Vail
& Co. 1889.
Tuis little work, as its title implies, is written in the effort
to prove that the immunity against disease acquired
through preventive inoculation is effected by means of
leucomaines. By leucomaines the author understands
the products of elimination which are the result of the
vital functions of the specific micro-organisms. ‘The im-
munity against any disease conferred by a previous attack
is not due, he holds, to the fact that the organism has been
deprived of substances necessary to the life of the microbe,
but rather to the presence of the leucomaines which have
been eliminated by the microbes during their previous
visit. The author appears to assume that preventive in-
oculations in rabies, cholera, etc., are efficacious, and
upon this assumption he bases in great part his argument.
Consequently his theory appeals only to those who are al-
ready convinced of the value of these inoculations. The
line of argument is well reasoned out, and the author’s
views are ingenious, if not wholly convincing.
COLLEGE BOTANY : INCLUDING ORGANOGRAPHY, VEGETA-
BLE PHYSIOLOGY, AND VEGETABLE ‘TAXONOMY. By
Epson S. Bastin, A.M., F.R.M.S., Professor of Bot-
any, Materia Medica, and Microscopy in the Chicago
College of Pharmacy. 8vo, pp. 451. Chicago: G. P.
Engelhard & Co. 1889.
THIS is a revised and enlarged edition of the well-known
Elements of Botany of the author. He has succeeded
very well in presenting his subject in an attractive and in-
teresting way to the ordinary college student, a thing very
much desired in these days. ‘There is evidence through-
out the work of a desire to teach the really practical
points of the science, such as any student of pharmacy or
materia medica may require as an introduction to more
elaborate and technical researches. The illustrations are
very many and very good. Altogether, the work will tend
to popularize the study of a very interesting and useful
science.
AMERICAN ARMAMENTARIUM CHIRURGICUM.
New York: George Tiemann & Co.
CATALOGUES, as a rule, are not interesting, but this forms
sucha notable exception that it deserves particular mention.
‘The publishers, so long known among the leading instru-
ment makers of the country, have compiled a mine of in-
formation as to the almost countless number of instruments
used in surgical operations, and have placed the profession
under obligations for much that cannot be found in
books, but still that should be known. No surgeon need ©
now inquire for the name or uses of any surgical appliance
within the range of his art, for here, in this formidably
sized volume, with hundreds of beautiful illustrations and
text descriptions, he has at hand everything he may need.
It is an addendum to his works on surgery, and is quite
indispensable as a book of reference whenever any new
instrument or apparatus may be required for surgical
work.
4to, pp. 846.
MALADIES DE LA LANGUE. Parle Dr. Henry T. BUTLIN,
traduit de l'Anglais par le Dr. DOUGLAS AIGRE, An-
cien Interne des Hôpitaux de Paris. 8vo, pp. 424.
Paris: Aux Bureaux du Progrès Médical. 188ọ.
Tuis is an admirable translation of Butlin’s work on Dis-
eases of the Tongue, a notice of the original edition of
which has already appeared in ‘THE RECORD.
August 17, 1889]
Œuvres ComPLÈTES de J. M. Cuarcot. MALADIES
DES POUMONS ET DU SYSTEME VASCULAIRE. Tome
V. Aux Bureaux du Progrès Médical; E. Lecrosnier
et Babé, Pp. 654. 1888.
Tuts volume is a collection of the articles and lectures
of Charcot upon diseases of the lungs, heart, and blood-
vessels, Among the contributions are some that were
delivered thirty years ago, and none are of more recent
date than 1877. The volume has in a large measure,
therefore, a personal and historical interest. But it also
contains many clinical and pathological data of perma-
nent value.
The work is ably edited by M. Bourneville, and it is
illustrated with woodcuts and lithographic plates.
Woop’s MEDICAL AND SURGICAL MONOGRAPHS. Consist-
ing of Onginal Treatises andof Complete Reproduc-
tions in English of Books and Monographs Selected from
the Latest Literature of Foreign Countries, with all illus-
trations, etc. Vols. I. and II. New York: William
Wood & Co. 1889.
THE first volume of these monographs is completed with
the March number. In a previous notice we referred to
the nature of this publication, and to the contents of the
first number. ‘The two succeeding numbers answer fully
the expectations created by the appearance of the first,
and together they make a volume in which every practi-
tioner may find something to interest and instruct him.
The first number contains “ The Pedigree of Disease,” by
Jonathan Hutchinson, F.R.S., a work which we have
before noticed in these columns. ‘The subject is one that
is of the deepest interest to every medical man, and it is
presented in a way that cannot fail to rivet the attention
of the reader, and furnish him with much food for thought
and earnest reflection. The second monograph is on some
of the “ Common Diseases of the Skin,” by Robert M
Simon, M.D., of Lundon. It treats of the ordinary cu-
taneous affections which the general practitioner will be
likely to meet in his daily practice, and is in every way a
thoroughly practical and useful work. ‘The number con-
cludes with fourteen ‘Clinical Lectures on the Varieties
and the Treatment of Bronchitis,” by Dr. Ferrand, of
Paris. The author has endeavored to classify the various
forms of bronchitis, giving in detail the symptoms and
distinguishing characteristics of each and their appropriate
treatment. ‘The second number contains an essay on
“ Gonorrhæœal Infection in Women,” by William Japp
Sinclair, M.A., M.D., “ A Critical Study of the Clinical
Value of Albuminuria in Bright's Disease,” by Dr. Pierre
Jeanton, of Paris, and a monograph on “ Giddiness,” by
‘Thomas Grainger Stewart, M.D., F.R.C.P.E., F.R.S.E.
The last-named work is part of a series of lectures
on important symptoms, in which the author defines the
various symptoms, studies the different lesions of which
they may be an indication, and traces the connection be-
tween the symptom and the underlying condition causing
it. The last number of this volume contains five most
valuable articles, two from the pen of Dr. H. von Ziems-
sen, the first on “ Neurasthenia and its Treatment,” the
second on “ Antipyresis and Antipyretic Methods of
Treatment.” ‘The third article is an exhaustive treatise
on “ The Tongue as an Indication of Disease,” by Dr. W.
H. Dickinson. It is illustrated by woodcuts and col-
ored plates showing the varying appearances of the tongue
in health and in disease. “The ‘Treatment of Cystic
Goitre ” is the subject of an essay by T. M. Hovell, F.R.
C.S, and the concluding monograph of the series is a
brief description of the new remedies introduced into
medical practice during the past decade, by Dr. C.
Cauquil, of Paris. This number also contains the title-
page, table of contents, and index for the entire volume.
This series of monographs is a new departure in medical
literature, and is one that is deserving of success, for it
puts in the hands of the general reader a mass of excel-
THE MEDICAL RECORD.
187
lent material that would otherwise be beyond his reach.
The editor has displayed good judgment in his selection
of articles, for even in this first volume there is hardly a
practitioner, be he a specialist or in general practice, but
will find one or more subje ts of interest to him. The
books are of a handy size, and the type, paper, and print-
ing are so good that it becomes a pleasure to read the
clear pages, apart from the interest aroused by the sub-
ject-matter of the different essays. Altogether, the sub-
scriber to this series will find little cause to regret his ex-
penditure, and much cause for congratulation in having
acquired at so small an outlay so large an amount of in-
structive literature.
‘The second volume of this series of monographs is fully
up to the first in point of interest and utility to the gen-
eral practitioner. ‘The first number of this volume, that
for April, contains an essay on “ Diabetes and its Connec-
tions with Heart Disease,” by Jacques Mayer, M.D., of
Carlsbad, and one on “ Blenorrhoea of the Sexual Organs
and its Complications,” by Dr. Ernest Finger, of Vienna.
The May number contains a paper by Sir Henry. Thomp-
son, on “ The Preventive Treatment of Calculous Disease
and the Use of Solvent Remedies,” and an excellent art-
icle on “Sprains: their Consequences and Treatment,”
by C. W. Mansell Moullin, M.D., of London. The third
number should be called a treatise rather than a monograph,
for its entire four hundred and fifty pages are devoted to a
translation of Dr. August Schreiber’s recent work on
“ General Orthopedics, including Surgical Operations,”
the latest, and one of the best orthopedic works published
in Germany. ‘This bare enumeration of the titles of these
monographs is sufficient to demonstrate the great value of
the series, and we can only add that the physician who
receives and reads these numbers as they appear, will find
himself amply rewarded by his increased knowledge of
the nature and therapy of disease obtained thereby.
LECTURES ON BRIGHT’S DISEASE. By ROBERT SAUNDBY,
M.D. Edin. ; Fellow of the Royal College of Physi-
cians, London ; Emeritus Senior President of the Royal
Medical Society; Fellow of the Royal Medico-Chi-
rurgical Society ; Member of the Pathological Society
of London; Physician to the General Hospital; Con-
sulting Physician to the Eye Hospital; and Consulting
Physician to the Hospital for Diseases of Women, Bir-
mingham. With fifty illustrations. New York: E. B.
Treat. 1889.
In this little volume Dr. Saundby has presented us with a
fairly exhaustive treatise on the subject of Bright’s diseases
of the kidneys, their pathology, symptoms, and treatment.
‘The work is divided into three sections, the first being de-
voted to a consideration of general pathology, with chap-
ters on albuminuria, the pathology of dropsy, of polyuria,
and of uræmia, the pathological relations of tube-casts,
the cardio-vascular changes, and the visual defects asso-
ciated with renal disease. ‘The second section deals with
the clinical examination of the urine, and the third with
the etiology, symptoms, prognosis, complications, and
treatment of the different affections grouped under the
name of Bright’s disease. ‘Throughout this section the
reports of a number of illustrative cases are introduced in
order to render more clear the author’s explanations and
descriptions. ‘The illustrations in the book are noteworthy
for their clearness, and most of them possess the merit of
being original.
CLIMATOTERAPIA ESPAÑOLA EN LA Tisis PULMONAR. Por
el Dr. D. AGusT{N BassoLs Prim. Barcelona: D.
Jaime Seix. 1889.
THIS is an interesting guide to the health-resorts of Spain,
the Balearic and the Canary Islands, which have been
found serviceable in the climatic treatment of pulmonary
phthisis. It contains also much valuable information on
the climatic treatment of this disease.
188
A REFERENCE HANDBOOK OF THE MEDICAI, SCIENCES:
Embracing the Entire Range of Scientific and
Practical Medicine and Allied Sciences. By Various
Writers. Illustrated by Chromo-lithographsand Fine
Wood Engravings. Edited by AtsBert H. Buck,
M.D., New York City. Vol. VII. New York:
William Wood & Co. 1889.
THERE is little to be said of this volume beyond what
has already been said repeatedly of the volumes that
have preceded it. The articles herein contained are
those, in alphabetical order, from ‘‘ Teratology” to
“ Worms,” and each subject is treated in the concise
yet complete manner with which those who possess the
earlier volumes are already familiar. It is difficult,
where there is so much that is excellent, to single out
any one subject as especially worthy of mention. Yet
we cannot refrain from commending with particular em-
phasis the articles on Tuberculosis. These include “ Tu-
bercular and Syphilitic Disease of the Kidney,” by Morris
Longstreth ; ‘‘ Tubercular Disease of Glands (Scrofula),”
by F. Forchheimer ; “ Historical Sketch of Tuberculosis,”
by James F. Whittaker; “ Pathology of Tuberculosis,”
by W. T. Councilman; and ‘Symptomatology and
Treatment of Tuberculosis,’ by Hermann M. Biggs.
“ Phthisis Pulmonalis,’’ by E. W. Schauffler, is found in
a preceding volume. We venture to say that such a
clear and satisfactory presentation of this subject, and
one that is so fully up to date, is to be found nowhere
else. But this subject is mentioned only because of the
peculiar interest that it presents, and we are far from
wishing to disparage by implication any of the other
articles, which are, almost without exception, above criti-
cism. One more volume will complete this invaluable
work,
LA PROSTITUTION AU POINT DE VUE DE L'HYGIENE ET
DE L'ADMINISTRATION, EN FRANCE ET A L’ ETRANGER.
Par le Docrrur L. Reuss. Paris: Librairie J. B.
Bailliére et Fils.
Tuts is a work showing a great deal of painstaking re-
search into a disagreeable subject. The facts and fig-
ures collected are most interesting, and cannot fail to
be of great value to all students of social questions.
A GUIDE TO THE PRACTICAL EXAMINATION OF URINE,
FOR THE USE OF PHYSICIANS AND STUDENTS. By
James Tyson, M.D. Sixth edition. Revised and
corrected, with a colored plate and wood engravings.
Pp. 253. Philadelphia: P. Blakiston, Son & Co.
1888.
THE appearance of a sixth edition of this little work
attests its popularity and value. It ranks among the
best of the numerous small manuals upon the subject of
which it treats.
DICTIONARY OF VoLAPUK. By M. W. Woop, M.D.,
Captain and Assistant Surgeon, United States Army.
Volapiikatidel e Cif. New York: Charles E. Sprague,
The Office Publishing Company ; London: Tribner
& Co. 1889.
Tue English-speaking students of Volapük, already quite
numerous in this country, will welcome this excellent
dictionary, the want of which has been greatly felt. ‘The
work is arranged on the plan of Bellows’ English-French
dictionary, the corresponding portions of the two vocab-
ularies being placed on the same page. The vocabulary
is very full, and will supply the needs of ordinary cor-
respondence or essay-writing, but we confess to a disap-
pointment in finding a great paucity of medical terms.
It may be said that they would be out of place in a gen-
eral dictionary, but as Volapük is intended for com-
mercial and scientific uses chiefly, its vocabulary should
contain the words suited to such purposes. However,
it is necessary to have a stock of common words for
use even in writing medical essays, and we doubt not
that, if ever the medical world is ready to adopt Volapük
THE MEDICAL RECORD.
[August 17, 1889
as its official language, the present deficiency in medical
and scientific terms will then be filled by a wealth of
words amply sufficient to describe the most comphcated
of pathological processes. Anyone who has faith in the
future of Volapük, and wishes to learn the language, will
find Dr. Wood's dictionary indispensable, for, as we have
said, with the exception of scientific terms, it is quite
complete, and is so excellently arranged, and gotten up
in so handy a form, that the thumbing of the book in search
of words becomes almost a pleasure instead of a
drudgery.
RECHERCHES CLINIQUES ET THÉRAPEUTIQUES SUR
L' EPILEPSIE, L’ HYSTERIE ET LI DIOTIE. COMPTE RENDU
DU SERVICE DES EPILEPTIQUES ET DES ENFANTS
IDIOTS ET ARRIERES DE BICETRE PENDANT L'ANNÉE
1887. Par BOURNEVILLE, Médecin de Bicétre, SOLLIER,
PILLieT, RAOuLT, Internes du Service, et le Dr. BRI-
con. Vol. VIII., avec 27 figures dans le texte. Pp.
263. Paris: Publications du Progrés Médical; E.
Lecrosnier et Babé 1888.
THESE annual volumes always contain matter of much
scientific interest, bearing especially upon the subjects of
epilepsy and idiocy. The present work is no exception.
Perhaps the most important contribution is one by Bour-
neville and Bricon on Procursive Epilepsy, in which this
peculiar type of disease is elaborately studied.
THE OPERATIVE TREATMENT OF HYPERTROPHIED PROS-
TATE, By Francis S—EpGwick Watson, M.D., Sur-
geon to Out-patients, Boston City Hospital, etc.
Pp. 167, 10x8. Boston: Cupples & Hurd. 1888.
New York: J. H. Vail & Co.
THE text of this work was read at the Congress of Amer-
ican Physicians and Surgeons, held in Washington last
fall. It gives the history of the various remedial pro-
cedures which have been devised to relieve prostatic
obstructions. It supplies a rational groundwork on
which the greatly-increasing frequency of these opera-
tions may rest. A full supply of woodcuts of instru-
ments, etc., is inserted, and thirty-four full-page photo-
gravure illustrations are given with descriptive text.
An epitome of the author’s teaching is as follows: In
prostatic obstruction, the radical operation is to be pre-
ferred, unless contra-indicated by the patient’s exhaus-
tion. Mercier’s and Bottini’s operations from the meatus
are objectionable because applicable only to a limited
number of cases, and they do not secure proper after-
drainage from the bladder. This narrows the field to
the perineal and supra-pubic methods. Anatomically,
two-thirds of all cases likely to be encountered are
operable through the perineum. Clinically, the perineal
operations are the safest. “The inevitable conclusion”
(says the author) “from these facts is, it seems to me,
this: In a given case, open the membranous urethra,
put in your finger, and explore. Twice out of three
times the operation can be completed by this route. In
the other third of the cases the long perineal distance, or
the form of the median enlargement, will render the
supra-pubic operation necessary. The work is a most
excellent résumé of the subject, and the illustrations are
of a high order. It is to be heartily commended.
By C. M
Lon
SKIN DISEASES OF INFANCY AND EARLY LIFE.
CAMPBELL, M.D., Edinburgh. Pp. 202, 6x4.
don: Bailliére, Tindall & Cox. 1889.
The author has endeavored to avoid alike the pro-
lixity of a standard treatise and the bald incompleteness
of a mere epitome. His efforts are welcome, as the
honest narration of an extensive clinical experience
always is, though it cannot be said that he has given us
anything essentially new. It will be to the man com-
mencing practice that the work will be especially val-
uable. The book possesses the value of being fully up
to date, and can be safely recommended to students and
recent graduates.
August 17, 1889] THE
MEDICAL RECORD.
189
Society Reports,
NEW YORK PATHOLOGICAL SOCIETY.
Stated Mectinz, March 27, 1889.
WILLIAM P. NorrHRuP, M.D., PRESIDENT, IN THE CHAIR.
THE special order of the evening was the presentation of
specimens illustrating
LESIONS OF THE GASTRO-INTESTINAL CANAL.
Dr. Jonn S. Ey presented a specimen showing
PIGMENTATION OF PEYER’S PATCHES,
supposed to be secondary to chronic congestion. Irregu-
lar, dark-brown streaks and spots of pigment gave a
shaven-beard appearance to the Peyer’s patches, and a few
spots of pigment in other parts of the intestine seemed to
be in the solitary lymph-nodules. The gut was from an
Italian, about thirty-five years of age, who had pleurisy
with effusion on the right side and broncho-pneumonia of
the left lower lobe. Dr. Ely said that but little notice is
taken in the books of this form of pigmentation, but that
two situations for it are described—in the centres of the
lymph-nodules and in the connective tissue around them.
He thought, from the appearance, that the latter was the
arrangement in the specimen presented.
Besides the pigmentation above referred to, there was
A DIVERTICULUM FROM THE ILEUM
about three feet above the ileo-cz#cal valve, the usual
site of Meckel’s diverticulum. It was about three inches
long and had the circumference of the small intestine. Dr.
Ely said that the usual point of origin of these diverticula
was opposite the mesenteric attachment, and that they
ordinarily had no mesentery, but that the one presented .
originated from the side of the gut near the mesenteric
attachment and was provided with a mesentery of its own.
Its cavity freely communicated with that of the ileum.
A blood-vessel of considerable size ran along the upper
wall of the diverticulum nearly to its end, and it was sug-
gested that this might be the remains of the omphalo-mesen-
teric vessels of the foetus. That the diverticulum was
lined with mucous membrane was shown by the presence
of one of the pigmented Peyer’s patches, half in the intes-
tine and half in the diverticulum.
Dr. Ely also presented a specimen for Dr. Hodenpyl,
_ illustrated one of the conditions which may result
rom
PERSISTENCE OF THE OMPHALO-MESENTERIC CANAL,
of which Meckel’s diverticulum is the remnant. ‘The
specimen was from a child, six months old, which since
birth had had a small tumor, somewhat resembling a poly-
pus in appearance, about three-fourths of an inch long, and
an inch in circumference, protruding from the umbilicus.
Dr. R. J. Hall, under whose care the patient was, discov-
ered an opening in the centre of this tumor, through
which a probe passed, apparently into the intestine. He
ligated the mass at its base and excised it. ‘lhe wound
healed rapidly. Microscopical examination showed the
tumor to be covered with mucous membrane closely re-
sembling that of the small intestine, but infiltrated with
small round-cells and broken down in parts. ‘These
changes were thought to be the result of exposure. ‘The
central canal, through which Dr. Hall had passed the
probe prior to operation, was also found to be lined with
mucous membrane similar to that covering the tumor ex-
ternally. Immediately beneath each layer of mucous
membrane the connective tissue and muscular layers of
the intestinal wall belonging to it were to be seen, so that
from without inward there was mucous membrane, submu-
cosa, circular muscular fibres, longitudinal muscular fibres,
subserosa, longitudinal muscular fibres, circular muscular
fibres, submucosa, and mucous membrane again, lining
the central cana]. In other words, there had been com-
plete prolapse of a portion of the persistent omphalo-
mesenteric canal.
At the meeting of December 14, 1887, Dr. L. Emmet
Holt presented a similar specimen to this Society, and —
afterward published the case in full, with a review of the
literature, in THE MEDICAL RECORD (xxxiil., 1888, 431).
Dr. Ely presented several other specimens for Dr.
Hodenpyl, illustrating
TUBERCULOSIS OF THE INTESTINE.
The first was interesting because the lesion in the intes-
tine was confined to Peyer’s patches, and resembled the
lesion in the early stages of typhoid fever. A distinguish-
ing feature was at once apparent, however, on inspecting
the peritoneal surface of the gut, for in the immediate
neighborhood of the Peyer’s patches the lymphatics were
distinctly outlined by miliary and submiliary tubercles
scattered along their course. In one place it was thought
that a miliary tubercle had blocked the lumen of the lym-
phatic and caused a damming back of its contents, since
the vessel was uniformly dilated and filled with a milky
liquid. ‘These changes are well described by Orth.
A specimen of
TUBERCULAR PROCTITIS
was shown. It occurred in a patient not known to have
tuberculosis, and had been diagnosticated carcinoma.
A third specimen illustrated
TUBERCULOSIS OF THE VERMIFORM APPENDIX,
which the speaker thought to be quite rare. ‘The patients
from whom these three specimens were obtained were all
affected. with chronic phthisis, and the lesions in the intes- _
tine were secondary.
Dr. Biccs said that he did not regard tuberculosis of the
appendix vermiformis as of very infrequent occurrence,
but, on the contrary, his experience led him to believe
that it was quitecommon. He had often found it at au-
topsies, sometimes even when no tubercular lesions were
to be encountered in other portions of the intestinal
N
canal.
Dr. T. MITCHELL PRUDDEN showed some
HAIR-BALLS FROM THE STOMACH OF A PIG.
The balls were made up of the hair of the pig, which
had been licked off and swallowed, mixed with sand and
other matters. ‘The hair had a curious spiral arrange-
ment showing the effect of the gastric movements. ‘These
hair-balls are found very commonly in the pig’s stomach,
but their occurrence is of interest by reason of the bear-
ing that it has on human pathology, since they are some-
times found in the stomach of man.
Dr. Prudden then showed two
HAIR-BALLS FROM THE STOMACH OF A YOUNG WOMAN,
which had been removed by Dr. Finder, of ‘Troy, and pre-
sented by him to the museum. There were two balls, one
considerably larger than the other, which were made up
of human hair, horse-hair, threads from blankets, pieces
of string, etc. The girl had been insufficiently fed in her
youth, and had got into the habit of swallowing many
kinds of inert and indigestible substances.
Other specimens were presented of hair-balls from the
cow’s stomach, and also a number of concretions removed
from the alimentary canal of an animal. ‘These concre-
tions were examples of
ENTEROLITHS,
which were formerly in great repute as drugs, being pop-
ularly considered as specifics in the treatment of nearly
every disease to which man is liable. l
Dr. HERMANN M. Bicos presented some specimens of
STRICTURE OF THE JEJUNUM,
associated with disease of the czecum and vermiform ap-
pendix.
190
For about ten years prior to 1884 the patient, a man,
forty-two years of age, had suffered from what he called
attacks of wind colic. In March of that year the pains
became localized in the right iliac region ; an abscess
formed, and was opened. ‘The wound healed rapidly at
first, but a small fistula remained through which air and
fecal matters were passed. ‘Three months later the ex-
ternal opening of this fistula was closed, as a result .of
treatment, but reopened after four years. During the
greater part of this time, however, he was unable to take
any solid food, on account of severe colicky pains which
it caused, and was therefore confined almost entirely to a
fluid diet. The amount of nourishment which he was
able to secure in this way was insufficient to give him
strength enough to permit him to work.
The patient was admitted to Bellevue Hospital in April,
1888, and was operated upon in June of the same year.
On following up the fistula a large opening was found in
the cecum. The operation-wound healed readily, but the
fistula did not close. In September Dr. Hartley operated
again. The edges of the rent in the caecum were fresh-
ened, and then united by two rows of sutures. The pa-
tient did well after the operation, but died in January of
the present year from an attack of facial erysipelas and
acute laryngitis.
At the autopsy an external opening was found in the
right inguinal region, communicating by separate channels
with the head of the cæcum and with the ileum. In
the lower portion of the jejunum was a very tight stricture,
barely admitting a small probe. ‘The intestinal mucous
membrane down to this point seemed to be perfectly nor-
mal. Below the seat of the stricture was found a small
cicatrix, but it was longitudinal in direction and was not
of sufficient size to cause any noticeable contraction. It
was easy to understand, from the presence of this stricture,
why the patient should have had wind colic. The vermiform
appendix was apparently absent, and a large sinus was
found extending from the cæcum just at the level of the
ileo-czecal valve. ‘The valve itself was almost obliterated.
There was a small opening, scarcely one-quarter of an inch
in diameter, directly between the colon and small intestine.
A second specimen was presented of
INTERNAL STRANGULATION OF THE INTESTINE.
The patient was a young unmarried woman who gave no
history of any previous illness. She had had a child four
years before. A few days before her death she was seized
with intense abdominal pain, nausea, and vomiting. The
latter persisted in spite of treatment, and increased in se-
verity. Cathartics failed to act, and the patient finally
died. At the autopsy old peritoneal adhesions were found,
and two or three small coils from about the middle of the
czcum had passed through an opening in these adhesions
and had become strangulated. ‘The condition, had it
been diagnosed, might easily have been relieved by a
laparotomy.
Dr. Biggs then presented a third specimen, illustrating
a form of disease in which we sometimes have very few
symptoms, viz.,
MALIGNANT DISEASE OF THE UPPER PART OF THE RECTUM.
The patient had complained of some trouble with the
bowels, but had very little pain, and was not supposed to
be suffering from any very serious disease. Suddenly very
severe pain came on, and the patient died in a short time.
At the autopsy a tumor was found in the upper portion
of the rectum. Very deep ulcerations were present, and
in two places the bowel was seen to be perforated. Both
these perforations opened into the same ulcer, although
they were separated the one from the other a distance of
from one-half to three-quarters of an inch.
Dr. L. EMmMet HOLT presented a specimen of
PIGMENTATION OF THE INTESTINE.
It was removed from a child, three months old, who had
died with marasmus without presenting any special clini-
THE MEDICAL RECORD.
[August 17, 1889
cal history. The pigmentation was very marked in
Peyer’s patches, in the colon, and in the mesenteric
glands. ‘There was no disease of the suprarenal bodies.
Dr. W. P. NoRTHRUP presented a gross specimen from
a case of
ACUTE GASTRITIS AFTER THE ADMINISTRATION OF TURPETH
MINERAL.
To a child, aged fourteen months, affected with diphtheria
of the larynx and croup, was given an emetic of turpeth
mineral] (gr. 1ij.). This did not produce emesis, and one
hour later ipecac was given and vomiting ensued. ‘Three
hours after the administration of the turpeth mineral the
patient died. Cause of death, diphtheria of the larynx
and broncho-pneumonia. ‘The irritating emetic was not
thought to have contributed to the fatal result, as the pa-
tient was in a dying condition when it was given.
This specimen and that of the following case were
shown together to illustrate the irritant action of this
mineral emetic.
On autopsy the stomach was empty, its walls in its
cardiac half coated with thick, tenacious mucus, embrac-
ing small scattered masses of yellow sulphate of mercury,
the mucous membrane beneath being intensely congested.
The remaining portions of the stomach were normal, and
the intestines were also normal.
The following was quoted from “ The National Dis
pensatory of Stillé and Maisch,” p. 786:
“ Turpeth mineral is a powerful irritant, and, in suffi-
cient doses, may act as a’ corrosive poison.
Several fatal cases are recorded. Ina recent instance a
healthy child, aged five months, died, poisoned by five
grains of this preparation eleven hours after taking it.
. . . Drs. Randolph and Roussel report the cases of
five men, each of whom had at first five grains, and later
three grains of the medicine. The employment
. of so dangerous a remedy in a disease which involves no
danger to life is inexcusable. The emetic action of this
preparation is the first stage of its poisonous operation.
The dose fitted to produce that effect is from two to three
grains for a child. It seems to be a superfluous
article of the materia medica.”
The same authors speak of its causing salivation.
Dr. Northrup then presented gross mounted specimens
and microscope-sections from
A CASE OF ACUTE ULCERATIVE GASTRITIS AND NODULAR
ENTERITIS, AFTER DIPHTHERIA OF THE LARYNX AND THE
ADMINISTRATION OF TURPETH MINERAL.
To a male child, aged three and one-half years, suffering
from diphtheria of the larynx and croup, was given an
emetic of turpeth mineral (gr. iij.). No emesis was in-
duced by it, and an hour later the dose was repeated.
Two hours after the administration of the first dose vomit-
ing ensued.
Twelve hours later the patient died. Cause of death,
diphtheria and broncho-pneumonia. Before the urgent
symptoms of croup set in the patient had been taking
corrosive sublimate, gr. y, diluted in an ounce of water,
every hour for twelve hours. ‘The bichloride frequently
reddens the mucous membrane of the stomach, and in
diphtheria the solitary and agminate lymph-nodules of
the small intestine are often enlarged moderately.
Dr. Northrup expressed the belief, however, that the
excess of the lesion was due to the action of turpeth
mineral.
On autopsy, in the cardiac half of the stomach, and
more especially along the greater curvature, were found
broad superficial ulcers, upon which was lying a thick
coating of tenacious mucus and necrotic epithelium, with
small scattered masses of turpeth mineral. ‘The mucous
membrane of the pyloric half and greater curvature was
intensely congested, coated with mucus, with a few flakes
of the mineral-emetic ‘distnbuted through it.
Intestine : ‘The lymph-nodules from pylorus to lower
third of ileum—single and agminate—were exceedingly
August 17, 1889] THE
MEDICAL RECORD.
IQI
enlarged. The mucous membrane was deeply congested
In areas, coated with dirty brownish and greenish mucus,
having here and there small masses of turpeth mineral
surrounded with greenish mucus. Resting upon a Peyer’s
plaque, at the lowest part of the ileum affected, was a
small mass of the emetic. The plaque was much con-
gested and dusky and swollen. ‘This point marked the
limit of the congestion and excessive enlargement of the
nodules and the presence of the mineral.
The remaining portion of the ileum and the colon were
not congested ; the lymph-nodules were slightly enlarged
and the surface was thinly coated with mucus. In the
colon was still castor-oil.
Case I. showed the effect of the presence of turpeth
minerał in the stomach for three hours—localized severe
inflammation.
Case Ii. shows the effects after twelve hours’ presence
—ulcerative gastritis—severe enteritis, with marked en-
largement of the lymph-nodules as far as the mineral had
advanced.
Microscope-examination of the seed-like bodies dif-
fusely scattered through the small intestine of Cases I.
and II. showed simple hyperplasia of the lymph-nodules.
Some other gross specimens and microscope-sections
were presented, illustrating a case of
ENTERITIS WITH SWOLLEN PEYER’S PLAQUES AND ENLARGED
FRANGIBLE SPLEEN.
A female child, five months old, wet-nursed, vomited two
or three times two days before death—temperature, 994° F.
in the rectum. Her bowels moved freely after castor-oil.
On the following day the patient went into collapse and
died two hours later. No convulsions.
On autopsy was found marked swelling of Peyer's
plaques and of a few solitary lymph-nodules of the small
intestine, swelling (universal) of the mesenteric lymph-
nodes, swelling and softening of the spleen. Heart, brain,
stomach, and kidneys, normal. Colon nearly normal.
Dr. Prudden made cultures from the case for typhoid
bacilli; none were found.
Microscope-examination of Peyer’s plaques showed
simple hyperplasia of lymph-nodules.
Dr. Northrup also presented gross specimens and
microscope-sections from a case of
DIPHTHERIA OF THE-PHARYNX AND CESOPHAGUS.
The interest of this case consisted in the particular loca-
tion of the diphtheritic process in the pharynx and the
extensive ulceration of the oesophagus.
One week before death the child, aged fourteen months,
was affected with ulcerative stomatitis. Five days later a
thin pellicle of pseudo-membrane was first discovered on
tonsil. ‘There was a suspicion that diphtheria was present
before this time, but no membrane could be found.
Diarrhoea the last two days of life.
On autopsy the tonsils were not swollen and no false
membrane was found, excepting at the very lowest part of
the pharynx, in the sinuses at the sides of the larynx
called laryngo-pharyngeal. These corners were ulcerated,
covered with rather thick slough, and on microscope-ex-
amination proved to be diphtheritic, having the usual char-
acteristics, including numerous colonies of micrococci.
There was then softening diphtheritic membrane in a po-
sition to drain directly into the beginning of the alimen-
tary canal. The cesophagus, when opened, showed two
Straight rows of ulcers, circular, punched-out, having
elevated walls, a little undermined, clean floor, varying in
size from seven to three millimetres. These two rows
were exactly opposed to each other before the cesophagus
was slit open. The microscope-examination added only
negative testimony, and the reasonable presumption was
that the ulcers were of diphtheritic origin and that the
necrotic tissue had sloughed away, leaving clean ulcers.
The stomach was covered throughout with a uniform
grayish pellicle, not tenacious, this resting upon a con-
gested mucous membrane. Microscopic examination
showed catarrhal gastritis—no pseudo-membrane. ‘There
was also catarrhal entero-colitis.
A card specimen of a microscope-slide was then pre-
sented, showing
TUBERCULAR TISSUE FROM A JOINT
removed by operation. The specimen was of interest,
showing unusually large and typical giant-cells, also the
close grouping of typical tubercle granules with very little
tissue between them—the whole arrangement being almost
“ schematic.”
Dr. HoLr, referring to the case of intestinal lesions
found after the administration of turpeth mineral, said
that he did not think the glands could have become so
greatly enlarged in so short a space of time as had elapsed
between the exhibition of the drug and. the death of the
child. Might not the lesions have been due to the action
of the diphtheritic poison, independent of the presence of
the mercurial?
Dr. MESSENGER said that he had used turpeth mineral
a number of times in the early stages of laryngitis, and
had never seen any but good effects from its employment.
He had, however, never given more than one grain at a
dose.
Dr. ROOSEVELT asked whether an analysis had been
made of any of the unused portions of the drug which had
not passed through the stomach and intestines, to ascer-
tain if possibly there were not some of the bisulphide of
mercury present. He did not think that the explanation
of the production of the intestinal lesions, offered by Dr.
Northrup, was entirely satisfactory ; for, if the inflamma-
tion in both the stomach and the small intestine were
caused by the turpeth mineral, why should it be most
marked around the collections of the drug in one organ
and be a diffuse inflammation in the other ?
Dr. PRUDDEN thought that it was a little hazardous to
refer the production of the intestinal lesions wholly to the
action of the turpeth mineral, since the diphtheritic poison
was capable in itself of causing a swelling of the glands.
Might not the lesions be due to the combined action of
the poison of diphtheria and of the turpeth mineral ?
Dr. NORTHRUP said that he still saw no reason to doubt
the correctness of his assumption. As far down the intes-
tine as the lesions extended the presence of the turpeth
mineral was found, but below this point, in the portions not
yet reached by the poison, the intestine was normal. ‘To
his mind the relation of cause and effect seemed most evi-
dent, despite the objections raised by the several speakers
discussing the case. 7
Dr. H. M. Biccs presented a specimen of
PERICARDITIS WITH EFFUSION IN A CHICKEN.
The amount of effusion was very great, and there was
almost a perfect mould of the pericardium, made up ap-
parently of fibrin and pus. ‘There were also some small
nodules on the surface, the nature of which he had not
yet had time to ascertain, as the specimen had been re-
ceived but a short time before and had not been carefully
examined.
A second specimen was one of
ACUTE MILIARY TUBERCULOSIS.
The miliary tubercles were present in enormous numbers
in the peritoneum, liver, lungs, and other organs. In
searching for the source of infection the only old tuber-
cular lesion to be found was in the articulation between
the first and second pieces of the sternum. Here there
was some cheesy matter containing tubercle bacilli. No
other source of infection could be found anywhere in the
body.
Dr. SARAH J. MCNUTT presented a specimen showing
INTRACRANIAL HEMORRHAGE
in a child eight and a half months old.
A male child, eight and a half months old, was admitted
to the Babies’ Hospital for gastro-intestinal catarrh and
192
congenital syphilis. Child died, March 26th, of inanition’
There had been no history of convulsions or injury.
Autopsy, twenty-four hours after death, showed marked
emaciation ; there was evidence of a gastro-intestinal ca-
tarrh of long standing, cedema of the lungs was present,
and the heart was distended by a dark clot. The liver,
spleen, and kidney were apparently normal. The bones
of the skull were thin, membranous in appearance, and
could be readily cut by scissors. ‘The anterior fontanelle
measured three inches in its antero-posterior, and two
inches in its transverse diameter. . On cutting through this
fontanelle two ounces of fluid, the color of weak coffee,
escaped. ‘lhe arachnoid membrane was seen to be thin,
transparent, and rafsed by a clear, colorless fluid, in marked
distinction from the rusty-colored fluid that had escaped
on opening the skull. Lining the right frontal and pari-
etal bones in their lower third, and also the adjacent skull-
bones, was a thin, very vascular membrane, covering an
area of two by three and a half inches, the vertical diam-
eter being the shorter. ‘This membrane, although adherent
to the dura, was readily separated from it, leaving it pale
and evidently free from hyperemia. Beneath this mem-
brane, at its centre, was a thin clot of blood about the size
of a quarter of a dollar. No rupture of the blood-vessels
of the pia could be found, nor any injury to the substance
of the brain. ‘The pathological condition would seem to
have been caused by a haematoma of the dura mater, as
in pachymeningitis haemorrhagica.
Dr. FRANK GRAUER presented some specimens illus-
trating
ACUTE MILIARY TUBERCULOSIS,
removed from the body of a young man who had died in
the Harlem Hospital. Up to four weeks before admis-
sion he had been apparently in perfect health. His chief
complaint then was of severe pain, which was thought to
be neuralgic. Upon admission his pulse was 68, temper-
ature, 100.5° F., and there was slight rigidity of the mus.
cles at the back of the neck. He soon became delirious.
A diagnosis -was made of meningitis. At the autopsy
there was found to be acute miliary tuberculosis. ‘The
lungs were studded with tubercles, and tubercles were
found also in the liver, spleen, and kidneys. The kidneys
also contained small abscesses. ‘The mesenteric glands
were enlarged, tubercular ulcers were found in the intes-
tine, and the brain also contained numerous tubercles.
A second specimen showed
ACUTE YELLOW ATROPHY OF THE LIVER.
At the time of admission to the hospital the patient was
jaundiced and had cedema of the lower extremities. He
was delirious, and remained in this condition until his
death. At the autopsy hemorrhagic infarctions were
found in both lungs. ‘The heart was very pale, the aorta
was atheromatous, and the coronary arteries were dis-
eased. The peritoneum showed numerous points of hem-
orrhage, and there were also hemorrhages in the mesen-
tery. The stomach and intestines were very much con-
gested. There was meningitis, not very pronounced, and
areas of hemorrhage were found in the brain. ‘The liver
was in a condition of acute yellow atrophy. Some fresh
sections of the liver were examined under the microscope,
but were not very characteristic of acute yellow atrophy.
Other sections had also been made, but had not yet been
examined.
The Society then went into executive session.
DEAFNESS IN OLD AGE.—Sapolini, of Milan, has de-
scribed a method of his which he states he has success-
fully employed in sixty-two cases of deafness of old age.
It consists in mopping the membrana tympani with a weak
oleaginous solution of phosphorus. He claims that the
treatment diminishes the opacity of the membrane, in-
creases the circulation, and improves the hearing.— K ansas
City Medical Index.
[August 17, 1889
Correspondence.
OUR LONDON LETTER.
{From our Special Correspondent.)
THE PRESIDENCY OF THE COLLEGE OF SURGEONS—THE
LOCAL GOVERNMENT BILL FOR SCOTLAND-——THE NOTIFI-
CATION OF INFECTIOUS DISEASES— SURGICAL TUBERCU-
LOSIS AND PHTHISIS—THE REGISTRATION OF TRAINED
NURSES—ENGLISH CONTRIBUTIONS TO THE PASTEUR
INSTITUTE—THE MUZZLING OF DOGS.
Lonpon, July 21, 1589
UNTIL the last few years the presidency of the College of
Surgeons has—unlike that of the College of Physicians—
been an annual office held in rotation by the senior mem-
ber of the Council. Seniority on the Council came to
be regarded as constituting a claim to the presidency.
Such a system easily became possible under the mode of
election to the presidency in force at the College of Sur-
geons, viz., by the Council selecting one of their own
number to occupy the presidential chair. ‘This method
stiil continues, and is in marked contrast to that in vogue
at the sister college, where the President is elected by the
general body of Fellows. By the election of Mr. Savory
to the presidency of the College of Surgeons, the old
rule of seniority was broken through, and by his re-elec-
tion for several successive years the tradition of looking
upon the office as an annual one has been extinguished.
‘Though a stanch opponent of democratic reforms in the
College, Mr. Savory has been an able President, command-
ing respect even from his opponents. I need not refer to
his eminence as a scientific surgeon. It is true that his
continued re-election did not take place without com-
ment, and it was rumored that Sir Joseph Lister’s retire-
ment from the Council was due to a feeling that he had
been passed over by the repeated re-election of Mr.
Savory as President. ‘The latter has now declined further
re-election, and the honor has therefore been conferred on
Mr. Hutchinson, in whom the College has a worthy suc-
cessor to Mr. Savory. Like Mr. Savory, Mr. Hutchin-
son is a Fellow of the Royal Society, and his name will
be familiar to your readers as an able exponent of British
surgery, and especially as an authority on syphilography,
dermatology, and ophthalmology, in each of which de-
partments, as well as in general surgery, he has left his
mark in the domain of original research. Mr. Hutchin-
son is facile princeps in so many branches of surgery that
he may be not unfairly described as a general specialist.
Nor has he confined his attention strictly to surgical sub-
jects, as witness his lectures on gout and rheumatism de-
livered before the College of Surgeons a few years ago.
By his election as President the London Hospital is
placed in the unique position of having upon its con-
sulting staff the presidents of both the College of Sur-
geons and the College of Physicians (Sir Andrew Clark).
It is curious to note that these gentlemen live next door
to each other in Cavendish Square.
By accepting an amendment to the effect that every
County Council in Scotland shall elect a medical officer of
health, the Government has decidedly increased the value
of the Local Government Bill for Scotland, now before
the House of Commons. I refer, of course, to its value as
a sanitary measure. The medical profession will, how-
ever, regard very differently the bill brought forward by
the Government for the Notification of Infectious Dis-
eases. It is proposed that such notification (to the med-
ical officer of health for the district) shall be dual, viz.,
both by the head of the family or other person in charge
of the patient, and by the medical man in attendance.
The imposing the duty‘of notification on the medical at-
tendant will be resisted by the medical Members of Par-
liament—it is to be hoped with success. Should the bill
become law, a redeeming feature of it is that it 1s not to
be compulsory, but only to apply to such districts as shall
August 17, 1889]
voluntarily determine to adopt it. Where thus accepted,
however. the above arrangement will be in force unless
the bill should be amended in this respect.
In Mr. Howard Marsh’s recent lectures on “ ‘Tubercu-
losis in some of its Surgical Aspects,” delivered at the
College of Surgeons, he remarked that one fact in con-
nection with age demanded particular notice. That was
that surgical tuberculosis and phthisis were prevalent at
different periods, and were, speaking broadly, separated
from each other by an interval of between five and fifteen
years. It was remarkable that pulmonary phthisis and
surgical tuberculosis very seldom occurred together, or as
complications, the one of the other. At the Alexandra
Hospital for .Hip-disease, phthisis was very rarely met
with, and he was informed by Dr. Douglas Powell that at
the Brompton Consumption Hospital tubercular disease
of the joints and caries of the spine were scarcely ever
met with among the patients with tubercular phthisis.
The scheme propounded by the Rritish Nurses Associa-
tion, for the registration of nurses and for the formation
of a Nurses’ Register, on somewhat parallel lines to the
Medical Register, is being strongly opposed. A “ Me-
morial of Nurse-training School Authorities” has been
drawn up, setting forth in brief some of the objections to
the proposed scheme. It has already been influentially
signed, among the signatures being those of representa-
tives of most of the metropolitan hospitals at which
nurses are trained.
The English fund in aid of the Pasteur Institute is
slowly augmenting. Meanwhile dogs within the Metro-
politan Police District are to be muzzled from August 1st
util the end of this year.
EXECUTION BY ELECTRICITY.
To THe Eviror oF THR Maepicat Racorp.
Sir: It is not my intention to enter into any contro-
versy regarding the electrical resistance of man, for that
subject has been ably investigated by several very compe-
tent observers, and the facts as stated by me can be veri-
fied by any one who will take the trouble to consult the
original writings of Jolly or Gärtner, or the recently is-
sued text-book of Lewandowski.
You appended a note, however, to my letter in your
issue of July 27th, making a number of statements which
I cannot allow to go unchallenged. I ask you, therefore,
to print this second and final letter. |
First: You state “the electrical experts who have re-
ferred to the enormous resistances of the human body
refer to it as taken under peculiar conditions.” This is in-
correct. ‘The resistances were determined by the use of
large, well-moistened electrodes, made of brass and cov-
ered with sponge (Jolly); or of zinc electrodes covered
with sponge and linen and dipped into a solution of zinc
sulphate (Gärtner). In every instance the electrodes were
accurately applied to the skin, with the aid of rubber
bands or some other contrivance, and the tests were made
on men and women of varying ages. ‘The tests were made
with the Wheatstone bridge. It seems to me, therefore,
that such testimony is very much to the point.
Second : “ With proper contact the human electrical
resistance is not likely to exceed 2,500 ohms.” This is a
statement which has gone the rounds of text-books for
years, but is absolutely disproved by the authors men-
tioned above. It is much nearer the truth to say that
2,500 ohms represent an unusually low human resistance ;
in fact it is near the minimum.
In therapeutic applications we can afford to wait until
the electrical resistance has reached its minimum; in ex-
ecutions by electricity death should be instantaneous.
This can be effected only in case the current is strong
enough instantly to overcome the highest resistance. This
resistance is as stated in my former letter. It is im-
portant also to keep in mind that the current flowing
through moist sponges ts the chief agent in reducing resist-
ance, and not the moist sponges alone.
. THE MEDICAL RECORD.
193
Third: The “ expertness ” of the testimony which in-
timates that the resistance is 500,000 ohms is called into
question, since Mr. Edison has shown (sic) that the resist.
ance of the human body, “with proper contact, ranges
from 660 to 1,500 ohms.” I am second to none in my
admiration of Mr. Edison’s genius, but he did not realize
the conditions of the problem he attempted to solve, and
he has simply determined (what medical men erroneously
determined a decade ago) the minimum resistance of the
human body, and not the maximum. Iam a little sur-
prised that any medical man should attach much impor-
tance to tests so hastily and so imperfectly made, and that
he should prefer them to the careful investigations of
medical men of the very highest repute. If man were a
mass of metal Mr. Edison might be right; as it is, he is
hopelessly wrong.
Fourth: Your statement that a current represented by
the formula CS = 94%, > passed through the brain in-
stantly kills, requires some qualification. I am of the
opinion that a current of one ampère may kill, but such
a current will not pass through the body until the resist-
ance shall have been reduced from 20,000 to 1,500 ohms,
and there will be a very appreciable lapse of time before
that figure is reached. It is a mistake to suppose that re
sistance 1s reduced instantly ; different parts of the body
vary in this respect. It has been shown that under strong
currents the resistance of the feet, for instance, after the
lapse of a minute, has been reduced only from 22,000 S
units to 20,000 units (Jolly).
The differences between us may be summed up thus:
You argue, let the executioner take his time, and when
the minimum is reached the victim will be dead. No
doubt ; but what will the victim’s sufferings be in the inter-
vening minute or two? I say, the current should kill in-
stantly, in spite of the maximum resistance of the crimi-
nal’s body. B. Sacus, M.D.
August 1, 1889.
[Our correspondent lays too much weight, we think,
upon the exceptional statements of certain experimenters.
The methods of testing human resistance are not diffi-
cult or’ complicated, and neither Jolly nor Gärtner can
be credited with any superior and exclusive knowledge of
the technique which would enable them to obtain more
certain results than have experienced electricians like Edi-
son. ‘The intimation that human resistance under ordin-
ary conditions of good contact is often 500,000 ohms is,
we must repeat, somewhat startling, if not absurd. Every
medical man who has dealt with human resistance knows
very well that 2,000 ohms is a fair average with good con-
tact. The formula referred to in point fourth was in-
correctly printed, it should have been CS = $$?9.—Epb. |
SOCIETY FEVER VERSUS YELLOW
To THe Eviror or THs MepicaLt RECORD,
Sir: In Tue MepicaL Recor for June 8th is an article
entitled ‘“ ‘The Cost of Yellow Fever Epidemics—The
Epidemic at Decatur, Ala., in 1888,” by W. E. Forest,
M.D.
The paper is valuable and instructive, but there are
two or three statements regarding the epidemic in Jack-
sonville Fla., which are decidedly at variance with the
facts. Dr. Forest, of course, is not responsible for these
errors, as he was not here and could only procure his in-
formation from unreliable sources.
He states that yellow fever reached Jacksonville as
early as February; that it ran a mild course through the
early spring and summer under the name of “society
fever,” but that its existence was concealed by the au-
thorities, and that they did not admit its presence until
August.
As one who treated a number of cases of this “ society
fever,” and who practised through the epidemic of yellow
fever and had the disease, I deny in the most positive
manner that there was any similarity between the two
FEVER.
194
diseases. ‘Those cases of fever that occurred in February
and March were purely enteric or typhoid fever. The
nickname of ‘society fever ” was given to the disease in a
foolish manner, because most of those attacked were
among those who had been dissipating at hops, etc., during
the season. It would be impossible for the veriest tyro
in medicine to make a mistake in diagnosis between ty
phoid fever and yellow fever. It presented all the marked
characteristics of enteric fever. ‘The temperature ranged
above normal from three to six or more weeks; the tongue
was brown or black, and dry ; the teeth covered with sordes ;
the passages from the bowels and bladder were frequently
involuntary ; there were delirium, subsultus tendinum and
carphologia, and all the other well-known symptoms of
typhoid. The fever in yellow fever lasts from one or two
days to five days, and the patient is generally on the street
in ten days. Not by the utmost stretch of imagination
could this so-called “society fever” be considered as
yellow fever. I am aware that Surgeon-General Hamilton
has made the same statement as Dr. Forest, but he has
had nothing upon which to base such a report, and it has
also been corrected by local physicians. Another and most
convincing proof that the two diseases were not the same
is furnished by the fact that I know of more than a half-
dozen cases of yellow fever (some in my own practice)
which occurred among those who had had typhoid fever in
the winter and spring, and three of these cases of yellow
fever died. Was it ever before known that a person could
have two attacks of yellow fever, and especially within a
few months ?
Dr. Forest states that there were only about ten thou-
sand people remaining in the city, and that more than
10,000 cases of yellow fever were reported before the epi-
demic closed. We should be obliged to infer from this
that a large number of people were not satisfied with
having one attack, but, contrary to precedent, insisted
upon having one or more additional attacks.
About one month after the fever broke out the Sani-
tary Association caused a census of the city to be taken.
It disclosed the fact that there were then in the city 13,757
people, of which 9,812 were colored. The report of the
Board of Health gives the total number of cases of fever
as 4,696, divided as follows: Whites, 2,173; colored,
2,523. Deaths: whites, 331; colored, gg.
Henry R. Stout, M.D.
JACKSONVILLE, FLA.
MISSOURI PHYSICIANS: AND THE
BOARD OF HEALTH.
To THe EDITOR or IHE MepicaL RECORD.
Sır : Will you kindly allow me to call your attention to
some errors in your editorial, “ Missouri Physicians and
the State Board of Health ” (THE RECORD, June 29, 1889).
The State Board of Health is still in existence and doing
as much work as the money at its disposal will allow.
The Legislature made appropriations as follows : For Sec-
retary’s salary, $3,000 ; for expenses of Board for 1889-90,
$1,000 ; to reimburse members of the Board for money
spent in the discharge of duty, $1,070.60.
‘The State Medical Association appointed a committee
of three physicians—Dr. E. A. Dourlan, St. Joseph ; Dr.
Pinckney French, Mexico, and Dr. Porter, St. Louis—to
devise means for creating public sentiment among the
laity in favor of the Board, and to also arouse the physi-
cians to their duty. The session of the Legislature was
almost at its close when the Association met, and before
any action could be taken adjourned.
State Medicine in Missouri is laboring under consid-
erable difficulty, and while it is true that the medical
profession is partly to blame for the present condition of
affairs, it is not true that they are altogether responsible.
I have taken the liberty of addressing you with regard
to this matter, and trust that you will let your readers
know the true condition of affairs with us.
Very truly, DANIEL Morton, M.D.
STATE
THE MEDICAL RECORD.
[August 17, 1889
THE PHYSICIAN IN THE SUNDAY-SCHOOL.
To tHe Eprror or Tue Mepicat Recorp.
SIr : Allow me to make a statement prompted by reading
your note in THE REcorD, July z2oth, on “ Going to
Church.” I have lived in this city for the past twenty-
four years, and during that time (when at home) have
seldom missed attending church once, and even twice, each
Sabbath. ‘Twenty-one years of the time I have been
superintendent of a Sabbath-school, and have seen its
numbers grow from one hundred and fifty to four hun-
dred and fifty. I have seldom been absent from my
school. I have never “hung around” my office on the
Sabbath-day to catch business, but have always attended
to necessary work. I have never reckoned the cost
whether my church duties were a financial gain or loss.
The duty was mine—the results belonged to God.
“ Trust in the Lord and do good ; so shalt thou dwell in
the land, and verily thou shalt be fed.” I have been fed.
Aside from duty, the change of mental work in these
labors has proved to be a real rest and pleasure. If this
little note should meet the eye of some young physician
standing in the pathway of life where the lines diverge,
allow me to say to you, earnestly, that you will secure
better health, more genuine friends, and more real enjoy-
ment by spending a spare hour each Sabbath in the Sun-
day-school, rather than on the base-ball ground. Life is
short, and the “ night cometh.”
Respectfully yours, _
G. W. H. Kemper, M.D.
Muncie, IND., July 22, 1889.
THE DANGERS OF BOTTLED MILK.
o
To THR EDITOR or THe MenpicaL RECORD.
Sır : When we take into consideration milk as being one
of the chief necessities of the sick-room and nursery, we
cannot deny that z7, above all things, demands our greatest
attention. Oftentimes it has occurred to me, when see-
ing bottles of milk brought into the sick-room, how easily
these may serve as a means of carrying poison or germs
from one place to another. Realizing the danger and im-
portance of this subject, I have given the matter some
attention, and investigated the methods of several prom-
inent milk-dealers of our city.
The first, and one important point to be considered in
bottled milk, 1s the great amount of dishonesty practised
among milk-dealers. It is very exceptional that the real-
ity is as we picture it. ‘There are very few firms who
bottle their milk in the country. On the contrary, it is
brought here about one or two o'clock in the morning (in
large cans), and put in bottles after its arrival. ‘Thus it
may happen that your next-door neighbor may get the same
milk for less money and of same quality for which you
yourself pay extra. ‘This is a great fraud, practised in our
own city, and few suspect it. Like in every other busi-
ness, the almighty dollar is the chief attraction. People
have fancies, and those fancies must be gratified in order
to retain their custom. The very thought of its being
bottled in the country, retaining the fragrance and purity
_ of the farm, is in itself sufficient to induce many people
to buy it in this form. Yet it is fair here to state that
some dealers are perfectly honest in this respect, while
others are deceptive.
Again, when we think of these bottles being cleansed in
a vat of water where dozens of others have been washed,
how can we expect thorough cleanliness ?
Many may say the large cans are no more thoroughly
cleansed. But observation and common-sense convinces
one that a large can could be much more thoroughly
washed than a narrow-necked and small bottle. Admit-
ting for a moment that the large cans were no better
washed than a bottle, we could not contract half the poi-
son, comparatively, from a forty-quart can as that could
frou forty one-quart bottles.
Here comes in the most important point in this paper,
August 17, 1889]
THE MEDICAL RECORD.
195
viz., the contagion which might result from the indis-
criminate use of these bottles. The very same bottles you
use this morning may have been standing in a sick-room
yesterday. . Patients oftentimes drink immediately from
the bottle. It is reasonable to suppose that, having stood
in the sick-room, they are as much impregnated with poi-
son as any article in the room. Often the bottles are
closed in the sick-chamber, thus shutting in the dreaded
germs and doubling thereby the extent of danger feared.
The ordinary cans from which milk is dipped never
enter a house, and hence must be more pure. ‘They stand
no chance of being contaminated with disease. The only
argument or point that can be raised in behalf of bottled
milk is, that no dirt can enter, as occasionally does, in
milk dipped from large cans. But who would not prefer
a trace of dust to a trace of some dreaded disease.
The risk certainly is great, and should receive our ear-
nest attention. : E. BLACKWELL, M.D.
4 East THIRTY-S&VENTH STREET.
PURE DRINKING-WATER.
To tae Epitror or Tug Mepicat RECORD.
Sir: The question of obtaining pure drinking-water, either
from our reservoirs in the cities or from wells and springs
in the country, and preventing the contamination of the
same, has been agitating the minds of the people for some
time ; and essays upon and discussion of the subject are
filling the columns of the medical and lay press. In none
of the recent publications, however, so far as I read them,
have I seen any notice taken of an important observation
made by Kraus, about two years ago, and published in
the German Archives for Hygiene, 1887, pp. 237-252.
Kraus made a number of carefully conducted experi-
ments on the behavior of various pathogenic and common
saprophytic bacteria in drinking-water, and found that
pathogenic bacteria of various kinds mixed with drinking-
water from reservoirs or wells invariably disappeared
from such water in a few days, having lost their ability of
multiplying. Of Koch’s vibrio, for instance, not a trace
could be found after twenty-four hours. Typhoid bacilli
cannot be demonstrated any more after six days, and
those of anthrax after three. Now, both the bacilli of
typhoid and Koch’s vibriones are known to have retained
their power of development in sterilized water for thirty-
two and eveu eighty-two days, and it appears to be per-
fectly logical, therefore, when Kraus infers that the rapid
destruction of the pathogenic germs in non-sterilized
water is due to the action of the common water-bacteria.
It is also interesting to know that the result of observa-
tion was the same, whether pure spring-water or impure
well-water had been used in conducting the experiments.
What science has demonstrated here has been prac-
tically known to observing country people for many years.
The farmers around ‘Tannersville, for example, where I
have been in the habit of spending my vacation for some
years, have to keep a pretty sharp look-out nowadays
to keep their wells and springs from poisoning by the
more or less defective or badly located drains of the
numerous boarding-houses and small hotels in and around
the village and on their own premises. But they tell me
that the infecting focus once discovered, and the ichorous
oozing from it to the spring effectually cut off, the con-
taminated spring-water will run pure again ina week or
two, and be fit once more for use without danger. I have
not seen them, however, use the water of suspected wells
in less than a month or two after cleansing them, and
thought well of their precautions in that respect. On the
strength of these significant researches of Kraus, to relax
our vigilance as to the various contaminating sources of
our water-supply would be folly indeed ; but it is of great
practical value to have it demonstrated that the common
water-bacteria will make short work of pathogenic germs,
and soon purify a polluted spring after we have succeeded
in removing the cause of its pollution.
LEONARD WEBER, M.D.
Aew Znstruments.
—
A NEW POCKET-CASE.'
By HENRY S. STARK, A.B., M.D.,
NEW YORK.
My experience in private practice has demonstrated to me
that the busy practitioner of to-day cannot satisfactorily
diagnosticate certain cases at his first visit to the bedside,
although he possesses the requisite ability and the disease
is sufficiently advanced for diagnostic purposes, for the
simple reason that the clinical apparatus and appliances |
that are required for this purpose are too numerous and
bulky to be carried in one’s pocket, and that no portable
method has heretofore been devised to obviate the diffi-
culty.
In consequence, it frequently enough happens that the
physician is only enabled to diagnosticate his patient's dis-
ease at a subsequent visit, when he comes armed with the
necessary paraphernalia ; in the meanwhile his treatment
had been symptomatic, and the disease had been allowed
to run its course, working its way for weal or woe.
Many of my readers will recognize the truth of this
statement, and can recall cases à propos of my statements.
‘That such a deficiency should have been tolerated in this
advanced state of the medical sciences is indeed deplor-
able, and that no way out of the difficulty should have
been devised is indeed a matter of surprise.
To illustrate my meaning, permit me to enumerate sev-
eral cases that came within my own observation,
Several months ago I was summoned to the bedside of
an apparently well-nourished man, about thirty-five years
of age, who lay in a state of coma; his radial pulse was
markedly weak and thready, pupils somewhat dilated and
not responsive, breathing stertorous, temperature normal.
The patient lodged with strangers who knew nothing of
his previous history. Having satisfied myself that no ac-
cident had befallen my patient, I naturally thought of
apoplexy, embolism, nephritic or diabetic coma. The
absence of cardiac murmurs, and the equally dilated pu-
pils, led me to exclude the first two; yet I was not ina
position to state which of the latter two was the disease
from which the patient was suffering.
It then occurred to me that if I had had with me the
necessary apparatus for the detection of albumen, and the
determination of the specific gravity of urine, I might
have been able to properly diagnosticate the disease.
A second case presented the alternative of diagnosticat-
ing acute pleuritis or pneumonitis in an adult. ‘The case
was of such a nature that the aspirator-needle alone could
have determined which disease was present ; but not hav-
ing a long aspirator-needle with me, and the hypodermatic
needle proving, on trial, too small, the decision of this 1m-
portant step had to be postponed until the next visit.
A third case. I was requested by a colleague to ad-
minister ether to a patient prepared for operation. On
looking at the patient, I asked the operator whether
the patient’s urine had been examined, as she looked
“ Brighty,” and that the administration of ether might be
likely to be followed by renal trouble. ‘The operator ac-
knowledged that this precaution had not been taken, and
that the examination at this stage would be impossible, as
neither oi us had with him the requisite outfit for the
gross examination of urine.
These cases will unquestionably serve to recall parallel
cases in the daily practice of my readers, and will indicate
the necessity of always having at hand, in our rounds from
house to house, a certain outfit intended for clinical and
diagnostic purposes.
A further inconvenience, occasionally encountered by
the general practitioner, is the delay occasioned in having
is he e eo ba tn ete ee
1 Read and demonstrated at a meeting of German Practitioners
January 25, 1889.
195
THE MEDICAL RECORD.
[August 17, 1889
a prescription prepared, especially in such cases where im-
mediate medication is indicated.
We are summoned, I will say, in the dead of night toa
severe case of hemorrhage, to a case of impending heart-
failure, or of heart-collapse, or of poisoning ; I venture to
remark that the time consumed
in writing a prescription, in wak-
ing the druggist and having him
fill out our prescription, and wait-
ing for the messenger with the
medicine, has often proved disas-
trous to our patients.
To obviate the two difficulties
indicated in my remarks, I have
devised the pocket-case repre-
sented in the accompanying
wood -cut.
The dimensions of the leather
case, 5 X 2ł x rt inches, make
it easily portable in the coat,
trousers, or even vest pocket.
The best conception of the
case can be gotten by glancing at
the drawing, which represents
the case with the upper cover
raised, exposing the
= contents to view. It is
partitioned off into an upper and a lower com-
partment, each fitted with a sliding cover. At
either extremity is a horizontal diaphragm with
various-sized perforations, intended to hold the
contents 77 situ.
‘The upper compartment contains (see Figure),
enumerating from left to right, a complete hypo-
dermatic outfit—barrel, two needles with wires,
a vial for morphine; two thermometers with
different-colored bulbs, the one intended for the
rectum, the other for parts other than the rec-
tum; a tongue-depressor, a pipette, a urinary
test-tube with a urinometer, an aspirator with a
three-inch needle, rendering it capable of use
in all serous cavities. ‘The barrels of the
syringes are also variously colored to indicate
their widely different purposes. ‘The needle
orifice of the hypodermatic syringe is enlarged
to permit the ready entrance of a compressed
tablet of some medicament intended for sub-
cutaneous injections (see diagram), and readily
soluble in water, which is afterward drawn into
the barrel.
The lower compartment is analogous in con-
struction to the upper, and contains compart-
ments for five small vials for compressed tablets
of such drugs as the physician selects, e.g.,
ergotin, digitalin, cocaine, atropine, etc. ‘There is also a
place for red and blue litmus papers.
It will be seen that this “ portable clinical pocket-case ”
affords the practitioner an opportunity of always having at
hand a certain clinical and chemical outfit, which is called
into constant requisition in a general practice.
270 Kast SEVENTH STREET.
||6.TIEMANNA&CO,
Army Fews,
Official List of Changes tn the Stations and Duties of Cfi-
cers serving in the Medical Department, United States
Army, from August 4, to August 10, 1889.
SMITH, ANDREW K., Colonel and Surgeon, by direc-
tion of the Acting Secretary of War is granted leave of
absence tor seven days. Par. 12, S. O. 178, A. G. O.,
August 3, 1889.
Janeway, Joun H., Major and Surgeon, is hereby
granted leave of absence for two months, with permission
to apply for an extension of two months. Par. 3, S. O-
52, Headquarters Division of the Pacific, July 29, 1889.
WOODHULL, ALFRED A., Major and Surgeon, by di-
rection of the Acting Secretary of War is granted leave of
absence for two months, on account of sickness, with per-
mission to leave the Division of the Missouri. Par. 5, S.
O. 178, A. G. O., August 3, 1889.
COCHRAN, JOHN J., Captain and Assistant Surgeon,
now on duty at Fort Adams, R. I., by direction of the
Secretary of War will report in person to the Command-
ing General, Department of the Platte, for temporary duty
with troops en route to and at the summer camp at Fort
Robinson, Neb. Upon the completion of this duty will
return to his proper station. Par. 10, S. O. 180, A. G.
O., August 6, 1889.
Gorcas, WILLIAM C., Captain and Assistant Surgeon.
By direction of the Secretary of War the leave of absence
granted him in S. O. 84, July 3, 1889, Department of the
Missouri, is extended two months. Par. 2, S. O. 182, A.
G. O., Washington, August 8, 1889.
BANISTER, WILLIAM B., First Lieutenant and Assistant
Surgeon. By direction of the Acting Secretary of War
relieved from further duty at Fort Wingate, N. M., and
will report in person to the commanding officer at Fort
Grant, Ariz., for duty at that station, relieving Captain
Arthur H. Taylor. Par. 4, S. O. 178, A. G. O., August
3, 1889.
TAYLOR, ARTHUR H., Captain and Assistant Surgeon,
upon being relieved at Fort Grant, Ariz., will proceed
to Fort Wingate, N. M., and report in person to the com-
manding officer thereof for duty at that post. Par. 4, S.
O. 178, A. G. O., August 3, 1889.
WWedical Items.
=- — — ——
THE Larte DR. 1. O. LEA.—At the last meeting of the
Richmond County Medical Society the following resolu-
tions were adopted :
“ Whereas, ‘The announcement through the public jour-
nals of recent date has informally brought the sudden and
untimely death of our late esteemed associate, Dr. Isaac
O. Lea, to the attention of this Society ; therefore,
“ Resolved, ‘That the Medical Society of the County of
Richmond recognized in the late Dr. Lea one of its
oldest, ablest, and most experienced members; a physi-
cian who, for the past thirty-four years, had held a posi-
tion in the medical profession of this county second to
none of his compeers. A genial, warm-hearted, and clear-
headed man, who, when questions of vital interest to the
profession were under discussion before this Society, never
failed to take a prominent part in its deliberations, and a
conservative position in regard to its action thereupon ; a
gentleman always in all his relations to his associates, and
a physician whose place among us it will be difficult to
fill. Peace to his memory.
“ Resolved, ‘hat this Society tender its profound sym-
pathy in their bereavement to the several members of our
deceased associate’s family, and that the Secretary be or-
dered to forward a copy of these resolutions, properly en-
grossed, to the son of deceased, as the family representa-
tive, and provide that the same be published in the county
papers and in the New York MepicaL RECORD and New
York Medical Journal.
“ Committee : F. E. Martendale, Chairman ; F. U. John-
ston; J. Walter Wood ; May R. Owen, Secretary.”
ASSOCIATED MOVEMENTS OF THE EYEBALL.—At a
recent meeting of the Vienna Medical Society, Dr. Fuchs
showed a child which was the subject of several con-
genital malformations, one of which was apparent absence
of the left eye, the skin of the forehead being continued
directly to the cheek, and no signs of eyelashes being
present. Through the skin, however, a body could be
felt, which was the eyeball. The movements of this eye
followed exactly those of the normal eye, and as the as-
sociated movements could not have been learned, Dr.
Fuchs insisted that they must be congenital.
“The Medical Record
A Weekly Fournal of Medicine and S urgery
= ee mamm T a
Vol. 36, No. 8
New YORK, AUGUST 24, 1889
Original Articles,
CHRONIC ENDARTERITIS AND ITS CLINICAL
AND PATHOLOGICAL EFFECTS.’
(CHRONIC BRIGHT’S DISEASE.)
By ARTHUR V. MEIGS, M.D.,
PHYSICIAN TO THE PENNSYLVANIA AND CHILDREN'S HOSPITALS, PHILADELPHIA, PA.
CHRONIC endarteritis is as much of a disease by itself—a
separate entity—as are typhoid fever and measles. It is
in the highest degree important that this fact should be
recognized, and that the disease should be transferred
from the position it now occupies among the obscure and
little understood pathological curiosities, to the rank it is
sure soon to claim for itself among the common and well-
known complaints of every-day life. Until clinicians
ordmarily are prepared to diagnosticate it during life and
to announce it as a cause of death among their patients,
its frequency of occurrence and importance will not be
fully perceived. ‘The name by which a disease is called
is not an unimportant matter, for, if a name be accurately
descriptive it is well received, and those who hear it easily
comprehend what is meant, and thereby knowledge is rap-
idly diffused. The name “‘arterio-capillary fibrosis,” pro-
posed a good many years ago by Gull and Sutton, has
never been commonly accepted, for the complaint cannot
justly be called a fibrosis, and disease of the capillaries
has never been proved to be an essential part of the pro-
cess, and therefore, their description of the pathology was
incorrect. ‘The fact that our knowledge of the complaint
is still most incomplete is no more reason for longer de-
laying to receive it among ordinarily recognized diseases
than ıt would have been right for Bnght to have withheld
his great addition to the sum of pathological knowledge
because there was still more to be learned in the same
line of thought. Since there has come to me the feeling
that I have more understanding of the pathology of the
disease than formerly, the clinical management of cases
often occasions a good deal of difficulty, by placing me in
an awkward position with my patients when they or their
friends ask: “ What is the disease with which they are
suffering?” To say Bright’s disease in every case in
which albumen and casts are found in the urine, would be
very far from a correct expression of my understanding
of the malady, for the instant conclusion of the public is
that the patient has a disease which is as incurable as can-
cer, and one which will terminate in death almost as
soon ; whereas in many cases I believe that complete re-
covery, so far as the further progress of organic change is
concerned, takes place, and I zow that in many others
the patients live in comfort tor long periods of years.
Such being the case, a name is needed by which to desig-
nate the disease, and it must be one from which the word
kidney will be excluded ; for it may be asserted that it is
now known that the disease does not necessarily, involve
kidney change, and, if it does, that such change is only a
very small part of the whole, and is subsidiary to some-
thing else. The pathological lesion which is always
present, and which, so far as investigations made up to
the present time show to be most widely diffused through
the organs and tissues of the body, is an inflammatory
thickening of the intima of the arteries and arterioles,
1 Read before the College of Physicians of Philadelphia, June 5, 1889,
——_— a — e --—— eee am ————
aaee aaaea aa
Whole No. 981
and, whether the future will show this to be the primary
and original change and the true cause or not, it is so
widely diffused and so important that to call s# the disease
seems to me much more correct and descriptive than any
other that has been proposed. Chronic endarteritis, a
simple inflammation of the lining of the arteries, is the
process by which the disease begins and thence extends to
almost any degree throughout the arterial system, to some
degree into the veins, and probably into the capillaries,
as has been proved by the observations of others and my
own.’ ‘This name should be modified to meet the needs
of individual] cases, as the pathological lesion attacks one
or another or several organs, by saying—chronic pulmo-
nary endarteritis, chronic cerebral endarteritis, chronic
cardio-renal endarteritis, or other combinations as may be
required to make the name accurately descriptive of the
variations of one case from another.
To illustrate somewhat the clinical aspect of the sub-
ject, a few cases will be, as briefly as possible, given to
show that the disease may be recognized during the life
of the patient by physical and rational signs as well or
better defined than are the diagnostic features of many
well-known diseases. The cases will be grouped strictly
according to their clinical features and the order of suc-
cession of symptoms, showing the disease to have taken
possession of one or another or several important organs
of the body :
Case I.—A man about fifty years of age, after a year or
two increasing very much in weight and becoming inac-
tive, though previously very strong, was seized in the night
with copious epistaxis, a thing he had not previously had
for thirty years. Examination of the urine showed the
presence of a trace of albumen and very numerous casts,
and a month later he had cerebral hemorrhage of which
he died in three days.
Case II.—A man about sixty-seven years of age, who
had always been typically strong and healthy, was taken
` with severe epistaxis several times within a day or two, a
thing he had not had in fifty years. Physical examination
of heart and lungs was negative, but there was some stiffen-
ing of the radial arteries. There were neither casts nor
albumen in the urine, but slight oedema of the ankles was
present. This observation was just made, and what shape
the disease will take remains for the future to decide.
Case III.—A woman about sixty-five years of age,
very strong and well preserved, was seized with severe
epistaxis; examination of the urine demonstrated the
presence of albumen and casts. From this time she en-
joyed quite good health, except that occasionally she
would be vaguely out of sorts, when albumen and casts
would be present in the urine, though at others absent,
until she was seventy-seven years of age, when she had
slight right facial paralysis, with partial aphasia and much
distress and confusion of mind, of which she was per-
fectly conscious. The paralysis soon passed entirely
away. After this there was gradually increasing loss of
memory, though no perversion of mental function, and at
seventy-nine years of age she was seized with sudden vio-
lent pain in the head, radiating down the back and into
the limbs, particularly the lower ones; stupor came on,
increasing to coma, and in a week she died.
Case 1V.—A woman about fifty-nine years of age, who
had always been unusually strong, except that she was sub-
1 THE MEDICAL RECORD, july 7, 1888, and Transactions of the
College of Physicians, Philadelphia, vol. x., 1888.
198
ject-to take cold and have quite violent cough, was seized
with epistaxis which recurred several times within a week
or two. Examination of the urine revealed the presence
of a trace of albumen, and after careful search by two
observers, one of them found one or twocasts. Physical
examination was negative, the lung and heart sounds be-
ing natural, though when she had cold and cough, bron-
chial rales would be present. From that time to the
present she has been very nervous, complaining of many
vague sensations, and having become visibly much older.
She cannot walk freely and with comfort, as her steps are
always short and uncertain and she tires easily. Now,
two years later, there is a distinct and rather harsh aortic
murmur which is systolic in time, and this, though she
has never had any acute illness in the two years that have
elapsed. A trace of albumen is constantly present in the
urine, and occasionally a few casts.
Case V.—A man of about sixty years of age, in the
hospital ward, suffering with typical chronic Bnght’s dis-
ease—dropsy, albumen and casts in the urine, hydro-
thorax, and great hypertrophy of the heart—declared
upon most careful cross-examination that the first devia-
tion from health with which he had suffered was a dispo-
sition to take cold readily and have violent cough, and
this for some time before any of the other conditions
mentioned came upon him.
Case VI.—A man about sixty-six years of age, was for
a year or two subject to violent spasmodic cough with
much expectoration ; he had bronchitis and some enlarge-
ment of the heart, and cedema of the ankles, but neither
albumen nor casts in the urine; five years later he is still
living, but there has been in that time no opportunity to
see or examine him.
Case VII.—A man fifty-six years of age, previously
healthy, except that he had at times passed gravel, had
bronchitis and coryza with more oppression than the
physical signs seemed to account for. Examination of
the urine revealed the presence of albumen and casts.
For four years subsequently albumen and casts were
found from time to time upon examination, but since
that period there has been no opportunity to test the
urine. With the exception of much rheumatic stiffness
and a tendency to take cold readily, he is still living and
healthy at seventy-one years of age.
Case VIII.—A man previously very healthy, had, when
about sixty years of age, an attack of pneumonia of suba-
cute character. Since that time he has never been the
same, having lost his activity and strength, and now, at
sixty-seven years of age, his condition is as follows: He
has lost a good deal of weight; some of the arteries are
rigid ; he is very easily fatigued, and complains that his
legs are almost paralyzed, so great an effort is it to him to
walk, though to all appearances his gait is natural enough,
except that it is rather shuffling. ‘The heart-action is
rapid and feeble. Neither albumen nor casts have been
found in the urine.
Case IX.—A woman, about sixty-five years of age,
complained of not being well, though she was not confined
to bed. Physical examination revealed dulness over one
lung posteriorly and very harsh bronchial respiration, but
no moist sounds or rAles.of any sort, and no expectoration
—plainly a case of pneumonia. ‘There was a slight mitral
valve murmur, and the urine contained albumen and
casts. ‘This condition of affairs continued, and she grad-
ually failed, though at no time having any urgent or alarm-
ing symptoms, and after four months died very quietly.
Case X.—A lawyer, fifty-four years of age, in full
practice, had an attack of acute catarrhal pneumonia.
He was ill for several months, and during the whole time
there were albumen and casts in the urine, and for be-
tween two and three years afterward. After that they
disappeared, and eight years subsequent to the attack the
urine was found to be healthy ; since then there has been
no opportunity to examine it, but the patient is still living,
appearing to be healthy, and practising his profession at
sixty-eight years of age.
THE MEDICAL RECORD.
[August 24, 1889
Te oo ee
Case XI.—A man about sixty-six or -seven years of
age, who had always been well, for a few months did not
seem quite like himself in strength, and finally had some
cough. Examination revealed the presence of subacute
pneumonia, and albumen and casts in the urine, though
there were not then nor subsequently any symptoms which
could be attributed to faulty renal action. There was ex-
treme atheroma, so much so that one radial pulse was
almost extinguished and the vessel very hard. After a
few weeks the lungs cleared and he got about again,
though continuing very weak. In about three months
there was a return of the pulmonary trouble, with cough
and expectoration, and the breathing was quite rapid,
though he declared he had no pain, or even oppression.
In a few weeks he died, fading out very quietly, without
violent or urgent symptoms of any kind.
Case XII.—A man who is now about eighty-four years
of age, and, for his age, quite active, has for the past fif-
teen years had very frequently albumen and casts in his
urine, and during most of that time his breathing has been
somewhat wheezing, with bronchial and asthmatic rales to
be heard in the chest.
Case XIII.—A man, who inherited gout, was, for ten
or twelve years, subject to the arthritic form. When be-
tween fifty-seven and fifty-eight years of age he began to
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Fic. 1 (x 17 diameters) represents the large branch of the left coronary artery
of the heart, which descends in the interventricular septum. The calibre of the ves-
sel is almost closed by overgrowth of the intima, the opening which remains bein
represented toward the left in the p'cture. The other spaces were either the result
of tearing in mounting, or were filled with some material which did not stain and
was transparent. The muscular coat is represented by lines, and the adventitia
by lighter ones outside; all the material inside these, represented by dots, is the
proliferated intima. The part of the vessel represented here contained no calcareous
material, though elsewhere there was abundant mineral deposit.
have some shortness of breath, and six months later had
one night an attack of oppression so violent that it was
thought he would die. Albumen and casts were found in
Fic. 2 (x 9 diameters) represents one of the first branches of the renal artery as
it entered ik hilus of the kidney. The great and irregular thickening of the
intima is very marked, and the plicated membrane is distinctly visible around the
greater part of the circuit forming the boundary between the intima and muscular
coat,
the urine, and from this time he failed, and died at sixty
years of age, having spent the last eight months of his life
in the house in most shocking suffering from general
dropsy and great oppression, and latterly quite insane
(not delirious), being very suspicious and having marked
delusions. ‘The heart was greatly hypertrophied and the
August 24, 1889]
THE MEDICAL RECORD.
arteries diseased (see Figs. 1 and 2), and once he had a
slight urzemic convulsion.
Case XIV.—A woman about sixty years of age had,
for a good many months, been getting less and less able to
walk. Examination revealed the. presence of albumen
and casts in the urine, stiffening of the mitral valve, and
a tumor in the right hypochondrium, which was thought
to be due to gall-stones in the bladder ; this, however, she
had had for a good many years, and it seemed quite
latent so far as giving rise to any irritation was concerned.
Many of the arteries were stiff. She walked very feebly
and with a shuffling gait, hardly lifting the feet at all,
though there was no true paralysis. The feebleness in
walking increased, and the legs wasted until the calves
could almost be spanned with the thumb and forefinger,
and it was with difficulty that she could even cross a
room. One day she fell upon the floor, simply losing her
balance, and broke the neck of one femur, and never was
able to walk again. After this, and before too, her intel-
lectual powers became less and less,*she lost memory to a
great degree, and at last became mildly insane, having
delusions. She failed gradually, and after two years died,
without having had any violent or active symptoms be-
yond those mentioned, except that for some time before
death there was marked general hyperesthesia.
Case XV.—A woman about sixty-two or -three years
of age has, during the past six years, been subject to
attacks of sharp fever which prostrate her very much
and keep her from one or two days to a week in bed.
At these times albumen and casts have very frequently
been found in the urine. She has the signs of slight
mitral valve stiffening. Except when suffering with an
acute attack, she lives a very active life, doing a great
deal of charitable work. During the last eight months
she suffers with most persistent prickling sensations (pins
and needles) in the hands and feet, and becomes easily
fatigued, complaining that her legs are often so heavy
that she can hardly lift or drag them along.
Case XVI.—A man thirty-two years of age had, a
little more than two years before his death, an attack of
acute rheumatism, after which he had always shortness of
Fic. 3(x 10 diameters) represents also the branch of the left coronary artery
of the heart which descends in the interventricular septum, The enormous and
irregular thickening of the intima is very evident ; the plicated membrane is dis-
tinctly visible around half the circuit upon the side of least thickening ; upon the
same side also the muscular coat is nearly twice as thick as upon the other.
‘There are two explanations for this irregularity of thickness of the muscular coat,
the one, that it is hypertrophied upon the side on which it is thickest, the other,
that upon the opposite side it has been partially destroyed by the invasion of dis-
case.
breath and palpitation on exertion. During the last
seven weeks of his life he had all the commonly accepted
signs of Bright’s disease—dropsy, albumen and casts in
the urine, frequent micturition, cough with bloody ex-
pectoration, enormous hypertrophy of the heart with
aortic regurgitation, great oppression and difficulty in
breathing, violent vomiting, and pain in the belly. He
died in great suffering. (See Fig. 3.)
Case XVII.—A man who during all his life had been
very strong, wds taken at about sixty-three years of age with
attacks of vertigo. Examination showed that his heart acted
with the most extreme irregularity, but that there was no
sign of valvular disease, and the urine contained neither
albumen nor casts. ‘These symptoms continued for about
199
one year, but during the last year, he being now about
sixty-five, the condition is much improved, as he seldom
has any vertigo and the heart is no longer very irregular,
though occasionally intermittent in its action. There is
some stiffening of the arteries.
Case XVIII.—An infant that was deserted by her
mother when between two and three weeks of age, having
already before this time lost weight and failed in general
appearance and condition instead of gaining, was placed
in an institution. ‘The urine was never examined. In
spite of all that could be done for her she soon presented
the appearance of marasmus in a most typical manner,
and at last, after having for a good while looked like an
old, dried-up woman, she died at five months of age.
(See Fig. 4.)
fmm
Fic. 4 (x 40 diameters), The infant was aged five months. This is the left cor-
onary artery of the heart just after its origin in the aorta, from Case XVIII. The
irregularity of thickening is very evident, and it seems equally positive that
the process of disease belongs to the lining of the vessel, for the muscular coat is
distinctly visible outside of the area of disease, and does not appear to be very
much altered, except that in some places the process seems to have invaded it, as
well as having produced masses inside the vessel. The plicated membrane is rep-
resented by two fine lines with a white space between them, and is visible around
the entire circuit, except in the thickening which is represented in the lower part of
the picture, where the process of disease has involved the muscular layers to a
great extent.
These cases were selected because they presented, in a
typical manner, the clinical symptoms it has been my de-
sire to group together, so that anyone who will study the
subject can readily and with precision make a diagnosis
of the disease. In Cases XIII., XVI., and XVIII. autop-
sies were made, and the arteries figured in the plates were
taken from them. I could have given a larger number m
which autopsies were made and the lesion found, and
such specimens are still in my possession, but the three
only were introduced because they are fair types of the
lesion, and the introduction of more would have made
this paper too long, especially as my desire has been to
deal now more with the diagnostic and prognostic feat-
ures of the disease, and to touch upon the pathology,
with which I have dealt more at length elsewhere,’ only so
much as was necessary to make plain my meaning, with-
out going so deeply into pathological technicalities as to
fatigue the ordinary practitioner. Only three of the cases
(V., XVI., and XVIII.) were hospital patients, the rest
being taken from the records of private practice, and
were selected because they were under observation, in al-
most every instance, for long periods.
Cases I., III., VII., X., and XII., have already been
alluded to in a paper which appeared in the “ Trans-
actions of the College of Physicians of Philadelphia,” vol.
vi., 1882, entitled “ Clinical Observations on Albuminuria,
Based upon a Study of Sixty-two Cases Seen in Private
Practice.”
One of the cases (X VIII.) may be thought to have been
improperly placed in the group, as it was one of ordinary
infantile wasting, or, if the name be not objectionable,
marasmus, and it presented no unusual clinical features or
symptoms ; but it has so long seemed to me that there
must be some parallelism between the disease under con-
sideration in adults and some of the cases of infantile
! Transactions of the College of Physicians, Philadelphia, vol. x.,
1888, and MEDICAL RECORD, July 7, 1888.
200
THE MEDICAL RECORD.
[August 24, 1889
wasting, that, upon finding the pathological lesion so typi-
cally developed (see Fig. 4), I added the case to the
oup; where from the pathological standpoint certainly
it justly belongs. Infants dying in this way grow to look so
exactly like those who die of old age, that everyone who
has written upon the subject has remarked upon the sim-
ilarity of the appearances presented, though the two modes
of death are the antipodes of human existence. Upon
previous occasions I have published three papers on this
subject, and it will be my endeavor not to unnecessarily
repeat what will be found in them. They are as follows :
“Clinical Observations on Albuminuria, Based upon a
Study of Sixty-two Cases Seen in Private Practice,” “ Trans-
actions of the College of Physicians, Philadelphia,” vol. vi.,
1882; “Cardiac Degenerations and Bright’s Disease the
Result of Changes in the Intima of the Arteries and
Veins,” American Journal of the Medical Sciences, June,
1888, and “ A Study of the Arteries and Veins in Bright’s
Disease,” “ ‘Transactions of the College of Physicians,
Philadelphia,” vol. x., 1888, and the MEDICAL RECORD,
July 7, 1888.
Symptoms and Diagnosis.—The symptoms of this disease
are of such a nature as, in marked cases at least, to make
the diagnosis an easy matter. Perhaps these symptoms
cannot be better elucidated than by passing them in review
and trying to collect them together in such groups as they
would seem most naturally to fall into, for to my mind
certainly they present a clinical picture which is most
striking and characteristic. Hemorrhage, whether it ap-
pear in the form of epistaxis or of cerebral apoplexy, is a
marked symptom, and one which should always rouse the
physician to investigate whether endarteritis has not taken
possession of some part of the vascular system of the pa-
tient. Epistaxis was the earliest symptom in the first four
cases narrated to draw attention to any deviation from
health in the patients. Any externally distinguish-
able stiffening of the arteries, commonly called atheroma,
is to my mind positive evidence of the presence of endar-
teritis, for I have yet to examine an atheromatous artery
exhibiting diseased middle and external coats and a
healthy intima. Many of the commonly received symp-
toms of kidney disease, though they do most certainly in-
dicate that that organ has undergone grave pathological
change, causing damage to a greater or less degree, and
which will be permanent and irreparable, show much more,
if the warning is but heeded, that extensive and often
much more dangerous degenerations are taking place in
other and perhaps far-away organs and tissues of the
body. Occasionally, in patients affected in this way, there
may be from time to time attacks of fever, and at such
times albumen and casts may be found in the urine, as in
Case XV.
‘The various manifestations of disturbance of cardiac
function are among the most constant accompaniments
of endarteritis in any form, and as far as present knowledge
leads us to a comprehension of the subject, among the
most important and of greatest gravity. It has long
seemed to me the merest folly, in all cases of demonstrable
cardiac valvular disease, to set it down as caused by rheu-
matism or chorea, or even to over-exertion of the body, as
is so commonly done by clinicians ; or, on the other hand,
to believe that rheumatism commonly induces endocardi-
tis and stops at that. Cases IV. and XVI. are types of
what may happen in these respects, and as they afford
positive evidence of what sometimes does take place, they
are of more value than many negative cases, for it 1s an
axiom in logic that it is hard to prove a negative. In Case
IV. the patient had no cardiac valvular disease two years
ago, now she has positive evidence of aortic stiffening, and
yet during that time she has never had any acute attack of
illness, but has most positive signs of endarterial inflamma-
tion—stiffening of the superficial arteries, albumen and casts
in the urine, the valvular heart disease, great nervousness,
with loss of muscular power, and general rapid aging in
every respect—all coming on after a violent series of at-
tacks of epistaxis which ushered in the loss of health.
Most certainly the valve change was not due to rheuma-
tism, or chorea, or over-exertion of the body in this case,
for no one of these possible causes has obtained, and if it
be not granted that the inflammation that certainly has.
existed in the lining of the arteries has crept slowly and
silently into the heart, there to accomplish the same fell
work that it has undoubtedly done in the vessels, no other
more reasonable explanation, at any rate, can be offered.
The history in Case XVI. seems equally positively to show
that the effects of rheumatism by no means stop after
having injured the endocardium and valves, for in that
case, from the time of the acute attack, the patient was
no longer well, and in about two years died of Bright’s
disease, with a typical development of the symptoms and.
pathological lesions (see Fig. 3). Looking at the case
from my own standpoint, I feel quite satisfied that the
man had rheumatic endocarditis, and at the same time or
soon after, and asa continuation of the same process of dis-
ease, endarteritis, at first acute and then continuing in a
chronic form after he-seemed well, and that by this ave-
nue and in this way almost all his organs became gradually
involved. It would be easy to accept the old mode of
explanation—rheumatic endocarditis, aortic regurgitation,
cardiac hypertrophy, increased arterial tension, hyper-
trophy of the muscular coat of the arterioles, venous
congestion of the kidneys, and thus Bnght’s disease sec-
ondary to the rheumatic heart disease. This, as an ex-
planation, has long seemed to me more than merely
theoretical—it is positively fanciful and visionary, and be-
sides, it totally fails to explain many of the most evident
and important of the pathological lesions. For the sake of
argument, suppose we accept the hypothesis as affording
an adequate explanation of the lesions so far as the heart
and kidneys are concerned—how are the diseased con-
ditions of the other organs to be explained? The lungs
were much infiltrated with cellular overgrowth and their
vessels were markedly thickened, especially the intima,
the liver in a state of granular disorganization, the blood-
vessels of the spleen very thick, and the aorta (though the
man was only thirty-two years of age) very atheromatous,
besides which the heart exhibited fibroid degeneration, and
its arteries were in the last stages of degeneration, not
hypertrophy (see Fig. 3). Asan explanation for all this,
is it not more easy to believe, and more consonant, too,
with our knowledge of the migratory habits of inflamma-
tion, that an endarteritis, rheumatic in origin, acute at
first, and then continuing as a chronic process, took pos-
session of the lining of the arteries, and creeping from
place to place by avenues so widely open as actually to
invite invasion, thus gradually produced the result, than
to distract our brains by trying to follow the intricacies
of the older explanation, which is so complicated that
from the time it was onginally proposed it has always
been looked upon with suspicion ?
(Edema coming on without discoverable organic lesion
sufficient to account for its presence, is often an indication
of the existence of endarteritis (Case II.), and the same
may be said of vertigo and irregular heart-action in some
instances (Case XVII.).
The fact that symptoms connected with pulmonary
disorder or actual lung diseases are often the earliest de-
partures from health in those who afterward die of what
has been called chronic Brights disease, was one of
the things which first caused me to feel any doubt of the
sufficiency of that mode of explanation of the train of
symptoms. Among the cases detailed this is plainly illus-
trated, for in eight at least, Cases V. to XII., inclusive,
the mode of origin was an attack of pulmonary disease,
and six of them certainly were cases that everyone would
agree to call Bright's disease. This phase of the com-
plaint may declare itself in the form of an attack of bron-
chitis, either by cough and expectoration without physical
signs ; or with a full development of bronchial rales, as
the case may be; or catarrhal pneumonia, a disease
which is capable of taking upon itself very many and
varying aspects; or of asthma or emphysema; or, lastly,
August 24, 1889]
there may be one of the forms of oppression, either sudden
and violent, or coming on gradually and being very persis-
tent, which are such common and well-known accompani-
ments of chronic disease of the kidney. ‘These manifesta-
tions of pulmonary disorder may be acute and accom-
panied by great fever and general disturbance of the
system, of such a character as to constitute an acute ill-
ness confining the patient to bed; or their onset may be
so insidious as to attract little or no attention until a
physician discovers that his patient is going about with
a lung half solid from pneumonia (Cases IX. and XI.).
Functional disturbance of the liver 1s not uncommon,
and the frequency with which the blood-vessels are thick-
ened shows it to be likely that it has here, too, some caus-
ative relation. The spleen is incapable of inducing clinical
symptoms of which at the present time we have knowledge,
but it is one of the organs in which the pathological
- change of the vessels is most commonly found.
Symptoms manifesting a disordered state of the nervous
system have long been well recognized as a common con-
sequence of this disease, and of late several interesting
and valuable communications upon the subject have ap-
peared in different medical journals ;* but the earliest
attempt probably to arrive at a scientific understanding of
their cause was made in the paper of Gull and Sutton.’
In these symptoms of disordered nervous function do we
find what affords perhaps the strongest confirmatory evi-
dence that the disease has its origin in the vascular system,
and at the same time the best proof that the old theory
of origin is totally untenable. There has never even been
an attempt made to explain the cerebral apoplexy and many
other less formidable symptoms of nervous disorder that
are sO common, and clinically so fully recognized, except
in a general way to allude to the many things that in-
creased arterial tension is capable of effecting. The most
common of these symptoms—as has already been some-
what brought out in the detail of cases given—are: cere-
bral apoplexy, general muscular weakness, with shuffling
gait but without actual paralysis, and, in some instances,
wasting of the muscles; change of temper and disposition,
nervousness and decline of mental power, especially loss
of memory, and even mild insanity ; and in old people in
the latter stages of the disease, most commonly after they
have got so weak as to be confined to bed, a curious gen-
eral hyperzsthesia which does not seem to be confined to
the skin, for there is great pain caused by any movement.
Rheumatism and gout seem to be near relatives of en-
darteritis, or at least closely bound up with it. In one
of the cases (Case XVI.) rheumatism, and in another
(Case XIII.) gout, seemed to set fire to the train that
finally led to the fatal result, and in both, as has already
been alluded to, post-mortem examinations were made,
and the lesions of chronic endarteritis in a typical state
of development found (see Figs. 1, 2, and 3), and they
both died with all the ordinarily recognized symptoms of
chronic Bright’s disease.
Prognosis.—In the clinical management of cases there
is nothing which occasions more difficulty than the ques-
tion of prognosis; for, to anyone who has had to deal
much with the disease, one thing at any rate is very plain,
that many cases that a few years ago would have been
looked on as necessarily fatal, recover entirely, and others
regain sufficient health to live for many years in comfort.
It is wonderful how differently two cases, that at the out-
set seemed very closely parallel, may terminate, the one
perhaps living for many years, and the other dying within
a few months; this is exemplified in Cases XI. and XII.
It does not seem possible to doubt that in Case X., for
instance, entire recovery has taken place, though as albu-
men and casts were present in the urine, and the patient
was in ill-health for more than two years, he certainly had
t Chronic Bright's Disease (Arterio-capillary Fibrosis) in its Rela
tions to Insanity, by E. A. Christian, M.D. The Journal of the Ameri-
can Medical Association, March 23, 1889.
2 On Changes in the Spinal Cord and its Vessels in Arterio-capillary
Fibrosis. Trans. Path. Soc. London, vol. xxviii., 1887.
THE MEDICAL RECORD.
_ part of the disease.
201
chronic Bright’s disease ; and Case VII. is one in which,
even if it cannot be positively asserted that complete re-
covery has occurred, at any rate there has been such a
physical condition that for fourteen years the man has
had a very enjoyable life. It seems possible to explain
this, so far as the kidney is concerned, only by the belief
that there was, at the time of the acute attack, a wedge-
shaped spot or spots of inflammation with round-cell in-
filtration, the broad base of the wedge being toward the
cortex, such as are so commonly seen in sections cut from
the organs of persons dying in this stage of the disease,
and that this has in the course of time healed, after having
destroyed a greater or less number of tubules, and left in
their place a small scar. Why it should so long have been
supposed that the kidney was incapable of getting over
the effects of an inflammatory process which is in no wise
different from what occurs elsewhere, when it is ‘perfectly
well known that every other organ and tissue in the body
can undergo regeneration to a greater or less degree, is a
thing which is incomprehensible! In view of these facts
we should, as physicians, be very slow to give a fatal
prognosis, except in cases in which the morbid changes
have progressed so far as to make our ground very certain.
There is no combination so bad, and none which so fully
seems to justify a very gloomy prognosis, as the presence of
albumen and casts in the urine, with general dropsy and a
heart evidently greatly enlarged, with much shortness of
breath. Of these symptoms, to individualize them, there
are none which have anything like the grave significance
of enlargement of the heart with heaving impulse and
constant shortness of breath; people with this combina-
tion seldom live more than a few months. Experience
has long since taught me to believe that the presence or
absence.of the signs of valvular change are, comparatively
speaking, of very secondary importance, and should have
little influence in determining our decision of the proba-
ble duration of life, but that all our efforts should rather
be turned to endeavor to form an estimate of the size of
the heart and state of its walls. |
Zreatment.—It would make this paper much too long
if any attempt was made elaborately to discuss the treat-
ment ; besides which, the question does not properly come -
under its scope as defined in the title. It need, therefore,
only be said that the disease is so wide-spread in its re-
sults, and produces such varying effects as the morbid
process takes possession of one or another part of the
organism, that no special plan of treatment could be laid
down which would cover all the different aspects it may
present. Drugs which have seemed to me to be capable
of effecting much good in certain phases of the com-
plaint are carbonate of ammonia with small doses of
digitalis—these should be given three or four times a
day, and their use persisted in for long periods, often for
as much as a yearormore. The advantages of this mode
of treatment were exemplified in Case XVII.
Pathology.—As was stated, the pathology of this dis-
ease has been discussed by me in papers already pub-
lished, and time fails, nor would it perhaps be desirable,
to go fully over the subject again. There are, however,
a few points to which allusion must be made. To my
mind it seems established as a fact and beyond the reach
of doubt that many cases of chronic Bright’s disease, if
not most of them, are in truth cases of arterial disease ;
this was years ago asserted by Gull and Sutton ; now, as
a result of more recent investigation, I believe it to be
established that endarterial inflammation is an important
In reaching this conclusion one
more step has been made in the direction of a final
understanding of the process, though whether we are
now near to this goal or still far away is a question which
the future only can determine.
It would be easy, but of no present advantage, to
speculate upon whether the endarterial inflammation is
but an extension of disease from the blood, the living and
moving tissue with which the lining of the arteries is
always in contact, or whether the process starts in the
202
Ca en - ——— — — — — m — — e -m
connective tissues, in which the arteries lie and of which
they are in fact a part, or whether again the inflamma-
tion has its true origin in the arterial intima. The proba-
bility is that the future will show the arterial inflammation
to be but an extension and consequence of some other pre-
existing change. Outside of the assertion that the disease
begins in the blood—and this is a theory which, though
exceedingly plausible and not unlikely to be correct, is
without a single fact of observation to establish its truth,
so little understanding have we at the present time of the
blood or its diseases—there has as yet been but one hypo-
thesis offered to explain an earlier beginning of the disease.
This hypothesis—for hypothesis only at present hasit a right
to be called—was mentioned in one of my earlier papers
(loc. cit.), and is that which was in the first instance pro-
pounded by Drs. Da Costa and Longstreth,’ and has been
further -elaborated by Dr. Da Costa in a later paper.’
These authors, after making post-mortem investigations
both macroscopic and microscopic, assert that there is
constantly present a lesion of the renal nerve plexus, and
Dr. Da Costa in his Jater paper states that lesions were
also found in the cardiac ganglia in cases of Bright’s dis-
ease. ‘These investigations are of the highest scientific
interest and exceedingly suggestive, for, from a purely
theoretical point of view, it is fully as reasonable to sup-
pose that the morbid process might begin in the nervous
system as in the lining of the arteries or elsewhere. In-
vestigation of the histological condition of the nerve-
trunks and ganglia of the sympathetic system offers a
field of the greatest interest, but at the same time great
difficulty, for, if the truth be told, but little is really
known at the present time of its ordinary condition in
human adults—that is to say, few, if any, pathologists
have been in the habit of examining the sympathetic so
frequently as to be very familiar with its ordinary con-
dition. Further study of this matter is much to be de-
sired, but even if such investigation should demonstrate
‘that a lesion of the sympathetic is as constantly present
as the endartenitis, it would still remain an open question
which, if either, was the causative lesion.
A point of great pathological significance, and to which
allusion has already been made, is that valvular disease of
the heart, as recognized by the ordinary clinical signs, may
come on in the course of this disease without the patient's
having at any time an acute attack of illness, and this is
proved by what took place in Case IV., the woman devel-
oping valvular heart-lesion in the course of an attack of
mild chronic Bright’s disease lasting two years, during
which time she had no severe illness or febrile attack—at
the beginning being free from valve change, and now hav-
ing its clinical evidences most unmistakably developed ;
showing, it seems to me, most positively that the endar-
terial inflammation has crept into the heart to twist and
distort the valve.
It is a curious fact, and one worth recording, though at
present [ can offer no explanation nor draw any deductions
from it, that in several different sorts of tissue removed
by operation by surgeons as incurably diseased, I have
found upon microscopic examination precisely the same
endarterial inflammation and thickening, in some vessels
SO great as to entirely close their calibre, as found almost
universally throughout the body in the cases of chronic
endarteritis or chronic Bright’s disease that have been de-
scribed. ‘These have been ovaries and Fallopian tubes
removed by gynecologists, a vulvo-vaginal retention cyst,
a cancerous uterus, and I think other tissues. -
The relation of old age to this process of chronic en-
darteritis, or Bright’s disease, I have discussed in former
papers, and it does not seem possible longer to doubt that
the conditions are in many respects parallel, if not iden-
tical, and a further confirmation of this view is afforded
-= ee
1 Researches on the State of the Ganglionic Centres in Bright's
Disease, American Journal of the Medical Sciences, July, 1880.
2 The Middleton-Goldsmith Lecture on the Relation of the Dis-
eases of the Kidney, especially the Bright’s Diseases, to Diseases of
the Heart, Medical News, May 5, 1888.
THE MEDICAL RECORD.
[August 24, 1889
of the lining of arteries has been found in the heart of an
infant dying of marasmus at five months of age (see Fig.
4). The arteries of young infants, just as all the rest of
their tissues, present histological appearances which are
different from those of adult life, and they may offer,
therefore, perhaps an opportunity to learn the true origin
of this process of atheroma, as it has been called, which
could never be had from the study of adult tissues. The
plicated membrane or fenestrated membrane of Henle
presents itself in the arteries of young infants, when ex-
amined in cross-section, as a folded line somewhat thicker
relatively than it is in the tissues of older persons, and in
healthy vessels appears to be entirely structureless, contain-
ing no nuclei which will take stain ; in the diseased artery
from the heart it seems as if this had, owing to some irri-
tation, become inflamed, and there are many proliferated
nuclei in the membrane itself, or lying inside of it, pro-.
ducing swellings in the lining of the artery, just as is so
commonly seen in the atheromatous processes of adult
life (see Fig. 4). It is impossible to avoid drawing a
parallel between these appearances and what is so well
known and has been so much studied in inflammation of
the cornea.
The drawings were made for me by Dr. B. A. Randall,
and they admirably represent the appearances intended to
be shown. As they were to be reproduced by photo-
graphic process, they were necessarily made somewhat di-
agrammatic, for many of the finer lines and shadings in a
drawing cannot have justice done them by the photographic
method as here applied.
It was my desire in this paper to deal more with the
clinical than the pathological side of the subject—to try
to formulate the symptoms so that a diagnosis may be
more easily made; and last, though by no means least,
it is high time to give the disease a name, so that it may
be commonly recognized and admitted to our every-day
classifications of diseases. To me it seems plain enough,
in the present state of clinical and pathological knowl-
| edge, that the morbid process is “‘ chronic endarteritis ”—
and so the disease should be named.
COSTO-CHONDRAL LUXATION OF FIRST TO
SIXTH RIBS, BACKWARD,
WITH ParRTIAL DISLOCATION OF RIGHT CLAVICLE, UP-
WARD AND BACKWARD.
By ALFRED E. BRADLEY,
ASSISTANT SURGEON, U. S. A.
H. H , a recruit, aged twenty-six, who had always-
been perfectly healthy, enlisted in Boston, February 14,
1889. While en route for the recruiting depot, on Feb-
ruary 16th,-he was struck and injured by a passing pas-
senger train in the following manner: With a companion
standing at his left, he was on a narrow platform, backed
closely against a wall of masonry, awaiting the passing of
a train which came on to them suddenly and unawares.
while at this point.
The train approaching toward his left passed without
touching either him or his companion, until the last coach,
presumably a sleeper, came up to them. This coach was .
rocking’ or swaying from side to side, and they state it was
wider than those which preceded it. At all events, as it passed
it struck H-——’s companion, a large, powerful man, on
the left shoulder, threw him forward, and carried or rolled
him around H in such a manner as to forcibly
crowd and jam them both against the wall behind them.
The force was thus expended in a rotary manner. After
being thus rotated and jammed against the wall, they fell.
to the ground, and sustained no further injury.
‘They were conducted to a railway station about half a
mile distant, H suffering but little at that time, while
his companion was in acute pain, due, as was afterward
ascertained, to fracture of the second and third ribs on the
August 24, 1889 |
left side, with traumatism of the lung, as evidenced by the
expectoration of blood. As his case is not further con-
nected in any way with this article, suffice it to say he
made a perfect recovery.
H was bruised about the head and face, and after
a careless examination by a physician at the station, was
informed he “ would be all right in a few minutes.”
Soon after, however, he began to experience much dif-
ficulty in breathing, and great pain in the right chest, this
being his first intimation of any injury more serious
than the bruises above referred to. The writer saw him
neta half an hour later, and his condition then was as
ollows :
THE MEDICAL RECORD.
There existed a condition of mild shock, with a feeble
pulse, considerable pallor, and a temperature of 97°.
He complained of great difficulty in breathing, and
pain in the right chest. Whiskey and aromatic spirits of
ammonia was administered in repeated doses, and on his
SUNITZER
recovering somewhat from the shock, careful examination
elicited the following rare, and one might say unique, in-
jury. On baring the chest, the eye of the observer was at
once arrested by the striking asymmetry that was pre-
sented.
At the right of the sternum, which seemed to be tilted
or turned on its long axis from left to right in consequence
of the asymmetry, a linear protrusion was seen, which was
easily ascertained to be caused by the over riding of the
costal cartilages on their respective ribs.
The ends of the mbs were depressed, and the protrud-
ing chondral articulating surfaces were made out by pal-
pation to form nearly a straight line from above, down-
ward and outward. Careful examination disclosed the
fact that all the ribs on the right side, from the first to
the sixth inclusive, were dislocated backward from their
chondral articulations. Further examination showed that
the sternal end of the right clavicle was also partially dis-
located upward and backward.
The supra-sternal notch was partially obliterated, the
sternal end of the clavicle was quite mobile, seemed al-
most free from its sternal attachments, and could be easily
reduced ; though the reduction was but temporary, it soon
resuming the former position, as evidenced by the fulness
to the nght and above the sternum and the partially oblit-
erated supra-sternal notch. ‘The lungs were in a condi-
tion of mild emphysema, but there was at no time any
expectoration of blood.
203
All efforts to reduce the dislocated ribs proved futile.
Both shoulders had been drawn backward, and the right
arm rotated outward to put the pectoral muscle on the
stretch ; but owing to the sternal and chondral insertions of
this muscle (as well as its costal) this proved ineffectual.
Extreme extension of the spine over a roll of pillows
in the dorso-lumbar region was then tried. -
An effort was made to reduce by forced inspiration, but
it was impossible for the patient to properly execute this
procedure, owing to the pain and extent of the injury.
All efforts to produce reduction having failed, this
dressing was then applied. For the partial dislocation of
the clavicle the right shoulder was drawn backward in
such a manner as to retain the head of the bone in the
proper position, and there held by means of broad adhe-
sive strips applied much after the manner of Sayer’s
dressing for fracture of this bone. For the luxated ribs
a wide, thick pad over the seat of injurv, and broad adhe-
il
ite A i
aiiin
NANNA
sive strips’ were used encircling the chest, also passing
from front to back over the right clavicle to give that bone
additional support. ‘The right-arm was then brought to
the side of the chest after placing a generous pad of
cotton wool in the axilla, and there fixedly retained by a
broad roller passing around the whole chest. After the
application of this dressing the patient expressed himself
as feeling very comfortable, and in little or no pain.
On the following day there existed considerable dysp-
noea, profuse frothy expectoration, and loud bronchial
and tracheal rales. He was given an ounce of sulphate
of magnesia, and ordered five grains of carbonate of am-
monia in three drachms of liq. ammon. acetat. every
two hours. His temperature was normal.
February 19th.—Was considerably easier ; temperature
morning and evening, 99°; respiration less difficult, but
there still existed considerable pain in the chest. Pulse
go; was ordered half an ounce of whiskey to be given
every four hours.
February zoth.—Was somewhat improved as to pain
and expectoration. Morning and evening temperature
99.4°. He was given gr. 4 of morphine at night.
February 21st.—Morning temperature, 100° Evening,
100.2°. Was given three drachms of Rochelle salts and
gr. 4 of morphine in the evening.
On the 22d his temperature was again 100”, but never
afterward reached that point.
Excepting a more or less continuous dyspnoea, the pa-
204
On the 24th
he became very short of breath, and loud bronchial and
tracheal rales were again heard, and death seemed threat-
ened by cedema of the lungs. He was ordered half-
ounces of brandy in four ounces of milk, and five
grains of carbonate of ammonia in half an ounce of liq.
ammon. acetatis, alternately every two hours, with occa-
sional doses of morphine for the restlessness.
This had the happy result of a speedy return to a com-
paratively normal respiratory action, and from this time
on his progress toward convalescence was uninterrupted.
On March roth the dressings were removed, and were
found to have answered admirably for the purpose for
which they were intended. The clavicle had been held
well and properly in position, and it was seen bone callus
had been freely thrown upward from the fractured first
-cartilage, but not in sufficient quantity to impede the mo-
tions of the clavicle to any degree.
At the present writing recovery is complete as far as
repair is concerned. The motions of the arm seem to be
in no manner impaired, and the sterno-clavicular articula-
tion in normal condition, though the deformity resulting
from the costo-chondral dislocation is marked, and is
ou well shown by the cuts, from photographs recently
en.
The following measurements, taken since recovery,
show to what extent the uninjured differs from the injured
side of the chest.
At the recruiting rendezvous, the recruiting officer had
taken measurements just on a level of the angle of the
scapular, and gives them as 34 and 364 inches respectively,.
as the circumference during forced expiration and forced
inspiration. As these were taken hurriedly, and probably
with not much accuracy, they cannot be depended upon.
However, it is well to know these former measurements
in relation to measurements taken since recovery, as the
latter show but 32 and 344 inches, respectively. It is
hardly probable that such. a difference actually existed,
though undoubtedly the respiratory action was enough in-
volved by the results of the injury, to account for con-
siderable of the discrepancy between the two measure-
ments.
Furthermore, from the spine to the middle of the
sternum on the right side, it is now 16 inches forced ex-
piration and 17 inches forced inspiration; and on the
left over the same region, the scapular angle, the dimen-
sions are respectively 16 and 174 inches.
From these measurements, and by careful inspection
and palpation, it is believed the over-riding of the carti-
lages is between 4 and 4 an inch. From the middle of
the sternum to the end of the protruding second cartilage
is tł inch; to the end of the fifth cartilage is 2§ inches.
As far as can be ascertained the union is osseous, as is
usual in injuries to these cartilages.
While the cure is by no means a perfectly satisfactory
one, viewing the remaining deformity, it is nevertheless
most gratifying for the patient to have escaped with his
life, after having been subjected to a compressive force
necessary to have caused so extensive and serious an in-
jury. It now gives him no inconvenience whatsoever, and
were it not for the remaining deformity, nothing would
remain to evidence so serious an injury ever having been
received.
It is impossible, of course, to predict exactly what in-
fluence the impaired capacity of the right chest will have
over the development of any possible pulmonary trouble
in the future. It is also highly probable, that any work
in the future which may call into active service the in-
jured parts, such as heavy lifting or any prolonged strain,
will undoubtedly be followed by evidences of weakness,
and more or less loss of power to the parts implicated.
After a painstaking search, it is found that the litera-
ture of this injury is very meagre indeed, but few cases
similar ever having been recorded, and still less in num-
ber ever’ having been accurately described. As there is
no synovial membrane or articulation proper between the
ribs and costal cartilage, but simply a fusion of the two,
it is still a question as to whether this injury can be cor-
rectly termed “dislocation,” or if it is in reality one of
fracture. It is true that it is difficult to distinguish be-
tween a true fracture of the cartilage, an injury as rare
as the one under consideration, and a separation of a rib
from its cartilage.
In the case described in this article, it seems that the
evidence is conclusive as to the character of the injury.
‘The line of separation downward and outward, the
measurements as compared to those taken on an osseous
skeleton, and on the uninjured side, the age of the patient
—all seem to, nay do, make it an undoubted case of sepa-
ration of the ribs from the cartilages, call it luxation or
fracture as we please.
Alfred Poland, in Holmes’s “System of Surgery,” vol.
ii., p. 570, submits a table of four cases, the fourth of
which, from the remarks here given, seems almost exactly
similar to the case herein described. It is the famous
case reported by Charles Bell, caused by pressure be-
tween a post and a carriage; it is said “ the majority of the
ribs were luxated on the cartilages,” and any more de-
finite details the writer has failed to find. In the writer’s
case six ribs on one side are luxated, caused by circum-
stances strikingly similar to Bell’s, pressure by a passing
railway coach against a wall.
It was not stated what treatment was used, or what
result followed, in Bell’s case. In the Lancet, 1882, vol.
i., p. 432 (dndex Medicus), a case is said to be reported
by Mulvaney in which the left costal cartilages were dis-
located backward (from ribs or sternum ?), accompanied
by a dislocation of the nght clavicle forward.
The writer has not had access to that volume of the
Lancet, and is uncertain whether it was a costo-chondral,
or a chondro-sternal luxation, the title of the article, as
given in the /ndex Medicus, not designating.
Careful investigation indicates that the cases recorded
in Holmes’s “Surgery” by Poland, above referred to, four in
number, are the only authenticated cases of dislocations
‘of the ribs upon their cartilages.
This conclusion is also reached in an admirable paper
by A. W. Blodgett, in the New York Medical Journal,
vol. xxxviii., 1883, pp. 34-62, in which are reported and dis-
cussed cases of injury to the cartilages, more especially,
however, the chondro-sternal luxations. The case now
reported by the writer swells the number to five, and
should the case of Mulvaney prove to be costo-chondral
instead of chondro-sternal, the number to six.
It is stated that the most constant symptom of this
luxation is the prominence of the chondral end of the
ribs in advance of their corresponding cartilages, while in
the case under consideration the conditions are reversed.
Undoubtedly this injury is usually or always the result
of violent compression of the chest.
Where the cartilages over-ride, compression would
seem to probably have been lateral ; where the ribs over-
ride, it would seem to have been antero-posteriorly, or
in the recorded cases upon the sternum.
Davin's Istanp, N. Y. H., May, 1889.
BLonpDES.—The process of training for a “ blonde ” was
in Venice, in the sixteenth century, a somewhat serious one.
The aspirant took dragon’s blood (i.¢., the resinous gum
of the dragon-tree), ashes, egg-shells, sulphur, orange-peel,
and sundry other trifles, all of which she boiled into asso-
ciation over a fire. With the essence of this mixture she
assiduously bathed and sponged her hair. When her
locks were deemed to be saturated sufficiently to dry
them, she was wont to ascend to the roof of the house,
and there sit in the sun, with a straw zone like the de-
tached brim of a hat fastened round her head, to protect
her from solar inconvenience. ‘The result is said to have
extracted admiration even from Moslem strangers.— Medi -
cal Press.
August 24, 1889]
AN EXPERIMENTAL STUDY OF THE BROWN-
SEQUARD THEORY.
By HENRY P. LOOMIS, M.D.,
NEW YORK.
THE position which Dr. Brown-Séquard has held and still
holds in the scientific world entitles any theory advanced
by him to the respectful consideration of the profession.
The recent one, relating to the use of injections of testic-
ular liquid, was properly presented through reputable pro-
fessional channels, and supported by experiments con-
tinued through a considerable period of time, and repeated
and confirmed by other observers. Unfortunately, there
has since been engrafted upon it much that has no shadow
of foundation in any contention of the originator, and it
has received a public and unprofessional notoriety which
is not only to be regretted on general principles, but may
possibly long prejudice us against any merit that it may
actually possess. A brief review of his proposition is ad-
visable.
The following is a fair statement of the physical effects
of the treatment as applied by Dr. Brown-Séquard to
himself :
From a condition of weakness, small appetite, and
sleeplessness, he entered into one of comparative physical
and mental strength. No record of the influence upon
the appetite or capacity for sleep is giver. He attributes
these changes to an increase in the power of the nerve-
centres, and notes, upon a cessation of the injections, and
after a period of four weeks, during which no marked
change occurred, a gradual reversion to his former state.
He denies that the beneficial effect is due to any personal
idiosyncrasy, as experiments conducted by Dr. Variot in-
dependently of himself, upon five elderly men, produced
similar results.
The conclusions he draws are :
1. That the spermatic fluid is potent to increase the
strength of the human organism, presumably in old men,
not by structural change, but by nutritive modification.
2. That the alterations in muscular structure not es-
sentially allied to old age may disappear, and a consequent
recovery of former power by the tissues may supervene ;
and,
Finally, that the subject is well worthy of further ex-
perimental i investigation.
In further definition of his position, Dr. Brown-Séquard
specifically affirms his continued belief in the fatality and
irreversibility of those nutritive actions which produce the
changes of advancing age, and acknowledges that the facts
presented are insufficient to solve the question of possible
structural change in muscles, nerves, and nerve-centres.
I can see nothing in this to support the accusation that
he claims to have discovered the source of perpetual
youth, but rather a flat denial of any such contention, as
though, in making his affirmation, he recognized the
danger of misrepresentation and made an effort to provide
against it. What he does claim is the discovery of certain
physical changes wrought by the injection of the mixture ;
that it was apparently beneficial in its action with pos-
sibilities of becoming more so, and that the phenomena
were important enough to invite careful study and anal-
ysis. At all events, my experiments have been made
with such interpretation of the proposition, and the de-
ductions given below are the present result.
Following Dr. Brown-Séquard’s instruction, and always
observing strict antiseptic precautions, I crushed in a
mortar a small portion of the tissue of the testicle of a
two-year-old ram, mingled with an equal quantity by
bulk of distilled water.
The resultant mixture, after infiltration, disclosed under
the microscope albuminous granules and crystals of sper-
mine that are formed of a phosphate of an organic base,
but no bacteria or spermatozoa. ‘Thirty minims consti-
tuted a dose, and fresh material was prepared on each oc-
casion. Not more than an hour was allowed to elapse
between the death of the animal and the operation.
‘THE MEDICAL RECORD.
205
Within the last three weeks I have injected fluid of this this
character into a number of men, with the following re-
sults.
Class I. includes only such as were patients in Bellevue
Hospital, who had no knowledge or suspicion of the char-.
acter of the liquid, and took no medicine during the per-
iod of experimentation.
Case I.—Charles G , aged fifty-six, shoemakér,
had been under treatment in Bellevue Hospital for a -
month, suffering from emphysema, chronic bronchitis, and
asthma. By treatment, his chronic bronchitis had been
cured, but his asthmatic attacks still continued, coming on
generally in the early evening. The patient was given
four injections of thirty minims each of the fluid, at inter-
vals of two days. A short time after the fitst injection
he said “ he felt as if he had taken a big dose of mor-
phine ;” that night he was not troubled with his asthma,
for the first time in over a month. During the following
day he felt much better, stronger, and with increased vi-
tality. ‘This improvement continued and increased up to
the time of the fourth injection. After the fourth injec-
tion, although the patient complained of no pain at the
seat of puncture, still for the twenty-four hours following
the injection his general condition seemed to be much
worse, his hands trembled, he complained of a burning
sensation, and appeared as one who had suffered a severe
nervous shock. At the expiration of the twenty-four
hours his condition became substantially as it was pre-
ceding the last injection. The return to this condition
took place about a week ago, since which time no injec-
tions have been administered. The seemingly beneficial
effects have gradually worn off, accompanied by a slight
return of his asthmatic attacks and loss of strength.
‘During the time of experimentation no change was no-
ticed in his pulse, which ranged between 62 and 70. His
respirations at the time of the first experiment were 24,
after the first injection they remained about 20. The dy-
namometer moved by the flexors of the right forearm reg-
istered 59 as against 5o prior to the injections.
Comments.— During the period of experimentation the
patient’s asthma improved, his respirations became less
frequent, his strength increased, and his general condition
was better. The improvement in the patient has not been
permanent.
Case II.—Wilham D——, aged sixty-two, a tailor,
sufferer from chronic diarrhoea, general debility and senil-
ity, while not actually on the sick list at the time of ex-
perimentation, had been in no particular materially
benefited by treatment. He received four injections at
intervals of three days. The day following the first injec-
tion he acknowledged that he “ felt better,” but attributed
his condition to an improvement in his diarrhoea. After
the second and third injections he affirmed that he “ felt
much better, livelier, and clearer in his head ;” “that he
was much better able to go about his work.”
His pulse during the period of experimentation re-
mained at 64, respiration at 20, and strength, as reg-
istered by the dynamometer, at 60.
Comments.—The patient’s statements of his improved
condition were fully within the apparent facts.
Case II].—Matthew M , aged seventy-seven, a
sufferer from senility, was under special treatment for
diarrhoea, which had lasted for about three weeks and
had been controlled by appropriate remedies. He re-
ceived three injections at intervals of two days, the first
being given, as in other cases, at about 5 P.M. By the
patient’s own statement, his improvement began to be
noticeable on the morning following the first injection.
His words in describing his condition were, that he “ felt
much livelier and better,” and the testimony of the attend -
ant physicians and nurses was to the same effect. The
estimate of the improvement in this case is much more
emphatic than in the others. The pulse was variable
both before and during the period of experimentation,
marked increase, however, being observed during the
twelve hours immediately following the injection. Res-
206
piration, which prior to the injection had averaged 16,,
then rose to 20. The registration on the dynamometer
-showed an increase frém 38 to 42.
Comments.—I regarded this case as the one best cal-
‘culated to test the efficacy of the fluid. The improve-
ment, while in no way sudden or extraordinary, has been
‘steady and decided. As insufficient time has elapsed
since the last injection, it is premature to estimate the
_ permanency of the improvement.
Case IV.—G. D , aged fifty-two, a sufferer from
chronic rheumatism, received a single injection without
general or specific result.
Case V.—John C——-, aged fifty-seven, seaman, had
been suffering for three weeks from the exacerbation of a
chronic rheumatism. He received two injections of 30
minims each with an interval of forty-eight hours. Not
only was no improvement noticed, but rather an increase
of symptoms.
Class II. embraces, with one exception, private cases.
All were men of intelligence and education, and were
familiar with the theory and method of treatment.
Case VI.—L. K , aged forty-eight, with a neurotic
family history, suffered from an entire loss of sexual
appetite, due no doubt to excesses in early life. He
complained of loss of memory, insomnia, and despondency.
He had had no erection since last March. Two injec-
tions of 30 minims each, with an interval of three days,
were given him without result.
Case VII.—George D——, aged thirty-five, was a
sufferer from no organic difficulty, but was a typical ner-
vous case, and had consulted many physicians with no im-
provement, ashe thought. He was confident this remedy
would effect his permanent cure. He received four injec-
tions at intervals of two days, with a marked increase of
nervousness. He seemed to be made worse by the treat-
ment.
Case VIII.—Doctor M—, aged fifty-seven, suffered
for the past five years from constant anzmic headache ;
with this exception he was perfectly well. As he had ob-
tained no relief from medication, he requested me to give
him an injection. He derived no appreciable benefit
from the injection, and his headache was not mitigated.
Case IX.—J. A. R , aged thirty-six, a sufferer from
what his physician diagnosed as chronic muscular rheu-
amatism, obtained no improvement from two injections.
Case X.—X. Y , aged forty-seven, had suffered for
five years froma peculiar nervous disease which had been
-diagnosed, by some specialists in Europe and this country,
.as locomotor ataxia. As this gentleman has education
-and exceptional ability, and is free from all prejudice in
regard to the treatment, I give his own description of the
‘effect of the first injection, which was administered at
‘6 P.M. “I noticed no sensation,” he said, “until 7.15
the same evening. ‘Then a comfortable feeling came
‘over me, as if I had taken a glass of champagne ; in a word,
I felt rested. On retiring, at nine o’clock, I noticed
some soreness in my leg, in the region of the puncture.
From this time until 2 a.m. I suffered from most pecu-
liar sensations. I was very restless and nervous ; my body
felt as if it were burning up, my mouth was parched, and
my face flushed. My wife, thinking I must have a high
fever, took my temperature, but found it normal. At this
time I was wide awake and my mind active. Most of
the time I was unable to control the shaking of my hands.
I slept from two o'clock until eight, when I awoke some-
what refreshed, and found that the soreness had left my
ileg. All the forenoon I felt seedy, but by afternoon I
began to improve, and by evening I felt better than I had
for months, stronger, and with more ambition. ‘This
effect has continued up to the present time (two days).
This patient is now under treatment, and has had four
injections, but I can see no improvement in his disease.
His gain, if any, is purely subjective.
I have received a number of reports of cases from
physicians to whom I have furnished the fluid. Some of
them state that there has been a wonderful improvement
THE MEDICAL RECORD.
[August 24, 1889
in their subjects. As, however, these cases have not
fallen under my personal observation, I refrain from
noting them. My observations upon the cases are as fol-
lows :
I. a. I can see no reason to anticipate danger of sep-
ticemia from the use of the fluid prepared under proper
antiseptic precautions, provided the material used be ab-
solutely fresh and free from all trace of disease. My at-
tention was called to the necessity for the closest scrutiny
in this last particular, by having discovered, in specimens
taken from an apparently healthy ram, a solitary tubercle
in which were demonstrated tubercle bacilli. In none of
the cases have I seen any bad results, and only in a few
has there been a moderate amount of pain at the point of
injection, lasting from six to eight hours.
6. I can explain the singular nervous affection ap-
parent in certain of the cases only on the theory that
upon the nerve-centres the mixture exerts some power-
ful but as yet unexplained influence, which, even if its
use be eventually proved beneficial in some cases, must
render its employment in others a matter of caution. It
is far from safe to say and proceed upon the belief that
“if it does no good it can do no harm.” |
II. a. I seem to see in almost all the cases of old men
subjected to the experiment an increase in strength and
vitality which certainly persists for several days. I have
noticed nothing in the least resembling the secondary de-
pression which so commonly follows the use of ordinary
stimulants. |
b. When used in cases of actual disease no modification
of pathological conditions or processes has been recog-
nizable.
I therefore conclude :
1. That the injection of this testicular mixture does, as
claimed, produce “ nutritive modification” in the tissues
of elderly men, due probably to the stimulation of the
nerve-centres. |
2. As far as my own experiments are concerned, suffi-
cient time has not yet elapsed to justify an affirmation or
denial of the correctness of Dr. Brown-Séquard’s second
conclusion.
3. There is in the theory sufficient ground for further
experimentation.
CONTRIBUTIONS TO THE SUBJECT OF TU-
MORS OF THE ORBIT AND NEIGHBORING
CAVITIES."
By CHARLES STEDMAN BULL, M.D.,
PROFESSOR OF OPHTHALMOLOGY IN THE UNIVERSITY OF THE CITY OF NEW YORK;
SURGEON TO THE NEW YORK EYE INFIKMAKY ; CONSULTING OPHTHALMIC SUR-
GEON TO ST. LUKB’S HOSPITAL.
Case I. Aaeno-sarcoma of the Lachrymal Gland.—The
patient, George G , aged thirty-five, presented him-
self to me for the first time on May 30, 1887, with the
following history: A little more than a year before he
had noticed a swelling or tumor, as he thought, of the
outer angle of the left upper lid ; but after a while he dis-
covered that the swelling was not in the lid, but was a
tumor beneath the lid, and on the outer aspect of the left
eye. There was at first no interference with the move-.
ments either of the lid or globe, and no sense of discom-
fort ; but the tumor gradually increased in size and began
to cause the patient some annoyance. It had never been
painful nor especially sensitive on pressure, nor was there
any interference with the vision. When I saw him, the
outer end of the left upper lid was somewhat bulging,
and the growth was seen to be applied closely to the eye-
ball on the upper, outer, and lower quadrants, and pre-
sented in the interpalpebral opening. On everting both
lids, and making the patient look toward the extreme right,
the growth was seen to extend backward and upward into
the orbit, and to be connected with a glandular tumor at
1Read before the American deere ical Society, at its
Twenty-fifth Annual Meeting, New London, July 17, 1889.
August 24, 1889]
the site of the lachrymal gland. The tumor was dis-
tinctly lobular, reddish in color, somewhat firm in charac-
ter, and perfectly movable beneath the ocular conjunctiva
and upon the globe. The motility of the eye was slightly
interfered with upward and outward. The media and
fundus were normal, and vision was $3+. The ocular and
palpebral conjunctiva was somewhat injected, but there
was no secretion of any kind. A diagnosis was made of
tumor of the lachrymal gland, and it was decided to at-
tempt its removal. The patient was etherized, and the
upper lid pulled downward as far as possible over the
lower lid. The eyebrow was then closely shaved, and an
incision was made from the middle of the eyebrow out-
ward, following the line of the supra-orbital margin for the |
distance of an inch and a half, through the skin and sub-
cutaneous tissue. The tarso-orbital fascia was then di-
vided, care being taken not to wound the tendon of the
levator palpebrze muscle. As soon as the orbital cavity
was opened and some of the orbital” fat pushed aside, the
tumor was seen to involve the lachrymal gland. By the
aid of the handle of the scalpel and a pair of blunt-pointed
scissors the adhesions between the growth and the upper
and outer walls of the orbit were carefully divided, no very
_ firm points of adhesion being found. The attachments
of the tumor to the eyeball were then easily separated,
care being taken to dissect off as much of the ocular con-
junctiva from the external face of the tumor as was pos-
sible, and the enlarged gland was then removed entire.
There was considerable hemorrhage from the divided ves-
sels, which, however, soon ceased, and the cavity was
then washed out carefully with a ‘solution of mercuric
corrosive chloride (1—1,000).
introduced through the entire thickness of the lips of the
wound, including the tarso-orbital fascia, and as many
more through the external lips of the wound as were nec-
essary to bring the edges into thorough coaptation. Sub-
limate dressings and a bandage were then applied. The
wound healed by first intention, and there was no sup-
puration, and in three weeks all signs of tumor or opera-
tion had disappeared. The tumor was hardened in Miil-
ler’s fluid and alcohol, and numerous sections were made
and carefully stained for future study. These showed
that the degeneration had begun near the centre of the
gland, for here nearly all traces of the normal glandular
structure were absent. It was impossible, however, to
determine whether the abnormal growth began in the
ependyma of the glandular tubules or in the connective
tissue around them. If it be true, as Berlin thinks, that
all adenoid tumors belong to the common type of cylin-
droma, then the tumor in question was a cylindroma.
Away from the centre, and near the periphery of the gland,
there were found many tubules in a healthy state, but
even in the midst of these normal tubules were others in a
distinct condition of hypertrophy, with numerous small
round cells. Inall parts of the growth, the connective-
tissue framework was crowded with small round cells, and
as the sections approached the centre of the gland these
cells became more and more numerous, until all the
glandular elements were crowded out and disappeared,
and nothing was visible but a closely pressed mass of
small round cells in place of glandular tissue. After a
careful examination had been made of the various
tions, the patient was told that the growth would in all
probability return, and that he must report at intervals
for examination. The tumor was removed in June,
1887, and the patient has been seen at intervals of two or
three months ever since, the last time in March of this
year. At this visit nothing abnormal was discovered in
the orbit or eyelids. I have termed the growth an adeno-
sarcoma of the lachrymal gland, as being most in conson-
ance with the results of the microscopic examination.
Case II. Abscess of the Ethmoid Cells, Frontal Sinus,
and Orbit.—The patient, a gentleman, aged forty-six,
consulted me on April 16, 1888, with the following
history: He had been long subject to naso-pharyngeal
catarrh, with frequent acute exacerbations and profuse
THE MEDICAL RECORD.
Six deep sutures were then '
207
discharge, and he had been under treatment of one kind
or another for many years. About Christmas of 1887 he
first noticed a swelling at the upper and inner angle of
the night orbit, though he had had a constant dull pain in
this vicinity for more than a year. ‘The swelling contin-
ued to slowly increase, without much change in the sub-
jective symptoms, until March, when he began to see
double. At this time his headache was constant, and
being alarmed he consulted his family physician, who
made an examination and discovered that with either eye
alone his vision was perfect, but that the diplopia, and
consequent disturbance of vision, returned when both eyes
were open.
Tincture of iodine was painted over the swelling of
the lid, and potassium iodide was given internally, but
without producing any beneficial effect, and he was finally
advised to consult me, which he did on April 16, 1888.
I found a rather marked protrusion of the inner half of
the right upper lid, and a dislocation of the right eye out-
ward and downward, and a little forward. ‘The motility
of the eye inward and upward was somewhat limited. The
lids were normal in action. Vision was $5+, and the
media, fundus, and field of vision were perfectly normal in
every respect. ‘The tumor or swelling was smooth, elastic,
irregularly ovoid in shape, and extended backward some
distance into the orbit. It occupied the supero-internal
angle and inner wall of the orbit. It was painless on
pressure, and showed no signs of any inflammatory pro-
cess. There was a profuse, almost purulent, discharge
from the right nostril. A hypodermic needle was intro.
duced through the skin of the lid, and pus was withdrawn
from the cavity. A diagnosis was made of abscess of the
frontal sinus, which had probably broken through the bony
roof of the orbit, and involved the latter cavity. The
patient was told that nothing but operative interference
would be of any use, and he consented at once to have
the operation done. On April 18th the right eyebrow
was shaved, and a long incision was made through all the
tissues down to the bone, beginning at a point at the
junction of the middle and outer thirds of the eyebrow,
and running parallel to, and just above, the supra-orbital
margin, across the root of the nose, to the inner end of
the eyebrow on the opposite side. As soon as the knife
penetrated the region of the swelling it was followed
by a flow of pus, amounting to about half an ounce, as
nearly as could be calculated. As soon as the incision
was completed the knife was withdrawn and the finger
introduced. A large irregular hole was felt just at the
inner end of the supra-orbital margin, extending into the
frontal sinus, and involving part of the lachrymal bone.
Pressure on the closed lids backward caused pus to run
from the incision, and the finger pushed into the orbital
cavity discovered that the abscess extended backward
into the orbit, and that there was an opening in the orbi-
tal plate of the ethmoid bone large enough to admit the
end of the middle finger. The walls of the frontal sinus
were distended in all directions, and were rough and cov-
ered with numerous osteophytes; but the bony septum
between the frontal sinuses did not appear to be perfo-
rated. The frontal sinus was first washed out with a sub-
limate solution (1-500), bringing away much pus and small
particles of bone, and after a brief period the fluid was
observed to drop from the right nostril, showing that a
communication existed between the frontal sinus and the
superior nasal meatus on this side. The same solution
was then used to wash out the cavity of the abscess in the
orbit, and also the ethmoid cells, and this also brought
away a large quantity of pus, After the entire cavity had
been cleansed thoroughly, a rubber drainage-tube was in-
troduced into the frontal sinus, and the rest of the exter-
nal wound kept open by pledgets of sublimated cotton,
and the patient was made to lie on his right side. The
lids were kept closed, and covered by a piece of gold-beat-
er’s skin, in order to prevent, as far as possible, any en-
trance of the purulent discharge into the conjunctival
cul-de-sac. ‘The cavity was washed out twice a day with
208
the sublimate solution, until the discharge of pus grew
very scanty, and then the irrigation was practis:d once a
day until all purulent discharge had ceased. The drain-
age-tube was finally removed at the end of the third week,
at which time all external swelling of the surrounding
parts had disappeared, the flow of pus was reduced to a
few drops, the eyeball had returned to its normal position,
and the diplopia had vanished. At the end of the third
month the cavity in the orbit had closed. and shortly after-
ward the external wound along the orbital margin filled
up with granulations, which first appeared from the edges
of the opening into the frontal sinus, and gradually the
external wound healed under a scab. At the end of the
fourth month close observation was needed to discover
that an operation had been performed. For about two
months previously systematic treatment of the nasal cav-
ities had been carried out, with the result of checking all
discharge from the nostrils, and converting the patie.t
from the state of a mouth-breather to a condition of nor-
mal respiration. The patient has not been troubled since.
This is one of quite a number of cases operated upon in
a similar manner, which have all recovered in a compara-
tively short time, and without any bad results.
Case III. Tumor of the Maxillary Antrum, Nasal
Fossa, Ethmoid Cells, Orbit, and Cranial Cavity; Op.
eration for its removal ; Death.— The patient, James
M-——, aged fifty-one, first consulted me on November
11, 1887, and gave the following history: He had
always been subject to profuse naso-pharyngeal catarrh,
which had been treated in an intermittent and spasmodic
manner for a number of years. In February, 1887, he
began to suffer from shooting-pains in the left side of the
nose, and along the course of the left supra-orbital and in-
fra-orbital nerves, and as the weeks elapsed this pain in-
creased in severity, and began to be localized in the left
orbit. In April there appeared a profuse purulent dis-
charge from the left nostril, and from. the pharynx. The
pain continued to increase in severity, and early in August
the left eye began to protrude from the orbit. The
ocular conjunctiva gradually became injected, and the
eyelids, particularly the lower lid, became swollen. He
at this time consulted Dr. E. G. Janeway, of New York,
who after a careful examination told him that he had a
tumor in the left orbit. The symptoms gradually grew
worse, and early in October the exophthalmus was so
marked that he could scarcely close the lids over the eye-
ball, and his vision began to be impaired. On November
11th, when I first saw him, his condition was as follows :
The left eye protruded forward, outward, and downward,
_ and the lids could not be closed over it. ‘The cornea
was clear. The lower lid was everted and partially con-
cealed beneath the protruding globe. The ocular con-
junctiva was markedly congested and the chemosis very
extensive. ‘The eye was absolutely immovable. Vision
was 4%, that of the other eye being normal. The oph-
thalmoscope showed a well-marked condition of “ choked
disc,” with hemorrhages. A protrusion of the growth
could be seen anteriorly at the inner angle of the orbit,
and an examination with the finger demonstrated that
the tumor could be felt at the inner canthus, and back-
ward along the inner wall and floor of the orbit. A
careful examination of the anterior and posterior nares
showed that the left inferior nasal meatus was entirely
occluded by a growth, anJ it was thought that the latter
also extended into the middle nasal meatus. The oc-
clusion of the inferior meatus was caused by the bones
being pushed down from above by the growth, this being
the opinion of both Drs. Lefferts and Asch, who kindly
examined the case with me. ‘The patient was then sent
for a further examination to Dr. William T. Bull, of this
city, who diagnosed a tumor of the antrum, nasal meatus,
and orbit, and advised non-interference, by reason of the
oy that the growth involved the deep bones of the
ace.
The pain was now so severe that the patient had to be
kept constantly under the influence of opiates. By De-
THE MEDICAL RECORD.
‘stertorous and he was found comatose.
[August 24, 1889
cember 3d.the eye had become entirely blind, and the
protrusion forward of the growth was very marked. It
was decided to attempt the partial removal of the tumor,
as a means of affording the patient some relief from his
suffering. On December sth the eye was enucleated,
under ether, with considerable difficulty, and then ¢om-
plete exenteration of the contents of the orbit was begun.
The conjunctiva was divided along the margin of the
lids, and the entire contents of the orbit were removed by
knife and scissors. ‘The bony floor of the orbit was en-
tirely absent as far back as the apex of the orbit, except
a narrow rim along the anterior margin. The maxillary
antrum was filled with the growth, and was entirely
cleaned out with forceps and curette. The opening from
the antrum into the nasal meatus was found enormously
enlarged, and the left side of the nose was filled with the
growth. Part of the lachrymal bone and the entire or-
bital plate of the ethmoid were gone, and the ethmoid
cells were filled with the growth. ‘There was a large rag-
ged opening through the roof of the orbit into the an-
terior fossa of the skull, and through this the growth also
extended into the cranial cavity. All operative proced-
ures were then stopped, the cavities of the orbit, maxil-
lary sinus, and nasal meatus were carefully washed out
with a solution of mercuric bichloride (1-2,000), and anti-
septic dressings applied. There was no unusual amount
of biood lost during the operation. On recovering from
the effects of the anesthetic the patient complained of
great pain in the head, which was relieved by morphia.
He remained fairly comfortable until about 9.30 P.M.
of December 6th, when his breathing suddenly became
In a few min-
utes the respiration became Cheyne-Stokes in character,
but this yielded to hypodermic injections of strychnine.
The patient died quietly, in a comatose state, at 7 A.M.
of December 7th, with regular respiration. Unfortu-
nately no autopsy could be obtained.
The tumor was carefully hardened in Müller’s fluid,
for about two months, and numerous sections were then
made through various parts of the growth, special care
being devoted to the growth removed from the maxillary
sinus. At first there was considerable difficulty experi-
enced in classifying the tumor, as the sections seemed to
be made up of nothing but cells. Of these there were
all kinds—round, ovoid, stellate, and fusiform—the small
round cells largely predominating. ‘There was a very
scanty fibrillar, intercellular substance, and the general
consistency of the growth at the time of its removal was
decidedly soft or medullary. This was particularly true
of the mass removed from the maxillary antrum. ‘The
growth in the orbit and ethmoid cells was decidedly myxo-
sarcomatous in character, and a careful study of sections
from ‘all parts of the tumor finally led me to class it asa
myxo-sarcoma. In some places, in both the orbital and
maxillary growths, there were small cavities, filled in the
fresh state with a yellowish fluid, which gave to the part
the character of a cysto-sarcoma. In all probability the
disease started in the maxillary antrum, possibly as the re-
sult of long-continued irntation and inflammation extend-
ing from the chronic naso-pharyngitis, and thence growing
in every direction—inward to the middle and supenor
nasal meatus, and thence into the cavity of the ethmoid
bone, and upward through the orbital plate of the maxil-
lary bone into the orbit. The absorption of a part of the
roof of the orbit, and the extension of the growth into
the anterior fossa of the skull, was probably the latest
stage of the disease. The direction of the growth inward
would of course make the extension outward through the
opening of the orbit a slowand protracted process, as was
proved in this case, the exophthalmus having been one of
the later symptoms. Still, it is the general opinion among
surgeons that growths originating in cavities near the
orbit, and involving the latter secondanly, are gener-
ally of very rapid growth. In the case in question all
the subjective symptoms occurred within ten months of
the death of the patient.
August 24, 1889]
@linical Department.
REPORT OF SIXTEEN CASES OF TYPHOID
FEVER, WITH REMARKS.
By O. C. TARBOX, M.D.,
PRINCETON, MINN.
“THE search for a specific treatment for typhoid fever is
not new. Indeed, ever since the disease was first de-
scribed, and theories advanced concerning its pathology,
the aim has been to find a specific for this long-continued,
and oftentimes fatal disease. Much has been written,
and many remedies advanced as curative.
Just now, when antisepsis governs medical and surgical
practice so largely, I desire to report these cases occurring
in my private practice as a further testimony to the value
of internal antisepsis in the treatment of this fever.
While an interne in Randall's Island Hospital, New York
City, my attention was called to the treatment originally
advocated by Bartholow, viz., by the use of carbolic acid
and tincture of iodine. One or two cases thus treated
in that institution recovered, but it was not until engaged
in private practice that I made such use of the treatment
that I could collect statistics of any value.
These cases, sixteen in number, were all treated by the
following prescription :
B. Acidi carbolici................. M, xxiv.
Tr Jodin neire aae m xlviij.
Mucil. acacia@...............005 Z iv.
Of this preparation one teaspoonful, according to age,
was given every two or three hours in a little lemonade or
ice-water. Little else was given, save antipyrin when the
fever ran too high, and a strict milk-diet. Of these cases
thus treated, one ended fatally, a girl aged fourteen,
who, after having been sick two weeks, was brought to my
office from her home, seven miles in the country, an ex-
posure that hastened the fatal issue.
The following are some of the points worth noting.
Fight patients had a temperature reaching or exceeding
104° F., two had hemorrhage of the bowels (none fatal),
and three had one or more relapses each. One case was
complicated by facial erysipelas, occurring in the third
week, one by suppurative synovitis of the left knee-joint,
and one took by mistake three-fourths of a teaspoonful of
carbolic acid (ninety-five per cent.)—a druggist’s blunder.
This latter case was a boy, aged twelve, who had safely
passed through four weeks of fever, and was convalescing
nicely when the acid was given to him. His mother's
presence of mind in administering some glycerine, milk,
and whites of eggs, coupled with a hypodermic injection
of apomorphia given twenty minutes afterward by myself,
saved his life, though only after a long relapse of fever.
The case of another boy, of eleven years, deserves es-
pecial mention from the severity of the disease. The
primary fever ran twenty-five days in this case, following
which, with a few days’ intermission only, were two re-
lapses, one of twenty, and one sixteen days, making a
total of sixty-one days of fever. He recovered and with
no sequelz.
Finally, I offer the following propositions as suggesting
themselves to me from the above experience, and in the
hope that they may be of use to others.
1. It is most rational to produce intestinal antisepsis in
this fever, knowing as we do its specific cause to be a
germ, and in carbolic acid and tincture of iodine we have
prompt and safe germicides. ‘The medicines are quite
easily borne by the stomach, if given in lemonade or lemon
sirup, and especially after taking some nourishment.
2. By such antiseptic treatment, if given early, I believe
the disease is shortened, and the severity lessened. With
the exception of the case mentioned abov:, a rare one in
point of severity, all of my cases ran a much shorter
course than under former plans of treatment. ‘There was
THE MEDICAL RECORD.
209
a noticeable absence of those nervous symptoms so com-
mon to typhoid fever in nearly all my cases, such as de-
linum, subsultus, carphologia, coma-vigil, and the like.
Not one of the sixteen cases had active delirium, requir-
ing restraint. |
Constipation was the rule in about every case. Al-
though I have not statistics on that point, I can remember
no case in which I was obliged to check or moderate a
diarrhoea ; oftener mild cathartics or enemas were neces-
sary.
3. The disease is more easily handled, and the danger
to others is less by this plan of treatment. In all cases I
used, of course, every precaution in that respect by venti-
lation, frequent change of clothing, and thorough disin-
fection of the discharges with copperas and chloride of
lime, and it has seemed to me I was most fortunate in
confining the disease in every instance to the patient, none
others taking it. ‘This is an all-important point, and I
believe the result was due largely to the intestinal antisep-
sis. Fortunate we shall be if we shall succeed in prevent-
ing the spread of enteric fever in a majority of cases.
The above report tends to show, in my opinion, that it
can be done.
LIVING TWINS WITH ONE BODY.
Dr. G. M. Cotuins, of ‘Tipton, Ind., writes: “On Mon-
day night, June 24, 1889, was born to Mr. and Mrs.
J—, near Groomsville, Tipton County, Ind., a pair of
twin girls with one body. ‘They unite in. centre of the
body, having but one umbilicus. There are two legs on
either side of body. The two children are well formed,
and at this writing have every appearance of living.
There is a well-formed vagina and anus on either side, be-
tween each pair of legs. ‘The two anuses are about one
and a half inch apart. Each child has a separate cir-
culation and organism. One will sleep while the other is
awake. One leg on each side of the body belongs to
each child, that is the same as if two children were lying on
their backs with their coccyges in contact, except that the
legs are on the sides. At birth their weight was twelve
and one-half pounds, and they were twenty-two and one-
half inches in length. The bowels and kidneys perform
their functions independently. At first the children could
bend up and hoth nurse at once, but now they are de-
veloping and do not bend so readily, and one nurses at a
time.
“ The spinal column is straight, and the two seem to be
united at the end of each body. The children are bright
and lively, have a fine head of hair and fine features.
Their mather is of slender build, and weighs about one
hundred pounds.”
A PEA IN THE AUDITORY CANAL FOR
THIRTY-TWO YEARS.
Dr. W. F. Morcan, of Leavenworth, Kan., reports
the following case: Mrs. William H——., German, aged
forty, called on July 17, 1889, complaining of her right
ear, stating that when eight years old she inserted a pea
into each ear; that her mother removed the one in her
left ear, but was unsuccessful in her attempts to remove
the other, which she believed to be still in the ear. The
patient was suffering from vertigo, nausea, and “ noises,”
in her right ear. ‘The watch could be heard only when in
contact with the auricle. Hearing of left ear normal.
After repeated irrigations, on three successive days, with
warm rain-water, and the removal of much hardened
cerumen, at the time of her third visit the pea was re
moved by a Sims uterine tenaculum. It was nearly per-
fect in form, but very black in color, after its sojourn of
thirty-two years in the canal. The watch can now be
heard at two feet, and all abnormal sensations have dis-
appeared, except slight soreness of the ear, which will
probably very soon entirely subside.
210
THE MEDICAL RECORD).
[August 24, 1889
THE MEDICAL RECORD:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., EDITOR.
PUBLISHED BY
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
New York, August 24, 1889.
THE SO-CALLED ELIXIR OF YOUTH AND
ITS ABSURD PRETENSIONS.
Ir is now a little more than a month since the news of
Brown-Séquard’s alleged method of rejuvenating the aged
reached this country. ‘The subject is one that naturally
appeals to public interest, since a long life and a vigorous
old age have always been among the chief objects of
human desire, and consequently it has received a much
greater share of newspaper attention than is usually be-
stowed on medical topics. This is most unfortunate, for
the public discussion of such an absurdity tends only to
bring scientific medicine into ridicule.
The method is on its face preposterous, its vaunted
effects are impossibie and ridiculous. It is opposed to all
known physiological and biological laws, and had it not
been bolstered up by the reputation of a Brown-Séquard,
it would scarcely have been heard of outside of the Paris
society where it was proposed, and no one would ever
have looked upon it in any other light than as the foolish
conceit of an old man, in whose mind the dreams of re-
turning youth had assumed the counterfeit of reality.
Supported as it was, however, by the weight of an author-
ity hitherto respected in the world of medicine, it was
necessary that it should be tested cautiously and in a
proper way, and that the method should not be actually
condemned until it had been proved as worthless, as were
its pretensions extravagant. For unreflecting and obstinate
scepticism in matters medical is as illogical as unreason-
ing credulity.
The experiments reported by Dr. Loomis in another
column are sufficient, we think, to satisfy the demands of
legitimate prudence. In fact, the subject has already re-
ceivedmore attention than it has deserved. ‘Ihe results of
these experiments seem to show that the injected material
may, in certain cases, act as a mechanical stimulant, but
that is all; they fail utterly to support the extravagant
claims of physical and mental rejuvenescence which have
been put forward in behalf of this method. What these
experiments do not so clearly show, since they were con-
ducted with a proper regard for surgical cleanliness, is
the imminent risk of septic poisoning or of tuberculous
infection to which the subjects of such injections are ex-
posed in the hands of incautious operators.
It is high time, therefore, to call a halt in this matter,
unless scientific medicine is to be made ridiculous in the
eyes of the public. If there are any not yet convinced of
the worthlessness of this method, let them continue their
experiments as long as they wish, but let them do so re-
moved from the public gaze and out of sight of the news-
paper reporters. It is repugnant to true science to pa-
rade such crude and untried theories before the public, as
though they had received the stamp of authoritative ap-
proval, and in the name of this science we protest against
it. The daily press is awakening to the true issues in-
volved, and will in its own effectual way bury the theory
out of sight, as soon as its falsity and absurdity have been
made manifest.
MUSCULAR ATROPHY AS A CAUSE OF JOINT PAINS.
ATROPHY of neighboring muscles accompanying, and de-
pendent upon, articular disease, is a fact of daily observa-
tion, and as such needs no proof. But, although con-
stantly noted, it is too often regarded only as a symptom,
as a phenomenon associated with the joint lesion, and
calling for no treatment apart from that bestowed upon
the articular disease. It is true that during the progress
of the affection the muscular atrophy may properly be
ignored, since it can be little benefited at this time. But
after the subsidence of the joint disease, the muscles
should receive a much larger part of the surgeon’s care
than they do in most cases.
The importance of treating the idar atrophy is
well illustrated in the histories of several cases related by
Dr. Bazy, in Ze Progrès Médical, No. 12,1889. In most
of these cases there was a history of a sprain of the ankle
or knee, followed by some pain and effusion. After a
variable period of rest and appropriate treatment, the in-
flammatory symptoms subsided and the patient was ap-
parently cured. The swelling in the joint disappeared,
and passive movements were free and painless. But when
the patient attempted to walk the pain returned and per-
sisted, in spite of blisters, the actual cautery, tincture of
iodine, etc., as long as any use was made of the joint.
Examination at this time showed an apparently normal
joint with free passive motion, and without effusion or
synovial thickening. Pressure, however, revealed the
presence of certain painful points, and these points cor-
responded almost invariably with the pome of insertion of
the articular ligaments.
This pain the author refers justly to abnormal traction
on the ligaments of the joint, permitted by the weakness
of the atrophied muscles. The rôle of the muscles in re-
lation to an articulation is not, M. Bazy contends, strictly
that of supplementary ligaments, as many wniters hold,
but rather that of guiding and directing the joint move-
ments. As long as the muscles are strong and act
promptly, the motions of the articulation are normal, and
any unusual excursions whereby the ligaments are put un-
duly on the stretch are prevented. But when the mus-
cles are weak and unable to perform their functions prop-
erly, these instinctive directing contractions do not occur,
and the joint is subjected to repeated slight sprains.
That the fault lies in the muscles, whether the author’s
explanation of their function be strictly accurate or not, is.
shown by the results of treatment, for on their restoration
by means of massage and electricity, the pains disappeared
and the normal functions of the joint were restored. In
some cases this treatment was supplemented with advan-
August 24, 1889]
tage by a firm bandage around the joint, which served to
restrict undue lateral movement.
The cases reported by the author furnish an additional
argument as to the necessity of treating the muscles, even
after the joint lesion has been cured, a measure that is of-
ten slighted under the belief that use will suffice to restore
in a short time the tone and power of the atrophied mus-
cles.
THE CURABILITY OF CIRRHOSIS OF THE LIVER.
In a lecture delivered some time ago at the University of
Naples, Professor Semmola called attention again to his
method ‘of treatment of cirrhosis of the liver, which he
had first,’proposed in 1879 at the Amsterdam Congress,
although he had suggested the possibility of curing the
disease ten years before that time. ‘Ihe method is a very
simple one, and consists in the enforcement of a pure
milk diet, no:solid food whatever being allowed. By this
diet, he claims, nutrition is sustained, while the least pos-
sible work is put upon the digestive organs, and it is upon
this physiological rest that he relies for a cure of the be-
ginning cirrhosis. It is, of course, only in the earlier
stages of the disease that a cure can be expected, that is,
during the stage of interstitial cee before atrophy of
the organ has advanced.
In this connection, the jeunes took occasion to inveigh
against too great a devotion to pathology, which tended,
he thought, to promote pessimism in therapeutics. At the
post-mortem table interstitial hepatitis is generally found
in its atrophic stage, when the newly-formed tissue has
become’ fibrous and contracted, and when no hope of
cure can be entertained. One who has such a picture
always before his mind, as the interpretation of the early
symptoms of the disease, is not encouraged to treat the
affection to the end of effecting a cure.
Professor Semmola reported several] cases in which the
symptoms pointed to an early stage of hepatic cirrhosis,
and in which a cure was obtained by means of a rigid ad-
herence to a milk diet without solid food or drugs.
URIC ACID AND GOUT.
AT a recent meeting of the Medical and Chirurgical Soci-
ety of London, a rather interesting discussion took place
on the relation of the gouty diathesis to uric acid. Dr.
Arnold Schetelig, of Hamburg, read a paper on the pres-
ence of free uric acid in the urine as a test of the exist-
ence of the gouty state. Free uric acid, he said, had a
tendency to crystallize out and conglomerate with any
other crystalline uric acid already present. Its quantity
was determined by first ascertaining the total quantity of
uric acid contained in a natient’s urine, and then allow-
ing an equal portion of urine to pass through a filter
charged with uric acid, the “lithic filter.” Free uric
acid remained on the filter while the urates passed through
unaffected. ‘The author had analyzed the urine in fifty-
five cases, and had found from twenty-five to fifty (and
more) per cent. of the total uric acid to be in the uncom-
bined crystalline form in the urine of patients who were
either troubled with some form of true gout, or had been
so previously. Dr. Schetelig suggested that this test might
be used to distinguish between cases of genuine and spu-
rious gout. ‘This form of uric acid, he said, could by
THE MEDICAL RECORD.
211
treatment with baths, or with alkaline waters, or both
combined, be diminished for a while, but would in most
cases reaccumulate.
The treatment of gout, considered in its relation to the
excretion of uric acid, was the subject of a paper by Dr. A.
Haig. ‘The author considered especially the influence of
phosphate of sodium on the excretion of uricacid. Pure
phosphate of sodium, he said, had long been known to be
a solvent of uric acid, and he had pointed out that
it lacreased the excretion of that substance. All speci-
mens of the salt, however, did not act equally well.
Analysis of several specimens showed that a small per-
centage of sulphate of soda was generally present. When
about fifteen per cent. of the latter salt was present the
mixture did not cause increased excretion of uric acid,
but caused marked pains in the joints, due probably to
retention of uric acid in them. Also, if a little dilute
phosphoric acid was mixed with the pure phosphate in
solution, it then did not cause plus secretion of uric acid,
but if a little bicarbonate of soda was mixed with it in-
stead the plus secretion was well marked. The addition
of a little bicarbonate of soda to each dose was therefore
advised as likely to insufe a sufficient excretion of uric
acid. Dr. Haig thought the phosphate was not likely to
be of use in acute gout because the acidity in this disease
was high, but it appeared to be of considerable value in
the mental depression of uric acid in which the acidity
was low and falling. l
THE MURDERER'S GUILT AND THE SURGEON'S RE-
SPONSIBILITY.
A LEGAL decision of considerable interest to surgeons was
rendered not long since in a murder trial in Liverpool.
A man named Vaughan was tried for the murder of a Mr.
Godfrey, whom he had struck on the back of the head
with an adze, inflicting a scalp-wound behind the ear.
The injured man was taken to a hospital, and there de-
veloped symptoms of compression of the brain. It was
thought that the skull was fractured, and on consultation
the surgeons determined to trephine. ‘This was done, and
the man died in consequence, apparently of hemorrhage
from a large vessel opened during the operation. At the
post-mortem examination it was found that there had
been no fracture of the skull. At the trial the defence
claimed that death resulted directly from the operation,
and was not to be attributed to the original injury. The
judge ruled, however, that this claim was inadmissible, as
no culpable want of skill or negligence on the part of the
surgeons could be proven.
Such questions have arisen before, and are liable to be
raised in any case in which the murdered man does not
die within a very short time after the injury has been in-
flicted. If the wounded man is saved by timely treatment
the defence is very willing to profit by the surgeon’s skill,
though seldom ready to acknowledge its agency. But if
treatment is unavailing in saving life, it is the surgeon,
they say, and not the assailant who has killed the man.
There is a precedent in the English courts for this ruling,
which is cited by Zhe Lancet in its comment upon the
Liverpool case. Edward Lawless Pym was tried at
Southampton, in the year 1846, for the murder of a Mr.
Hawkey, and had the advantage of being defended by
Mr. Cockburn (afterward Chief Justice of England).
212
Mr. Pym had shot Mr. Hawkey in a duel and wounded
him. An operation was subsequently performed, and the
wounded man died. Mr. Cockburn proposed to show
that the operation performed was unnecessary, and that
without it the patient might have lived. But the presid-
ing judge, Mr. Justice Erle, after consulting with Baron
Rolfe, laid it down as law that “ where a wound is given
which, in the opinion of competent medical advisers, is
dangerous, and the treatment which they adopt is the im-
mediate cause of death, the party who inflicted the wound
is criminally responsible.”
This ruling would seem to be a very just one, and
moreover one that will ultimately be of benefit to the ac-
cused in similar cases. For the surgeon, assured that the
death will not be laid to his door, can accept the responsi-
bility of treatment with greater confidence, and the success
of his efforts will not be jeopardized by nervous appre-
hension of failure. |
Hews of the Week.
Tokio FEMALE HospiTaL.—-The Empress of Japan
has always taken great interest in this institution, and
lately made it a present of over $7,000.
‘A Puysician Sixty YEARS oF AGE killed himself not
long ago, in Paris, because he was unable to make enough
from his practice to pay his rent. A very similar case
occurred here not long ago, when an aged physician shot
himself after vainly seeking death by poison.
POST-GRADUATE INSTRUCTION IN Lonpon.—Charing-
Cross Hospital, in London, gives a short post-graduate
course ; but this is said to be the only facility offered in
that city for post-graduate instruction, and it is suggested
that a school similar to those in New York, Vienna, and
Berlin be established there.
A DICTIONARY OF MEDICAL SPECIALISTS is the title of
a book that has lately appeared in London, which pur-
ports to give a complete list of all practitioners in Lon-
don who devote themselves to any specialty. ‘The work
is edited by a lawyer.
WHERE AND WHO was THE Doc ?—Our esteemed
contemporary the Pittsburg Medical Review speaks in
the following enigmatical manner concerning the last
meeting of the American Medical Association: “ The
covert snarl of that mean beast, the Dog in the Manger,
was perceptible to practised ears at the Newport meeting.
It is a pity that this offensive canine must intrude at the
Association meetings. He should be kept chained at
home, or at least muzzled by his more judicious friends
when allowed at large.”
THE END OF COLLECTIVE INVESTIGATION IN ENGLAND.
—The Collective Investigation Committee of the British
Medical Association states in their report this year that
the returns upon the subjects proposed for study have
been so few that they think it best to discontinue the
work entirely, and ask that the Committee be allowed to
lapse at the end of its current year, in October. The
editor of the British Medical Journal thus briefly and un-
sympathizingly announces its demise: “ Its success has
been so dubious, that.after a brief period of existence its
THE MEDICAL RECORD.
[August 24, 1889
animation has, I regret to see, been suspended. I pointed
out its sources of inherent weakness, and the improbabil-
ity that it could fulfil the large expectations formed of it
here, and which for a moment attracted the imagination
of other associations and of the International Medical
Congress. It was born with great ¢c/at, baptized with
many benedictions, welcomed with loud soundings of
trumpet at Copenhagen ; but neither energy, liberal sub-
sidy, nor the devotion of some of the finest intellects in
Europe could keep it alive.”
THE MEDICAL Practice Law passed by the last legis-
lature of Maine has been declared invalid. ‘There was
some technical defect in the law, which the next legislature
will be asked to rectify.
THE AGENCY OF DISPENSARIES IN SPREADING CONTA-
GION.—To-one who sees the often crowded waiting-room
of any of the larger children’s dispensaries of this city,
the danger of the spread of contagious diseases through
their agency seems no slight one, and they may not in-
aptly be called the clearing-houses for contagious disease.
The existence of this evil has recently been brought to
the notice of the authorities of Paris, and they have been
requested to construct additional waiting-rooms for chil-
dren suspected to be suffering from infectious diseases, and
to delegate a medical officer to each dispensary for the
purpose of making a selection of the cases, allowing only
children recognized to be free from contagious disease ac-
cess to the common waiting-room.
Dr. ALEXANDER Brown Mort, of this city, died of
pneumonia, in Yonkers, on August 12th. He was the
son of Dr. Valentine Mott, and received his medical
degree in 1850, after having studied a number of years in
this country and in Europe.
The following minute was adopted by the Faculty of the
Bellevue Hospital Medical College on August 15th :
“The Faculty of the Bellevue Hospital Medical Col-
lege desire to record in their minutes an expression of
deep sorrow at the death of their associate, the late Pro-
fessor Alexander B. Mott. Professor Mott was one of
the few remaining members of the original Faculty of the
College. For twenty-eight years he had given his best
efforts to the institution of which he was one of the foun-
ders; and many thousands of alumni can bear testimony
to the value of his teaching. Endeared to his colleagues
by long and intimate association, his death is felt by each
one as the loss of an earnest teacher, a good and a true
friend. AUSTIN FLINT, Secretary.”
A SuMMER HEALTH-RESORT.—The name of the
author of a paper with this title, published in the issue of
August 3d, is Dr. Wm. H. Dukeman, and not Dakeman
as printed.
SUNSTROKES IN NEw Or LeEans.—In the week ending
July 23d, there were thirteen deaths from sunstroke in
New Orleans, a very large number for that city, where
deaths from this cause are much less frequent than dur-
ing the heated spell in our northern climate.
DEATH OF Dr. HiILpRETH.—Dr. C. C. Hildreth, of
Zanesville, O., died in that city on August 11th, of cerebral
apoplexy. He was born in 1811, and had been in active
medical practice for fifty-six years.
August 24, 1889]
THE First ANNUAL MEETING of the American Pzedia-
tric Society, will be held in Washington, D. C., on Sep-
tember 20 and 21, 1889, under the presidency of Dr. A.
_Jacobi, of this city. ‘The sessions will be held at the
Army Museum Building, but one of the afternoon meet-
ings will be held in the Johns Hopkins Hospital, Balti-
more, Md., by invitation of the director of the hospital.
The following papers are announced: Address by the
President ; ‘“‘ Notes on a Case of Ataxia in a Child of
Ten Years,” by A. D. Blackader, Montreal, Canada; “A
Study of some of the Bacteria.Found in the Dejecta of
Infants Afflicted with Summer Diarrhoea” (second com-
munication), by W. D. Booker, Baltimore, Md. ; ‘“ Noisy
Respiration,” by Dillon Brown, New York ; “ Prolapsus
Recti due to Large Stone in the Bladder in a Girl Three
Years Old,” “ ‘Two Cases of Nystagmus Associated with
Choreatic Movements of the Head in Rachitic Babies,”
“ Septic Diphtheria with Unusual Sequele,” “ Personal
Prophylaxis in Diphtheria,” by A. Caillé, New York;
“ Subcutaneous Emphysema in Children,” “ The Necessity
of Prolonged Rest after Some Attacks of Diphtheria,”
“Two Cases of Carpo-pedal Contraction,” by Charles
Warrington Earle, Chicago, Ill.; “The Treatment of
Scarlet Fever and its Complications,” by J. Henry Fruit-
night, New York; “Spurious Meningocele,” “ Double
Empyema,” by Francis Huber, New York ; “ Aneurism in
Early Life,” by A. Jacobi, New York; “A Contribution
to the Summer Dhiarrhoeas of Infancy,” by John A. Jef-
fries, Boston (by invitation) ; “ ‘Tuberculosis of the Testis
in Childhood,” by H. Koplik, New York; “ Cases of
Spastic Paraplegia,” by Thos. S. Latimer, Baltimore,
Md.; “Scarlet Fever,” by I. N. Love, St. Louis, Mo. ;
“ The Artificial Feeding of Infants,” by Arthur V. Meigs,
Philadelphia, Pa. ; “ Case of Diaphragmatic Hernia, with
Operation,” “The Apparent Physical Contradiction In-
volved in the Reinflation of a Collapsed Lung while an
Opening remains in the Pleural Sac,” by J. O’Dwyer,
New York ; “ A Case of Simple Muscular Atrophy of the
Facio-scapulo-humeral Type,” “‘ Cerebral Sclerosis in Chil-
dren,” by Wm. Osler, Baltimore, Md. ; “ Diphtheria,” by
A. Seibert, New York ; “Some Practical Points on the
Diagnosis and Treatment of Malaria in Children,” by
H. N. Vineberg, New York ; Tities not yet announced,
W. T. Northrup, New York; J. L. Smith, New York ;
and V. W. Vaughan, Ann Arbor, Mich.
ANTIPYRINE AND LANOLINE have, it is stated, been
adopted as official in the new edition of the Austrian
pharmacopceia.
THE TERCENTENNIAL OF THE MICROSCOPE.—Prepara-
tions are already being made in several German university
towns to celebrate next year the three hundredth anniver-
sary of the invention of the microscope. Zacharias
Janssen, of Magdeburg, is credited with having con-
structed the first microscope in 1590.
AN INTERNATIONAL CONGRESS OF DEAF-MUTES.—The
first international congress of deaf-mutes was held in
Pans on July ro to 17, 1889. The subjects discussed
were the relations of the deaf-mute to society, to labor,
and to the laws of his country. There was also read an
historical sketch of the benefactors of deaf-mutes from the
time of the Abbé de l Epée to the present. The congress
also celebrated the centenary of the Abbé de l'Epée, who
THE MEDICAL RECORD.
213
died in July, 1789, and erected a commemorative tablet
upon the site of his birthplace at Versailles. The ques-
tion of sign language was also discussed, and while most
of the members agreed upon the necessity of teaching ar-
ticulation, all were of the opinion that the sign language
was of prime necessity as a medium of expression, and in-
dispensable as an aid to the acquirement of knowledge
and to the cultivation of the mental faculties.
THE DAILY NEWSPAPERS, at least, have cause to bless
Brown-Séquard, for he has given them a very taking sub-
ject with which to while away the “ silly season.”
MARSHALL VOUGHT, for sixteen years warden of the
almshouse on Blackwell’s Island, died suddenly on August
13th, of heart failure.
ACTING ASSISTANT SURGEON MONTANYE, of the
Marine Hospital Service, died in San Francisco on Au-
gust 13th.
A UsEFuL Girr.—A citizen of Leipsic, possessed of
ample means, and of the still rarer gift of knowing how
to make them useful to his fellow-man, has just presented
to the medical relief fund of that city and its neighbor-
hood two extensive estates in the Saxon Erzgebirge,
specially purchased by him as places to which the poor
laborer or artisan, recovering from illness, may be sent for
the completion of his cure. Roth estates—the one near
the Schneeberg, the other near the Schwarzenberg—are
finely situated in a healthful, well-wooded, well-watered
region, and have been pronounced, on the highest medical
authority, to be admirably adapted for their purpose.
The donor has made it a condition of his gift that his
mame be kept undivulged.— The Lancet.
THE LATEST NICKEL-IN-THE-SLOT MACHINE.—The
latest in the way of development in automatic machines
is one recently brought out in England, by means
of which anyone can have his sight tested and receive
an order for spectacles. The following is a descrip-
tion of the machine by a wnitet in the Provincian Medi-
ca! Journal. ‘There is the usual case, somewhat after the
model of the weighing machine, but on the front face are
two eye-holes, with depression underneath for the nose.
You place a penny in the slot, press one foot on a pedal,
look through the eye-holes, and by turning a small crank
you bring a series of lenses into position. You are look-
ing at a card, on which some words are printed, as, “ If you
can read this you do not require spectacles.” If writing
can only be read with certain lenses, then the number
of spectacle required is also read, and on satisfying one-
self that these lenses suit, on withdrawing the foot a box
is set free, in which are order forms, on which the number
can be entered. Convex and concave glasses are used for
testing in this ingenious manner. The company offer to
supply spectacles to order at 4s. 6d.
Eau DE CoLocne TiPpPLINc.—It is said that the practice
of drinking cologne is becoming very common both in
Europe and in this country, and as an indication of this
that the sale of the perfume has increased greatly of late
years. Women are more addicted to the habit than men,
and a writer in the Quarterly Journal of Inebriety, says
that the presence of obscure and complex nervous dis-
orders in a woman who uses cologne externally should
always suggest the possibility of its internal use.
214
THE TENTH INTERNATIONAL MEDICAL CONGRESS.—
The following notice has been received : We, the under-
signed, do hereby give notice that, according to the re-
solution passed at the Washington meeting, September
9, 1887, the tenth International Medical Congress will be
held in Berlin. ‘The Congress will be opened oh the 4th
and closed on the gth day of August, 1890. Detailed
information as to the order of proceedings will be issued
after the meeting of the delegates of the German Medical
Faculties and Medical Societies at Heidelberg on the
17th of September in the current year. Meanwhile, we
should feel sincerely obliged, if you would kindly make
this communication known among your medical circles,
and add in the same time our cordial invitation to the
Congress. von Bergmann, Virchow, Waldeyer.
MME. DEJERINE KLUMPKE, an American wife of a
Frenchman, has won the degree of “ Doctoresse” from
the Paris Faculty of Medicine, with high honors. The
subject of her thesis was: “ A Contribution to the Study
of Polyneuritis in General, and of Lead Paralysis and
Atrophy in Particular.”
THE KoLa-Nut.—The value of the kola-nut (seeds of
Sterculia acuminata) as a dietetic and therapeutic agent
has been recently tested by Surgeon R. H. Firth. These
nuts are allied in composition to cocoa, coffee, and tea,
but contain a relatively large amount of caffeine. The
properties ordinarily assigned to kola are those of a
strong tonic and stimulant to the nervous system, counter-
acting and removing the sense of exhaustion after fasting
and fatigue ; it has also been credited with having an an-
tagonistic action to alcohol, and it has been said to purify
water. From his observations Surgeon Firth concludes
that kola is in no sense a food ; that it increases the total
urinary water, with a slight reduction of its total solids,
and a marked reduction of the extractive ; that it has a
peculiar stimulant action on the nervous system, tempo-
rarily strengthens the heart-beat, and increases the arterial
tension. In times of exertion and fasting it wards off the
sense of mental and physical depression and exhaustion.
As a therapeutic agent in convalescence, and as an an-
tagonist to alcoholic sequelz, kola has not yielded any
positive results in Surgeon Firth’s hands. For the purifi-
cation of water it does not appear to be superior to other
mucilaginous seeds, its action being purely mechanical.
In this report due prominence is given to the importance
of separating seeds which contain no caffeine, such as
Garcina kola and Sterculia cordifolia, as these would
speedily discredit the employment of kola by the troops
under conditions when it might possibly be of service. It
appears that an infusion, from its astringent action, might
be used for those suffering from diarrhoea.— Lancet.
THE TREATMENT OF ACUTE RHEUMATISM.—Dr. W.N.
Maccall read a paper upon this subject at the Clinical
Society of Manchester. After reviewing the previous
treatment of acute rheumatism during the last twenty-five
years, Dr. Maccall considered the value of the present
routine treatment by salicylic acid and its allies or derivat-
ives under the following headings: 1. In relieving pain
and lessening fever in acute rheumatism, the salicyl treat-
ment is undoubtedly the most effective we know of. 2.
The salicylates do not preuent the rare complication of
hyperpyrexm, and are absolutely useless in its treatment.
THE MEDICAL RECORD.
[August 24, 1889
3. It is doubtful if they prevent endocardial or pericardial
troubles, the percentage remaining about the same (fifty
per cent.) since the salicyl treatment as before. They
seem to have no influence in curing these troubles when
they do occur. 4. There is no proof that the salicylates
prevent relapse. 5. It is not proved that the salicylates
lessen the duration of the disease, or that they prevent
anemia. With regard to the particular form of the
remedy, most writers recommend (and Dr. Maccall agrees
with them) salicylate of soda in twenty-grain doses, at first
every hour, for three or four hours, according to circum-
stances. It should be continued in diminishing doses for
at least eight or ten days after all pain and pyrexia have
gone, and in most cases should be followed by iron. Sali-
cylic acid, salicin, and salol might be tried in exceptional
cases where the soda salt was not well borne. In young |
children antipyrin might be substituted with advantage.
In convalescence, Sir A. Garrod’s alkaline mixture, fol-
lowed by iron, was advised; and, if any joint remained
stiff or swollen, blistering or painting with iodine was use-
ful. Dr. Braddon expressed himself as disappointed with
the salicylate treatment, and preferred, as a rule, the alka-
line combined with Dover’s powder. Dr. Railton con-
sidered salicylic acid or its salts to be comparatively useless
in acute rheumatism, except as regards the relief of pain.
A RESPIRATION CHaIR.—In a graduation thesis Dr.
Carl Grunert, of Halle, discusses and describes the
treatment of emphysema and asthma by means of the res-
piration chair. ‘The chair is so constructed as to effect
by means of levers and bands attached to it pressure and
traction on the thorax similar to that exerted by the mus-
cles in forced respiration. A cuirass makes backward
and downward pressure on the thorax, while a broad
band compresses the abdomen and so increases the intra-
abdominal pressure ; the abdominal viscera then force the
diaphragm upward, and the latter mses. ‘The ultimate
effect, according to the author, is to make a forced ex-
piration possible, to considerably decrease the volume of
the thorax, and to empty more completely the hitherto
badly aerated alveoli, so that at the next inspiration more
oxygen enters; any bronchitic mucus which may be oc-
cluding the alveolus is also expelled. This is followed,
of course, very soon by diminution of the dyspnoea. The
disturbance of the circulation of the blood in consequence
of emphysema is recognized by the abnormal loudness
of the second pulmonary sound. ‘This was found to de-
crease in three patients after a treatment of from three
to six weeks in the respiration chair, while the first mitral
sound - increased, showing that the cardiac muscle had
become stronger. Emphysematous patients treated in the
chair lost more or less completely their chronic bronchial
catarrh ; the attacks of coughing improved greatly, per-
mitting sleep to be obtained without disturbance ; the
asthmatic symptoms, too, were frequently cured. A
number of cases treated by this method in the chair are
described, and the results obtained tend to show that
in many instances the respiration chair may prove an
advantageous method of treatment.
‘“‘ZYMOTIC DISEASES, CONSIDERED WITH REFERENCE
TO THEIR CAUSE, EXTENT, AND PREVENTION,” is the title
of an interesting and instructive pamphlet recently pub-
lished by Dr. R. French Stone, of Indianapolis.
August 24, 1889]
THE MEDICAL RECORD.
215
THE Scorcu MEDICAL ScHOOLS.—A proposition was
made recently in the House of Lords to abolish the med-
ical faculties in the Scotch universities. As might be
expected, it met with but little favor in or out of Parlia-
ment.
Reviews and Potices of Books,
A COMPENDIUM OF DENTISTRY. By JULIUS PARREIDT,
Dental Surgeon at the Leipsic Surgical Polyclinic.
Translated by Louis Ottory, Chicago; with Notes
and Additions by G. V. Biack, M.D., D.D.S., Chi-
cago. 8vo, pp. 229. Chicago: W. T. Keener.
1889.
` ACCORDING to the authors preface, the family medical
adviser should always be acquainted with a few facts con-
cerning dentistry. He should know the indications for
filling teeth. He should be able to trace the possible con-
nection between diseased teeth and neuralgia, and other
nervous disorders, meningitis, pyzemia, attendant on inflam-
mation of the jaws, etc. All of this information he can
obtain from this volume, which is, however, intended for
students of dentistry rather than of medicine. It would
be a useful book of reference for the library of a general
surgeon. An attractive typography, numerous and well-
executed illustrations, together with creditable work on the
part of the translator, combine to make an attractive vol-
ume.
HANDBOOK OF SKIN Diseases. By ARTHUR VAN HAR-
LINGEN, Professor of Diseases of the Skin in the Phila-
delphia Polyclinic. Second edition. 12mo, pp. 410.
‘Philadelphia : P. Blakiston, Son & Co. 1889.
AFTER a brief summary of the primary lesions of the
skin (macules, papules, etc.), with a table of classification,
follow in alphabetical order (titles in bold-faced type) the
various skin diseases, remedies, etc. Under each title
pathology is briefly considered, while diagnosis and treat-
ment are given at greater length. Cutler’s “ Manual of
Differential Diagnosis ” is largely drawn upon for the for-
mer. Naturally, in the various descriptions occurs the im-
press of his own views. Ina foot-note under “ Acne”
the author denies that masturbation is a cause thereof,
ard strongly deprecates the use of cold sounds as‘a cura-
tive agent, and hopes “that this cynical procedure will
rarely be employed ;” the colored plates and woodcuts
are better executed than is usually the case in works of
this class. The manual is interesting as the exponent of
the views of a writer of reputation and ability, and stu-
dents will find it remarkably well adapted to preparing
them for their examinations.
MATERIA MEDICA, PHARMACY, AND THERAPEUTICS. By
CUTHBERT Bowen, M.D. 12mo, pp. 366. Philadel-
phia: F. A. Davis. 1889. :
Tus belongs to the Physicians’ Ready Reference Series.
It consists of a compilation from lecture-room notes, and
the various text-books on the above topics. It is managed
in the form of questions ‘and answers, and according to
our conviction, may be useful to Philadelphia medical
students, but certainly to no one else.
ELECTRICITY IN THE DISEASES OF WoMEN. By G. BET-
TON Massey, M.D., Physician to the Nervous Depart-
ment of Howard Hospital, Philadelphia, etc. 12mo,
PP. 210. Philadelphia and London: F. A. Davis.
1889. i
‘THE present discussion on the general topic of gynæco-
logical electro-therapeutics gives much interest to this
systematic presentation of ideas. After a description of
the apparatus required in galvanism, follows an interest-
reference is made to the action of concentrated currents.
The physiological effects of Faradism and Franklinism
are in turn discussed, together with the operative details
of pelvic electro-puncture and intra-uterine galvano-chem-
ical cauterization. Then succeed chapters on the applica-
tion of the proper current to the various gynzecolougical
maladies. So much for the general outline of the work.
The writer believes that gynecological electro-therapeu-
tics are due to a “dawning reaction from the ultra-
mechanical methods of the followers of the late Marion
Sims.” He is right in saying that an acquaintance with
physics is essential to a proper conception of what elec-
tricity can do in pelvic diseases, and of how it should be
used. In regard to the greatest mooted point of the present
day—the Apostoli theory of curing uterine fibroids, the
writer expresses himself somewhat cautiously. We quote
(p. 123): “ Diminishing bulk, checking hemorrhage, easy
menstrual periods, relief of pressure symptoms, and gen-
eral restoration of the patient has been the usual result in
all cases so far operated upon by the author; and this is
invariably the verdict of all those who have used currents
intelligently for this condition.” Dr. Massey believes
that the lessening of bulk of fibroids may be due, not only
to the denutritive and atrophic action of the current on
fibroid tissue, but also to its contractile influence on the
muscular tissue of the uterus and on the true myomatous
tissue of the growth itself. We can heartily recommend
the book as an epitome of the most recent views on this
topic.
A DIALOGUE AGAINST THE FEVER PESTILENCE. By WIL-
LIAM BULLEIN. From the edition of 1578, collated with
the earlier editions of 1564 and 1573. Edited by
Mark W. BULLEN and A. H. BuLLEN. Part I. The
Text. London: Published for the Early English Text
Society by N. Triibner & Co. 1888.
THis book was a popular one some three hundred years
ago, being full of alleged “ merrie tales,” and divers archaic
disquisitions upon men, mortality, and the pestilence.
THE ANATOMIE OF THE BODIE OF Man. By THOMAS .
Vicary, Sergeant of the Surgeons to Henry VIII., etc.
Surgeon to St. Bartholomew’s Hospital, London, 1548-
62. The edition of 1548, as re-issued by the Surgeons
of St. Bartholomew's in 1577. With a Life of Vicary,
Notes on Surgeons in England, Bartholomew's Hos-
pital, and London in Tudor Times. An Appendix of
Documents and Illustrations. Edited by FREDERICK J.
FURNIVALL, M.A., HONORABLE Dr. Puiwip and PERCY
FURNIVALL. A student of St. Bartholomew’s. Part I.
EARLY ENGLISH TexT Society. Extra Series, LIII.
London: N. Triibner & Co. 1888.
Vicary's Anatomy was the first English work on the sub-
ject, and it was, with various supplements, the standard
text-book for one hundred and fifty years. The republica-
tion of so historic a work will gratify many physicians inter-
ested in the development of anatomical science. The
book will interest all who are fond of the quaint and
curious in literature. l
TRANSACTIONS OF THE 'l'HIRTY-FIFTH ANNUAL SESSION OF
THE MEDICAL Society oF NorTH CAROLINA (for the
year 1888). 8vo, pp. 252. Edited by the PUBLICATION
COMMITTEE. Wilmington. 1888.
One of the most interesting chapters of this creditable
volume relates to the doings of the State Board of Exam-
iners. ‘They are working faithfully and practically. We
believe, by the way, that our Southern friends were the
pioneers in this direction.
REPORT OF THE CONNECTICUT STATE BOARD OF HEALTH
FOR THE YEAR 1888. 8vo, pp. 199. New Haven:
Tuttle, Morehouse & Taylor. 1889.
ing chapter on the action of concentrated milliampére cur- | An attractive volume, full of vital statistics. Papers on
rents on organized tissues. Throughout the book special
water pollution and State hygiene.
216
THE STUDENT'S TEXT-BOOK OF PRACTICE OF MEDICINE.
By ANGEL Money, M.D., London, Assistant Physician
University College Hospital, London. 12mo, pp. 444.
H. K. Lewis. 1889.
‘THis is a remarkably well-written, comprehensive, and con-
cise epitome of the practice of medicine, and is well calcu-
lated to meet the needs of the student who is attending
lectures or preparing for the various examinations.
AMERICAN RESORTS, WITH NOTES UPON THEIR CLIMATE.
By Busurop W. James, A.M., M.D., Member Ameri-
can Association for the Advancement of Science, etc.
8vo, pp. 285. Philadelphia and London : F. A. Davis.
1889.
THE reader will be somewhat disappointed in the perusal
of this work, as it does not cover the intended ground,
and is entirely too superficial in the treatment of the sub-
ject. The general idea is a good one, as it is free from
any appearance of advertising watering-places or other
health-resorts ; but, scientifically speaking, it is little more
than a general railroad guide to different parts of our con-
tinent, with an incidental reference to the character of the
climate in different sections. The foundation is laid
broadly enough, but useful details are almost everywhere
wanting. ‘There is an excellent official railroad map of
the United States, which gives the work its chief value.
THE ESSENTIALS OF PHYSICAL DIAGNOSIS OF THE CHEST
‘AND ABDOMEN. By I. WaLLAcE ANDERSON, M.D.,
Physician to the Royal Infirmary, Glasgow. 12mo,
pp. 152. New York: Macmillan & Co. 1889.
Tus little work maintains its claim to recognition as one
of many of its kind, and proves the author to be an exact
and careful teacher.
THE OLD HOSPITAL AND OTHER Papers. By D. B. Sr.
Joun Roosa, M.D., LL.D. 8vo, pp. 320. New York:
William Wood & Co. 1889.
“ THE central idea of the papers in this volume,” says the
author, “is an attempt to define and adjust the relations
of the medical profession to the community which it
serves.” The author has succeeded exceedingly well in
his attempt to do this. Although an enlarged edition of
the author’s former work, “ A Doctor’s Suggestions to the
Community,” it appears almost as an essentially new work,
not only as regards its elegant typographical execution,
but as to interesting material which has been added.
The descnption of the old New York Hospital is the first
article, and is written in the author’s best style. To read
it is to have been there and lived there. The other
sketches have also merits of their own—all interesting,
practical, suggestive, and charmingly written. ‘The author
has the happy faculty of riveting an argument by an apt
illustration, thus not only making it more impressive, but
if possible more convincing. Essentially broad in his
grasp, he takes high ground and opens up large views of
the situation and prospect. Aside from its sound doc-
trine, the work will be read for its intrinsic literary merit,
and this will be one of its strong holds with the lay public.
Without wishing to make invidious distinctions, we confess
to partiality for “ the coming medical man,” “ the relations
of the medical profession to the State,” and “ the means
of effecting the unity of the medical profession ”—all well
written and sourd. But what shall we say of the sketch
of Little? We all loved Little, and so did the author.
The makeup of the book is a marvel of the printer’s art.
KIRKES’ HANDBOOK OF PuysioLocy. By W. MORRAND
BaKER, F.R.C.S., Surgeon to St. Bartholomew’s Hos-
pital, etc., and VINCENT DORMER Harris, M.D., Lon-
don, Fellow of Royal College of Physicians, etc.
Twelfth edition. 8vo, pp. 757. New York: William
Wood & Co. 1889.
‘THE present edition of this admirable text-book has been
rearranged, revised, and rewritten, and is at present fully
up to the times in its treatment of the subjects which are
THE MEDICAL RECORD.
[August 24, 1889
the leading ones in the study of physiology. Many im-
portant additions have been made in the chapters on
blood, heart, and muscular system, while the articles on
the reproductive organs and the nervous system have been
to a great extent rewritten. The necessity for the latter
was quite apparent, considering the advances made in that
department of study even within the last few months.
The illustrations are accurate and numerous, and add very
much to the intrinsic value of the work. Altogether it is
one of the best text-books on the subject for the use of
teachers and students.
TRANSACTIONS OF THE AMERICAN SURGICAL ASSOCIATION.
Vol. vi. Edited by J. Ewinc Mears, M.D., Recorder
of the Association. 8vo, pp. 568. Philadelphia: P.
Blakiston, Son & Co. 1888.
THIs is an unusually interesting volume, and is full of well-
written and practical papers on surgical subjects. ‘The
proof of this is indicated by the following list: ‘“ Relation
of Social Life to Surgical Disease,” by D. Hayes Agnew ;
“Study of Excision of Larger Joints,” by John Ashhurst,
Jr., M.D. ;“ Relation of Micro-organisms to Injuries and
Surgical Diseases,” by N. Senn, M.D. ;“ Three Successful
Cases of Cerebral Surgery,” by W. W. ’ Keen, M.D. ;“ The
Formation of an Artificial Urethra in Prostatic Obstruc-
tions,” by Hunter McGuire, M.D. ; “ The Operations of
Supra-pubic Lithotomy, and the Surgical Management of
Typhlitis and Perityphlitis,” by W. T. Bull, M.D. ; “ Surgi-
cal Interference in Perforating Typhoid Ulcer,” by J.
Ewing Mears, M.D. ; “ Ligation of Carotid and Subclavian
Arteries for Innominate Aneurism,” by John H. Packard,
M.D. ; “'Tracheotomy and Intubation in Croup,” by George
W. Gay ; ; “ Pregnancy and Operative Surgery,” by Louis
McLane Tiffany, M.D. ; “ Nerve Stretching,” by N. P.
Dandridge, M.D. ; “ Nephrectomies for Gunshot Wounds
of Kidney,” etc., by DeForest Willard ; “ Shock,” by David
W. Cheever, M.D.; “ Experiments with Pyogenic Bac-
teria,” by Roswell Park ; “ Cyst of Pancreas Successfully
Removed,” by W. S. Tremaine, M.D.; and “ Pelvic and
Abdominal Drainage,” by David Prince, M.D.
TRANSACTIONS OF THE ROYAL ACADEMY OF MEDICINE
IN IRELAND. Edited by WıLLIAM THOMPSON, M.A.,
F.R.C.S., General Secretary. 8vo, pp. 472. Dublin :
Fannin & Co. 1888.
THE volume is one of the most interesting of the series, is
full of practical papers on different branches of medicine
and surgery, and is plentifully supplied with beautiful
plates. Altogether it is a model of its kind, and well sus-
tains the reputation of this Academy for accurate and
solid work.
MERCK’s INDEX. A catalogue of the various products of
the celebrated Darmstadt firm. Useful for reference.
MEDIASTINAL DISEASE. By HoBaRT AMORY HARE,
M.D., Demonstrator of ‘Therapeutics, University of
Pennsylvania, etc. 8vo, pp. 150. Philadelphia: P.
Blakiston, Son & Co. 1889.
Tuis essay gained for its author the Fothergillian Medal
of the London Medical Society in March of last year.
Dr. Hare deserves great praise for writing upon a subject
of which very little systematic knowledge has hitherto
been had. No attempt has been made to touch upon
mediastinal disease affecting well-defined organs in this
part. Chapters are included on mediastinal tumors (can-
cer and sarcoma, lymphoma, lymphadenoma, and fibroma),
inflammations, abscess, hematoma, cysts (dermoid and
hydatid). In all, the records of five hundred and twenty
cases have been investigated and collated in these pages.
In these latter days, when everyone rushes into print with
hasty reports of cases, it is a pleasure to observe the care
with which the present volume has been prepared. Of
-this kind of literary medical work we cannot have too ~
much. The present instance reflects great credit alike
upon the writer and American literature.
August 24, 1889]
upon Medical Examinations for Life Insurance. By
CHARLES F. STILLMAN, M.S., M.D., Medical Ex-
-aminer for the Mutual Life Insurance Company for
the General Agency of the City of New York ; Exam-
ining Surgeon of the Travelers’ Insurance Company of
Hartford, Conn., for the City of New York; Clinical
Professor of Orthopzdic Surgery in the Woman’s Medi-
cal College of the New York Infirmary ; Orthopadic
Surgeon to the New York Infant Asylum; Member
_of the American Orthopedic Association ; Permanent
Member of the American Medical Association; Fel-
low of the New York Academy of Medicine; Mem-
ber of the New York Medico-legal Society, and of
the New York County Medical Society. New York
and Chicago: The Spectator Company. 1888.
A New field of activity for the physician, we might almost
say a new profession, has arisen within the past few years
in connection with life insurance. The examination of
an applicant for insurance is no longer the perfunctory
performance it was a few years ago, but is a thorough
investigation of the physical condition of the person who
seeks insurance on his life. And in proportion as the
examination has become a more searching one, has its
importance increased, until now the position of medical
examiner to a life insurance company is one of great re-
sponsibility and trust. As an evidence of the growing
dignity of this branch of the profession, may be mentioned
the fact that the University of Vermont has added to its
courses of lectures one on life insurance examinations,
the first occupant of this chair being the author of the
work before us. The book is notable for its practical
character, the aim of the author having been to provide
the medical examiner with a reliable guide which will
point out to him clearly what he is to do, and what not to
do, when an applicant comes to him for examination.
The first part deals with life insurance formalities, giving
the reader an idea of the forms used by different com-
panies, with the questions put to the applicant. In the
second part directions are given for the examination of
the applicant ; and the third part is devoted to a consid-
eration of the diseases relating to life insurance. An
appendix contains some statistical tables, instructions
to agents, and an abstract of a paper by Mr. John M.
Taylor on some legal questions as to the office and evi-
dence of the medical examiner. The bibliography of
life insurance examination is very meagre, and the author
had almost a virgin soil to work upon, but he has tilled
it so well and so thoroughly that he has left nothing to
be desired. Some of the instructions are rather elemen-
tary, but that can scarcely be called a fault, and those
who do not need them will overlook their presence for
the sake of the others, few we hope, to whom they may
be a help. The book is one which should be in the
hands of every life insurance examiner ; and indeed, we
know of one large company, at least, which has presented
a copy to each of its examiners, an example which other
companies would lose nothing in following.
ELECTRO-THERAPEUTICS ; OR, ELECTRICITY IN ITS RELA-
TIONS TO MEDICINE AND SuRGERY. By WILLIAM
Harvey Kinc, M.D. New York: A. L. Chatterton
& Co.
Tus work is one of a number of similar text-books
which have been published for the instruction of students
since electricity has come to be recognized as one of
our most active therapeutic agents. It has nothing spe-
cial to give ita higher claim to recognition than its
predecessors.
Ture DIAGNOSIS AND TREATMENT OF EXTRA-UTERINE
PREGNANCY. By JOHN STRAHAN. M.D., M.Ch.,
M.A.O. Pp. 134. Philadelphia: P. Blakiston, Son
& Co. 1889.
Tuts essay is the first to receive the William F. Jenks
memorial prize, given by the College of Physicians of
THE MEDICAL RECORD.
217
—
the work done in this difficult branch of obstetrics up to
the present time. The writer has been thorough and
conscientious in his researches, careful in his statements;
and methodical in his manner of presentation. All
physicians who are likely to encounter cases of extra-
uterine pregnancy should certainly read carefully this
monograph. Itwill be a great assistance in the midst
of the distracting perplexity which surrounds such a case.
PsyCHOLOGY AS A NATURAL SCIENCE APPLIED TO THE
SOLUTION OF OccULT PsycHIC PHENOMENA. By C.
G. Rane, M.D. Pp. 541. Philadelphia: Porter &
Coates. 1889.
Tus is a work which the busy practitioner will have no
time for. The author bases his psychology on the work
of Dr. Friedrich Eduard Beneke, and endeavors to ex-
plain psychological phenomena in a non-materialistic
manner. He thinks he has proven the possibility of an
intercourse between departed spirits and this corporeal
world. :
PHYSIOLOGICAL NOTES ON PRIMARY EDUCATION AND
THE STUDY OF LANGUAGE. By Mary PUTNAM-
Jacosr, M.D. Pp.120. New York: G. P. Putnam's
Sons, 1889. .
THIs volume contains the two essays published several
years ago in the Popular Science Monthly, entitled “ An
Experiment in Primary Education,” as well as an essay
on the * Flower or the Leaf,” and one on “The Place
for the Study of Language.” Space is lacking for a de-
tailed analysis of these interesting and suggestive papers,
which deal with some of the most perplexing subjects of
pedagogics, The whole value of the methods employed
in the “‘ Experiment in Primary Education,” could not be
estimated until the child had reached adult life, and was
placed in comparison with those whose education had
been formed in another mould. Moreover, to test such a
system a number of children, with their different minds,
would have to be put through the same process. The
aim of Dr. Putnam-Jacobi is admirable and one worthy
of high consideration, that of imbuing a child early with
a scientific method. There is no doubt that much is lost
for the child in permitting it to waste its brain-force on
trifling, unimportant things which - will never be of the
slightest use to it, when it might have been amused and
instructed at the same time with the fundamental truths
of nature.
PROCEEDINGS OF THE CONNECTICUT MEDICAL SOCIETY
FOR 1888. 8vo, pp. 240. Edited by N. E. WORDEN,
M.D., Secretary. Hartford: Case, Lockwood &
Brainerd Co. 1888.
Tus Society is nearing its centennial, having been estab-
lished in 1791. The present records are up to its high
standard in the past, and contain many papers of interest.
INTERNATIONAL POCKET MEDICAL FoRMULARY: With
an Appendix Containing Posological Table: Formulz
for Inhalations, Suppositories, Nasal Douches, Eye
Washes, and Gargles; Hypodermic Formulz; Table
of Hypodermic Medication ; Use of Thermometer in
Disease ; Poisons and their Antidotes ; Post-mortem
and Medico-legal Examinations; Artificial Respira-
tion ; Ligation of Arteries; Obstetrical Table ; Urin-
alysis; Differential Diagnosis of Eruptive, Typhoid,
and Typhus Fevers; Tables of Pulse, Temperature,
Respiration, Motor Points, etc. By C. SUMNER
WITHERSTINE, M.S., M.D., Associate Editor “ An-
nual of the Universal Medical Sciences ;” late House
Surgeon Charity Hospital, New York ; Visiting Phy-
sician Home for the Aged (Little Sisters of the Poor),
Germantown, Philadelphia. London and Philadel-
phia: F. A. Davis. 1888.
WE regret that we cannot praise this work as much as
we can the diligent research made by the compiler in
collecting so many formula, and the good taste of the
218
THE MEDICAL RECORD.
[August 24, 1889
publisher in getting up the book in such a convenient
-and tasteful shape. We do not like the book because
we do not approve of ready-made prescriptions, for the
physician who does not know enough of the action of
remedies and of the art of prescribing to enable him to
devise his own formulz as they may be required, ought
to seek some other employment. Unfortunately, how-
ever, there are medical practitioners of this kind, and to
these we can recommend the work most highly. If they
will consult it frequently, and always when they feel
called upon to order any medicine, they will in most
cases do no harm to their patients, and may occasionally
be able to benefit them. The diseases are arranged
alphabetically, and under each are given the different
formulz which have been recommended at one time or
another by various authorities. The book is interleaved
so that the owner can add such formulz as he may find
in the course of his reading.
THE Yrar Book oF TREATMENT FOR 1889: Being a
Critical Review of the Practice of Medicine and Sur-
gery during 1888. Philadelphia: Lea Brothers &
Co. 1889.
THERE is a great deal of useful knowledge contained
within the covers of this little book, and though an at-
tentive reader of any good medical journal will find
little here that he has not seen mentioned in his journal,
he will find it systematically arranged and convenient for
reference. It 1s impossible, of course, to review and ab-
stract everything that has been published during the year,
and the reader would be disappointed if he expected to
‘find everything he wanted in this book; but of all the
year books, large or small, none is better than this, and
ak contains so much that is useful in so compact a
Orme
INTESTINAL SURGERY. By N. Senn, M.D., Ph.D., At-
tending Surgeon to Milwaukee Hospital , Professor
of the Principles of Surgery and Surgical Pathology,
Rush Medical College, Chicago, Ill Pp. 257.
Chicago: W. T. Keener. 1889. |
In this branch of surgery, which, from its intrinsic in-
terest and great importance, has taken so prominent a
place in science, Dr. Senn is a pioneer, and no greater
authority is there than he. He has devised several in-
genious operations, one of which, intestinal anastomosis
by perforated decalcified bone plates, would in itself win
him fame. His new work, consequently, is both valuable
and welcome. It consists of three papers, which have
- been read before medical associations and have appeared
in various journals, hence any exhaustive review is un-
‘necessary. The first is “The Surgical Treatment of
Intestinal Obstruction.” It is very thorough, treating
exhaustively irrigation of the stomach, distention of the
colon with fluids, rectal insufflation of gas, tubage of
colon, taxis, massage, puncture, compression, enterotomy,
colotomy, and abdominal section. The latter subject is
perhaps the most valuable, as it details his methods of
Intestinal anastomosis, especially that with the use of
-bone-plates or catgut rings. The second paper gives
the results of years of experiments in intestinal surgery
on men and animals, with special reference to obstruc-
tion. A more interesting paper would be hard to find,
and the conclusions drawn are of inestimable value.
That comparatively new operation, omental grafting and
omental transplantation, is discussed and detailed. The
third and last paper, which was read before the Ameri-
can Medical Association in 1888, is entitled “ Rectal In-
sufflation of Hydrogen Gas an Infallible Test in the Di-
agnosis of Visceral Injury of the Gastro-intestinal Canal
in Penetrating Wounds of the Abdomen.” He main-
tains that the alimentary canal is permeable to insuffla-
tion, either by the mouth or anus, but especially by the
latter; that it is a safe operation, and is a sure means of
diagnosis. All in all, the work can be criticised only to
praise.
EXPERIMENTAL SURGERY. By NICHOLAS SENN, M.D.,
Ph.D., Attending Surgeon to the Milwaukee Hospital ;
Professor of the Principles of Surgery and Surgical
Pathology in Rush Medical College, Chicago. Pp.
522. Chicago: W. T. Keener. 1889,
In writing this work Professor Senn, who is recognized
as one of the leading and most original surgeons of the
day, has again made debtors of the profession and the
public. For a number of years he has been carrying on
experimental work, and this book is a clear, beautifully
written, and intensely interesting account of these experi-
ments, with their results. He first takes up that thorn
of every surgeon’s flesh, intra-capsular fracture of the
neck of the femur. He shows theoretically and by ex-
periment that bony union may not only be hoped for,
but that nothing short of bony union of the fragments
should satisfy the surgeon. If the fracture is impacted,
manipulate as little as possible and fix by a plaster band-
age on the body and both legs. If unimpacted, he puts
on the plaster and obtains lateral pressure by an in-
genious screw, the frame of which is worked into the
plaster during application. A sure method, and the one
to be adopted if the patient is in good condition, is to
nail the fragments together with aseptic steel, ivory, or
bone nails. The subject of intra-capsular fracture is
most exhaustively treated, and an admirable résumé of
the literature of the subject is given. He next discusses
the ligature of blood-vessels, and in this day, when there
is so much difference of opinion on the subject,
the work is most timely. The method of cicatrization
is thoroughly studied—in short it is a complete work on
ligatures, interesting and valuable alike to both student
and practitioner. The conclusions drawn are about as
follows: That the aseptic catgut ligature is the safest
and most reliable agent in securing either provisional or
definitive closure of blood-vessels ; the thrombus formed
does not organize and takes no active part in the oblit-
eration which results from connective tissue and endo-
thelial prolifération ; in ligation, the sheath of the vessel
can be safely opened freely; in ligating large arteries in
their continuity near a collateral branch, the double aseptic
catgut ligature is preferable to the single ligature, and
should be used in tying varicose veins. Air embolism,
the result usually of the entrance of air into the veins
during operation at the neck, is next studied both ex-
perimentally and clinically. It is shown that the chief
cause of death in such a condition is mechanical over-
distention of the right ventricle of the heart, and asphyxia
from obstruction to the pulmonary circulation conse-
quent upon embolism of the pulmonary artery. The
latter is relieved if the heart is kept acting long enough
to drive the air into the systemic circulation. The oper-
ative treatment, after stimulation, etc., consists of aspir-
ation of the right ventricle, or, if the air entered through
the internal jugular, catheterization of the right auricle
through the vein. By these means, the air and spumous
blood are removed, and very often the patient could be
saved. The doctor makes an admirable and able argu-
ment in favor of this treatment. A hundred pages or
more are devoted to the surgery of the pancreas. The
literature on the subject is very scanty, and found only in
medical journals. This is the first attempt to put it to-
gether and present it in a systematic form. Besides
being a résumé of the literature of the subject, the article
contains the results of the author’s own researches, and
most valuable they are: wounds, gangrene, abscess,
hemorrhage, cysts, tumors, etc., are all thoroughly
treated. The remainder of this most excellent work is
made up of two papers: First, “ An Experimental Con-
tribution to Intestinal Obstruction,” read in the Surgical
Section of the Ninth International Medical Congress ;
second, “Rectal Insufflation of Hydrogen Gas an In-
fallible Test in the Diagnosis of Visceral Injury of the
Gastro-intestinal Canal in Penetrating Wounds of the
Abdomen.” Both of these articles are presented in his
new work on intestinal surgery which is reviewed below.
August 24, 1889]
THE MEDICAL RECORD.
219
EE OEE a E SSS mm
Society Reports.
NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting, April 10, 1889.
WILLIAM P. NORTHRUP, M.D., PRESIDENT, IN THE CHAIR.
REPORT OF THE COMMITTEE ON MICROSCOPY.
EXAMINATION of the specimen referred to the Committee
by Dr. S. J. McNutt, at the meeting of March 27th, shows
it to be the newly formed membrane of pachymeningitis
interna hemorrhagica. No lesion in the substance of
the brain was apparent. Respectfully submitted, JOHN
S. ELY, IRA VAN GIESON.
Dr. H. P. Loomis presented a specimen of
* MEDULLARY CANCER OF THE KIDNEY.
The tumor was removed from the body of a woman, twen-
ty-eight years of age, who died in Bellevue Hospital. The
principal complaint was of intense pain in the left side.
At the autopsy the left kidney was found greatly enlarged,
and on section the tumor was found to be a medullary
cancer. It consisted of a thick, grumous material, and
scarcely any true kidney tissue was found. The condition
was rather a rare one in the speakers experience.
Dr. Loomis also presented a specimen of
CHRONIC DIFFUSE NEPHRITIS, WITH CONTRACTED KIBRNEY,
IN A CHILD ELEVEN YEARS OLD.
“ The patient was a girl, eleven years of age, the second
of four children. The eldest is now sixteen, and the
youngest died in infancy of hydrocephalus. Her father
contracted syphilis one year before the birth of his first
child, and died when the patient was six years of age, hav-
ing been an invalid for a number of years. Her mother
has always been well. There is no history of gout in
either parent’s family. Her mother’s family is rheumatic,
and her father’s phthisical. The patient was of feeble
physique, but had never been severely ill, except with
whooping-cough and chicken-pox.
“ The first symptoms of renal disease developed about
a year before her death. Albumin and casts were con-
stantly found in the urine during the last eight months of
life, and there was gradually developed marked left ven- .
tricular hypertrophy. The other usual symptoms of chronic
diffuse nephritis were well marked. ‘The direct cause
of death was lobular pneumonia, attended by suppression
of urine and urzemic symptoms.
“ Autopsy, made fifteen hours after death.— Body ema-
ciated ; some oedema of the ankles; slight puffiness under
the eyes.
“ Heart: the wall of the left ventricle was one inch in
thickness, the cavity was not dilated, and there was no
valvular lesion.
“ Lungs: there were the characteristic appearances in
both lungs of lobular pneumonia. The liver and spleen
presented a normal appearance.
‘The kidneys were about one-third their normal size ;
capsule thickened and adherent ; surface granular ; color
pale ; cortex diminished in a few places ; markings generally
absent. A microscopical examination showed the following
changes: An obliterating endarteritis of almost all the
smaller arteries ; the external coat of the arteries was also
thickened ; there was a large amount of connective tissue
increase not only around the tufts and between the tubes,
but also in dense patches throughout the cortex. Many
of the glomeruli had the appearance of having undergone
amyloid change, but the gentian-violet test showed that
the material was not waxy. The tubes showed granular
fatty degeneration.
“ About a year ago the patient’s older sister, without
any apparent cause, developed all the symptoms of Bright’s
disease, and has been growing steadily worse ever since,
following a similar course to her sister. ‘To-day she has
cedema under her eyelids, hypertrophy of the left ventri-
cle, complains of severe headache, and is often so drowsy
that she can with difficulty be aroused. Albumin and
casts appear in the urine at times.
“ In reviewing the history of these two cases the only
conclusion which I can come to is, that the syphilitic
taint inherited from the father showed itself in the chil-
dren by the development in the kidney of the changes
which are characteristic of such a condition.
‘‘ Neither of the children had had scarlet fever, nor were
there any signs of renal disease until they reached in the
one case the age of ten, and in the other the age of fifteen
years. ‘This seems to bear out the statistics of Fournier
of 212 cases of hereditary syphilis, in which he found the
symptoms of the inherited infection showed themselves in
the maximum number of cases about the twelfth year.
“ The kidneys were well-marked specimens of contracted
kidneys, such changes are rarely met with excepting in a
gouty or syphilitic diathesis. I find the records of such
changes in children are exceedingly rare even in the off-
spring of gouty and syphilitic parents. Ziegler in his work
on Pathological Anatomy says that in congenital syphilis
induration and contraction of the kidneys have in some-
what rare instances been observed. Possibly these kid-
neys would come under this category. Certainly neither
child presented any other evidence of hereditary syphilis.
“In looking up the literature of the subject I find that
Foster, in ‘ Jahrbuch für Kinderheilkunde,’ describes two
almost identical cases of contracted kidneys in children—
a boy and a girl, aged respectively four and a half and
nine and a fourth years—the offsprings of a syphilitic fa-
ther. The kidneys were small, and with adherent cap-
sules. There was also left ventricular hypertrophy.
These cases had also been referred to by Dr. Delafield in
his last article on Bright’s disease.”
Dr. S. T. ARMSTRONG presented the following speci-
mens :
HYPERTROPHY OF THE TUNICA VAGINALIS IN A CASE OF
HYDROCELE.
W. P——, aged twenty, a native of France, a negro,
was admitted to the hospital February 14, 1888. He had
had gonorrhoea the previous month, with subsequent
hydrocele. On the date of admission he was tapped,
200 c.c. of fluid being removed. (The fluid was used
for bacteriological purposes.) On February 22d he was
tapped, and tincture of iodine was injected, and one week
later he was again tapped ; the tunica was then so thick
that the needle penetrated it with difficulty ; iodine was
again injected. On April 2d he was tapped once more,
and on April gth he was chloroformed, and the sac excised.
The sac showed marked hypertrophy -consequent upon
new tissue formation. Its serous surface was roughened
by the injection medium. (This case is reported at length
in the “Annual Report of the U. S. Marine Hospital
Service for 1888.”)
EPITHELIOMA OF THE PENIS.
T. D——, aged thirty-eight, New York, admitted Janu-
ary 30, 1889, for ulceration of the penis and prepuce.
‘The remains of the latter were. removed under cocaine.
At first it was supposed that the ulceration was phage-
denic, notwithstanding the history that in January, 1888,
a sore appeared on his penis, and was followed by a pap-
ular eruption on his body. Subsequently a hard growth
remained at the site of the initial lesion, and in the two
months previous to admission this had rapidly enlarged.
The entire glans was involved, presenting a red, fungous
appearance. ‘The penis was amputated, examination hav-
ing revealed the epitheliomatous character of the growth.
Dr. Armstrong believed that this disease was of rare oc-
currence, at least it was so in the experience of the Ma-
rine Hospital Service.
TUBERCULOSIS OF THE EPIDIDYMIS.
H. D——-,, aged twenty-nine, Ireland, admitted Febru-
ary 29, 1888. In 1886 the left testicle was injured by a
blow from a truck-handle. Subsequently he was operated
220
on, a small portion, he said, of the testicle being removed.
A deep sinus existed, at the time of admission, in the skin
of the left scrotum, involving the epididymis. This was
incised, but it did not heal. Its tubercular character
being demonstrated by examination of the pus, the tes-
ticle was extirpated. The patient was discharged April
17th. It is of interest, in connection with the relation
of local to general or pulmonary tuberculosis, that this
patient was readmitted for tubercle of the lungs on No-
vember 2oth, and now has large cavities.
CHRONIC ORCHITIS.
O. F. O , aged twenty-nine, Norwegian, was ad-
mitted to the hospital January 4, 1889. In 1886 the left
testicle became enlarged without cause, as far as he knows.
Two years ago he was treated in New Zealand for hydro-
cele. An ulcer of the skin occurred at the point of tap-
ping that never healed. When admitted there was a
large ulcer of the skin on the anterior surface of the scro-
tum, involving the testicle. All the lymphatic glands
were slightly enlarged, probably in consequence of syphilis
acquired sixteen months ago. ‘The testicle was extirpated,
and on section showed almost complete fibrous degenera-
tion, but little of the tubular structure of the gland re-
maining. Undoubtedly the tapping for the hydrocele was
an inciting cause, and the short period occupied in the
production of the degeneration (two years) is a matter of
interest.
Dr. F. N. Oris said that he had been somewhat sur-
prised to learn that epithelioma of the penis was such a rare
condition in the experience of the Marine Hospital Ser-
vice, for he had seen and had operated upon quite a num-
ber of cases, and was of the opinion that the disease was
one of moderately frequent occurrence in private practice.
The results of operation in his cases had been quite satis-
factory, and in those which he had been able to follow up
there had been no return of the disease.
In regard to the case of thickening of the tunica vagi-
nalis, he asked whether, in Dr. Armstrong’s opinion, the
thickening was the result of the treatment—of irritation
caused by the penetration of iodine. He had seen some
cases of thickening of the tunica from ordinary injury.
One case occurred in a boy, sixteen years of age, who
was struck by a base-ball, and had a hydrocele following.
This was tapped several times, and subsequently a hydro-
cele developed on the opposite side. Dr. Otis saw the
boy some two or three years later, and then the scrotum
was enormously enlarged, measuring between five and six
inches in its long diameter. Several efforts were made to
draw off the fluit, but without success, and at last the
speaker made up his mind that no ordinary instrument
could pass through the thickened tunica vaginalis, and
concluded to incise it. He went down through at least
half an mch of the most dense fibrous tissue before com-
ing to the fluid. He did a Volkmann operation. No
portion of the tunica was removed, yet the thickening
gradually disappeared, and the boy made a perfect recov-
ery. In other cases a similar result had been obtained, and
he had found that Volkmann's operation was all that was
necessary to restore the tunica to ‘its normal propor-
tions. l
Dr. ARMSTRONG did not think that the thickening of
the tunica vaginalis in his case was due to the action of the
iodine employed. He had at first intended to perform
Volkmann’s operation, but had abandoned the idea, as he
feared it would not suffice to effect a cure. Since learn-
ing of Dr. Otis’ experience, however, he thought that
very possibly he might have been successful had he ad-
hered to his first intention.
THE PRESIDENT remarked that the effect of the Volk-
mann operation upon the thickened tunica vaginalis, in
the cases related by Dr. Otis, was perhaps similar to that
obtained by the gynecologists in the case of subinvolu-
tion of the uterus, as a result of repairing a lacerated cer-
vix.
THE MEDICAL RECORD.
[August 24, 1889
- Dr. Joun S. ELY presented some specimens showing
HYPERTROPHY OF THE PROSTATE, CYSTITIS, AND PYELO-
NEPHRITIS.
“The patient, an American, sixty years of age, first came
under observation toward the end of November, when he
presented himself at Bellevue Hospital with retention of
urine. A soft rubber catheter was passed without difficulty.
Enlarged prostate and cystitis were diagnosticated, and the
bladder was washed out with one per cent. boric acid
solution daily till all pus disappeared. He was then
taught to use a soft rubber catheter, and was discharged.
He returned to the hospital on January 4th, again with
retention, which was easily relieved. ‘Toward the end of
January thick pus was noticed to be flowing from the
urethra, and abscess of the prostate was diagnosticated.
Dr. Hall performed external urethrotomy. The man did
well for about a week, then had two chills at about thirty-
six hours’ interval, was slightly irrational at times, and had
a considerable elevation of temperature. He gradually
became weaker and died on February 7th of exhaustion.
“ At the autopsy the prostate was found to be very much
enlarged, especially the left lobe, which measured 6 x 34 X
3 ctm., the whole gland measuring 6x5x3 ctm. The
prostatic urethra was compressed su that its lumen was
completely occluded. When cut, the prostate presented
the ordinary appearance of the hypertrophied organ.
There was no sign of abscess.
“ The wall of the bladder was much thickened (1} ctm.),
and its mucous membrane was velvety, congested, and
covered with pus. A small amount of thin pus was in
the bladder. The ureters were much dilated, the left
somewhat more than the right, which measured about 24
ctm. in circumference. The pelves of the kidneys were
also much dilated and filled with thin pus. The mucous
membrane was much congested, and velvety in appear-
ance. The capsule of the kidneys was somewhat adher-
| ent, the cortex was thickened and cloudy, and there were
occasional points of light yellow color, suggesting small
collections of pus. Many of the collecting tubules were
much dilated.
“ Microscopical examination of the kidney showed the
characteristic changes of chronic diffuse nephritis, and
also many collections of small round cells, with degen-
erating nuclei.
“ Though this is but an ordinary case, I have thought it
worth while to present it to-night, because the picture is `
so typical and because a practical lesson seems to be
pointed by it. I have repeatedly heard Dr. Sands say
that the liability to suppurative nephritis after operation
was greatly increased by the existence of chronic Bnght’s
disease. He always caused the urine to be carefully ex-
amined, and often refused to operate when albumin was
present. When pyelitis exists the tendency to infection
of the kidney must be great. So long as the strength of
the patient can be kept up this may be counteracted in
many cases. But weaken the patient by the additional
drain upon his resources imposed by operation, and no
wonder that the equilibrium before existing should be de-
stroyed.”
Dr. Ely then presented a specimen, on behalf of Dr.
Hodenpyl, showing an
ENLARGED MIDDLE LOBE OF THE PROSTATE
which had caused a moderate degree of retention, though
it had not given rise to very much trouble in this respect.
He could give no accurate clinical history of the case.
Dr. Ely also presented a third specimen of
SUPPURATING HYDROCELE.
There was no history of the case, and the specimen had
not been obtained until it had become somewhat decom-
posed.
Dr. ARMSTRONG asked whether any strictures of the
urethra had been found in the first case reported.
Dr. Ety replied that there were no strictures.
August 24, 1889]
THE MEDICAL RECORD.
22I
Dr. Otis said that the third specimen seemed to be
one of ordinary hematocele.
Dr. H. P. Loomis presented a specimen of
MULTIPLE ULCERS OF THE STOMACH IN A MORPHINE
HABITUEE.
“ The specimen was removed from a woman, forty-two
years of age, a nurse by occupation, who was admitted
to Bellevue Hospital the 29th of March. Her parents
died of old age. She denied alcoholic habits and a spe-
cific history. The patient was strong and well, up to
twelve years ago, when she had to have her foot ampu-
tated, and as a result of attempts to relieve a severe neu-
ralgia in the stump, she became addicted to the use of
morphine. Since this time she had never been well, and
had always taken morphine to excess. For the last three
months she had been troubled with incessant vomiting and
a severe pain in the epigastric region, and had been
growing weaker and weaker.
“On admission to the hospital the patient was vomiting
almost constantly ; the material consisted of partially di-
gested food, mucus, and, once or twice, some black coffee-
ground material. A microscopical examination of the
urine showed it to be normal. After a few days, by keep-
ing the patient on a peptonized milk diet, giving oxalate
of cerium and morphine, the vomiting stopped, the pain
over the stomach improved, and the patient seemed to be
doing so well that the visiting physician, after careful ex-
amination, directed that she be transferred to Chanty
Hospital. While sitting in the ward, waiting to leave the
hospital, the patient fell over and died almost immediately.
« Autopsy, eight hours after death.—Lungs : the right
lung was normal, with the exception of some old adhe-
sions at the apex. The lower lobe of the left lung was
bound completely to the chest-wall by new connective
tissue-bands, and was almost airless; the upper lobe was
normal. The heart-walls and cavities presented a normal
appearance ; there was some thickening at the base of the
aortic and mitral valves, and the aorta was atheromatous.
The spleen was enlarged and soft. The liver was of nor-
mal size, and showed the ordinary appearances of fatty
infiltration. The kidneys were intensely congested ; other-
wise of normal appearance. The brain showed a slight
opacity along the vessels of the convexity, which were in-
tensely congested. Stomach: The organ was of normal
size and empty. On opening the stomach, the mucous
membrane was seen to be intensely congested, and the
surface presented the ordinary appearance of a chronic
catarrhal inflammation at the pyloric extremity. On the
posterior surface, and near the lesser curvature, were four
ulcers, the largest a half inch in diameter, the smallest the
size of a pea. They were of circular shape, with ‘ clean-
cut’ edges; their floor showed no active inflammatory
changes. One of the ulcers had penetrated as far as the
muscular coat, another to the peritoneum, which could be
seen as a thin membrane by holding the stomach up to
the light. ‘The largest ulcer had perforated, and looked
like a clean hole punched out of the wall of the stomach,
the edges of which were rounded and smooth. There
was no evidence of peritonitis. The intestines were very
anzemic and small, but no lesion was found in them.”
Dr. JOHN C. PETERS said that he had seen some cases
of ulcer of the stomach in which the lesions were seated
in the upper portion of the organ. The patients were
perfectly comfortable as long as they ate only small quan-
tities of bland food ; but a large meal would cause pain
and discomfort ; and, in one instance, a perforation took
place in consequence of an indiscretion in this respect.
The Society then went into executive session.
A New MINERAL Sprinc.—In boring an artesian well
for an Indianapolis hotel, water was reached at a depth of
about a thousand feet, and was found to be strongly
saline. A rough analysis has shown the presence of
chloride of sodium, hyposulphite of sodium, and several
sulphides.
Correspondence.
OUR LONDON LETTER.
(From our Special Correspondent.)
TUBERCULOSIS IN SOME OF ITS SURGICAL ASPECTS—REST
VS. EXCISION IN THE TREATMENT OF TUBERCULAR
JOINT DISEASE—COLOR-BLINDNESS IN THE MERCANTILE
MARINE— THE PROPOSED HOSPITAL INQUIRY—SPECIAL
HOSPITALS AND THE METROPOLITAN HOSPITAL SUNDAY
FUND—THE BRITISH MEDICAL ASSOCIATION.
, LONDON, August 5, 1889.
In Mr. Howard Marsh’s concluding lecture on “ ‘Tuber-
culosis in Some of its Surgical Aspects,” delivered at the
College of Surgeons, the lecturer remarked that, speaking
of the general group of tubercular diseases met with in
surgery, he believed that, when they were detected early
and were adequately treated by prolonged rest, in not
more than at the most ten per cent. did they develop to
any formidable degree. It wasa rule to which he had
seen but few exceptions, that when, for example, a knee or
an elbow, which was the seat of tubercular disease of less
than three months’ duration, was enclosed in well-fitted
splints and kept at rest, the case gave no further real
trouble. ‘The symptoms began at once to subside, and
the improvement, though slow, went on without material
check until the joint was apparently free from disease ;
while, after a longer period of rest, complete recovery was
secured. In early cases the period required for treatment
did not, as a rule, exceed twelve or eighteen months, and
he had met with many cases in which, after this time, no
trace of disease beyond slight muscular wasting remained.
In more advanced cases, though the period occupied was
longer, the same treatment would lead to good repair.
His experience as to cares of the spine accorded with
what he had seen in the joints. When prolonged rest was
- secured, though these cases were tedious—for tubercle,
once deposited, could not be got rid of quickly—there
was nothing inveterate about them. ‘They responded at
once to treatment, and steadily improved ; in the great
majority complete recovery, though often with some de-
gree of deformity, took place: ‘They became unmanage-
able only when they had been allowed to advance for a
twelvemonth and upward before treatment was com-
menced. In fact, it was with caries of the spine as it was
with diseases of the joints. Early diagnosis and adequate
treatment would lead to recovery, but if the process were
allowed to advance month after month, or year after year,
neither present nor future surgery could bring about satis-
factory results. General tuberculosis occurred in some
instances as the result of infection, either from any of the
joints or from the spine. He had occasionally seen such
cases, but he felt convinced that the percentage here was
much the same asin the case of the hip-joint (in the
preceding lecture Mr. Marsh estimated this as five per
cent.).
After discussing at length some statistics relating to the
subject, the lecturer observed that if we placed the results
of excision, so far as recorded, side by side with the re-
sults of continued rest, there could be no doubt as to the
conclusions at which we must arrive. Referring to various
published series of cases in which the mortality varied
from sixteen to thirty-six per cent., Mr. Marsh said he was
confident that in cases of suppuration treated without
operation the mortality was not more than ten per cent.,
and his strong impression was that it was materially less
than this. As to the ultimate condition of the limb, our
information as to the results of excision was limited.
Some of these results were quoted, but the lecturer said
he did not doubt that, as operative surgery improved, the
immediate results of excision would be greatly superior
to those referred to. ‘They would be so good, especially
when the operation was performed early, that, unless the
results to be obtained without operation were kept well in
222
THE MEDICAL RECORD.
[August 24, 1889
view, excisions would, he ventured to think, be performed
much too commonly. It must be remembered that the
mere healing of a wound did not show that an operation
was the best thing for the patient, or afford any proof that
it ought ever to have been undertaken. ‘The main defect
of excision was in the ultimate result as regarded the use-
fulness of the limb, when this was compared with a limb
in which no operation had been performed, and in which
the joint, instead of having been removed, had been re-
stored to that considerable degree of usefulness which
could generally be secured by rest. He believed it was
now generally recognized by most surgeons that, although
the immediate result of excision of the knee, in children,
might be all that could be desired, yet the ultimate result
was unsatisfactory. The union between the bones gradu-
ally yielded in many cases, the bones grew imperfectly,
deformity ensued, and the functions of the limb were
materially interfered with. He thought it would be much
the same in the case of the hip. In both cases alike—
in the knee and in the hip—when one of the principal
joints of the lower extremity had been removed during
childhood the patient had been seriously crippled. l
A good deal of attention has of late years been given to
the subject of color-blindness, not only in professional
but in lay circles. The danger of allowing color-blind
persons to engage in certain occupations, such as those of
seamen and railway men, has been repeatedly pointed out
by ophthalmic authorities. It is therefore satisfactory to
find that the Government has appointed a departmental
committee to investigate the subject of color-blindness
among the seamen of the mercantile marine. The re-
port of the committee, however, will not be laid before
the House of Commons till next session.
. On Monday last, in the House of Lords, the long-talked
of petition (promoted by the Charity Organization Society)
in favor of an inquiry into the working of voluntary and
other medical institutions in the metropolis was presented
by Lord Sandhurst. In doing so he referred to the
various branches of the subject, pointing out some of the
abuses known to exist. The President of the Privy
Council, while mentioning some of the difficulties which
beset the subject, said that the Government would con-
sider the case for inquiry, and next session he might be
able to announce what course they proposed to take. I
am not very sanguine that the proposed inquiry, if held,
will lead to much. Apart from the difficulty of interfer-
ing with institutions supported by voluntary contributions,
there is the still more serious one of rival and conflicting
interests to be dealt with. The most that can be hoped
from a public inquiry is that it will bring the force of
public opinion to bear upon institutions in which waste-
ful methods of management are in force, and thus lead to
wise economies being enforced. A good deal has been
recently said against special hospitals. There is no doubt
that these are too numerous, and yet during the last few
years new ones have been springing up like mushrooms—
soon, in most cases, to get deeply involved in debt. It is
significant that the Hospital Sunday Fund have this year
refused the usual grant to two special hospitals, viz., St.
John’s Hospital for Skin Diseases and the West End Hos-
pital for Diseases of the Nervous System.
It was lately announced that the annual meeting of
the British Medical Association would be held in London
next year. It was supposed of course that the matter
was settled, and that the acceptance (in the general meet-
ing at Leeds) of the invitation of the Metropolitan Coun-
ties Branch was merely a formality remaining to be done
to clinch the matter. It appears we were mistaken. Some
of the wire-pullers connected with the Branch want to
undo this, and have accordingly summoned a meeting for
to-morrow at which they hope, by a snatch vote, to re-
scind the vote given at the annual meeting of the Branch
a month ago. No doubt the plan may succeed, especially
considering that many members of the Branch have now
left town. If so, offence will doubtless be given to many,
but the executive of the Association will care little for
that. They are indeed past masters in the art of giving
unnecessary offence. If any illustration of this were
needed, it would suffice to refer to the manner in which a
letter to the Journal from a well-known hospital surgeon
was recently suppressed, while at the same time an insult-
ing paragraph animadverting on the writer was inserted,
—to which, however, he was not allowed to reply.
OUR PARIS LETTER.
TREATMENT OF INTESTINAL OBSTRUCTIONS BY ELECTRIC-
ITY—HEREDITARY MYOPIA— A NEW FORM OF TUBER-
CULOUS DISEASE—THE SECOND CONGRESS FOR THE
STUDY OF TUBERCULOSIS—HONORS TO DR. NACHTEL.
Paris, August 2, 1889.
ABOUT twelve months ago Dr. Larat read a note at the
Academy of Medicine on the treatment of intestinal ob-
structions by electricity. At the meeting of the Academy
of last week Dr. Hérard read his report on the merits of
the work. After having analyzed some of the observa-
tions related by Dr. Larat, Dr. Hérard considers that in
presence of an intestinal occlusion, before having recourse
to laparotomy or the formation of an artificial anus, one
must first employ purgatives ; if these do not succeed,
belladonna, full doses of opium in subcutaneous injec-
tions, enemata of siphons of seltzer water, and finally,
electricity should be employed. The mode of electriza-
tion which appeared to give the best results in acute
strangulation is faradization. On the contrary, in the
forms of intestinal occlusion which are slow in their
course, accompanied with intestinal paresis, galvanization
succeeds the best. In order to insure a proper action
one must employ, simultaneously, inducted and continued
currents. M. Boudet, of Paris, a well-known electrician,
in the first instance, then Dr. Larat, had the happy idea
of disseminating the galvanic electricity over a larger sur-
face of the intestinal mucous membrane by means of an
enema of salt water. This method appears to be the
most efficacious. Dr. Le Fort thinks that it is necessary
to make some reserve on this method of treatment, as,
after all, Dr. Larat counts only ten cures out of twenty-
four cases, and of these cures it is probable that some of
them were cases not of true intestinal obstruction, but of
obstinate constipation. He thought that it was well to
employ electricity when one was in the presence of a pa-
tient presenting the symptoms of an intestinal occlusion ;
but, if this should not succeed in the twenty-four hours,
one must without hesitation intervene surgically. It will
be remembered that Dr. Duchenne de Boulogne was the
first to try to overcome intestinal obstructions by the
action of faradic electricity. Since then it has been re-
marked that smooth muscular fibres, like those of the in-
testines, were more sensible to the galvanic current; but
the formation of eschars was feared, and the employment
therefore of the continued current is exceptional. By
an ingenious arrangement, however, adopted by M. Boudet,
all danger is averted. One of the poles is formed by a
large plate placed in contact with the abdomen, the other
by a metallic stem enclosed in a sound of India-rubber,
which is introduced into the rectum. ‘The sound has
an isolating property, so that, to pass the current, one
introduces into the rectum one litre of salt water, which
establishes the contact between the metallic stem and
the intestinal parietes. Dr. Constantin Paul remarked
that it was better to place in the intestine the negative, and
not the positive pole, as recommended by Dr. Hérard ; by
this means one obtains more energetic intestinal con-
tractions.
Dr. Duclaux communicated to the Academy of Sci-
ences, in the name of Dr. Boucheron, a note relative to
hereditary myopia and its treatment in adolescence. The
children of myopes are not born myopes, they become so,
but at an age more and more young, according as genera-
tions succeed. Thus, a grandfather who became myopic
at twenty years, having a son myopic at fifteen years, they
August 24, 1889]
THE MEDICAL RECORD. `
223
would both have a slight myopia, and would be able to
read without spectacles in their old age ; but their grand-
children will become myopic at twelve years, and will al-
ready have been so to a great degree. The great-grand-
son will be a myope at eight years, will arrive at six
dioptrics of myopia at fifteen years, at eight dioptrics at
thirty years, will lose an eye at thirty-five years, and will
have great difficulty in preserving his second eye to the
end of his days. It is therefore necessary that this state
of things should be more rigorously attended to. Dr.
Boucheron remarked that in children somewhat the same
thing happens with the muscles of the eye as what occurs
in writers cramp. ‘The child strains in writing, contracts
himself and there is produced cramp of the accommoda-
tion of the eye, and this abnormal accommodation tends
to become permanent in myopic pupils. Dr. Boucheron
examined roo lycéens, and took the measure of their my-
opia. He instilled atropine into their eyes, and their my-
opia was modified. Hence, beyond the principles of
hygiene, so easy to institute, he recommends the employ-
ment, in feeble doses, of atropine, duboisine, or simply
cocaine.
M. Chauveau presented a note at the Academy of
Sciences, for Dr. Curmont, Preparator at the School of
Medicine of Lyons, on a new bacillary tuberculosis of bo-
vine origin. ‘The bacillus of Koch commits in the bovine
species the same ravages as in the human species. But
there exist other bacilli which also engender tuberculosis
in oxen. Dr. Curmont has just discovered one, which is
very singular by its morphological and physiological char-
acters. This bacillus inoculated into the rabbit also de-
termines tuberculosis, it invades not only the principal
organs but also the blood. Inoculated into the guinea-
pig it does not communicate tuberculosis to it, but it pro-
duces a general infection which is fatal. If, with the
residues of its culture, one tries to determine, as is done
habitually, immunity by inoculations, not only this immu-
nity is not obtained, but, on the contrary, the animal is
rendered more apt to contract infection. The guinea-pig
dies in twenty-four or twenty-five days after the simple in-
jection. After the inoculation and the new injection it
dies much more rapidly in a few days. These facts are
very singular, and in contradiction with what we have
known till now.
The Second Congress for the Study of Tuberculosis will
take place at the end of July, 1890, under the Presidency
of Professor Villemin. ‘The following questions are pro-
posed for discussion: 1. The identity of tuberculosis in
man and of that in cattle, fowls, and other animals.
2. The bacterian and morbid associations of tuberculosis.
3. The hospitalization of tuberculous subjects. 4. On
the agents capable of destroying the bacillus of Koch,
non-injurious for the organism, in regard to the prophy-
laxis and to the therapeutics of human and animal tuber-
culosis. Adhesions and subscriptions (twenty francs) are
‘to be forwarded to M. G. Masson, Treasurer, 120 Boule-
vard Saint Germain, and all which concerns ee
tions for the Congress should be addressed to M. le
docteur L. H. Petit, General Secretary, 11 Rue Monge
Paris.
Dr. Nachtel, on the recommendation of the Minister of
Public Instruction, has been nominated an officer of the
Academy of France, in recognition of his great services in
connection with the city ambulances.
ELECTROTHANASIA.
To THe Epitor or Tus MepicaL RECORD.
Sır : Ever since the passage of the law in this State re-
quiring the use of electricity as a means of capital execu-
tion, there has been much discussion as to the method of
employing it, the apparatus, human resistance, the pos-
sibility of killing at all, etc. I say since the passage of the
law, for, singularly enough, the method was legally adopted
before any practical point had been settled with regard to
electrothanasia (the writer would suggest the use of this
word in the place of such a barbarous term as “ electro-
cution,” which appears in some of the daily papers). The
commission that drafted the law had a few dogs killed at
Buffalo in the following manner: They were partly im-
mersed in a zinc-lined box containing water, which served
as one pole; the wire of the other pole was inserted into
the mouth or wound around the nose. The current was
furnished from an electric light wire. It was upon such
experiments as these that the new law was based! As to
the electromotive force, the resistance, the current strength,
the kind of current used, not one of these facts seems to
have been known or noted.
In the summer of 1888, Mr. H. P. Brown, a practical
electrician of this city ; Mr. A. E. Kennelly, chief elec-
trician of the Edison Laboratory, and the writer, made a
large number of careful experiments upon lower animals,
but not for the purpose of determining any facts con-
cerning the employment of lethal currents in execution.
One object was to study the well-known differences be-
tween high-tension continuous and alternating currents,
both of which have been fatal to many human beings in
this country, and whose dangerously high voltage has been
limited by law in England and France; and another ob-
ject was to observe the physiological "and pathological
effects of death-currents (Z/ectrical World, August 11,
1888). In all, some twenty-four dogs were killed. Sub-
sequently the writer was made chairman of a committee
of the New York Medico-Legal Society, to report upon
the best method of execution by electricity, and the ex-
periments already undertaken were found to have valu-
able application in a study of this subject. Additional
experiments were conducted before this committee and a
number of State prison officials, several calves and horses
being killed. The committee then recommended, in legal
procedures, the application of good-sized, ‘metallic,
sponge-covered electrodes to the head and spine, after
careful saturation of the skin and sponges with a warm
saline solution ; the use of a 3,000 vòlt dynamo, and a
current potential of 1,000 to 1,500 volts, alternating 300
times per second, for a period of time, from fifteen to
thirty seconds.
There is no doubt that the current thus applied will
kill in every instance without regard to human.resistance,
and that unconsciousness, and cessation of pulmonary and
ventricular movements will be instantaneous.
The objections, upon the ground of enormous human
resistances, so ably set forth by Dr. Sachs, in his letters to
THE MEDICAL ReEcorpD of July 27th and August 17th,
can be met by accurate statements of facts already known.
In the first place, the writer does not dispute the cor-
rectness of Jolly and Gärtner in their determination of
resistances in the human body amounting to as much oc-
casionally as one-half of a megohm ; but it must be borne
in mind that this resistance is the initial resistance to ex-
ceedingly small electromotive forces, even as low as one
volt, to which even less than 500,000 ohms would seem to
be almost complete insulation. Thestrong current referred
to by Dr. Sachs as reducing the resistance of the feet
from 22,000 S units to 20,000 in a minute, had certainly
not over forty volts as its electromotive force.
Now it is a fact that the greater the electromotive force
the more rapidly is resistance reduced, and this is espe-
cially true of interrupted and alternating currents. For in-
stance, the primary current of a faradic battery, which is
an interrupted, and the secondary, which is an alternating
current—neither one of these appears to meet with much
resistance in the human body, for after the skin and
electrodes are moistened the effect upon the sensory-
motor apparatus of closing the circuit is so instantaneous
that one almost questions whether there is any resistance
at all. To be sure the electromotive force is quite high in
a faradic battery, as it is multiplied by every turn of the
coils, and this may explain the sudden overcoming of re-
sistance. The writer is not aware of any special study
having been made of resistance in connection with faradic
224
THE MEDICAL RECORD.
[August 24, 1889
currents, with interrupted galvanic currents, or with
“ voltaic alternatives,” which, if made to occur two to
three hundred times per second would be our industrial
alternating current. But the animals sacrificed last sum-
mer were carefully measured as to their resistances, and
some of the facts then obtained have value as an argu-
ment here :
A dog with 7,500 ohms resistance took 800 volts of a
continuous current for two seconds. During the two
seconds the index of the ammeter rose rapidly to 1 ampére,
which was as high as the instrument was made to register.
Hence the resistance dropped from 7,500 to 800 ohms,
or less, in two seconds. Another dog, with 6,000 ohms
resistance, received one instantaneous shock of a 1,000
volt continuous current. The ammeter gave its_ full
register of 1 ampére. Hence here was an instantaneous
fall from 6,000 to 1,000 ohms, or less. A third animal,
with 27,500 ohms resistance, received 160 volts of an
alternating current for five seconds, causing immediate
death. As the ammeter could not be used with this form
of current, we were unable to determine the current
strength. But surely the resistance must have been enor-
mously reduced in five seconds, y4$85 = y4$5 = rri
or nearly 6 milliampéres, which of course did not kill the
animal. Supposing even that as little current as one-
tenth of an ampére killed the dog, we have a fall in five
seconds from 27,500 to 1,600 ohms!
Further instances need not be cited, but attention
should be called to the fact that the resistances of these
dogs, as given, must be considered as minimal rather than
maximal, and do not therefore represent the much larger
initial resistances that these strong currents overcame at
the first instant of closing the circuit.
As regards differences in resistance between man and
the lower animals, they cannot be great, and must be due
to analogous causes. In dogs, calves, and horses, the
resistance was found to vary between 1,300 and 200,000
ohms, while in man it has been shown to vary from some
600 to some 500,000 ohms. Bones, muscles, saline fluids,
viscera, do not differ so much in the human and lower
species that these resistances can be said to be due to va-
riation in their composition ; but the skins containing these
tissues do vary widely in thickness, blood and sweat
supply, and hairy and epidermal coverings, not only in
various species of animals, but in different parts of any
individual of any species. At the same time, minimal re-
sistances do not differ greatly between men, provided
similar parts be subjected to the same treatment for the
purpose of measurement. . .
The experiments made by Mr. Kennelly recently for
Mr. Edison were conducted upon three hundred persons.
The hands were immersed in very dilute KHO as far as
the wrist, and every measurement was taken as nearly as
possible thirty seconds after the beginning of the passage
of the current. No resistance exceeded 2,000 ohms, the
average being 1,000. Doubtless the initial resistances,
say in the first two or three seconds, would have been
vastly higher with the small voltage employed ; yet could
anyone say that a 1,500 volt continuous current would
not have been dangerous to life under these same condi-
tions to every one of these three hundred persons dunng
the first five seconds of contact? And if, instead of a
continuous current, a 1,500 volt interrupted current, or
300 “ voltaic alternatives” per second from a 1,500 volt
dynamo had been used, could anybody bring forward one
single fact to prove that death would not have taken
place in every instance within ten or fifteen seconds ?
These facts have been adduced by the writer from an
impartial stand-point, for he would disclaim looking with
any favor upon electrothanasia as an ideal method of
legal execution ; and, indeed, is opposed to it, but upon.
other grounds than its uncertainty.
It is absolutely certain, if the apparatus and circuit are
in perfect order. But the tetanic rigidity into which the
victim is always thrown, the relaxation of the sphincters of
the bladder and rectum generally occurring dunng the
contact, and the necessity of extraordinary care in the
arrangement of the apparatus by an expert electrician,
render it far from a desirable means for the legal extinc-
tion of human life.
FREDERICK PETERSON, M.D.
201 WEST Firty-PourTH STREET.
_— + —=e- - ey
Army and Rany Mews.
Official List of Changes in the Stations and Duties of CH-
cers serving in the Medical Department, United States
Army, from August 11, to August 17, 1889.
By direction of the Secretary of War a board of medi-
cal officers, to consist of Lieutenant-Colonel ANTHONY
HEGER, Surgeon ; Captain JoHN O’SKINNER and Captain
James C. MORRILL, Assistant Surgeons, will assemble at
the U. S. Military Academy, West Point, N. Y., on
August 25, 1889, or as soon thereafter as practicable, to
examine into the physical qualifications of the candidates
for admission to the Academy. Par. 9, S. O. 185, A. G.
O., August 12, 1889.
GARDNER, WILLIAM H., Major and Surgeon, Washing-
ton Barracks, is hereby granted leave of absence for one
month. Par. 1, S. O. 183, Headquarters Division of
the Atlantic, Governor’s Island, New York City, August
13, 1889.
MATTHEWS, WASHINGTON, Major and Surgeon. Pro. |
moted to Surgeon, with rank of Major, to take effect from
the roth day of July, 1889, vice ‘Town, promoted. War
Department, Washington, D. C., August 14, 1889.
HAVARD, VALERY, Captain and Assistant Surgeon, is
granted leave of absence for one month, to take effect
about October 1, 1889, with permission to apply to
Division Headquarters for an extension of one month.
Par. 3, S. O. 86, Department of Dakota, St. Paul, August
10, 1889.
PORTER, JOSEPH Y., Captain and Assistant Surgeon,
now at Jacksonville, Fla., by direction of the Secretary of
War will, if the state of his health permit, proceed to
Jackson Barracks, La., and report to the commanding
Officer of that post for temporary duty, and by letter to
the commanding general, Division of the Atlantic. Par.
16, S. O. 186, A. G. O., August 13, 1889.
Official List of Changes in the Medical Corps of the United
States Navy for the week ending August 17, 18869.
Rocers, B. F., Surgeon. Detached from U. S. S.
Alliance and wait orders.
Harmon, G. E. H., Surgeon.
S. Constellation, August 13th.
Lowxpes, C. H. T., Assistant Surgeon.
the U. S. S. Constellation, August 13th.
DECKER, C. J., Assistant Surgeon. Detached from U.
S. S. Lancaster, and granted four months’ leave of absence.
BALDwIn, L. B., Passed Assistant Surgeon. Detached
from U. S. S. Ranger, ordered home, and wait orders.
Harvey, H. P., Surgeon. Ordered to the U. S. S.
Ranger.
LovERING, P. A., Passed Assistant Surgeon. Ordered to
the Receiving Ship Wabash, at Boston Navy Yard.
SIEGFRIED, C. A., Surgeon. Ordered to the Naval
Station at New London, Conn.
Ordered to the U. S.
Ordered to
FRENCH Mopesty.—A Parisian medical society re-
cently appointed a committee to consider the question of
a universal language of science. The report of the com-
mittee was presented in the form of three questions, upon -
which the society voted as follows: ‘Shall a universal
language be adopted?” “Yes.” “Ought this to be one
of the dead languages?” ‘ No.” “Shall it be the French
language ?” “ Yes.”
The Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 36, No. g
Original Articles.
ON THE COMPARATIVE STUDY OF DISEASES
OF THE NERVOUS SYSTEM.
BEING THE ADDRESS IN MEDICINE DELIVERED BEFORE
THE BRITISH MEDICAL ASSOCIATION.
By J. HUGHLINGS JACKSON, M.D., F.R.C.P., LL.D.,
F.R.S.
PHYSICIAN TO THE LONDON HOSPITAL, AND TO THE NATIONAL HOSPITAL FOR
THE PARALYZED AND EPILEPTIC.
First of all, I beg the President and Council of this great
Medical Association to accept my heartiest thanks for the
very high honor they have conferred on me in asking me
to give this address. I have had much difficulty in choos-
ing a subject, the difficulty being mainly in finding one on
which I thought I had something to say, and on which I
had not already said the little I was capable of. Finally, I
concluded to consider once more, with all the care I could
and with as little recapitulation as possible, the most im-
portant of general doctrines bearing on the science of
medicine.
We have multitudes of facts, but we require, as they
accumulate, organizations of them into higher knowledge ;
we require generalizations and working hypotheses. We
have, so to speak, ready made for us, the hypothesis of
evolution, one verified in numerous different cases. Hux-
ley * writes: “ The peculiar merit of our epoch is that it
has shown how these hypotheses [one of which is the doc-
trine of evolution] connect a vast number of seemingly in-
dependent partial generalizations ; that it has given them
that precision of expression which is necessary for their
exact verification ; and that it has practically proved their
value as guides to the discovery of new truth.” I do not
advocate the application of the doctrine of evolution to
the classification of diseases for practical purposes, but
believe, nevertheless, that its indirect value to clinical
medicine is very great indeed, and that before long it will
be directly helpful. Thinking that for clinical purposes
we must continue to have arrangements of cases “bv
.” > I once more urge that we should also attempt a
parallel study of diseases as they are dissolutions—that is,
reversals of evolution. By the latter means I hope that
we shall be able to make broad and yet precise generaliza-
tions of great value.- The man who puts two old facts in
new and more realistic order deserves praise as certainly
as does the man who discovers a new one. There is an
originality of method. Gaskell has found out much that
is new 1n his recent well-known researches on the nervous
system ; but I imagine that the greatest merit of his work
is that he has made fruitful generalizations, and has set
many things long ill assorted in realistic order. By
doing this he will have put a stop to certain loose ex-
planations in which the sympathetic figures. I do not
pretend to be able to define generalization as that term is
used in science. May I say that it is the classification of
things which are for the most part very different by some
fundamental peculiarity each of them has? It is easy to
see how one may be misunderstood when making general-
izations after this fashion ; one may be supposed to over-
look important differences—not to be putting things in
order but to be trying to organize confusion. I will give
1 Reign of Queen Victoria, vol. ii., p. 340.
2 British Medical Journal, July 14, 1888.
New YORK, AUGUST 31, 1889
Whole No. 982
a series of illustrations of the method spoken of, because
it is one I follow largely in this address.
1.1 A patient of mine had lost one hand, but, as is
most often the case, he had, representing it, a phantom
hand; this was always in a position as if encircling a ves-
sel; the member had been blown off when he was hold-
ing a cylinder to be charged with an explosive. 2. An
aphasic patient of mine frequently uttered, on being ques-
tioned, but with no relevance to anything going on, “ Come
on,” or “ Come on to me;” he was a signalman, and had
been taken aphasic and hemiplegic on the railway in front
of his box; the presumption is that he was saying, or was
about to say, those words when taken ill. 3. An epileptic
patient told me that his first fit occurred when he was’ a
soldier, and at the very time he was “ numbering off ;”
after every subsequent fit, and before regaining conscious-
ness, he used to count; this we observed when he was in
hospital. 4. A woman I was asked to see in a surgical
ward in the London Hospital, who had fractured her skull
by a fall when laying down oil-cloth on a staircase, kept,
during partial unconsciousness a few hours before death,
manipulating the counterpane of her bed. We supposed
this to be a sort of continuance of the action of laying
down the oil-cloth ; the patient desisted, for a time at least,
when the nurse assured her that “it was properly laid.”
These illustrations will appear incoherently grouped to
those who do not happen to see that the intention in stat-
ing them is not to deal with stumps, aphasia, epilepsy, and
injury to the head, but to make a basis for the discovery
of the reason why there is a fixation of states, which are
normally temporary, upon the sudden occurrence of lesions
of the nervous system ;* very different cases are chosen in
order to make the basis a broad one. This is by way of
illustration, but I hope that such facts are of some value
toward the methodical study of persisting delusions. I
suggest, quite hypothetically, that some very grotesque
delusions may be a fixation of absurd beliefs in dreams
in cases where a sudden morbid change, or sudden in-
crease of it, has occurred in the brain during sleep—such
delusions as one mentioned to me by Dr. Savage ; a pa-
tient of his believed himself to be a jar of Indian pickles.
Before going further, I must mention that most valuable
work has been done by Anstie, Ross, Ribot, Mortimer,
Granville, Mercier, and Bland Sutton in the application
of the principles of evolution to normal and abnormal
conditions of man’s body. We ought not to forget that
nearly half a century ago Laycock extended the doctrine
of reflex action to the brain, and that so long ago as
1829 Von Baer announced “ his great discovery, that the
progressive change from homogeneity to heterogeneity is
the change in which organic evolution essentially con-
1 In his magnificent work, Diseases and Injuries of Nerves, 1872, p.
S, Weir Mitchell writes as follows: ‘* E.C , aged thirty-two, lost
is left arm, five inches below the shoulder, nine years ago. When
shot, the thumb turned into the palm, and continued in this state of
spasm, so that when, six hours later, the limb was removed, the nail
of the thumb had cut into the palm. He several times lifted the
thumb, but it always returned to the same spot. For nine years the
absent thumb still remains cutting into the palm.” After speaking of
various positions of phantom parts of limbs, Weir Mitchell writes
(op. cit., p. 354): ‘‘ Another class has the hand constantly in some
ainful position which it occupied before the operation, so that the
ast real sensation is so stamped upon the sensorium as to forbid its
erasure by any future impression.”
2 In the case of No. 1 the hand was blown off at a time when par-
ticular nervous arrangements of the nervous centres, from highest to
lowest, were being discharged. The persisting memory, so to call it,
of the last position of the lost hand implies a persisting state in the
highest centres. Why that state remained permanently it is tor me
impossible to say.
226
sists.” > I need scarcely mention the name of Herbert
Spencer, except to express my vast indebtedness to him ;
the first edition of his “ Principles of Psychology” ap-
peared so long ago as 1855, five years before the publica-
tion of the “ Origin of Species.”
In the doctrine of evolution we have principles which
no doubt apply to the whole organism and to every one
of its diseases ; it is at once a means of scientific classifi-
cation and a guide to the discovery of new facts. Limit-
ing myself in this address fo the nervous system, I submit
that ultimately those principles will help us to a more
realistic explanation of symptomatologies so different
as those in a case of paralysis of an external rectus and
those in cases of insanity. The comparative study of
nervous diseases—the study of them as dissolutions
—is a process of generalization. To attempt this
generalization without prior careful analysis of the
things concerned, needing minute clinical study of
individual cases, is not likely to lead to anything of per-
manent value. To compare and cortrast the mere local
lesions and the symptoms directly dependent on them
only in the two cases instanced is not good method. The
symptomatology of each must be regarded as the result
of a flaw in an evolutionary whole. It is one merit of
the method I am urging that it deals not only with the
local lesion—with that, I mean, which disease (in the
strict sense of pathological change) causes—which alone
is dissolution, but also with the healthy rest ; that is, it
takes into account the evolution going on in the undam-
aged remainder of the nervous system. The full symp-
tomatology of a case of ocular paralysis is not to be in-
telligently stated even unless activities of healthy centres,
including the highest (all centres above the peripheral
lesion) are considered ; and a case of insanity is not prop-
erly analyzed unless undiseased parts of the highest cen-
tres and all lower centres are considered (vide infra). In
the two cases a great part of the symptomatology is owing
to over-activity of perfectly healthy nervous arrangements ;
the erroneous projection, and diplopia in the first, and the
illusions, delusions, and all other positive mental symp-
toms in the second. ‘To insist on the principle im-
plied, I say in recapitulation that every case of nervous
disease is a problem, not only in dissolution but in evolu
tion: in example, he who is studying the physical prucess
during an illusion in an insane patient, is as certainly deal-
ing with evolution as he is who is studying that process
during the perception of a healthy person.
Before I give particular illustrations of dissolution, I will
make brief statements concerning some different aspects
of the one process evolution, of which dissolution is the
reversal : (1) evolution is a passage from the most to the
least organized. I must stay to remark on the term or-
ganized. ‘ Highly organized,” is frequently used synon-
ymously with “ very complex ;” but by degrees of organi-
zation I mean degrees of perfection of union and certainty
of action of nervous elements with one another. Using
the term organized in this sense, I say that the highest
cerebral centres are the least organized (the “ most help-
less centres”), although they are the most complex,
whereas the lowest centres are the most organized, al-
though the least complex. In other words, we may say
(2) that the evolutionary ascent is from the least to the
most modifiable. If the highest centres were not modifi-
able, we should be very simple machines ; we should
make no acquirements. If the lowest (“ vital”) centres
were to become as modifiable as the highest are, life would
cease. It is only another aspect of this statement—that
the progress in evolution is from the most to the least
organized—to say (3) that the passage is from the most
automatic to the most voluntary (properly, “ to the least
automatic”); equivalently, it 1s (4) from structures inher-
ited most nearly perfected (acquirements of the race and
of prehuman beings), such as the cardiac centres in the
medulla oblongata (some centres of the lowest level of
1 Fiske: Cosmic Philosophy, vol. i., p. 342.
THE MEDICAL RECORD.
[August 31, 1889
evolution)—from those comparatively perfectly evolved at
birth—to those of-the highest nervous arrangements of the
highest centres, which are only incipient nervous struct-
ures, and which are evolving during the latest new mental
states ; (5) the process of evolution is from the simple
to the complex ; (6) from the general to the special. Re-
versals of evolution are effected by pathological processes,
and are called dissolutions ; they are reductions from the
least organized, etc., toward the most organized, etc.
I can give no good illustrations of dissolution from le-
sions at the periphery. Nor can much that is definite be
said in this regard of lesions of the spinal system (lowest
level of evolution of the central nervous system). Yet
we may say that in most cases of the ordinary form of
progressive muscular atrophy the muscles first morbidly
affected are the small muscles of the hand, and that in
most cases of Duchenne’s bulbar paralysis the tongue is
first invaded. In these two cases the most special parts,
in manipulation and in articulation respectively, fail first.
Going higher up in the nervous system we find definite and
certain illustrations. It is plain that hemiplegia from dis-
ease in the mid-cerebral region is a failure in the order
from “ most voluntary ” toward most automatic ; whether
chorea and paralysis agitans are due to morbid changes in
the region mentioned or not they certainly illustrate dis-
solution in the very same way as hemiplegia does. The
numerous different phenomena of cases of aphasia are the
best illustrations of the process of dissolution, but I have
stated them several times.’
Dr. Donald MacAlister has pointed out, in his admir-
able Croonian Lectures,’ that the febrile process exempli-
fies dissolution. ‘ ‘The thermal nervous system,” to use
his words, “ has three parts ; let us call them briefly the
thermotaxic or adjusting, the thermogenic or producing,
and the thermolytic or discharging mechanism. ... In
the ascending scale of evolution,” he continues, “ we seem
to rise from the thermolytic to the thermogenic, and
thence to the thermotaxic nervous system.” He considers
fever as a process of dissolution, and, next, recovery from
fever as a process of re-evolution. Some, presumably all,
cases of insanity illustrate dissolution. I will content my-
self with quoting very briefly from that part of Dr. Savage's
important work, “ Insanity,” where he deals with general
paralysis. In these cases, he writes, that the disease
“ affects first the highest intellectual and motor acquire-
ments is undoubted.” He says, too, “ Both Dr. Mauds-
ley and I have independently taught that in this progress-
ive degeneration the last and highest acquirements fail
first.” .. . We have very good illustrations of dissolution
in the symptomatology of drunkenness. Long ago Charles
Bell wrote :* “ It is a fact familiar to pathologists that
where debility arises from affection of the brain, the influ-
ence is greatest on those muscles which are, in their nat-
ural condition, most under the command of the will. We
may perceive this in the progressive stages of debility of
the drunkard, when successively the muscles of the tongue,
the eyes, the face, the limbs, become unmanageable ; and
under the same circumstances, the muscles which have a
double office, as those of the chest, lose their voluntary
motions and retain their involuntary motions ; the force
of the arms is gone long before the action of breathing is
affected.” * Lauder Brunton, in his “ Pharmacology,” third
edition, p. 146, writes: “In the action of such poisons
as alcohol, the nervous system appears to be paralyzed in
inverse order of its development; the highest centres
going first, next the middle, and then the lowest. After
this comes paralysis of the motor nerves, and, lastly, of
the muscles themselves.”
I now give a curious illustration. We see, not dissolu-
tion, but, this time, evolution illustrated by certain sur-
gical cases—by the order of persistence of spectral repre-
1 British Medical Journal, March 29, 1884.
2QOn the Nature of Fever, Lancet, March 26, 1887,
3 Nervous System, 3d ed., p. 165.
4 My friend and colleague, Dr. Gowers, drew my attention to this
passage: I gave the quotation, Lancet, February 15, 1873 (On the
Anatomical and Physiological Localization of Movements in the Brain).
August 31, 1889]
sentatives of parts of limbs lost by unas Weir
Mitchell writes :' “ The limb is rarely felt as a whole ;
nearly always the foot or the hand is the part more dis-
tinctly recognized, and, on careful questioning, we learn
that the fingers ånd toes are readily perceived ; next to
these the thumb; then more rarely the ankle or wrist ;
and, still less frequently, the elbow and knee. Very often
some fingers are best felt, especially the forefinger.”
This, the order in which the lost parts remain most vividly
represented in consciousness, is almost exactly the order
in which the parts physical do fail in dissolution of the
nervous system.
Speaking most generally, and ignoring some very ob-
vious qualifications, we may say that the hemiplegic man
is reduced to a more automatic condition of movement,
the aphasic to a more automatic condition of language,
and the ifsane man to a more automatic condition of
mind. ‘There is a reduction to a lower level of evolution
in each series.’ Dissolution is exemplified in each of
the following exceedingly different symptoms: 1. Most
epileptiform seizures begin in the thumb or index finger,
or in both; these digits are the most special parts of the
body. 2. "The words most often left to an aphasic who
is, for the rest, entirely speechless, are “ yes,” or “no,” or
both ; these “ words,” as I called them, are the most gen-
eral of all propositions. 3. ‘The aphasic may be unable
to put out his tongue when told, although he moves it
well in other ways; loss of the “most voluntary ” move-
ment, with persistence of the more automatic movements
of that organ. 4. In what is called word-blindness there
is inability to recognize the latest learned, and very arbi-
trary, “ objects,” letters, and words, while the recognition
of objects, properly so-called, is unimpaired, or compar-
atively so. 5. In early stages of atrophy of the brain,
say, in that occurring so often after hemiplegia in men
past middle age, there is defect of memory for recent
events with seemingly good remembrance for long past
circumstances, and there is at the same time loss or de-
fect of the “ finest,” latest acquired emotions, with obtru-
sion of the coarser and earlier acquired. Different as
these five examples are, they are alike in that dissolution
is definitely illustrated by each of them.
I here stay to remark on what I think is the evolution-
ist’s measure of mind. Opinions will differ vastly as to
who are the men of greatest mental elevation. Some
would put Napoleons highest, others Shakespeares and
Goethes. But evolution, I think, supplies us with asci-
entific measure, which ignores superior and inferior, as
these termsare ordinarily used with regard to men’s minds.
‘This measure is according to the intellectual and emo-
tional differences between lower and higher races of
mankind, and to those between children and adults.
- Higher races of men and adults have the latest acquired
faculties, and these, according to Spencer, are, intellect-
ually, the power of abstract reasoning, and, emotionally,
the sentiment of justice. So that, instead of saying that
a person is superior or inferior to most other men, we
may say that he has more or less of the latest faculties of
the race that most other men have. I by no means think
that to have the latest intellectual faculties most highly
developed is the same thing as being most endowed intel-
lectually. I submit that the poet inherits in some ways
more of the earlier acquired faculties of the race, and has
less of the latest than the scientific man has; yet no one
would say that poets are' mentally inferior to scientific
men. Inthe cases of atrophy of the brain recently in-
stanced, there first occurs defect of the two “ latest” fac-
ulties I mentioned ; the patient easily becomes confused
by consideration of things of a little complexity, and of
which the elements are not before him, and is often
peevish and selfish.
3 Op. cit., p. 350.
®Dr. Mortimer Granville, who has for some years applied the doc-
trine of dissolution, uses the term ‘‘ denudation,” and takes note of
the “ exposure ” of the lower layers, which I call the lower levels of
evolution, remaining.
THE MEDICAL — RECORD.
I admit that I have selected cases cach will suit my
purpose best. Some cases seemingly exceptional are not
so. It is not meant that in every case of nervous disease
the most voluntary of all parts of the body suffer first and
most. Were that so all nervous diseases would affect
first and most the thumb and index-finger. The word
voluntary, a psychological term, is not the right word to
use when speaking of physical processes. ‘The progress
of dissolution, properly stated on this aspect, is from the
least automatic toward the most automatic. And in dis-
ease of any centre it is only supposed that the “ most vol-
untary ” (least automatic) parts represented by that centre
suffer first and most. In an epileptiform seizure, begin-
i ning in the leg, the great toe is nearly always the part first
in spasm ; the “most voluntary” part of the leg suffers
first and most from the cortical discharge.
To take a more extreme illustration. It may be said
‘that the symptoms from morbid changes in the cerebellum
do not accord with statements made as to the process of
dissolution. I believe that all the skeletal muscles are
represented in the cerebrum in one set of movements, and
that all of them are represented in the cerebellum in an-
other set of movements. In rough and only partial state-
ment the order of representation in the cerebrum is of
movements of the arm, leg, and spine. ‘This agrees with
a popular doctrine, for the order is that of the degree in
which the three parts of the body are “ under command
of the will.” The order of representation in the cerebel-
lum is of movements of the spine, leg, and arm. ‘This
accords with the current: doctrine that the cerebellum
co-ordinates (vide infra) movements of locomotion. (I
presume that a man’s spine must be braced up before his
legs can come into play in walking.) So that, ignoring
the term voluntary on account of its psychological impli-
cations, and using the term special, we say that the arm
is the most special part in the cerebral series, and fails
first in disease of the brain proper ; and that the back 1S
the most special part in the cerebellar series, and fails
first in disease of the cerebellum.
I now try to consider evolution and dissolution more
methodically. I submit the following statements: By
aid of the doctrire of evolution we shall discover a har-
mony or rational parallelism between (1) psychology, (2)
the anatomy and physiology of the nervous system, and
(3) that important part of clinical medicine which deals
with diseases of this system. It will help us toward a
comparative study of all diseases of the nervous system,
and in particular to the realistic comparison and contrast
of cases of insanity—diseases of the highest cerebral
centres—with diseases of lower centres.
The doctrine of evolution implies that the whole ner-
vous system has a sensori-motor constitution. It has long
seemed to me that only on this basis can we show how it
is that such very different sets of symptoms as convulsion
and insanity (and, as I think, paralysis) are owing to dis-
ease of the cerebrum proper. ‘The assignment of such a
constitution to the whole of the nervous system shows
that, when I speak of diseases of that system, reference,
explicit or implicit, is always to parts of the body. (By
“ parts of the body,” I mean non-nervous parts.) It is a
merit of the method that parts of the body are neces-
sarily taken into account in all nervous lesions. ‘The ner-
vous system by itself is a functional nothing ; it is only
something as representing parts of the body.
I carry the doctrine of sensori-motor constitution of the
nervous system further than anyone else, so far as I know,
since I urge that the highest cerebral centres (the “ or-
gan of mind” or anatomical substrata of consciousness)
represent parts of the body as certainly as that of the
lumbar enlargement does ; they are evolved out of lower
centres, which, as everybody admits, do represent parts of
the body. No one denies that the highest centres contain
sensory elements ; no one denies that very many, if not
all, parts of the body are represented sensorily in the “ or-
gan of mind.” But to their representation motorily in
that organ there seems to be great objection. It is not
228
many years since the ascription of motor representation to
any part of the cerebrum proper was denied. It is agreed
upon now that some convolutions (Rolandic region) contain
motor elements—. and, according to some, nothing else.
The prze-frontal lobes (convolutions in front of the Ro-
landic region) are said to be, or to be part of, the “ mental
centres.” I admit that they are a great division of these
“ mental centres,” but say that they are motor too—that
they are the highest motor centres. And Ferrier, who
agrees with me in thinking that these lobes are motor,
finds that, after their ablation in monkeys, there is degen-
eration of fibres “ descending ” as low as the medulla ob-
longata, but no lower ; this is proof positive that the præ-
frontal lobes are, at least to some extent, motor. I will
here state in outline what I believe to be the hierarchy of
the motor centres, only alluding to that of the sensory
series and ignoring the cerebellum.
1. The anterior spinal horns and their homologues
higher up (nuclei of motor cranial nerves) are the lowest
motor centres (both of the cerebral and cerebellar systems).
These lowest motor centres, with the corresponding sen-
sory centres, make up the lowest level of evolution of the
central nérvous system.
2. The convolutions of the Rolandic region are the
middle motor centres of the cerebral system. With the
corresponding sensory centres they make up the second
or middle level of the central nervous system.
3. The prz-frontal lobes are the highest motor centres
of the cerebral system. With the corresponding sensory
centres they make up the third or highest level of the
central nervous system, that is, “the organ of mind.”
Here I may best remark on the differences between
muscles and movements, a matter of vast importance.
To speak figuratively, the central nervous system knows
nothing of muscles, it only knows movements. I have
already stated the speculation that all muscles of the skeie-
ton are represented in the cerebrum in one set of move-
ments, and all in the cerebellum in another set. I here
give another illustration simplifying it in several ways.
There are, we shall say, thirty muscles of the hand ; these
are represented in the nervous centres in thousands of
different combinations—that is, as very many movements ;
it is just as many chords, musical expressions, and tunes
can be made out ofa few notes. I now speak of the rep-
resentation of the muscles of the hand in the three orders
of motor centres just spoken of. 1. In some lowest motor
centres (anterior horns) which are evolved out of the
muscles of the hand, these muscles are represented in
numerous different combinations, as simple and very
general movements. 2. In the middle motor centres
(Rolandic region) which are evolved out of the lowest
motor centres, the same muscles are represented (re-rep-
resented) in still more numerous different combinations,
as complex and special movements. 3. In the highest
motor centres (prz-frontal lobes), which are evolved out
of the middle motor centres, the same muscles are rep-
resented (re-re-represented) in innumerable different com-
binations, as most complex and most special movements.
Anticipating in part what is to come, the last representa-
tion is of “ finest ” movements of the hands in the anatomi-
cal substrata of tactual ideas and of other mental states.
I fear the doctrine of sensori-motor constitution of the
“ mental centres ” will be a hard oné to many of my medi-
cal brethren. My contention, nevertheless, is that the
highest centres (“ organ of mind”) have no other function
than that.of representing or co-ordinating parts of the
body ; bearing in mind the subordinate centres, we may
say that they represent parts of the body triply indirectly.
Function is a physiological term, and it is, I submit, im-
proper to speak of states of consciousness as being “ func-
tions of the brain ;” we can only say that states of con-
sciousness attend functioning of the brain, of those parts
of it, at least, which are the highest cerebral centres. We
can only affirm concomitance. and why immaterial pro-
cesses always go along with the material processes of our
brain 1s, as yet at any rate, inexplicable. The late Pro-
THE MEDICAL RECORD.
[August 31, 1889
fessor Clifford wrote :* “ I may very well say that among
the physical facts which go along at the same time with
mental facts, there are forces at work. ‘That is perfectly
true, but the two things are on utterly different platforms,
the physical facts go along by themselves, and the mental
facts go along by themselves. ‘There is a parallelism be-
tween them, but no interference of one with the other.”
It is neither more nor less easy to understand the nature
of the relation of the two utterly different and yet con-
comitant things if the physical thing, the “ organ of mind,”
has a sensori-motor constitution, than it is on any other
hypothesis as to the constitution of that organ. Here is
an express repudiation of any intention on my part to at-
tempt to explain psychical states by anatomico-physiologi-
cal states. It is not the mind, but the physical basis of
mind, which is a product of evolution ; it is the organ of
mind, not the mind, which, being an evolution out of the
rest of the body, is representative of it. When tracing
an evolutionary ascent from the muscles of the hand to
the highest cerebral centres nothing was said even re-
motely implying that the most complex, etc., representa-
tion of these muscles became, or became part of, tactual
ideas ; it was only said that this most complex, etc., repre-
sentation was part of the physical basis of those ideas. I
know of no evolutionist of repute who has attempted the
marvellous feat of “getting the mind out of the body.”
For my part, I am content with “ getting” the organ of
mind out of the rest of the body.
I contend that the highest centres represent all parts of
the body, literally all parts supplied by nerves—not only
sensory regions and muscles of such parts as eyes and
hands (“organs of special sense”), but of legs and arms,
of internal viscera, of external viscera (as sweat-glands),
and all the rest. Under the head of movements, one
takes in effects produced in glands by what the physiolo-
gist calls their motor nerves, and also negative move-
ments, so to call them, that is, effects on musculatures
produced through the intermediation of inhibitory nerves.
The highest centres are centres of universal representa-
tion or co-ordination. When dealing with the phy-
sical condition in coma, Dr. Mercier writes: “ Thus we
arrive at this most important conclusion: that the high-
est nervous processes, which form the substrata of the
most elaborate mental operations, represent at the same
time not only the most elaborate forms of conduct and
muscular movements, but also every part of the organism
[italics in original] in some degree.* Ribot, in his re-
markable and most valuable (work on “ Personality,”
writes: “Nous pourrons dire que la couche corticale
représente toutes les formes de Tl activité nerveuse;
viscérale, musculaire, tactile, visuelle, significatrice.”
No one doubts that the lowest level of evolution
(roughly, pons, medulla, and cord) represents all parts of -
the body; it is certain that motor effects in nearly all
parts of the body are produced by discharges of the so-
called “motor region” (motor division of the middle
level). I am only going a step further when I suggest
that the highest level (although “ for mind ” in the sense
of being the physical basis of mind) is also universally
representing. A higher level of evolution is, so to put it,
the lower “raised to a higher power.” Each of the
levels being universally representing their evolutionary
differences are in the degree of complexity, etc., in which
each represents all parts of the body.
The phenomena of an ordinary epileptic fit, epilepsy
proper (I am not speaking of epileptiform seizures, which
are owing to sudden discharges beginning in parts of the
mid-cortical convolutions, or, as I call them, middle
motor centres), seem to me to accord with the inypothesis
of sensori-motor constitution of the highest centres and
of their universality of representation.” Cessation of
1 Fortnightly Review, December, 1874, p. 728.
2 Brain, January, 1887.
3] have considered in detail the phenomena of epileptiform partx-
ysms with reference to the hypothesis of universal representations by
the highest cerebral centres in the Bowman Lecture, Trans. Oph.
Soc., vol. vi.
August 31, 1889]
_~ eS
a a.
consciousness being the first, or a very early, psychical
event in the paroxysm, I presume that the first correla
tive physical event must be a discharge (here a sudden
and excessive one), beginning in some part of the
physical hasis of consciousness (highest centres). Now,
it is certain that in a severe epileptic fit there are
effects produced in nearly all, presumably in all, parts of
the body, and obviously the effects we see are motor or
their equivalents. In a slight fit of epilepsy (/e petit mal),
the effects are widely distributed ; they are so various as
pallor of face, increase of saliva, arrest of respiration, and
emission of urine. ‘The effects are crude, but this does
not invalidate them as witnesses to the representation of
parts of the body in the highest cerebral centres; the
process by which they are produced is a crude one; the
“epileptic discharge ” differs from normal discharges in
being sudden, excessive, and rapid; and also, I submit,
in starting in some small part of the highest centres (a
“ discharging lesion ” or physiological fulminate ” ).
That artificially induced discharges of parts of the Ro-
landic region (middle motor centres of the cerebral system)
produce effects in nearly all parts of the body, visceral in-
cluded, is demonstrable. No one doubts that in this
region all the skeletal muscles are represented in move-
ments; but the organic parts also, presumably all of
them, are represented in it. If curara be given to a
dog, its skeletal muscles are, by paralysis of their motor
nerve-endings, put out of reach of the effects of central dis-
charges ; upon Faradic excitation of the curarized animal’s
sigmoid gyrus (artificial respiration being kept up) the fit is
limited to the organic parts; we witness effects on viscera
or their apparatus which we can never observe in man;
the dog’s abdomen having been opened, there are seen,
among other effects, increased flow of bile, a little paling
of the kidneys, and contraction of the spleen. In this case
the artificial discharge is started in part of the middle mo-
tor centres; but, at any rate, that universal effects are so
produced gives some countenance to the supposition that
the convolutions in front of these centres, highest motor
centres, are also universally representing.
Another way of stating the function of the highest cere-
bral centres, is to say that while a man is having states of
consciousness (in artificial analysis, Willing, Remembering,
Reasoning, and Feeling), there are occurring correlatively
with those purely psychical states the physical things,
shght discharges of nervous arrangements of his highest
centres representing the whole of his body. In differing
states of consciousness different nervous arrangements of
these centres representing or co-ordinating different par-
ticular parts of his body more than all the rest will be
engaged.
It is just here that the harmony of psychology
with the anatomy and physiology -of the nervous
system is, I think, to be best seen; it is here, too, that
the basis for the comparative study of cases of insanity
(diseases of the highest centres) with diseases of lower
centres is established. I have elsewhere’ analyzed very
briefly, and, I admit, very imperfectly, the highest cere-
bral centres considered as they form the physical basis of
consciousness." The conclusion from that analysis was
that the highest cerebral centres are sensori-motor arrange-
ments representing all parts of the organism in most com-
plex, etc., ways—a conclusion agreeing with the hypothe-
sis of evolution, and strictly according with the phenomena
of epileptic paroxysms. If that analysis be valid, there is
no difficulty in seeing how it is that epilepsy proper is a
disease of the “organ of mind.” The epileptic convulsion
is a brutal development of the most complex. etc., move-
1 Croonian Lectures, Journal, April 12, 1884.
2 I then spoke of centres for will, memory, reason, and emotion,
the artificially distinguished elements of consciousness. It was a mere
artifice to imagine such centres. The evolutionist does not try to
localize volition or any other mental faculty in the brain; he is con-
tent with attempting to localize parts of the body in the highest cere-
bral centres. For my part, I think there are not in the cortex cerebri
any abruptly demarcated centres for any kind of representation. The
recent researches of Beevor and Horsley on the mid-cortex seem to
me to show that the current hypothesis as to localization is untenable.
THE MEDICAL RECORD.
229
“faculties” mentioned, alorg with a development of the
less complex, etc., movements represented by the middle
and lowest motor centres.
I will here analyze the physical basis of but one mental
State, artificializing largely. ‘here is no such thing as a
separate centre for tactual ideas, but for simplicity of ex-
position, we may imagine some part of the highest centres
to be such a centre ; popularly, it is a centre for objects
explored by the hands. When we actually explore an ob-
ject the skin of our fingers and the muscles of our hands
are engaged; and at the same time all sensory centres
from lowest to highest, and all motor centres from highest
to lowest. The tactual centre represents the skin and
muscles of the part of the periphery mentioned—is sen-
sori-motor in that way. The sensory element in the tact-
ual centre corresponds to the surface of objects (the
homologue of color in visual perceptions and ideas), the
motor element to their extension (shape and size). I
have already mentioned the motor element when speaking
of the hierarchy of motor centres. I illustrated by the
representation of the muscles of the hand; their final
representation (re-re-representation) in the highest centres
is the motor element in the tactual centre.
During the actual exploration of an object there is a
vivid mental state; we may call it a tactual perception.
Now suppose we think of the object when it is absent,
popularly, “have an idea of it;” there is then a faint
mental state, a tactual idea. In both cases the centre for
tactual ideas is engaged ; a tactual idea is a faint tactual
perception, and a tactual perception is a vivid tactual
idea ; the centre for tactual ideation and for tactual per-
ception is one; it is made up of the same sensori-motor
arrangements of the highest centres.
But it may be said that while thinking of the object
there is no movement, and it may be averred that the
correlative physical process is sensory only; but the sen-
sory element corresponds only to surface; the extension
requires accounting for; the object thought of has shape
and size. I submit that there is corresponding to exten-
sion slight discharge of the motor nervous arrangements
of the tactual centre, which, when strongly discharged in
the actual exploration, did move the hand ; there is “ nas-
cent movement.” The physical difference more fully is
that (1) during exploration of the object, having a tactual
perception, the tactual centre is strongly discharged from
the sensory periphery, and reacts upon the muscular per-
iphery ; there is strong and complete sensori-motor ac-
tion, all orders of centres being engaged ; while (2) dur-
ing thinking of the object, having a tactual idea, the tactual
centre is slightly discharged, and the discharge is limited
to the centre ; there is weak and incomplete sensori-motor
action ; the highest centres alone are engaged. In both
cases there is sensori-motor action, in both the same nerv-
ous arrangements of the highest centres—those represent-
ing the skin of the fingers and the hand muscles—are dis-
charged. So far for two degrees of normal discharges
of the tactual centre. Now let us suppose that a sudden,
excessive, and rapid discharge (such a discharge as that
which produces an ordinary epileptic fit) begins in some
part of the tactual centre, and soon involves the whole of
it. We should then have a miniature epileptic fit. Dur-
ing the onset there would be tingling referred to the
fingers ; there would be (middle and lowest centres being
subordinately engaged) also convulsion of the hand.
No tactual ideas would arise during such a discharge.
Asking you to accept provisionally the conclusion that
the anatomical substrata of will, memory, reason, and
emotion (together states of consciousness), represent
parts of the body (together, all parts of it, sensorily and
motorily), in most complex, etc., ways, I go on to speak
of the relevance of that hypothesis to the study of some
important diseases. ‘There is no difficulty in understand-
ing that insanity arises from disease of the organ of
mind. But we have to face this question. How ıs it
that the superficially seeming quite different phenomena,
230
THE MEDICAL RECORI).
[August 31, 1889
1, convulsion with cessation of consciousness (an epilepti¢
fit); and, 2, insanity results from morbid affection of the
“organ of mind” (highest centres)? This problem is
forced upon us. We cannot consider one of the two by
itself, and ought not to try to explain each quite separ-
ately. For often enough there is the sequence, an epi-
leptic convulsion with loss of consciousness, and then
temporary insanity, for example, epileptic (post-epileptic,
I think) mania. Moreover, I believe that paralysis also
results from negative states of the highest centres; I sub
mit that it exists in temporary post-epileptic insanities,
indeed in every case of insanity.
After epileptic fits there is often insanity. There are
two degrees of it ; there is, according to the severity of
the paroxysm, mania, or coma, physically two depths of
dissolution effected by the prior epileptic discharge. I
first take coma,’ which is acute temporary dementia
rapidly produced. Here I remark again on the need of
distinguishing psychical states from nervous states. If
any one compares and contrasts post-epileptic coma as
a negative psychical state with a case of paralysis,
say hemiplegia, which is a negative physical state, he
is attempting a pseudo-comparative study. I sub-
mit that the negative affection of consciousness
in the comatose patient implies a correlative nega-
tive state of more or less of his highest centres
which causes paralysis. It is not the negative affection
of consciousness, but the paralysis from the negative state
of elements of the highest centres which that negative af-
fection of consciousness implies, which we can reasonably
compare and contrast with the hemiplegia. It is true
that in post-epileptic coma there is not limited, regional
paralysis, such as hemiplegia or monoplegia ; there is sup-
posed to be some universal, | do not mean total, paralysis.
I am not speaking of paralysis of the muscles. There is
loss of some movements of all parts of the body. That
there is some universal paralysis after a severe epileptic
fit accords with the hypothesis of universal representation
by the highest centres, and is in harmony with the uni-
versality of the convulsion in the prior paroxysm. If a
man cannot move an arm after a convulsion limited to that
limb, no one hesitates to call that condition a paralytic
one. Why then should not the name be given to universal
motionlessness after a universal convulsion? To say that
the patient who is unconscious does not move because he
is unconscious is to give an explanation which explains
nothing. Beevor has noted lateral deviation of the eyes
after epileptic fits; surely this is indirect evidence of
some paralysis. Moreover, Westphal, Gowers, and Beevor
have observed alterations of “ deep reflexes” after such
seizures, and this too accords with the view that the man
comatose after such seizures is paralyzed. Here let me say,
once for all, that no doubt in post-epileptic coma, besides
paralysis from loss of most complex movements repre-
sented in the highest centres, there will be after a severe
fit some paralysis from loss of less complex movements
represented in the middle motor centres, and some from
loss of simplest movements represented in the lowest mo-
tor centres. For in the prior severe epileptic fit all cen-
tres are engaged ; there is an excessive process from high-
est centres to muscles. Indeed (Westphal, Gowers, and
Beevor), after some epileptic fits there is temporary loss
of the knee-jerks, showing exhaustion of the lumbar cen-
tres, which are some of the lowest centres.
The conclusion about post-epileptic coma is very im-
portant, for from it we make the hypothesis that there is
paralysis in all cases of insanity, a widespread or universal
paralysis—that is, paralysis of a kind corresponding to the
universality of representation of the body by the highest
centres, which are certainly diseased in cases of insanity.
I must now briefly analyze these cases of disease of the
highest centres.
.-———
1 I would refer all interested in the application of the doctrine of
evolution to the investigation of diseases of the nervous system to Dr,
Mercier’s masterly article “ Coma” (Brain, January, 1887), a most
lmportant contribution to the methodical study of insanity.
In cases of insanity the mental condition is, as Dr.
Monro long ago insisted, duplex; it is of two opposite
elements, one negative and one positive ; cases of perfect
dementia, if there be such a thing, where the mental con-
dition is entirely negative, are excepted. Ignoring perfect
dementia, there is always some negative affection of con-
sciousness (negative mental symptoms) in cases of insanity ;
there are degrees from slightest defect of it, such as that
existing in trifling confusion of thought, to nearly complete
loss of it, as in dementia, or in coma, which is acute de-
mentia. We must not speak as if there were no degrees be-
tween perfect consciousness and unconsciousness. ‘There
_are also positive, often superpositive, mental symptoms
coexisting with the negative. The defect of consciousness
and the consciousness remaining (that is what I just
called the positive mental symptoms) in cases of in-
sanity vary inversely. When the positive mental symp-
toms are many and elaborate, and the defect of con-
sciousness therefore little, the former may attract exclu-
sive attention. Slight degrees of defect of consciousness
are often disregarded. A patient may be said to be
“ perfectly conscious,” and be said to have illusions, delu-
sions, etc., as if these positive mental symptoms were his
sole symptoms; but surely these positive symptoms
of themselves imply the co-existing negative states of
some non-recognition and some non-reasoning, that is,
they really imply some co-existing defect of consciousness.
A patient may be said to be “ perfectly conscious,” al-
though, when his symptoms are given, he is described as
apathetic, as forgetful, as confused, and as having lost re-
gard for others; these popular statements are nearly, if
not quite, equivalent to the technical statements that the
patient is defective in will, memory, reason, and motion
—in other words, that he zs defectively conscious.
The correlative physical condition of the highest
centres in cases of insanity is correspondingly duplex.
The negative affection of consciousness implies a
negative state of, or of elements of, some nervous ar-
rangements (temporary loss of their function or actual
loss of them) of the highest centres. It is this negative
state alone which implies paralysis ; this alone is dissolu-
tion, this alone is the result of disease in the sense of
pathological change.
Now for the physical condition corresponding to the
positive mental symptoms. As before said, when speak-
ing of the case of paralysis of an external rectus and of
cases of insanity, every nervous disease is to be considered
as a flaw in an evolutionary whole ; and the assertion was
then made that great parts of symptomatologies are owing
to activities of healthy nervous arrangements. I submit
that all the positive mental symptoms in the symptoma-
tology of insanities occur during activities of healthy
nervous arrangements remaining in the maimed highest
centres ; they are, or are parts of, the insane man’s men-
tation ; they are, or are signs of, his lowered conscious-
ness ; his illusions, as we call them, are his perceptions,
and his mental symptoms altogether are lower homologues
of his normal mentation, and are his will, memory, reason,
and emotion. Putting the matter still otherwise, the
positive mental symptoms do not signify dissolution ; they
signify evolution going on in what disease has spared ;
they are signs of survival of the fittest states on the lower,
but now the highest, level of evolution remaining. The
sensori-motor arrangements of this lower level (sub-level
of the highest level) may be over-active from loss of con-
trol, but this is a physiological abnormality ; when I say
that they are healthy, I mean that they are untouched by
any pathological process; they are in the same case as the
heart is when it is beating more frequently after section
of the vagus. When a general paralytic believes himself to
be Emperor of Europe, I submit that this delusion does
not arise during activities of any nervous elements touched
by any sort of pathological process; but, on the contrary,
that it is framed during activities in what remains of his
highest centres, that is to say, in what disease has spared—
presumably the posterior lobes and what is left intact of
August 31, 1889]
the anterior. This delusion (his belief ) signifies evolution
going on in the remains of a mutilated nervous system, as
certainly as his beliefs when sane signified evolution going
on 1n an entire nervous system.
I can now consider the other degree of post-epileptic in-
sanity, mania. Manifestly the mental condition is duplex ;
the patient is “ unconscious” (significant of dissolution) as
well as furiously acting (evolution going on). By artifice,
speaking of layers (sub-levels) of the highest centres, I will
suppose that his “ unconsciousness” signifies loss of func-
tion of the highest two layers of his highest centres. ‘This
produces some universal or widespread paralysis, but less
than that in post-epileptic coma, in which, a deeper dis-
solution, we shall imagine that the highest four lay-
ers are functionless. . But the positive symptoms of
the post-epileptic (unconscious and) maniacal patient
are owing to over-activity of sensori-motor arrange-
ments of the healthy third layer and of still lower lay-
ers of his highest centres; these layers, now his highest,
are in great hyperphysiological activity, being uncon-
trolled by the normal highest two layers which have been
suddenly rendered functionless. To say that there is some
universal paralysis and yet universal activity is not con-
tradictory. “It would be a flat contradiction if it were said
that all the patient’s muscles were perfectly paralyzed and
at the same time in great activity. There is supposed to
be loss of some movements of all muscles, with over-
development of other movements of those same muscles,
Let me consider the matter analogically. Often do we
encounter cases of imperfect hemiplegia ; here, although
clinically we may say that the muscles of the limbs are
weak, there is really loss of some movements of all the
muscles of the limbs, with persistence of others of those
same muscles. Į can now consider the sensori-motor
constitution of the nervous system more widely.
In order to make a proper comparative study of ner-
vous diseases on a large scale we must reduce different
Symptoms to a common denomination. The widest asser-
tion in accord with the hypothesis of sensori-motor con-
stitution of the whole nervous system is, that negative
lesions of every part of it produce paralysis, sensory or
motor, or both, and nothing whatever else.
I will illustrate this dictum further, speaking, however,
of motor paralysis only, by which I always mean loss of
movements. ‘The assertion made is not a mere truism.
For instance, it may be said that negative lesions of the
highest cerebral centres cause loss of consciousness. I
have been urging that they produce paralysis. I admit
that consciousness ceases or diminishes correlatively with
loss of function in these centres; but this is not contra-
` dictory of the statement that the loss of function causes pa-
ralysis. So anxious am I to make out a good case for the
sensori-motor constitution of the highest centres that I will
state a comparatively simple example of artificially produced
insanity, dementia, in a lower animal. When a rabbit’s
cerebrum is cut out the animal is demented. But move-
ments of every part of its body can be evoked by ap-
propriate incitations. Nevertheless, I declare that the
animal is paralyzed. It retains all simple movements
represented on the lowest level of evolution, which is
pretty much all that is left of its cerebral series. But I
submit that it has lost all the more complex movements ;
all those it no longer makes—all those movements which,
in the human subject, we should distinguish as the physi-
cal aspect of cunduct—and is, therefore, universally para-
lyzed. Further illustrations must be given in outline and
briefly. We ought to analyze symptomatologies very care-
fully ; the positive or super-positive symptoms in any case
of negative lesion of any nervous centre cannot possibly
result directly from that lesion. For example, the destruc-
tion effected by a tumor of the middle lobe of the cere-
bellum cannot produce the disorder of co-ordination which
nevertheless is present in such a case. My submission
s that this lesion produces paralysis only; this is first, I
think, loss of some movements of the spinal muscles.
The positive symptoms, the erratic movements of the legs
THE MEDICAL RECORD.
231
by which the patient in an early stage of his ailment does
somehow get along, are the outcome of over-activity of
perfectly healthy nervous arrangements; these are doing
more than their normal share of work. So that, comparing
and contrasting such a case with one of hemiplegia, the
things comparable and contrastable are not the “ disorder of
co-ordination of locomotor movements” with the hemi-
plegia ; the comparison and contrast are of two qases of
paralysis, of loss of movements of the spinal muscles with
loss of movements of the limbs. I submit that the for-
mula describing all inco-ordinations with negative lesions
of nervous centres is that there is, negatively, loss of some
movements, paralysis (this alone being the result of patho-
logical change), with, positively, forcing of some other
movements of the same muscles. In saying this, the as-
sertion I made early in this address, and repeated wher.
stating the duplex condition in cases of insanity—that
much of the symptomatologies of nervous diseases is ow-
ing to activities or over-activities of healthy nervous ele-
ments—is implicitly reiterated. Now for other examples
of paralysis from negative lesions of centres.
I believe that in what is commonly called tremor in a
case of disseminated sclerosis, say of an arm, there is
paralysis in the sense of loss of some movements of the
limb ; the tremor itself is owing to the fact that the ex-
cursions of the limb have to be effected by fewer, and
presumably less fit, movements than normal. Observe
there is loss of some and retention of other movements
of the same muscles. The movements by which
the limb does carry, although erratically, a cup to
the mouth are not blameworthy; they are the best
in the evil circumstances, the next best to the
normal; they are produced, I suggest, by discharges of
healthy nervous arrangements. Let me illustrate the
principle involved by a very simple case, and this time by
one in which the muscles are paralyzed. When a man
has paralysis of the extensors of the forearm, his grasp is
weak and the hand moves clumsily in all its uses. But no
one thinks of blaming the flexors for the weak grasp and
for the clumsy operations of the limb ; the flexors are act-
ing faithfully ; what they do is badly done because the
extensors will not co-operate. So I suggest that in the
kind of tremor spoken of, the fault is that certain move-
ments being lost they no longer co-operate with others
which, being unaided, move the limb erratically ; the real
fault, what the pathological change causes, is paralysis.
That a patch of sclerosis, if it be an absence of proper
nervous elements, can cause any movements, good or bad,
is an impossible thing; the tremor has, however, been
ascribed to imperfect function of intact axis-cylinders in
the parts sclerosed. Now for another example. I have
long held that the lesion in cases of aphasia produces
paralysis in the sense of loss of complex, etc., movements
of the articulatory muscles. It may, however, be urged
that the articulatory muscles move well; so they do in
simple operations, but they never move so as to make ar-
ticulations (syllables). I have so recently dealt with this
matter ' that I will say no more of it. I will, however,
allude to what I said of Semon and Horsley’s experiments
on the representation of the vocal cords in the cortex.
These experiments demonstrate that in one case at
least there may be loss of some movements of a
muscular region, with persistence of so many other
movements of that region that no disability in the
working: of the muscles is discoverable. (‘These ex-
periments are a strong confirmation of Broadbent's well-
known hypothesis, for one case at least.) There are
other cases in which paralysis exists in which it is not ex-
pressly thought of. In cases of pernicious diabetes the
lesion is supposed to be of a certain part of the great
vaso-motor centre ; if so, then what the disease (patholog-
ical process) produces is nothing but paralysis of the
hepatic arterioles. Speaking figuratively, the medulla
oblongata knows nothing of glycogen or sugar ; it only
. = umamin m eng
1 British Medical Journal, July 14 and 21, 1888.
knows the hepatic arterioles. Thus, in a scientific clas-
sification, pernicious diabetes is a paralysis from lesion of
a part of the spinal system (lowest level of evolution of
the central nervous system) as certainly as that ordinary
progressive muscular atrophy, or anterior-polio-myelitis, is.
I suggest that the xerostomia (“dry mouth”), first de-
scribed by Hutchinson, and soon afterward by Hadden, is
also a paralysis—that it is owing to a negative lesion of
the centres for the motor nerves of the salivary and other
oral glands. J
I submit that the essential thing, that which disease, in
the strict sense of pathological change, produces, in cases
of insanity, “disorders of co-ordination” with negative
lesions, tremor, aphasia, pernicious diabetes, and xeros-
tomia is paralysis. ‘This way of looking at cases is most
important when we are engaged in the comparative study
of nervous diseases, and especially of insanities (diseases
of the highest level) with diseases of the lowest level.
I will now give aseries of fragmentary illustrations, largely
hypothetical, of losses of some and persistence of other
movements of the same muscles, the movements lost and
those persisting varying according to the level of evolu-
tion damaged. I submit the hypothesis that (1) progres-
sive muscular atrophy, (2) paralysis agitans, and (3) gen-
eral paralysis are homologous diseases. The comparison
and contrast is not of wasting of muscles, tremor, and a
negative psychical defect. Analysis shows, I think, that,
artificially limiting illustration to the hand, there is loss
respectively of (1) simplest, (2) more complex, and (3)
most complex movements of the hands. ‘The compari-
son is of three cases of paralysis. The lesion is supposed
to be wasting of cells, in the order from smallest to-
ward largest, of lowest, middle, and highest motor cen-
tres respectively. The cases differ according to the level
of evolution morbidly affected. Referring back to what
was said on the hierarchy of motor centres, I now go into
more detail.
1. In progressive muscular atrophy there is loss of
simplest movements of the hands (cerebral and cerebel-
lar), of those represented in some of the lowest motor
centres (anterior horns). In this case the muscles are
cut off from the influence of the whole central nervous
system and waste. It is important to note that there is
retention of more complex (middle centres) and most
complex (highest centres) movements of the hands, cer-
tainly of motor nervous arrangements for them. Did not
motor nervous arrangements still representing the hand
remain in the highest centres the patient could neither
think nor dream of moving the part, and would have no
physical basis for tactual ideas.
2. In paralysis agitans there is (this is, of course, hypo-
thetical) loss of more complex movements of the hand,
those represented in the middle motor centres. ‘There is
retention of the most complex movements represented in
the highest motor centres, and also of the simplest re-
presented in some lowest. With this loss of more com-
plex movements (we might say “middle movements ”)
there is, in the tremor, development of simplest move-
ments of the same muscles, the latest stage being rigidity.
I submit that these movements are the result of mere
physiological over-activity of the healthy lowest motor
centres. To repeat, there is a duplex condition of the
hand ; negatively loss of complex (middle) movements of
its muscles, and, at the same time, super-positively, over-
development of simplest (lowest) movements of the same
muscles. ‘This case (2) differs doubly from (1), for in (1)
the movements lost are (a) simplest, and (4) both the cere-
brum and cerebellum are cut off from the muscles, while
in (2) the movements lost are (2) more complex, and (å)
the cerebellum remains united through the lowest motor
centres with the muscles. (I have suggested that the
cerebellum co-operates with the anterior horns in pro-
ducing the tremor.)
3- In general paralysis there is loss of some of the most
complex (“finest”) movements of the hands, those rep-
resented in the highest motor centres, of those entering
THE MEDICAL RECORD.
[August 31, 1889
into the physical bases of tactual ideas and of other men
tal states. Here there is retention of less complex (mid-
dle) and of simplest (lowest) movements.’
Of course the negative psychical defect in general
paralysis is wider than that answering to loss of motor
elements in the highest centres representing the hand. I
have been artificially limiting the illustration. Yet if
Spencer be right in saying that all other ideas have to be
translated into tactual ideas, to lose tactual ideas 1s to
become imbecile. I will here make further remarks on
the negative mental defect in cases of general paralysis.
I ask you to bear in mind the suggestion that the positive
mental symptoms in this insanity, as in all other insanities,
correspond to activities of healthy nervous arrangements ;
if so, we have nothing to do with them at the time when
we are dealing with the effects of pathological processes.
Most mentation is carried on in visual and tactual
ideas, and by aid of words. ‘To have negative affection
of consciousness is therefore to have especially loss of
these three—I shall limit consideration to - them—and
thus it implies that there is correlatively a negative state
of their sensori-motor bases. In general paralysis the
lesion, if of the highest motor centres, is of the motor
elements in those sensori-motor nervous arrangements—
is loss of more or fewer of the most complex ocular,
manual, and articulatory movements ; the lesion there-
fore produces paralysis in the sense of loss of “finest”
movements of the three parts. I submit that,
taking an early stage of general paralysis, the
tremor of the hands is indirect evidence of loss
of most complex movements of these parts, and
further evidence is the lack of dexterity in manipula-
tion. Similarly for the defective articulation. Now for
paralysis corresponding to loss of visual ideas ; in these
ideas most of all mentation is carried on. Here I admit
a discrepancy. It is said that there are no abnormalities
in ocular movements in general paralysis; but I think
that there is, in some cases, a want of even gliding of the
eyes in their different excursions. I say this diffidently,
and, instead of founding anything on it, will admit that I
can show no evidence of paralysis answering to loss of
motor elements of the physical bases of visual ideas in
cases of general paralysis.
DETAIL IN SURGERY.
BEING THE ADDRESS IN SURGERY, DELIVERED BEFORE
THE BRITISH MEDICAL ASSOCIATION.
By T. PRIDGIN TEALE, M.A., F.R.C.S., F.R.S.
In deciding what line of thought to select for this ad-
dress, I had to consider whether, following the example
of many of my predecessors and of the earlier retrospec-
tive addresses, to give an account of recent advances and
changes in surgery, or to select some definite subject per-
haps not entirely in accordance with precedent.
Happily, my immediate predecessor devoted his ad
dress to a review of the surgery of the last half century,
absolving me from the obligation to adopt a similar
course, and setting me free to choose a subject more con-
genial to my habit and work.
“ Detail in Surgery” is the title selected for this ad-
dress, in which I hope to show how much some of the
triumphs and shortcomings of modern surgery are made
or marred by the carrying out of detail, detail which 1s
essentially embodiment ot principle, not the mere multipli-
cation of points of practice such as may not materially
further the end in view.
In working out this line of thought, I hope to be able
profitably to employ the time at my disposal, and to give
—-- —
1 Of course I do not mean that the lesions in general paralysis are
limited to the highest motor centres. I am dealing with what I sup-
pose to be the effects of lesions of those centres in this disease, and
am taking but one fragment of these effects in illustration, More-
over, general paralysis is not a well-defined clinical entity.
August 31, 1889]
THE MEDICAL RECORD.
233
prominence to conclusions which have been formed dur-
ing a surgical life of over thirty years, made up not of my
own work alone, but very largely of the freest interchange
of thought and experience with most friendly and active-
minded colleagues, medical and surgical, with whom it
has been my great happiness to be associated. In so
doing, it has been my endeavor to be as little egotistical
as is compatible with the attainment of the end in view.
Ligature of Arteries.—It happened not long ago that I
had to deal with a wound of the brachial, at the bend of
the elbow. Esmarch’s tourniquet enabled me to expose
beautifully to the eye a longitudinal slit in the artery. Of
course I was obliged to apply a ligature on .both sides of
the puncture. There were then clearly exposed to view
the two ligatures, and about half an inch of the artery
containing the slit. It occurred to me to divide the artery
between the ligatures, and so to relieve obvious tension.
I then appreciated what I had never before fully realized
in connection with ligature of an artery, the immense
elasticity of the arterial coats. The separated ends re-
ceded fully half an inch from one another. The question
at once occurred to me, Can it be right ever to tie an
artery by a single ligature, and to leave this powerful
force of elasticity to work for ulceration of the coats and |
gaping of the ulcer, with the risk of final disturbance by
retraction of the divided ends when ulceration has com-
pleted its work? May we not here find an explanation
of the numerous failures of ligature of the great arteries
of twenty and thirty years ago, and of the fatal secondary
hemorrhages, chiefly from the distal end? Some may
say that antiseptics and the cutting short of the ligature
have changed all that, have reduced the risk of ulcera.
. tion of the coats of the artery and of secondary hemor-
rhage. Well, antiseptics fail now and then ; and if they
should fail we may be thankful for the additional protec-
tion of a doubly-tied divided artery. Secondary hemor-
rhage and fatal result will be thereby rendered extremely
improbable. Recently I assisted my friend, Mr. R. N.
Hartley, in a case in which he first ligatured the femoral
and, a week later, the external iliac on the same side in
the same patient. On both occasions he doubly tied and
divided the artery with admirable result. ‘This principle,
proposed by Abernethy and afterward forgotten, has re-
cently been restored to practice at St. Bartholomew's
Hospital by Mr. Walsham, and is, I believe, practised
elsewhere. May we not call this “a detail” in the oper-
ation of tying an artery? Does it not embody a princi-
ple—the principle of physiological rest? Are we to rec-
ognize and act upon the fact of the elasticity of an artery
or are we to ignore it, and to place our patient at the
mercy of elastic drag, tension, ulceration, retraction when
liberated, and secondary hemorrhage? Does it not also
involve the larger principle of rest as an important factor
in the healing of any tissue.
Stricture.—There is a form of instrument for the treat-
ment of stricture which has been but little written about, and
although at last slowly making its way into use, has not
met with the attention which I feel sure it deserves. It
is known to me by the name of “ Lister’s sound,” and
was invented by Sir Joseph Lister.
From the very commencement of my pro-
fessional life I have been familiar with and have
been taught to use in the treatment of stricture
“ bulbed” steel sounds, which seem to have existed as
traditional instruments in the Leeds Infirmary, were con-
stantly used by my father and the older surgeons, and
were, I believe brought to Leeds by the late Mr. Sam-
uel Smith, who had learnt their use from his master,
Sir Charles Bell, in Edinburgh. The virtue of the bulb
is this: that, the stem of the instrument being neces-
sarily smaller than the bulb, as soon as the bulb has
passed through the stricture the instrument is free, and
the touch of the surgeon is at liberty to perceive the
character of the succeeding part of the urethra. Com-
pared with the bulbed sound, the ordinary catheter, which,
as a student, I frequently witnessed in use in the treat
ment of stricture, was clumsy and eminently unsatisfactory.
The defect of the bulbed sound, in common with most other
methods of treating stricture, was, that as soon as one
size had been passed through a stricture, the same pro-
cess of difficulty had to be encountered in passing the
size larger. Some twelve years ago, while I was con-
sidering how to overcome this difficulty, our house-sur-
geon, Mr. Rowell, on his return from a visit to Edinburgh
said to me: “ Here is the instrument you want, a Lister’s
sound.” I ordered a set, and I have used them ever
since, exclusively, and have never flinched one moment
from my allegiance to them. The principle of the instru-
ment is this. It is bulbed at the point, like our old
bulbed sounds: ‘Then after the narrow neck the stem
gradually increases until it attains, at a point about four
inches from the bulb, a calibre two sizes larger than the bulb.
Thus: No. 1 at the bulb swells to No. 3 or 4; No. 9 to
12; No. 11 to 14. It is clear, then, that if you can once
pass No. 1 safely into the bladder you have prepared the
` way by the thickness of the stem for the more easy intro-
duction of a sound with a bulb of the size of No. 2, and
so on, each number passed rendering the way more easy
for its successor. As a matter of fact, the larger sizes are
passed with constantly increasing facility.
Have we not here a “ detail” in the form of an instru-
ment which solves many difficulties, combining the ad-
vantages of the bulbed sound with those of the conical
sounds and bougies, and avoiding the disadvantages of
both? It destroys the need of catheters with the hollow
eye capable of carrying concealed poison, of gum-elastic
catheters, and catgut bougies with the possibility of septic
material lurking in interstices and cracks, and reduces
very greatly the need of perineal section or internal ure-
throtomy.
Let me sum up my own experiences of the use of
Lister’s sound, which for the last twelve years has been,
both in hospital and private practice, most satisfactory.
Since their adoption, as far as I can recollect, I have only
once had to perform perineal section from inability to get
through, or to satisfactorily dilate a stricture. I have
never performed internal urethrotomy, nor felt the need
of it. Rigors are extremely rare after the use of Lister's
sounds. ‘This rarity of rigor I am irclined to attribute to
the fact that in nearly every instance dilatation has been
carried, at the first sitting, up to 10, 11,or 12. It
is my belief that full dilatation at the first sitting is
safer than the older method of partial and gradual
dilatation, and for this reason: Even in partial dilata-
tion there is frequently some laceration or bruising of
the surface at the strictured point. If the stricture
be only partially dilated, there remains a narrow-
ing at this sore point sufficient to materially arrest
the flow of urine, and therefore there is uri
pressure on the raw surface ; whereas in full dilatation the
urine flows along the urethra equably and without undue
pressure at any point; and puts no stress upon the tender
and perhaps lacerated surface of the stricture.
In a small number of cases I have failed to introduce
Lister’s No. 1, but these have been got over by the aid of
‘leevan’s filiform guide, which in every case was success-
fully passed. ‘The guide having been introduced through
the stricture, its outer end is then screwed into the tip
of a conical sound, like Lister’s, with the bulb cut off.
The filiform bougie guides the solid instrument through
the stricture, and thus dilatation up to 4 or 5 Lister is se-
cured, with the usual easy sequence up to 12 or 14.
Effective drainage may be defined as “such a provision
for the escape of fluid from any cavity as shall secure that
the discharges, which when secreted are sweet, shall escape
from the cavity before they have time to putrefy, and shall
be received into one of the aseptic absorbent materials
with which surgery is now so: abundantly provided.”
Formerly the idea of drainage was almost limited to
“ free incision and a dependent opening.” ‘This idea was
true to a certain extent and in some cases, of which the
following is a brilliant example: A man was received
234
into the Leeds Infirmary suffering from pneumothorax on
the left side, frọm broken rib. The air was rapidly ab-
sorbed, but shortly the pleural cavity became full of fluid.
This was drawn off twice, and on the second occasion was
purulent. For some reason or other, the patient being
extremely ill, an opening was made into the chest in front.
‘He continued to lose strength and flesh, became extremely
emaciated and albuminuric. Asa forlorn hope, an incision
was made into the pleural cavity posteriorly, whereby a
free, dependent, self-draining opening was secured. In
three months the wounds had healed, the patient had
gained forty-two pounds in weight, had lost his albumi-
nuria, and was well.
But a dependent opening is not always the most effi-
cient or the best. I was requested by my colleague, Mr.
Mayo Robson, to see with him a lady with pelvic suppu-
tation discharging through the rectum, that is, by a de-
pendent opening. It was the source of much pain and of
occasional febrile attacks and ill-health. A tumor about
the size of an orange, and supposed to be the source of
the pus, was felt by rectum and vagina. Mr. Robson
carried out the following treatment, agreed upon at our,
consultation: Having exposed the tumor by direct ab-
dominal incision, he stitched the peritoneum of the edge
of the incision to the upper surface of the tumor, leaving
a small area of the tumor exposed, and rendered thereby
extra-peritoneal. He then cut into the tumor until he
reached a collection of offensive pus, and washed out and
drained the cavity. Immediately pus ceased to appear by
rectum, that is, by the downward drainage, and in four
weeks the whole was healed and the patient was well.
Until recently surgery has been too much a slave to the
principle of a dependent opening. A dependent opening
may be for the moment efficient while the cavity is dis.
tended, and yet, after it is emptied and collapsed, may
become valvular and inefficient. Moreover, when a large
cavity has been emptied, the walls may, by their collapse,
shut off portions of the surface from satisfactory drain-
age. Drainage, therefore, is a “ detail ” which needs to be
studied in reference to each individual case. The leading
idea should he so to provide, whether by position of open-
ings, by shape of opening, or by use of drainage-tube, that `
secretions shall escape from every part before they have
time to become septic, remembering that if a way of es-
cape for fluid without risk of imprisonment be provided,
we generally have to aid us the elasticity, or contractility,
or displacing compression of surrounding tissues, and that
we may be, to a great extent, independent of mere gravi-
tation.
Such ideas, clearly held, will set us free, and encourage
us to continue, as we now ‘do, to drain abdominal cavities,
abscesses, irremovable cysts, distended gall-bladders, pel-
vic abscesses, and, perhaps, even abscesses connected with
diseased hip-joint, by a mode of drainage which is any-
thing but a dependent opening, but which we have learnt
how to render efficient.
This idea of drainage, combined with the principle of
rendering a cavity extra-peritoneal, is the key to some of
the recent masterly developments of abdominal surgery,
whereby deeply seated cavities containing offensive and
septic materials can be treated with comparative safety.
Peritoneal Stitching.—Another detail in surgery which
I have only recently learned to appreciate is that of the
independent stitching of the peritoneum. The looseness
of the attachment of the peritoneum to the abdominal
wall allows it to be dealt with with great freedom, as has
already been referred to in the paragraph on “ Drainage.”
A few months ago, when I was about to stitch up the ab-
dominal wall after ovariotomy, Mr. Hartley, who was
assisting me, asked, Why not stitch up the peritoneum
alone, and then unite the rest of the abdominal wall by a
separate set of stitches?” I at once acted upon the sug-
gestion, knowing that it had been practised by others.
The effect was to make the closing of the abdominal wall
much simpler, and not more tedious. ‘The advantages
appeared to be: (a) absence of tension on the peritoneal
THE MEDICAL RECORD.
[August 31, 1889
union, (4) very little bleeding from the peritoneal stitches,
and (c) greater facility in uniting the abdominal wall, from
not having to provide for the accurate adaptation of the
peritoneal edges. After the operation the patient seemed
to be more free than usual from discomfort in the wound.
It is possible that further advantages may accrue, such as
diminished proneness to hernia of the scar, and less lia-
bility to suppuration in the track of the sutures. So
much for the value of this detail in ‘ovariotomy and
abdominal section. But the lesson thus learnt went
further. Not long ago I was called in the middle of the
night to a patient suffering from strangulated umbilical
hernia, who had been admitted into the Leeds Infir-
mary in order that she might undergo an operation for
radical cure, strangulation having suddenly set in while
she was waiting for the operation. After reducing the
bowel and removing a large mass of omentum, I was pre-
pared to close the abdominal ring, which had a diameter
of aninch. ‘To close this in the ordinary way by sutures,
so as to secure union of the peritoneal edge, which is ad-
herent to the margin of the ring, is no easy nor certain
proceeding. I therefore, with the scalpel, incised round
the margin of the ring, and thereby got a starting-point
_whence I could strip the peritoneum from the under sur-
face of the abdominal wall over a radius of about an
inch. The edges of the opening in the peritoneum were
then easily brought together, and closed by a row of five or
six stitches. ‘The peritoneal cavity having been thereby
closed and cut off from the wound, two wire sutures were
inserted into the aponeurotic ring of the linea alba, so as
to bring the opposite sides together, and were cut off, to
be left as a permanent barrier. It seems likely that such
a proceeding may increase the safety of operations for |
umbilical hernia, whether undertaken to relieve strangula-
tion, or for radical cure.
The Sphincter Ani in the Surgery of the Rectum.—
There is a detail in operations on the rectum or anus
which, rightly carried out, contributes very greatly to ease in
operating, to the comfort of the patient after the operation,
and to the permanency and perfection of the result. As
a preliminary step, in every operation on the rectum or
anus, there should be dilatation of the sphincter ani by the
fingers. ‘To some this may seem a truism, a self-evident
proposition, which it were waste of time and breath to as-
sert. The fact, however, is that it is far from self-evident
to many surgical minds, and has not been acted upon as a
general rule, and, until very recently, has been absolutely
ignored by many rectal specialists, and by writers on gen-
eral surgery.
First and most conspicuous in this relation are bleeding
internal piles. Some twenty five years ago, I was asked to
operate for bleeding piles on a gentleman about thirty
years of age. On mentioning the case to my father, he
said, “ Dilate the sphincter, and most likely you will
never have to operate on the piles; they will be cured.”
His anticipation proved to be correct. The advice was
acted upon, and the gentleman has remained well to the
present time. So late as in 1887 did M. Verneuil bring
this subject as a novelty before a meeting of surgeons in
Paris, nearly all of whom were entirely ignorant of the
question. ‘This experience was amply confirmed by sub-
sequent cases, and I now rarely operate on internal hemor-
rhoids without having previously tested the effect of simple
stretching of the sphincter. In more severe cases, requir-
ing the removal of hemorrhoids, the stretching, as a pre-
liminary to operation, at once displays the piles to view,
and places them in a ready position for being seen, seized,
and dealt with. Another advantage is that, after the
operation, the parts remain at rest, and the wounded
tissues are not liable to protrude and to be strangled by a
resentful sphincter. Also, if there be bleeding, there is
great facility for the escape and discovery of the blood,
and therefore less danger of concealed hemorrhage, which
may fill the rectum with a large clot, perhaps only to be sus-
pected from the pallor and feeble pulse of the patient. A
further advantage is that wounded and granulating sur-
August 31, 1889]
faces within the rectum are not interfered with, or kept
in a painful or irritable state, after the fashion of fissure,
by an over-active, excitable sphincter. ‘Two cases have
recently been under my care in which long-continued suf-
fering, after removal of piles without stretching of sphinc-
ter, was at once cured by simple dilatation.
Contrast with this the clumsy and unscientific plan,
until recently recommended in the text-books, of request-
ing the patient to “ bring down” the piles by sitting over
hot water before operation, so as to afford the surgeon an
opportunity of playing hide and seek with the elusive
hemorrhoids, aided by their confederate sphincter.
In operations for fistula in ano, dilatation of the sphinc-
ter is an essential preliminary. If the internal orifice be
close to the anus, it is at once displayed or brought with-
in easy reach. If it be at some distance, and beyond
the sphincter, this proceeding renders it possible to cure
the fistula without extending the incision up to the in-
ternal orifice, and so risking loss of control over the ac-
tion of the bowel by too free division of the sphincter
ani. Such deeply burrowing fistulas I have cured on
several occasions in the following manner. The sphinc-
ter having been freely dilated, the external orifice of the
fistula was enlarged laterally in such a way that the open-
ing in the skin was the base of a triangle with its apex at
the other end of the fistula, where it communicated with
the bowel. The track of the fistula was freely scraped,
and a drainage-tube was inserted, so as to reach within
half an inch of the opening into the bowel. Undoubtedly
the key to a successful result in such a case is the “ de
tail” of dilatation of the sphincter, which by its relaxation
allows the contents of the bowel to pass away easily, and
without forcing secretions backward into the fistula, until
time has been given for the freshly scraped surface to
unite and seal the offending track. ‘Time will not allow
me to say much more on this far-reaching topic, but there
is one point I must not omit. Of late years, the question
of dilatation of the os and cervix uteri, and of treatment
of the cavity of the uterus for endometritis and other
metritic troubles, has come very much to the front. In-
deed, it is a selected subject of discussion at the present
meeting in the Obstetric Section. In some of the discus-
sions by gynecologists I notice that much is said of con-
stipation as a factor in these cases, and as one that ought
to be treated and remedied, of course by medicines, as a
preliminary to any special interference with the uterus.
In some cases I know, and in many others I suspect, that
the cause of the constipation is a tight, or spasmodic, or
irritable sphincter. In such a case stretch the sphincter,
and you may “ throw physic to the dogs.” And let me
note in passing that there are instances in which the
sphincter may cause constipation and its train of symp-
toms, without any evidence of fissure, or anal pain, or
bleeding ; or there may be what I have often observed,
but have never seen described, a peculiar ngidity, a sort
of inelastic ring, like a fibrous degeneration of the mus-
cle, which does not resist the introduction of one finger,
but bars the rectum as with a ring of iron to the introduc-
tion of two. In such cases only artificially softened evac-
uations can escape. May we not consider dilatation of
the sphincter to be a “ detail” in surgery worth study no
less by the physician than by the surgeon ?
Ether versus Chloroform.— This is a subject on which
I wish to speak with a sense of grave responsibility—the
more so that I have to express views which are strongly
opposed to those uttered at Glasgow last year by my pre-
‘decessor in this chair.
If anyone asks why I venture to differ so widely and
strongly from one whose surgical experience is probably
not less than my own, and may be greater, my plea is as
follows :—
For the first fifteen years of my surgical life, which
includes ten years as surgeon to the Leeds Infirmary, I
knew little of any anesthetic but chloroform. So far,
probably, our experience runs parallel. During the last
fifteen years ether has almost superseded chloroform in
THE MEDICAL RECORD.
235
my practice. Here the parallel ceases. Sir George
Macleod’s second fifteen years are still devoted to chloro-
form. He cannot speak from fifteen years’ experience of -
ether. As a result of the comparison of these two periods,
I unhesitatingly assert that ether is, for safety to the pa-
tient and for comfort and convenience to the operator,
immeasurably the better anesthetic of the two. Ether
can be given “tude, cito, et jucunde!” I say can be;
would that I could say #s always so given.
My earliest experience of ether was in the method
introduced by Dr. Joy Jeffreys, when, at the Inter-
national Ophthalmic Congress in 1872, he preached
his crusade against the almost universal use of
chloroform prevalent in the United Kingdom, and com-
pelled British surgeons to take up the question of ether.
He appealed to our sense of duty in reference to the
fearfully increasing fatality of chloroform, and we respond-
ed to his call, in spite of the grave disadvantages of the
clumsy, wasteful, nay harmful, method of giving ether, by
lavishly pouring it into a cone formed of a towel, to which
he introduced us. The disadvantages of ether so given
were great and obvious. ‘The struggling of the patient,
the icy coldness of the inhaled air, the saturation of the
air of the room by twelve, fifteen, or twenty ounces of
ether spent upon a single case, and the not infrequent,
and occasionally fatal, bronchitis which followed, were
such obvious drawbacks that the wonder is that ether sur-
vived as an anzesthetic in England until it had time, by
improved methods and increased experience, to win its
way to the pre-eminent confidence which it now com-
mands. ‘The towel was, after a time, superseded by the
wicker grid—brought over from America by a late chap-
lain to the Leeds Infirmary, the Rev. E. Spencer Gough—
an improvement on the towel, but sharing with it the
chilling of every inhalation by the evaporating ether as
well as a high percentage of waste of the anesthetic. The
method of administering nitrous oxide gas before giving
ether was, in his later years, largely given up by Clover.
Next came the great step which was the saving of ether
as a British anesthetic. Ormsby, of Dublin, invented the
inhaler in which the exhaled warm air, charged as it is
with ether, was received into an india-rubber bag and
breathed over and over again, thus economizing the heat
of about ninety per cent. of the exhalations and reducing
the waste of ether. This idea was taken up by Clover
and developed into the present form of inhaler, which, as
far as I know, is unapproached by any method of giving
ether that has come into use. But, Won cuivis homini
contingit adire Corinthum. It is not everyone who knows,
and there are some who are incapable of learning, how to
administer ether, even with Clover’s inhaler.
There are many hospitals in England, and still more, I
believe, in Scotland, where the use of ether is practically
unknown, or where, if ether is given, the obsolete towel
or the grid, or the very inferior inhaler of Ormsby is used ;
or even should the hospital possess a Clover, it may not
possess an etherist who knows how to use it to the best
advantage. To administer ether badly is to bring it down
nearly to a level with chloroform as to safety, and to
render it inferior to chloroform as to comfort to the pa-
tient. A bad etherist will cause fear, coughing, distress-
ing sense of suffocation, excitement, struggling, blueness
of lips, mucous rattling in the trachea and bronchi. He
will take many minutes, five to ten, in getting his patient
under the anesthetic, will use twice or thrice as much ether
as is needful, will keep his patient when unconscious over-
charged with ether, in a state of profound stertor, and will
now and then set up a dangerous bronchitis. A good
etherist will win the confidence of his patient, even of the
most timid, by judicious encouragement, and by first ap-
plying the mouthpiece alone. As confidence becomes
established he adds the reservoir, and then the india-rub-
ber bag, slowly turning on the ether as tolerance of the
vapor becomes established, and unconsciousness begins to
steal on. ‘Then he more rapidly increases the proportion
of ether, and the patient quickly falls into complete
236
anesthesia. Such an administrator will, in nine cases out
of ten, have his patient ready for operation in two or three
_ minutes, and not infrequently in about a minute and a half,
without a struggle, without coughing, often without even
a transient sense of suffocation, and with the expenditure
of about half an ounce of ether, and will need but about
one ounce of ether for eaca quarter of an hour that the
anzesthesia is kept up. In such a case we need fear no
danger at the time, nor subsequent bronchitis. So much
for the patient.
But there is another side of the ether question which I
have never seen adequately stated. The advantages to
the operator of using ether instead of chloroform are very
great. In the first place, his anxiety is less, his fear of a
fatal issue is less, and when obliged to trust to an inex-
perienced administrator, as he must do at times in sudden
emergencies, he can more efficiently keep an eye on the
patient’s condition, and superintend the administrator,
than when chloroform is used.
In the second place there is a saving of time, a patient
being brought under the influence of ether in two or
three minutes, whereas chloroform, in my experience,
needs eight or ten. Such a saving is of no slight mo-
ment in modern hospital practice now that the sphere of
surgery has become so enormously extended.
In the third place, under ether return of conscious-
ness to pain generally lags behind the return of men-
tal perception, and thus anesthesia can easily be re-
established without interrupting the operation. So
marked is this fact toward the end of a prolonged
operation that sometimes the surgeon may continue
to operate for ten minutes or a quarter of an hour
without re-application of the inhaler, and even con-
verse with his patient while stitching up a wound.
This is hardly, or rarely, the case with chloroform. Let
anyone who is not yet a convert to ether, or who, having
used ether, is wavering in his allegiance to it, ask himself
these questions. Have I myself studied the details of
successful etherization? Am I using the best form of
inhaler? Have I taken pains to have those who act for
me properly taught and trained? If not, let him ask him-
self one more question—Have I done my duty ?
Instruments—The Scalpel.—An essay on “ Detail in
Surgery” would hardly be complete without some words
about “instruments.” Instruments bearing the same
name are apt to vary in shape. Some forms are certainly
better than “other some.” Certain good forms and types
are, apt to go out of fashion, to “get out of print,” and to
be superseded by inferior types. It is often difficnlt to
get the best type of instrument, or to renew a lost form,
so great is the tendency to degeneration and departure
from the original type. Take as an illustration one of
the simplest and most frequently used, a “ scalpel.” How
rare it is to meet with a scalpel of good form; and yet
we have the pattern admirably drawn in the work on
Surgery, by that master hand in the selection, designing,
and handling of instruments, Sir William Fergusson.
The scalpel should be to the surgeon what the pencil is
to the artist. The surgeon should be conscious, even
with his eyes shut, where the point of his scalpel is, his
eye should be upon the tissues he is about tocut, not in
continual search for the point of his instrument. And
how can he feel where the point of his instrument lies un-
less the point be central; and how can the point be cen-
tral except the scalpel be truly lancet-shaped? How few
of our instrument makers turn out truly balanced central
pointed scalpels. Fewer still can keep our scalpels in
order without grinding the point away until it reaches the
level of the back of the knife, giving us, instead of the
beautiful, sawing, lancet-shaped curve of edge, an edge
belly-shaped, flat toward the point, ready to be blunted
by the first plunge into the skin.
The Director.—Another simple, universally used instru-
ment, is the “ director,” which is rarely met with of good
form, as generally offered for sale. It is straight, instead
of having an elegant double curve, slight indeed, but such
THE MEDICAL RECORD.
[August 31, 1889
as would enable the surgeon to insinuate the instrument
along curving passages, or more conveniently to bring the
point to tell from beneath against the skin. It is often
too deep or too narrow in the groove, and the groove, in-
stead of shelving off to a vanishing-point and allowing
the bistoury to continue its course, ends in a full stop, and
spoils both the course and the point of the knife. Another
faulty point is the handle. A director should be capable
of being held firmly, the handle being substantial, not thin,
long enough and not stumpy, and horizontally roughened
and not slippery. You may perhaps think this a long tale
about a small matter.
Catheters and Sounds.—The metallic catheter or sound
is, or was, an instrument used by nearly every medical
man. As with the scalpel so with the catheter, the sur-
geon should be able to feel, that is to be conscious, where
the point of the catheter or sound is, and without seeing
it, as he cannot have his eye upon the point when in use.
In order that we may feel where the point of the catheter
is, the straight stem should be continued into a true curve,
that is, a segment of a single circle, probably exactly a
quadrant. And yet what do we generally find? A curve,
which at one part is the curve of a one-sized circle, at an
other part is a curve of a circle of a different size, or the
catheter may terminate with about one inch of its length
which is a segment of no circle whatever. The same ap-
plies to sounds, and even to some sets of Lister’s sounds.
My own had to be remodelled and brought to a correct
curve. |
_ Volsellum Forceps.—Perhaps no single instrument has
been made in greater variety of form and shape than
the “ volsellum forceps,” of which I possess a consid-
erable variety. The principle on which the majority
are formed ıs that of one, two, or more pairs of teeth
or claws, or fangs, which sometimes fit accurately when
closed, so as to present no projecting points, some-
times expose unguarded points which interfere with
easy manipulation, and may prick the surgeon’s finger
when guiding them to their destination. Probably
the best of this class is the hawk’s-claw forceps, designed
by Mr. R. B. Hewetson, of Leeds, copied from a bird's
claw. It consists of five prongs, which fit so accu-
rately at the points as to present when closed, a smooth
rounded surface. Forceps of this class are essentially
grouped hooks, and like hooks are apt to tear through
tissues when any forcible drag is put upon them. The
needs of abdominal and uterine surgery have, however,
created a demand for a form of forceps which shall be
capable of maintaining a firm grip without tearing of tis-
sue, even under the stress of considerable drag. This
need forced itself upon my attention when working out a
satisfactory method of rapid dilatation of the os and cer-
vix uteri. Marion Sims taught us the value of drawing
down the os uteri by a hook. But the hook will not pro-
vide for a prolonged and powerful drag, such as is needed
to fix the uterus in dilating the os internum. ‘The other
forms of hook were tried, and the claw-like volsellum
forceps, and all at times disappointed me, until, taking
a hint from a small pair of forceps which were found in
the collection at the Leeds Infirmary, I həd made by
Messrs. Weiss a pair of forceps which has proved most
satisfactory. The teeth, seven in number (three and
four), are short, and so fit into one another when closed,
that they not only act as seven hooks, but also close upon
and nip firmly the tissues that lie between them. ‘They
are also provided with a catch, so that they will hang, or
can be held by a single finger passed through one ring.
The key to satisfactory uterine dilatation is the power of
holding the os uteri down toward the vulva, and no form
of forceps that I have met with is equal in efficiency to
the one now described. Had I possessed them years
ago, they would have saved me hours of work, and per-
haps sometimes failure, in operations for vesico-vaginal
fistula.
The Twitch Tourniquet and Torsion Clamp.—some
years ago Messrs. Weiss made for me an instrument
August 31, 1889]
THE MEDICAL RECORD.
237
named the “twitch tourniquet,” which has not yet been
It has proved useful to me on many
occasions as an easy means of controlling the cord in ex-
tirpation of the testis, as a more handy and manageable
clamp in amputation of the penis than the ingenious vul-
canite plate of Clover, and as an aid in removal of intra-
uterine fibroma. The idea was suggested by the “ twitch”
used by veterinary surgeons for controlling horses by a
described in print.
hold on the upper lip. ‘The idea stood me in such good
stead when in a great fix not long ago that I have devel-
oped out of it the “uterine torsion clamp,” designed to
do the work of Kceberlé’s and Lawson Tait’s clamp in
hysterectomy. The emergency was as follows: A few
months ago, when operating on a supposed simple ovarian
tumor, at the Leeds Infirmary, I unexpectedly found that
it was so completely united with the -back of the uterus
that I must include the uterus in the pedicle. Kceberlé’s
clamp was produced, but the screws would not bite, and
we had no other clamp at hand, We were suddenly face
to face with an extreme difficulty. Mr. Littlewood, who
was assisting me, suggested the wire ¢craseur as a way out
of the difficulty, and the thought struck me at once that,
having surrounded the pedicle with the wire, I might
tighten by torsion instead of by the mechanism of the
écraseur. The result was so satisfactory that I deter-
mined to modify the “ twitch tourniquet ” so that it might
admit of the use of suitable flexible wire, which, having
been tightened by torsion to any desired extent, could be
teleased and left on the pedicle as a clamp.
Conclusion.—Those of my hearers, and readers—for an
address to the British Medical Association is practically
delivered urdi et orbi—those, I say, who have expected to
hear a triumphant record of the astonishing progress of
surgery, or a pean on our local] surgical achievements,
may be disappointed at the humble theme which I have
attempted to work out, and may think that I have failed
to do justice to colleagues who have done much to leave
a mark upon the progress of surgery. My aim has been
not to sound the praise of individuals, much as they de-
serve it, but rather to leave an impression on the practice
of surgery.
If any of you shall have been induced to study afresh,
and from the point of view put forward in this address,
the question of division of an artery between two liga-
tures, the bearing of the sphincter ani upon the surgery
of the rectum and disturbed functions of the colon; the
substitution of Lister’s sounds for older methods in the
treatment of stricture ; the emancipation of “drainage”
from red-tape rules ; and, lastly, the proper method of
administration of ether so as to raise it as an anesthetic to
a position of incontestable superiority to chloroform—if
such should be the outcome of this address, your time in
listening will, I trust, not have been wasted, and my labor
in composing it may not have been in vain.
SIMPLE METHODS FOR MAKING CORROSION
PREPARATIONS SHOWING THE GROSS
ANATOMY OF LARGE VISCERA.’
By J. WEST ROOSEVELT, M.D.,
ATTENDING PHYSICIAN AND ASSISTANT PATHOLOGIST TO THE ROOSEVELT HOS-
PITAL; VISITING PHYSICIAN TO BELLEVUE HOSPITAL, NEW YORK.
My object in presenting these preparations of the heart,
lungs, and kidney is to direct attention to the value of the
method for study, and also to show that little but patience
Is required to make them. It is needless to say that no
originality is claimed. Some of the details have not,
however, been described before, as far as I know.
Corrosion preparations are usually broken by handling ;
by currents in the corroding fluids ; by unequal corrosion;
and a consequent tendency of the specimen to turn sud-
denly over in the solution as its centre of flotation is
changed, or to break because of the unequal support
1 Read befor: the New York Pathological Society, April 24, 1889.
given when the ends of the specimen tend to float higher
or lower than the middle.
It is evident, therefore, the first thing is to avoid hand-
ling. This is easily done if the organ be fastened to a
proper support. All the indications are fulfilled if the
various tubes be fastened together and to some support,
and if the corroding agent be so applied as to avoid mak-
ing currents. The support should be arranged so that it
prevents sudden turning, and also so that it holds the
organ at nearly the same position in relation to the cor-
roding agent, if this latter rise or fall, or if the organ
changes its centre of flotation. The method first de-
scribed applies to all viscera with which I have experi-
mented (heart, liver, spleen, pancreas, and kidneys) except
the lungs, which require special treatment.
The cannulz may be of glass or hard rubber, and are in-
serted and fastened in the usual way. The injection may
be made with a syringe or in any other manner. All the
pipes should be as large as possible.
After the cannule are in place the organ is put into a
rather deep glass jar, nearly filled with warm water (102°—
110° F.).' The injection is then made, and the organ
removed to another jar containing cold water. As soon
as the mass has cooled in the cannulz the organ is raised
by them so that they are above the water-level. A
short, stout §-hook of glass is now tied either to the can-
nulz or to the injected vessels. After this the vessels and
the hook are all fastened together, either by pouring
melted paraffin over them, or by means of melted shel-
lac. It is then hooked over a piece of thin rubber tub-
ing, which is to be fastened across the mouth of the jar
after most of the water has been siphoned off. This tub-
ing should be sufficiently elastic to allow considerable rise
and fall of the viscus with the changing fluid level, and
also allow it to sink deeper as the lower parts become dis-
solved. The water is next siphoned off until only enough
remains to support the specimen. Strong hydrochloric
acid (commercial) is then poured over the surface of the
organ in quantity sufficient to raise it nearly to the top
of the jar. The rubber tubing, which has until now been
left loose, is next fastened to the jar or some convenient
object. (It is frequently better to have an independent
support for the elastic tube. A shallower dish may then
be used for the specimen, and this may be put over a
deeper one. ‘The various corroding agents may then be
allowed simply to overflow the sides of the shallower dish
and be siphoned off from the deeper when necessary.)
Sufficient strain should be made on the rubber to lift the
specimen partly out of the fluid, so that a small portion |
of its surface is exposed.
After the specimen has been twenty-four hours or more
in the acid, this may be replaced by water, poured in
through a funnel, the tube of which is carried down to the
bottom of the jar. If water supply be available, a glass
tube attached to a faucet by rubber tubing may be car-
ried down to the bottom of the jar and a gentle stream
turned on. The specimen may remain from one to
twenty-four or more hours in water. After this more
hydrochloric acid may be added, and the process repeated
as often as necessary.
When the specimen is clean it is carefully removed
from the jar. If it be very large, several cords may have
to be attached to it at different points. It is better, with
delicate specimens, to remove the fluid by a siphon than
to try to lift them. The siphon makes less current. If
paraffin be the basis of the injection, varnish may be now
applied, in the manner soon to be described, before any
further manipulation.
In dealing with the lungs the process is different, since
these organs tend to float so high. If possible, they should
be injected in the unopened thorax, the latter being sub-
sequently opened and the lungs treated i” sit. As this
procedure is rarely possible in the human subject, we must,
if a fairly accurate specimen is desired, take a cast of the
1 If cold masses be used, of course no warm water is needed.
238
pleural cavity in plaster, and from this make another in
wax or paraffin. The lung may be laid in the latter and
carried through all subsequent processes. For most cases
_ itis sufficient to proceed as follows: One of the short arms
of a glass T -tube is introduced and tied in the bronchus, and
cannulz are tied into such vessels as it is desired to inject.
To the long (perpendicular) arm of the T a rubber bulb,
such as is used in atomizers, is attached. The injection
mass is introduced through the other arm. A piece of
rubber tubing, having a clip on it, is put on this latter arm.
The clip being closed the lung is inflated by means of the
bulb with air. It is then placed in a shallow dish, partly
filled with melted paraffin. Some of the latter is poured
over all the tubes. ‘The injecting syringe is now inserted
into the rubber tube attached to the T. The clip is re-
moved and the injection made. When enough of the
mass has entered, a little cold water is poured over the T,
and the mass is thus hardened and the tube plugged.
The artery is next injected, the vein last. After the in-
jection has cooled a little, several shallow incisions are
made on the upper surface. These forma holding-ground
for the acid. ‘The upper parts should be first dissolved.
Chromic acid in powder is the best agent I have found
for this. It is spread over the surface and wetted a little
and allowed to deliquesce. It penetrates with wonderful
speed. It should be washed off with hydrochloric acid.
If the chromic acid does not change to a dark brown color
in a few minutes, and rapidly eat its way into the tissue,
a little fluid containing organic matter, as saliva, will start
it. One danger in the use of this acid is that it sometimes
produces a good deal of heat, especially if it come in con-
tact with fat. The hydrochloric acid or water will pre-
vent this. The green color produced by the chromic acid
reduced by hydrochloric is easily washed off in water acid-
ulated with nitric acid. A dirty white precipitate may be
produced on the specimen. This also is washed off with-
out difficulty. The lungs should not be warmed lest the
injection flow too readily.
Most of the masses which I have used have been made
of paraffin, one to three parts ; yellow wax, one part; and
melted dammar, about one-twentieth part. Paraffin of
rather high melting-point seemsbest. This is melted with
the wax. The gum is melted in a separate dish. Both the
paraffin-wax mixture, and the gum must be raised to a high
temperature and then mixed, the gum being added in small
quantities at a time and well stirred. It is doubtful
whether this mass will stand our summer heat. Probably
others made of varnish will be better. ‘The paraffin mass
is much strengthened if, after the specimen is dry, a quan-
tity of “ fixative” varnish be sprayed over it, so as to
coat it completely.
The coloring agents which seem best are vermilion,
cobalt blue, chrome.green, and chrome yellow. `
Cold masses I have only recently begun to use. They
have many advantages over the hot. My experience with
them is not sufficient to enable me to speak of them.
Many beautiful preparations have been made with them
by others.
In conclusion, let me say that to make corrosion prep-
arations these points must be remembered: 1. Fasten
the tubes together to some support. 2. Do not change
the fluids too rapidly. 3. Do not handle more than is
absolutely necessary, and when you must, always remem-
ber what you wish to avoid injuring. 4. The process
cannot be hurried. The only thing to do is to fasten
everything securely and wait till the specimen is finished.
This merely needs patience.
CREMATION IN BERLIN.—The police authorities of Ber-
lin have recently refused the request of the Cremation
Society to be allowed to cremate the bodies of all those
who had signified their wish to be so disposed of.
1 This mass melts at a rather high temperature, but it remains ue
uid at a temperature sufficiently low to be safe.
THE MEDICAL RECORD.
[August 31, 1889
ON THE MODERN VIEWS OF THE ETIOLOGY
OF RHEUMATISM, WITHA CLINICAL CON-
SIDERATION OF THE TREATMENT OF THE
SAME.
By LEONARD WEBER, M.D.,
NEW YORK.
In preparing myself for the opening remarks of a dis-
cussion on the above subject, before a recent meeting of
the German Medical Society of this city, I found not only
a good deal of interesting material in recent publications,
but also some valuable clinical observations recorded in
my note-books, and thought it might be well to elaborate
these matters in the subsequent paper.
Inflammatory rheumatism—polyarthnitis rheumatica—is
known to us as a disease well characterized by fever, by
inflammatory affections of the joints and the heart, and
by various complications, and is now supposed to have a
distinct etiology and pathogenesis. To the labors of Im-
mermann, Edlefsen, Friedlander, and their pupils, we are
mainly indebted with regard to a decided modification of
our views of the origin of the disease, and the following
data may now be considered as nearly proven :
1. Inflammatory rheumatism is not produced by taking
cold, z.¢., refrigeration of the heated surface of the body.
2. It belongs to the class of miasmatic infectious dis-
eases, assuming an epidemic-like character at certain
times, in so far as we are apt to see a larger number of
cases when there is decreasing rain and moisture, while
with an increase of the same the number of cases is di-
minished.
3. Rheumatism is ai a house disease, the under-
ground of houses in certain locations being infiltrated with
the virus, which will be set free after prolonged dryness.
and by the air-currents carried into the apartments.
One or the other of the three main symptoms of rheuma-
tism may be absent, and yet the affection in question has
the same etiology, as, for instance, acute muscular rheu-
matism, acute endocarditis, acute sero-fibrinous pericardi-
tis, and a good many cases of chorea, though they may
not just follow an attack of rheumatic polyarthritis.
Furthermore, Immermann has shown us a masked form
of rheumatism, presenting itself in the shape of neuralgia
of the trigeminal, sciatic, spinal accessory, or other nerves.
In March last I had a gentleman under my care who,
having repeatedly suffered from gout and rheumatism, had
at that time an exquisitely painful affection concerning
the left spinal accessory and branches of the fifth pair, as- .
sociated with slight febrile motions. I failed to relieve
him until I gave him the alkaline and salicylate remedies
in large doses, when he rapidly improved and got well.
Edlefsen goes further than Immermann, and says that
all neuralgias, with.the exception of those caused by dis-
eases of the central nervous system, syphilis, meningitis,
or intermittens—have an etiology in common with articular
rheumatism. Urticaria is considered of specific rheu-
matic origin by Friedlander and some other authors, but
I do not remember more than a very few cases of this af-
fection which showed themselves amenable to antirheu-
matic remedies in my hands; while the majority appeared
to me of neurotic origin, requiring constitutional treatment,
and proving more or less refractory at that, particularly
as far as the subacute form is concerned.
With regard to scarlatinal rheumatism the opinions
are as yet divided—Immermann and others believing the
scarlatinal poison to be also the cause of the joint affec-
tions, Edlefsen and his followers considering scarlatinal
rheumatism to be articular rheumatism, so that a mixed
infection would be present in such a case.
Among the many cases of scarlatina that have come
under my observation there have been so few of them as-
sociated with articular rheumatism that, by this somewhat
negative experience alone, I am inclined to believe in the
identity of scarlatinal and articular rheumatism. And
further than that, rheumatic diseases had occurred in
some of the houses where 1 saw such complications, and
August 31, 1889]
the usual antirheumatic treatment was of good service in
relieving them.
It would appear from the above views that the field of
rheumatism has been rather enlarged ; but we shall not
find it so, if we come to separate from it a number of dis-
eases which do not belong to it any longer. First of all,
the many painful affections of the locomotor apparatus,
some neuralgias and paralyses of motory nerves—particu-
larly of the facial—which may be, and often are, produced
by a rapid cooling off of the surface of the part in ques-
tion, and eminently so when that surface has been hot
and perspinng. Erb and Immermann propose to use the
word refrigerate in designating all such cases, which have
thus far been erroneously called rheumatism. Refrgera-
tion is the most important, if not the sole factor in their
etiology, and when we speak of refrigeratory myositis, or
myalgia, or facial paralysis, we know exactly what we mean
by it.
And we have further to expunge from the chart of:
rheumatism the painful affections of the muscles after se-
vere exertions (Robin’s pseudo-rheumatism), the rheu-
matoid complications of gonorrhoea, chronic bronchitis—
bronchectasie, hamophilie—all of which are due to poison-
ous influences different from that of rheumatism. Also
rheumatoid purpura, or s. c. peliosis rheumatica, as shown
already by Senator ( “ Ziemssen’s Spec. Path. and Ther.,”
vol. xiii., 1, p.62). Ihave seen a case of severe and widely
spread purpura in a man, fifty years of age, associated
with inflammatory hypertrophy of the liver,, that ended in
cirrhosis, of which he died ; another with chloranzmia, in a
hard-working girl, twenty-two years of age; another with
mercurialism, in a syphilitic man, thirty-six years of age;
a number of them of very moderate extent and severity
in neurasthenic and anemic persons, but I have not had
a case in which antirheumatic treatment has been of any
service. The pains in the limbs and around the joints in
such cases are due to cedema, and the more or less cachec-
tic general condition, but not to rheumatic inflammation.
Bacteriological research has not succeeded in advancing
our knowledge as to the etiology of rheumatism, but more
has been learned by observations of another kind, for the
Origination of which we are indebted to Edlefsen. Ina
paper read before the Fourth German Congress for In-
ternal Medicine, in 1885, he argued pretty conclusively
that the theory of the influence of cold (refrigeration) was
untenable with regard to rheumatism, and showed that
while there was a decided connection between the mean
temperature of the months and the frequency of laryngitis
and bronchitis, the existence of the same connection could’
not be maintained as to articular rheumatism ; and he fur-
ther proved that the number of cases of rheumatism be-
come less as rain and moisture increases, and more with
the decrease of the same, and that pretty frequently a se-
ries of cases would occur in one and the same dwelling,
and the adjoining houses in particular streets. These ob-
servations would show that inflammatory rheumatism is
a miasmatic infectious disease, that its virus is of an or-
ganic nature and often has its lodgement in the under-
ground of dwellings. ‘These statements were supported
at the time of the discussion of his paper by Jiirgensen,
and Friedlander ; later on, by Hirsch, Mantle, Feltkamp,
and others. My own records show that the greater num-
ber of my cases of polyarthritis rheumatica occurred in
February and March, and again in the hot and dry sum-
mer months. It might be said that butchers, grocers,
marketmen, and saloon-keepers, for instance, which form
the majonity of the cases I treated, are just the persons who
are more exposed to cold than others, and that alone
might account for their rheumatism on the basis of
the old theory; but they are also the persons who
carry on their business, and frequently live in dwellings
which are habitually damp, and the underground of which
furnishes, in a most luxurious way, the conditions required
for the development of the rheumatic poison. In a sim-
ilar way the frequency of rheumatism among sailors could
be explained.
THE MEDICAL RECORD.
239
To be sure, frequent exposure to cold and its con-
sequences might create a predisposition to rheumatism,
just as we know of well-observed cases where acute rheu-
matism broke out after a sprain or distortion of a single
joint.
If we accept the modern views of the etiology of rheu-
matism, and put it into the group of the miasmatic infec-
tious diseases, to which it apparently belongs, it will not
be difficult to work out a general idea of the pathogenesis
of the disease. There is a virus present in the circulation
which in one case attacks principally the joints, the endo,
and the pericardium ; in another, the muscles ; and in an-
other, the nerves, etc.
Therapeutics——Among the many valuable remedies
with which modern chemistry has presented us salicylic
acid stands in the foremost rank, and its therapeutic pow-
ers in inflammatory rheumatism may be considered as
great as those of chinin in intermittent. Many of us
prescribed the alkaline treatment in the early period of
our practice, basing it upon the lactic-acid theory then in
vogue, and combining the same with the free use of -
chinin to control the rheumatic fever. And the results
obtained, were they generally unsatisfactory? By no
means, The great majority of the patients got well; but
more of them so treated drifted into the subacute stage,
or acquired endocarditis, leading to valvular disease, or
died of hyperpyrexia, than of those that are given the
salicylates in the proper way. Experience has taught me
that salicylate of soda, mixed with its bulk of bicarbonate
of soda, is borne better by the stomach than the salicylate
by itself, while it loses none of its efficacy. For a num-
ber of years, therefore, I have prescribed, in acute rheu-
matism, fifteen grains of each salt to adults, and one-half
of that to children, every three hours during the day, and
the night also in severe cases, until the temperature and
pulse became normal, and that very generally was the case
on the third or fourth day from the beginning of the
treatment. Dr. A. Seibert, of this city, a careful observer,
to whom we are also indebted for collecting some valu-
able statistics which appear to confirm the theory of the
miasmatic-infectious origin of rheumatism, prefers giving
the salicylate every hour, in order to overcome the action
of the rheumatic virus as soon as possible. When he
finds the stomach intolerant to the remedy he introduces
it by the rectum, and gives it, in children’s practice, always
that way. He reports to have seen many cases in which
pulse and temperature became normal, and the joints
free from pain and swelling, in a day, and considers this
method perfectly safe and satisfactory. Now, although
the salicylate is a great remedy, it is neither omnipotent
nor can it be administered in every case with safety and
comfort. I have had to deal with many a case in which
the head and stomach would not bear it, or a weak heart
would soon forbid its use, and others in which it did no
ood.
j There are some observers who have used antipyrin, or
antifebrin, or oleum gaultherii in such refractory cases
with confidence and success ; have even gone further and
laid aside the salicylate, and operated with the remedies
just mentioned in preference to the standard one. Ire-
gret to say that my experience with them in rheumatism
has not been such as to induce me to praise them highly.
Whether my failure was due to want of patience or want
of courage to give them in large enough doses, rather
than to the inefficacy of the remedies, I do not care to
inquire into now, but am ready to throw those three, and
the phenacetin besides, overboard for salol, a compound
which has yielded me very good results in cases where
the salicylate failed to act or could not be continued. To
illustrate by an example. Mrs. S——, aged thirty-six,
quite stout and rather strong, pulse regular but weak,
heart apparently sound, had inflammatory rheumatism
some six years ago, being laid up with it for eight weeks
at that time. In March last she was taken with pneu-
monia of regular type, of which she recovered completely
in the course of the second week, and two or three days
240
thereafter quite an acute attack of inflammatory rheu-
matism set in, with high fever and all the other usual
symptoms, except endocarditis, of which there was no
sign at any time of the four weeks during which she was
confined to her bed. ‘The salicylate given during the.
first week failed to cure, and likewise antipyrin and phena-
cetin given in the second week. ‘The alkaline remedies,
ordered in large doses, in conjunction with the tincture of
colchicum all during the third week, brought some relief,
but did not prevent relapse and extension of the disease
to some joints of the upper extremities at the beginning
of the fourth week. I then gave of salol fifteen grains
every three hours, z.¢., five times a day, and had the swollen
joints blistered coup sur coup, and the patient carefully
nourished and stimulated. At the end of that week she
was relieved of all troublesome symptoms. I continued
the use of salol, refracta dosi, for another week, when she
was discharged cured.
It would be easy to add five or six cases more of a sim-
ilar nature, but this would be needless supererogation.
I prefer to say a few words more of the comparative fre-
quency of relapses. of acute rheumatism, the subacute
forms, and those cases in which the disease settles, so to
speak, in one or more joints, invalidating or crippling the
patient. To expect here to cure bya prolonged course of
the salicylate or salol, or another of the modern specifics,
would be a vain hope indeed, and end very probably in
disappointment to both physician and patient. A great
deal can be accomplished, however, and many a case
cured by a bold but judicious and prolonged use of the
alkaline treatment, with the iodide of potassium in every
case where the stomach will take the latter, no matter
whether there is a combination with syphilis or no. I
have found such treatment very good in rheumatism con-
cerning fat persons, and those bloated with malt liquors
when they have not yet anemia and weak heart. Where
the latter complication is associated with rheumatism it is
good practice to improve the patient’s condition by ap-
propriate general regimen and the exhibition of the muri-
ate tincture or other preparations of iron in large, and
digitalis in small doses, and then proceed with specific
treatment, prolonged warm baths—natural or artificial—
change of air and domicile when there is cause for it, sea-
voyages, and the like.
To cite one or two cases may be sufficient for illustra-
tion. Mrs. W , aged thirty-four, had had rheumatism
for about two years before I saw her in 1884. There was
no valvular disorder, but one wnist, shoulder, and knee-joint
were the seat of old exudation, more or less swollen, and
distorted and painful, and the patient was scarcely able to
be about, and quite unable to do her work. Beginning
with a short course of the salicylate, which I am in the
habit of doing in almost every case, and generally with
some benefit as to recent exudation in old cases, I fol-
lowed it up with a solution of iodide of potassium and
liquor potassze, which the patient took steadily for nearly
six months, when she was free from rheumatism, looked
well, and had the use of her limbs as good as before.
Her means were such that reasonable care and good food
could be provided; but nothing in the way of baths,
change of air, or other adjuvants to assist the action of
the remedies. Syphilis was not present. Further, I was
consulted by a gentleman, some years ago, who suffered
in a similar but more pronounced way, and in whose case
syphilis could also be excluded. He said he had had all
the necessary remedies, and enough of them, would take
no more drugs, but was ready to follow any other good
advice that I might be able to give him. I asked him if
he was a good sailor, and upon receiving an affirmative
answer I suggested a prolonged sea-voyage in a sailing
vessel. He did not relish the idea of being on board of
such craft, but immediately engaged passage on a slow
but comfortable steamship line, and crossed and re-
crossed the Atlantic six times in the course of the sum-
mer, when he considered himself cured. On his third
voyage he was already able to walk the deck without sup-
THE MEDICAL RECORD.
[August 31, 1889
port, and had good use of his limbs during all the others.
However, even after an apparently perfect restoration from
chronic rheumatism, the proneness to relapse remains,
and the patient, if not already taught by experience, ought
to be informed of it, as he will then be more readily in-
clined to undergo a further course of treatment, which
need not be long when begun without delay. Immobilizing
dressings I have. often used in the subacute form of
rheumatic joint affections, when I found much tender-
ness, swelling, and gelatinous exudation that would not.
vield to medical treatment. Such appliances were always
productive of great comfort to the patient, never did any
harm, and very often favored absorption and helped to
cure. Blisters over the joints in the acute, relapsing, and
subacute forms—an old mode of local treatment, by the way
—I have been taught by experience in numerous cases to
value highly, and never hesitate to apply them wherever
the exudation does not quickly yield to medicine. .The.
-ice-bag I have never ordered to be laid over a joint in-
flamed acutely by rheumatism. I have never seen any
good accomplished by it, but remember a few cases in
which the rheumatic disease appeared to linger in the
very joints which had the ice-bag on.
That a great many joints, more or less diseased and
quite unfit for use by chronic rheumatism, have been im-
proved and cured by massage and medical
tics applied by experts, there is not the least doubt. But
there still remain a number of chronic cases, in which
such an amount of mischief has heen done that various
joints may be in a more or less disorganized condition,
crippling the unfortunate patient for life.
In the experience of Dr. F. Lange, of this city, a num-
ber of cases of this kind have come under his care, in which
searching inquiry failed to elicit any other cause but
rheumatism for the destructive joint-lesions, and in which
more or less surgical treatment was required. to afford re-
lief.
25 Wast FORTY-SIXTH STRERT.
THE ACTION OF ASTRINGENTS.—In an experimental in-
quiry upon the mode of action of astringents, Dr. R.
Heinz, of Breslau (Virchows Archiv, 116, Hft. 2), finds
that, as regards their property of contracting vessels, the
minimum strength of solution is, of corrosive sublimate,
0.005 per cent.; of nitrate of silver, acetate of lead, and
sulphate of zinc, o.or per cent; of cupric sulphate, per-
chloride of iron, tannin, and alum, 0.05 per cent. ; while,
in respect to the degree of vascular contraction excited,
they may be ranged in the following order: Nitrate of
silver ; acetate of lead and sulphate of zinc; corrosive
sublimate, cupric sulphate, perchloride of iron; tannin
and alum. Upon.the interesting question of the preven-
tion of inflammation by the use of these substances,
Heinz made many experiments on the mesentery of the
frog. He found, in the first place, that when the exposed
membrane was treated with such solutions, the leucocytes,
although accumulating within the vessel along its walls, did
not exude and collect outside the vessel, as in the ordinary
experiment of mere exposure of the membrane, which is
kept moist by salt solution. If a certain amount of in-
flammation were excited prior to the application of the
astringent, the latter caused an immediate arrest of the
process. That this was not due to the narrowing of
the vessels was proved .by using solutions of greater
strength (¢.g., of tannin, one-half per cent.; alum, two
and a half per cent.), whereby dilatation of the vessels
is caused. Still higher concentration of the solutions
injure the tissues and excite inflammation ; and yet, curi-
ously enough, if the application of such be continued for
a longer time, inflammatory action is held in check.—
Lancet. l
PARAMONOBROMOACETANILIDE is the name of a new
substance experimented with by Cattani, of Milan, and
which he calls, on account of its most noticeable prop-
erty, antisepsine.
August 31, 1889]
THE MEDICAL RECORD.
241
THE MEDICAL RECORD:
A Weekly Fournal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Epiror. |
PUBLISHED BY
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
New York, August 31, 1889.
THE ARMY MEDICAL SERVICE.
THE Medical Department of the Army has recently made
a change in its method of filling vacancies in its ranks.
Formerly a medical board of some permanence held its
daily sessions in the Army Building in this city, and to it
all candidates recommended by the Surgeon-General and
the Secretary of War were referred for examination ; but
as the work involved in niling vacancies did not suffice to
keep the board fully occupied, it was dissolved in the in-
terests of economy, for the utilization elsewhere of the
services of its members. Under the new system a special
board is convened to meet the requirements of the service.
As soon as it is ready for work fifteen to twenty-five can-
_didates appear before it at a stated time. Not all these
undergo the full course of the examination. Some drop
out on the first day on account of physical disqualif.cations,
and others from day to day thereafter as they become dis-
couraged by finding, on careful study, how poorly their
text books sustain them in certain matters which they had
that day discussed in writing for the scrutiny of the ex-
aminers. On the conclusion of their examination a
second detachment of fifteen to twenty-five is ordered up
and disposed of in like manner ; and so on until the
whole of the candidates have undergone the ordeal or
dropped by the wayside. ‘The aggregation of its work
enables the special board to examine in a month as many
men as were examined by the old board in a year ; but
this economy of the time and services of the medical
officers constituting the board is not all clear gain to the
service. Under the old system a young graduate who
desired to appear for examination was able to accomplish
his purpose shortly after he took the initiatory steps, be-
cause the board was always there ; but now, he may have
to wait a year before a board is convened to examine him.
Meanwhile some opening in civil life may be presented,
and the promise of its future changes his views as to the
manner of his professional career; or, the temporary
pressure of some engagement, family affairs, or personal
ailment may prevent him from appearing when the board
is ready—and the young years of life are too valuable to
be spent in waiting. Formerly the army secured every
capable man who felt a vocation for the military life, but
now some of the best men will slip away from it— between
the sessions of the board.
Hitherto the character of the examinations for position
in the Army Medical Department has been as a sealed
book to those who were most interested. We print. else-
where in this issue a set of the questions submitted to candi-
dates by the board recently in session. At the end of the
written examination the trials culminate, and end in some
clinical work in the hospital and operations on the cad-
aver. After this the successful men find themselves
almost immediately commissioned and under orders from
the War Department, for as the examination was held to
fill existing vacancies no time is lost in filling them, now
that the men have been found.
For a young man who has no financial resources or
family influence to protect him during the building up of
a civil practice the army service offers special induce-
ments. The passed candidate enters at once into a
position of responsibility, with the rank, pay, and emolu-
ments of a first lieutenant of cavalry, a rank which is sel-
dom attained by the graduates of West Point under a
service of ten or twelve—usually twelve—years as a junior
or second lieutenant. At first he may be sent to some
large post in the East, where, under the orders of an officer
‘of long service, he will gather experience in the military
as well as medical line of his duties. Then he goes out
West and has a post of his own, when all the responsibili-
ties of his profession will press heavily on him, and, on
account of his inability to call in others for consultation,
make him cultivate that preparation for the management
of emergencies and difficult cases which gives self reliance
to a medical man. During this time his expenses are a
trifle compared with his income, which may be largely
increased by private practice in the neighborhood of his
post, so that at the end of a few years he has saved enough
to enable him to settle in any locality if he find army life
to be not all that his fancy painted it. Usually, however,
the inducements for him to stay, held out at the end of
five years’ service, largely outweigh all other considera-
tions. Some of these are: the rank of captain, which is
reached by the line officer only after a quarter of a cen-
tury of service ; a ten-per-cent. increase on his pay as a
captain ; a leave of absence for four months, with a trip
to Europe, if desired ; and, as a matter of fact, not many
of those who have stayed for this length of time think
now of resigning. The grade of major is not usually
reached until after twenty years of service, but as an off-
set to this, every period of five years brings an additional ©
ten per cent. of pay, until forty per cent. accrues about
the time that a majority is attained. At one time this
rank of major was the highest that a medical officer could
look for ; but now that the corps has six colonelcies and
ten lieutenant-colonelcies, besides the Surgeon-Generalcy,
and a compulsory retirement law which enables the
younger men to move up as the older men reach the age
of sixty-four, every medical officer can look to retirement
with seventy five per cent. of a colonel’s income asa
provision for his later years.
The medical officer of the army has one grand advan-
tage over his professional brethren in civil life. He is
free from all the financial worries and anxieties which
break down so many men who have to struggle for their
income. ‘There is no uncertainty about his future. He
has no occasion to provide for the proverbial rainy day.
If sickness assail Kim his income drops into his hand
monthly, as if he were in the steady. performance of his
work ; and in old age he is on the retired list. The won-
242
der is not that so many of our young graduates go before
the Army Medical Board, but that all of our best men are
not seduced into the ranks of the army.
STATE EXAMINATIONS FOR LICENSE TO PRACTISE.
ONE by one the different States are swinging into line
along this very important reform in medical education,
and it seems a pity that the conflict of various interests
delays progress in our own State. We have read with in-
terest the report of the Minnesota Board of Examiners,
as given through the columns of one of our Western
exchanges. The work of the board has extended over
two years. Of ninety-four candidates, thirty have been
rejected.
In looking over the list of questions of an examination
just held, we are impressed by their straightforward char-
acter. They ask for just what every practitioner should
know. ‘The number of them is greater than is generally
given on our leading college papers, but they bear, on the
whole, a more practical nature. Special papers on his-.
tology and pathology are inserted in addition to the more
general questions in - medicine and surgery, requiring
knowledge on these points.
‘These satisfactory results have not been attained with-
out opposition. Low grade institutions in neighboring
States, whose graduates could not pass the Minnesota ex-
aminations, have endeavored to secure repeal legislation,
but fortunately the law has stood. It is not without some
chagrin that we,.in this State, contemplate the advances
which are being made in these respects in other commun-
ities. It is not a matter affecting sects or particular in-
stitutions, but rather the standing of the profession in’ its
broadest sense, and the welfare of the community. The
fact is that the greatest advance in this direction has been
made by States, with the exception of Virginia, which are
not generally regarded as medical centres. In our own
State there are many conflicting interests to harmonize;
not so many, however, but that each one could have a
full representation in a State Board. Mutual supervision
would be sure to prevent any one side from securing an
undue advantage.
Some details of the Minnesota statute are not without
interest. The percentage required for securing a license
differs with different subjects. Sixty-five per cent. is re-
quired from all applicants in materia medica, surgery,
practice of medicine, obstetrics, and gynecology. Fifty
per cent. is required in all other branches from gradu-
ates of less than five years standing; for all others, but
thirty-five per cent. is required in these same remaining
branches,
A NEW OPERATION FOR LACERATED PERINEUM.
A NEW operation has been proposed by Mr. Alexander
Duke, for the repair of lacerated perineum, which seems
to possess some advantages, in certain cases at least, over
those at present in vogue. The procedure, which is de-
scribed in the Dublin Medical Press of May 9, 1889, is
apparently quite simple, and if it prove to be as effica-
cious as Mr. Duke believes it will, it ought to take rank
among the recognized operations for the relief of this
condition.
‘The method is in brief as follows: The patient is
THE MEDICAL RECORD.
[August 31, 1889
placed either in the lithotomy or Sims position, the left
index-finger being introduced almost its entire length into
‘the rectum; a long, straight, double-edged bistoury is
made to pierce the tissues in front of the anus at right
angles to the vulva; and, guided by the finger in the rec-
tum, is made to penetrate the septum for two and a half
inches upward, the incision being enlarged laterally to two
inches at least, as the knife is withdrawn. On the two
points of incision being pressed together from side to side
a lozenge-shaped opening appears, and when all the su-
tures required have been introduced and are properly ad-
justed and approximated, the two cut surfaces are brought
into direct apposition. The sutures are introduced by a
strong cycle-shaped needle with eye in the point mounted
on a handle, strong silver wire being the suture preferred.
The needle is introduced at the centre of the skin incision
below, and, guided by the finger in the rectum, is made to
travel over the cut surface to its full extent above, describ-
ing the arc of a circle, and, on the point of needle ap-
pearing directly opposite, it is threaded with the suture
and drawn through. When all the necessary sutures have
been introduced and approximated,:a finger of each hand
passed into the rectum and vagina will at once recognize
the gain in thickness of the septum, the external tissue
being pushed fully an inch forward from the anus, ard
forming a thick and solid perineal body. The incision
being a deep one, on union taking place between the raw
surfaces, a considerable depth of support must be afforded
where a pessary is required, or where there is much ten-
dency to prolapse of the uterus or vaginal walls. _
Mr. Duke’s experience of the operation, although up to
the present limited, has satisfied him, he says, with the
results, and, there being no loss of tissue whatever, should
the operation fail, it cannot add any difficulty to a sub-
sequent one. The following are the advantages which he
claims for the operation :
1. The simplest of performance as yet proposed. No
danger of hemorrhage, the surfaces being brought to-
gether at once, and the wound is dry and clean.
2. No danger of sepsis, as the incision is not open for
the admission of any discharge from either vagina or rec-
tum during the healing process. .
3. No loss of tissue, and consequently no harm done
should the operation fail.
PHOSPHORUS IN THE TREATMENT OF RICKETS.
THE use of phosphorus in rickets, so much vaunted by
Kassowitz and others a couple of years ago, has not, we
believe, found much favor in this country. A very exten-
sive trial of the remedy has recently been concluded by
Dr. L. B. Mandelstam, of Kazan, who publishes the re-
sults in Vratch, Nos. 5, 7,9, 10, and 11, 1889. These
experiments extended over a period of nearly three years,
and the number of patients upon whom the phosphorus
was tried was 450, their ages running from three months
to four years. Of this number, however, 234 were ex-
cluded from the statistics, either because they did not take
the phosphorus long enough, or in the proper way, or be-
cause the disease in them was not sufficiently pronounced
to make the experiment a satisfactory one.
Of the remaining 216 children, 120 were cured, 43
were markedly benefited, in 30 no improvement was
August 31, 1889]
THE MEDICAL RECORD.
243
noted, and in the remaining 23 the treatment was discon-
tinued on account of some intercurrent disease. The
remedy was given dissolved in cod-liver oil, in the propor-
tion of one part to ten thousand of oil, of which a tea-
spoonful was given once or twice a day. When it was
not deemed advisable to give cod-liver oil, the remedy
was administered, after the formula of Kassowitz, in a
mixture composed of ;}, part of phosphorus, 15 parts
each of gum arabic and sugar, 30 parts of almond oil, and
40 parts of distilled water. Dose, a teaspoonful once or
twice a day. No other remedy was employed, except
when diarrhoea was present, and then an attempt was
made to cure this before giving the phosphorus.
The following are the conclusions which the author
feels himself justified in formulating as a result of these
experiments :
1. Clinical observation justifies fully the employment
of phosphorus in rickets.
2. Phosphorus acts better, more quickly, and with
greater certainty than any other remedies.
3. This drug, when given in small doses, even for long
periods of time, is well borne by children, and causes in
them no unpleasant effects.
4. Phosphorus is especially efficacious in controlling
the nervous manifestations of rickets.
5. Periodical measurements and weighing of the chil-
dren, as well as observation of the osseous structures, show
that the disease is actually arrested in its course and
cured, in the great majority of cases, under the influence
of phosphorus.
Another trial of the same remedy was made by Dr.
Shabanova, whose report is presented in Vratch, Nos. 16, 17,
18,and 19, 1889. She treated 105 patients, and obtained
perfectly satisfactory results in 77. In 22 an improvement
was noted, and in 6 cases there was an aggravation of the
disease while the treatment was being continued. The
first effects of the remedy were seen in an improvement
in the nervous symptoms, and later, in favorable cases, a
change for the better was seen in the general health, and
in the condition of the bones and muscles.
_
Bews of the Week.
THE FOURTH ANNUAL MEETING OF THE ASSOCIATION
OF AMERICAN PuHysICcIANS will be held in Washington, on
September 18, 19, and 20, 1889. ‘The Association will
meet in the building of the Medical Museum and Library.
- The following programme is announced : ‘The President's
inaugural address, by Dr. Francis Minot, of Boston ; “ The
Early Stage of General Paralysis,” by Dr. C. F. Folsom,
of Boston ; “ Tetany,” by Dr. James Stewart, of Montreal ;
“ Tetany and a New Theory of its Pathology,” by Dr.
John T. Carpenter, of Pottsville, Pa. ; ‘‘ ‘Thrombosis of
the Cerebral Sinuses and Veins,” by Dr. A. B. Ball, of
New York; “ Chylous Effusions into Serous Cavities,” by
Dr. S. C. Busey, of Washington ; ‘Substitutes for Opium
in Chronic Diseases,” by Dr. J. F. A. Adams, of Pitts-
field, Mass. ; “ A Remarkable Case of Slow Pulse,” by
Dr. D. W. Prentiss, of Washington ; a discussion on
‘The Relation between Chlorosis, Simple Anzemia, and
Pernicious Anemia, including Leucocythemia and Hodg-
kin’s Disease,” by Dr. Frederick P. Henry, of Philadelphia,
Referee, and Dr. F. Forchheimer, of Cincinnati, Co-Ref-
eree ; “ Primary Cancer of the Duodenum,” by Dr. E.
N. Whittier, of Boston ; “ Primary Cancer of the Gall-
bladder and Ducts,” by Dr. John H. Musser, of Phila-
delphia ; “ Gastric Neurasthenia,” by Dr. G. M. Garland,
of Boston ; “Specimens from Two Cases of Cretinism,”
by Dr. W. F. Whitney, of Boston ; “ ‘The Anatomical and
Physiological Relations of Lesions of the Heart and
Kidneys,” by Dr. H. F. Formad, of Philadelphia; “The
Contagium of Diphtheria,” by Dr. P. Gervais Robinson,
of St. Louis; “A Supplementary Inquiry into the Fre-
quency with which Lead is found in the Urine,” by Dr.
James J. Putnam, of Boston ; a discussion on “ ‘The Re-
lations of Rheumatism to Rheumatoid Arthnitis,” by Dr.
William Osler, of Baltimore, Referee, and Dr. Morns
Longstreth, of Philadelphia, Co-Referee ; ‘“‘ How far may
a Cow be Tuberculous before the Milk becomes Danger-
ous as a Food-supply?” by Dr. Harold C. Ernst, of
Jamaica Plain, Mass. ; “ The Bacillus Tuberculosis,” by
Dr. J. T. Whittaker, of Cincinnati; and “ Hot-air In-
halations in Tuberculosis,” by Dr. E. L. Trudeau, of
Saranac Lake, N. Y. The annual dinner will take place
on Thursday, September roth.
A PRIZE FOR AN Essay oN BacTerRia.—The Dutch
Scientific Society in Haarlem offers a prize of one hun-
dred and fifty gulden for a critical review and exhaustive
description of the different kinds of bacteria contained in
drinking-water before and after its filtration through sand,
and of the methods of determining the characteristics of
every kind. The judges will award an extra prize of one
hundred and fifty gulden if they consider the successful
competitor worthy of it. All competitive essays must be
filed with the Society’s secretary before January 1, 1890,
and must be written in the French, Dutch, or German
language.
Dr. E. Parsons, of Savannah, Ga., who is said to
have been the oldest practising dentist in the United
States, died at his home in that city on August zoth. Dr.
Parsons was born in Northampton, Mass., in 1806. He
was educated in Cincinnati and Philadelphia. In 1843
he went to Savannah, and until a few months ago has
been practising his profession.
THE NEXT MEETING OF THE AMERICAN MEDICAL AS-
SOCIATION.—Our esteemed contemporary the Nashville
Journal of Medicine and Surgery remonstrates with us
gently for not having approved fully of the choice of the
American Medical Association of Nashville for the place
of its next annual meeting. He reminds us that that city
is-no village, and assures us that it will be well able to en-
tertain as many members of the Association as may put
in an appearance. We never once doubted the hospital-
ity of Nashville ; it was only the question of its ability to
provide for such a number that caused us some apprehen-
sion. But we assure our contemporary that our fears are
now removed, such is the effect of his convincing elo-
quence.
St. Joun’s Gui_tp.—Over twenty-three thousand sick
children and their mothers have been carried on the
fresh-air excursions of the St. John’s Guild floating-hos-
pital barge this season, and the sea-side hospital of the
Guild at New Dorp, S. I., has been constantly filled to its
utmost capacity.
244
THE MEDICAL RECORD.
[August 31, 1889
Dr. J. R. TAYLOR has been elected to the chair of
Pathology, Practice of Medicine, and Clinical Medicine
in the Medical College of the State of South Carolina at
Charleston, S. C., vice Dr. John Guitéras, who has re-
signed, to accept the chair of Pathology at the University
of Pennsylvania.
Two More Younc Livine Færuses.—Dr. Henry K.
Palmer, of Trinidad, Col., writes that he had had a case
similar to those previously reported in these columns. A
woman ceased to menstruate on May 31st, and on Octo-
ber 28th was delivered of a living child, nine inches in
length, and weighing eighteen ounces. The child was
wrapped in cotton and lived for twenty-seven hours after
birth. Dr. W. K. Prichard, of Cloverdale, Ind., reports
another case of like nature. ‘The mother menstruated
last on February 11th, and the child was born on June
26, 1889, four and a half months later. The child lived
five days, and its bowels and kidneys acted normally,
though the nurse said that the urine looked like milk.
The child’s eyes were closed at birth and remained so
throughout its brief existence. Cases of this sort are not
so very rare. It is uncommon, indeed, to see a viable
foetus under the seventh month ; but one of five or six
months or even younger, ií living when expelled from the
uterus, must take time to die just as well as an older
child.
Dr. SIGMUND LUSTGARTEN, formerly of Vienna, has
removed to America and intends to reside in New York.
Dr. Lustgarten was for some time Privatdocent in Vienna,
and in that way is known to many Americans. He is also
more widely known as the discoverer of the bacillus of
syphilis which is called by his name.
AN EPIDEMIC OF DIPHTHERIA.—The town of Moscow,
O., is reported to be suffering severely from an epidemic
of diphtheria. ‘The time will come when an epidemic of
disease in a place will be looked upon as a disgrace to
the community, as great, if not greater, than would be a
series of robberies, or rapes, or of any other crime.
A Case OF INOCULATED LEPRosy.—At the Dermato-
logical Congress held recently at Prague, Dr. Arning gave
an account ofa case of inoculated leprosy in the Sandwich
Islands. In 1884 he was permitted to inoculate a con-
demned criminal, with the latter's consent. The man
whom he inoculated had no inherited taint. ‘The immedi-
ate result of the inoculation was negative, but four weeks
later the man was attacked with an affection resembling
subacute rheumatism without fever. ‘The first joint involved
was the left elbow, and then other joints became attacked,
the attack lasting for four months. Then occurred some
swelling of the left ulnar and median nerves, which
subsided in the course of six months. Meanwhile there
had developed on the scar at the site of the inoculation a
typical leprosy nodule, from which abundant bacilli were
obtained. Since Dr. Arning had returned to Europe he
had learned that the disease had made considerable prog-
ress, and the unfortunate man was now in a condition of
marked marasmus.
AN UNRECOGNIZED MEDICAL SCHOOL.—The Hudson
County, N. J., Board of Health refused recently to allow
two young men, graduates of the New Jersey College of
Medicine, to register as practising physicians. The col-
lege is a new concern, started by some eclectics, and
these men were its first graduates. ‘The counsel of the
Board, it is reported, said that the college was chartered
by the State, and that the Board therefore had no right to
refuse to register the applicants. The Board did so re-
fuse, however, for it decided that the college had no right
to grant diplomas.
Dr. James L. CABELL, professor of physiology and
surgery in the medical department of the University of
Virginia, died in Albemarle county on August 13th. He
received his medical degree in 1833, and afterward studied
in Paris. Dr. Cabell was widely known in Virginia, and
had served at different times as president of the State
Medical Society, of the American Public Health Associa-
tion, and of the National Board of Health.
Dr. HERMAN B. INCHES, one of Boston’s oldest physi-
cians, died in that city on August 19th, aged seventy-seven.
He was a graduate of the Harvard Medical School in 1834.
THE FIFTEENTH ANNUAL MEETING OF THE MISSISSIPPI
VALLEY MEDICAL ASSOCIATION will be held at Evansville,
Ind., September roth, 11th, and 12th. Those who will
attend are advised to take receipt for full fare going to
Evansville, that they may secure return tickets at one-third
fare. ‘The titles of nearly one hundred papers have been
received for the programme, and the indications are that
the meeting will be larger than any yet held by the Associ-
ation. “Ihe problem confronting the members will be, not
how to fill up the time of meeting, but how to stretch out
the meeting sufficiently to accommodate all the papers.
Perhaps fewer papers more leisurely discussed would be
productive of better results in the end.
Dr. FERDINAND HvueEpPE, the author of the well-known
“« Methods of Bacterial Study,” and who has for several
years directed the bacterial department of Wesenius’ cele-
brated laboratory in Wiesbaden, has been elected professor
of hygiene in the University of Prague. The addition of
Professor Hueppe to the working and teaching force of
the University of Prague is an important feature in the
growing attractiveness of Prague to American medical
students who go to Europe for a few months of quiet study,
and wish to avoid the overcrowded courses and distract-
ing bustle of the larger medical centres.
THE HYGIENE oF TUBERCULOSIS.—At a recent meeting
of the Paris Academy of Medicine, M. Villemin read a
report of the Special Committee appointed by the Con-
gress for the Study of Tuberculosis last year, which it was
proposed to publish, with the object of instructing the
laity as to the nature of the disease and the bést means
of avoiding contagion. The report calls attention to the
fact that pulmonary phthisis is not the only form in which
tuberculosis manifests itself, but that many cases of
pleurisy, peritonitis, meningitis, and bone and joint dis-
eases are often tuberculous. ‘The report insists upon the
contagiousness of the disease, and refers to the various
ways in which the bacillus may gain entrance into the
body. Since the sputa of phthisical patients usually con-
tain the bacilli in large numbers, special care should be
paid to the immediate destruction of all expectorated
matters. The report also insists upon care in the matter
of food, since milk, beef, and fowl are found not uncom-
monly to contain the bacilli. Milk should, therefore, be
boiled before being given to children, and meat thoroughly
cooked.
August 31, 1889]
THE MEDICAL RECORD.
245
Society Reports,
BRITISH MEDICAL ASSOCIATION.
(Special Report for the THe MepicaL Recorp.)
Fifty-seventh Annual Meeting, held at Leeds, England,
August 13, 14, 15, and 16, 1889.
TUESDAY, AUGUST 13TH—F RST Day.
Dr. W. T. GAIRDNER, the retiring President, occupied
the chair, and, after the reading and approval of the very
voluminous minutes of the last meeting, delivered a short
address. He said that it was now his duty to put an end
to his official existence, and although it was, under the
circumstances, a pleasant duty, he nevertheless wished to
do it as briefly as possible. It was not desirable that a
dying actor should remain too long on the stage. As
President he might be said to be in a moribund condition,
and to be handing on his torch, such as it was, to his suc-
cessor, who did not, however, come out of the dark. Mr.
Wheelhouse had been long before the Association, not
only as one of the most active members of the profession
in Leeds, but also as their representative on the General
Medical Council. It was within the knowledge of those
who had long been members of that Council that no man
in it stood higher than did Mr. Wheelhouse in the opinion
of that body. He was recognized as possessing tact, bus-
iness talent, and every other quality that went to make a
good Medical Councillor. He need not say that such a
man, who added to those qualities high distinction as
a surgeon, was eminently qualified to be the President of
the Medical Association. He should himself resign the
chair with feelings of warm gratitude toward all the mem-
bers and officials of the Association for the way in which
they had held up his hands during the period of his presi-
ency.
Mr. G. C. WHEELHOUSE, the President-elect, then took
the Chair and made the following remarks: If in receiv-
ing the torch from Dr. Gairdner’s hands he could carry
the light still further before them, and could guide them
aright, he should, of course, have the greatest possible
pleasure in doing so; but he was not unaware of the fact
that the task was a very difficult one. It might seem to
those who came to the annual meetings, and only saw the
happy, social side of the work, an easy thing; but those
who knew anything of the hours spent in Council trying to
guide the Association in its proper lines, and to do that
which was right by every member of the Association,
now numbering 13,900, were aware of the difficulty of
the undertaking. He had not willingly accepted the
honor they had done him in placing him in the chair,
but he would, nevertheless, do all in his power to fulfil
a the grave task which had been imposed upon
im.
THE ANNUAL REPORT OF THE COUNCIL
was then read. In referring to the growth of the Associa-
tion the report took the three meetings at Leeds as mile-
posts showing the rapid strides in membership. At the
time of the first meeting at Leeds, in 1843, there were only
about 1,600 members; in 186ọ the Association again met
in that city, and then numbered nearly 5,000; now, at
the time of the third meeting in Leeds, the membership
exceeded 13,000. The finances of the Association were
in a very flourishing condition. The report closed with
an expression of confidence in the ability of the editor of
the Fournal and in his devotion to the best interests of
the association.
After some discussion the report was adopted. It
was then resolved, on motion, that the members of the
Royal College of Surgeons shall have a voice in the
E En of the college and in the election of its
council.
A VOTE OF THANKS TO THE RETIRING PRESIDENT
was then moved and carried with great acelamation, and
he was then elected Vice President for life
THE INEBRIATE’S LEGISLATION COMMITTEE
made a report in which it was stated that at length a per-
manent measure had been enacted for the benefit of in-
ebriates. The members of the profession were coming
very generally to the belief that inebriety was not always
a crime, but was, in many cases, as clearly a disease as
gout or insanity. ‘This was encouraging, and the commit-
tee hoped that the good work already begun would be
continued until public opinion had been educated to a
point where it would be universally recognized that it was
the duty of the Government to provide for the care and
treatment of diseased inebriates.
Reports were also presented from the Committees on
Scientific Grants, on Therapeutics, and on Collective In-
vestigation. ‘The last-named committee complained of a
want of support from the profession at large, said that its
inquiries were not responded to very generally, and sug-
gested that it be allowed to lapse at the end of its official
year in October next.
In the afternoon a special service was held in the par-
ish church of Leeds, when the Bishop of Ripon preached
to a crowded congregation on the subject of
DIVINITY AND MEDICINE.
He took for his text the words, *“ I have compassion on
the multitude” (St. Matthew xv. 32). The conflicting
thoughts and opinions of men were, he said, chiefly on the
surface, but deep down there was union, and when petty
differences were put aside all men were at last found to
be of one mind in a house. There might be differences
between religion and science, yet divines and physicians
often walked side by side under the guidance of the prin-
ciple of compassion. If divinity had had among the isl-
ands of the ocean a heroism like that of Father Damien,
consecrating his life to disease and to death, medicine
had had in their hospitals those brave men who had not
hesitated to put their lips to the poison and draw death
to themselves to save the child or the weak. Those
things were their common heritage, for, after all, were they
not expressions of.the one great principle of compassion ?
They marched together thenceforward.
In the evening the members assembled in the Coliseum
to listen to
THE PRESIDENT’S ADDRESS.
Mr. WHEELHOUSE dwelt first upon
THE VARYING PROGRESS MADE BY MEDICINE
through the ages. Sometimes, he said, in the current of
events her progress has been labored and slow; with
halting and uncertain steps, with Arabian mythologists,
astrologers, and such like visionaries as her companions,
she has picked her way through gloomy times of mystery,
uncertainty, and doubt. At times the light of truth has
shone upon her path more brightly and has cheered her on
her way ; and with the Harveys, the Sydenhams, the Jen-
ners, and the Hunters, the Dupuytrens, Laennecs, and
Pasteurs of the world for her companions she has walked
with firmer steps until at last she has become an acknowl-
edged power, and stands forth as the companion of- even
the exact sciences. Each generation of her votaries, as
it passes across the stage of the world’s history, is hence-
forth bound to leave a mark behind it as its contribution
to the sum of existence, and that mark must, in the ag-
gregate, be the result of individual efforts. ‘To some it is
given to do great things, and to stand revealed by the un-
mistakable stamp of genius; to some, by more prolonged
and patient effort, to leave an impress which, if it be not
so brilliant, is yet equally fruitful and enduring ; and to
everyone of us, however humble may be the current of his
life, it is permitted to make his mark, to add his little
contribution to the total sum of a ceaseless progress, and
to advance it or to hinder its advance.
246
He next referred to
THE COMPARATIVE ISOLATION OF PRACTITIONERS IN FOR-
MER TIMES,
and to changes which had been brought in these later
times by the wonderfully improved means for personal
communication which have come by the advent of rail-
ways and the telegraph. The facilities for the spread of
knowledge are now so increased that no discovery, in
whatever part of the world it may be made, can wait long
before becoming the general property of all.
The speaker then drew a picture of
THE GENERAL PRACTITIONER OF SEVENTY YEARS AGO.
He was usually a hard-working, industrious man, who
thought little of bodily exertion, and who spent the
greater part of his time in his saddle; a hard-thinking
man, but one whose mental training had not been great,
nor his education elaborate ; whose opportunities for the
acquisition of professional knowledge had been few and
short. Knowledge and practice alike were purely empir-
ical with him, and though he could treat disease with skill,
and could, in most cases, give a good account of his war.
fare, it was purely by empirical means that he did it. His
great panacea for all ailments was blood-letting, and his
pocket was never unarmed with the all-potent lancet.
_He next turned to a consideration of
MEDICAL SCIENCE OF THE PRESENT DAY,
which was, he said, and the fact could not be gainsaid, far
in advance of that of the beginning of the present century.
PUBLIC MEDICINE
was the next theme dwelt upon by the speaker, and which
he defined as a science which seeks ever, even at the risk
of its own extinction, to exterminate the causes of disease
and death, and to eradicate from the world the very
springs and sources from which they arise. It was now
impossible for any epidemic to run riot asit did in former
times. Can any work, he said, be nobler than this.
The subject of
MEDICAL EDUCATION AND EXAMINATIONS
was then considered at some length, and an ideal course
of instruction for the medical student was sketched.
In concluding, the speaker said that, notwithstanding
the infinitely greater knowledge and utility of the practi-
tioner of the present day, there was a limit to his power
—there was
ONE PLAGUE-SPOT
which even he will fail to conquer, and which will remain
to fester, to kill its thousands, to maim, disfigure, and to
sap the health of millions, of deserving and of undeserv-
ing alike, and, as the great curse of humanity, to baffle
all our efforts to arrest the progress of disease, and to
render them futile and abortive. ‘This is the curse that
steadily and vindictively pursues the track of licentious-
ness, of ungoverned passion, of hateful sensuality ; and
so long as human nature remains what it is, and is left in
unbridled possession of the mearis of gratification, no ray
of either light or hope will fall on that dark track. Some
day men may have become sufficiently enlightened to
submit to
NECESSARY LEGISLATION
and restrictions on this and cognate subjects ; but, until
they do, the foul stream will continue to meander hither
and thither, and whithersoever it will through the world
of life, will poison its springs, will wither even its fairest
blooms, and destroy its richest fruits without selection
and without mercy. By the cultivation of bacteriology
and cognate sciences, by a deeper and more profound ac-
quaintance with natural phenomena and laws, the time will
come when the whole range of zymotic and exanthematous
diseases will have been subdued and conquered ; when the
seeds of each will have been isolated, and so studied that
THE MEDICAL RECORD.
[August 31, 1889
—-— -
they will grow and those in which they will lie sterile will
be known and appreciated, and be brought under cultiva-
tion by the hands of the medical men of the day; and
when, by the spread of sanitary science, the whole human
race may be protected from their evil influences. It will
not be in our day that these mighty triumphs will be won,
but our successors will undoubtedly achieve them ; and
the time will certainly come when the kingdom of disease
will be so closely narrowed down that only the necessary
accompaniments of the changes and vicissitudes of
natural laws, the evils attendant upon the wilful disobe-
dience of those laws, the innumerable accidents to which
life'and limb must be forever liable, and the inherent de-
fects and deficiencies in the harmonious working of the
parts of a machine so exquisitely and delicately constructed
as is the frail body which for a time we inhabit will be
the only kingdom in which the professors of medicine
and surgery will be called upon to exercise their sway.
Then
THE VICTORY OF MEDICINE WILL BE COMPLETE,
and the day will have come when the world will be called
upon to acknowledge that the labors of the physician and
the surgeon, patient, enduring, untiring‘as they have been
through all time, have not been in vain, and have reached
their final consummation.
After a vote of thanks to the President had been moved
and carnied,
A PROTEST AGAINST THE MANAGEMENT OF THE “ JOURNAL,”
signed by Sir Joseph Lister and others, was read. In this
letter the writers threatened to resign from the Associa-
tion if their protest was not heeded.
On motion of Mr. Lawson Tait, seconded by Dr. Rob-
ert Barnes, the steps taken by the Council for the man-
agement of the ¥ournal, were approved, only one dissent-
ing vote being recorded.
WEDNESDAY, AUGUST 14TH —SECOND Day.
Dr. BRIDGWATER moved that the Council be empow-
ered to arrange for a place of meeting for 1890, and also
to appoint a President elect. It was stated that no defi-
nite invitation had been received for this meeting.
Dr. J. HUGHLINGS JACKSON then delivered the Address
on Medicine (see p. 225) entitled
A COMPARATIVE STUDY OF DISEASES OF THE NERVOUS
SYSTEM.
On motion of Dr.Eddison, seconded by Dr. Bristow, a
vote of thanks was unanimously tendered Dr. Jackson for
his address.
Dr. BRIDGWATER, in a few well-chosen words, then an-
nounced the
AWARD OF THE STEWART PRIZE.
This prize had been founded by the late Dr. Alexander
P. Stewart, who had left a sum of money, the interest of
which was to be given each year to one who had done
the best work of the year in the study of epidemic dis-
eases. The prize for this year had been awarded to Dr.
Klein for valuable researches on micro-organisms, and
more particularly for work in connection with the etiology
of scarlet fever.
Dr. KLEIN, in a few words, returned thanks for the
honor conferred upon him in the award of this prize,
which he chose to regard as an acknowledgment of the
services rendered to the science of medicine by bacteri-
ology.
The President, Council, and Senate, gave a reception
to the members of the Association at the Yorkshire Col-
lege, and in the evening the President and the Local Ex-
amining Committee gave a conyersazione in the municipal
their individuality will be recognizable ; the soilsin which ' buildings.
August 31, 1889].
NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting, April 24, 1889.
WILLIAM P. NorTHRUuP, M.D., PRESIDENT, IN THE
CHAIR.
Dr. EucENE Hopenpyt presented a series of specimens
illustrating
LESIONS AND MALFORMATIONS OF THE HEART.
Two hearts were shown in which there were chord
tendinez stretching across the cavity of the left ventricle.
The speaker thought that this was not a very rare con-
dition, and that it would be found more commonly than
it Is, were care used in opening the ventricle. In one of
these cases a murmur was heard before death, but no
particular importance was attached to it. He asked what
had been the experience of the members present in re-
gard to the production of murmurs by these chorde. He
had seen about fifteen cases of this sort recently, and in
only one had the existence of a murmur been noted.
DILATATION OF THE HEART WITH BUT SLIGHT HYPER-
TROPHY.
A young man had suffered all his life from symptoms
of cardiac trouble. He also had Potts disease of the
spine. At the autopsy there was found an enormous
dilatation of the left ventricle, with comparatively but a
slight degree of hypertrophy. ‘The aorta in this case was
of very small size.
ANEURISM OF THE MITRAL VALVE.
This heart was removed from the body of an old man
who had been in the hospital for some time with
symptoms of heart disease. He was found dead in bed
one morning. At the autopsy the heart wall was found
fatty throughout, and there was very marked thickening,
with stenosis of the aortic valve. The aorta was athero.
matous. An aneurism, about the size of a filbert, was
found on the mitral valve.
AN INCORRECT DIAGNOSIS OF AORTIC ANEURISM.
The specimen was removed from the body of a woman,
forty-seven years of age, who had suffered from what was
supposed to be an aneurism of the aorta. At the autopsy,
however, no aneurism was found, there being only a very
moderate degree of dilatation of the arch of the aorta.
The aortic valves were thickened and stenosed, and one
cusp was almost entirely obliterated. ‘There was also a
band of fibrous tissue stretching across the cavity of the left
ventricle. On the surface of the lungs, beneath the
pleura, were numerous little air-sacs.
APOPLEXY OF THE OVARIES.
The same patient also had two fibroid tumors of the
uterus, and the ovaries were rather peculiarly diseased.
The surface of the organs was ofa purplish color, and
on section the cut surface wasfound to be almost jet-
black mottled with white. The black color was found on
examination to be due to the presence of altered blood,
and the white spots were probably old ccrpora lutea.
MULTIPLE ANEURISMS.
A man about fifty years of age was admitted to the
hospital, suffefing from an aneurism of the subclavian
artery. ‘The treatment consisted in ligation first of the
- carotid artery. The patient did well after this operation,
and then the third part of the subclavian was ligated.
‘This was not so successful, and the man had a secondary
hemorrhage. ‘Then the axillary artery was tied, but the
patient died shortly afterward. A few days before death
he suffered intense dyspnoea and hada severe cough. At
the autopsy an explanation of the dyspnoea was found in
the presence of a rather large aneurism of the innominate
artery which pressed upon the trachea, narrowing its
lumen. There was also a fusiform aneurism of the aorta,
which had not been suspected during life.
THE MEDICAL RECORD.
247
Dr. GEeorGE R. Lockwoop, JR., said, in regard to the
production of a murmur by chordz tendinez stretching
across the ventricle, that such might very readily occur if
the chordz were attached to a papillary muscle, and were
thus rendered tense. In the specimens shown by Dr.
Hodenpyl, however, there was no such attachment ; the
cord would therefore become relaxed during systole, and
consequently there could be no vibrations in it to cause a
murmur. l
Dr. FRANK W. JACKSON thought it would be a very dif-
ficult matter to diagnose the presence of intra-ventricular
bands. It was sometimes comparatively easy to diagnose
an intra-ventricular murmur, and he had a patient now
under observation with a heart murmur which he was con-
fident was intra-ventricular; but it was a very different
matter to determine the cause of this murmur, since sev-
eral distinct conditions might occasion it.
Dr. F. S. MCHALE presented a specimen showing
TUBERCULOSIS OF THE PERICARDIUM.
It was removed from the body of a man forty-five
years of age, who had had a cough for the past three
years. Three weeks before admission to hospital, after
exposure to the wet, he had an increase in the cough,
which now became very severe, and pain over the entire
length of the sternum. His face was drawn, flushed, and
covered with perspiration. Fora time there was some’
cedema of the leg, but this disappeared in about a week.
At the autopsy no marked gross lesions were found any-
where except in the heart. This organ was enlarged, and
the pericardium was irregularly thickened, and its cavity
contained fibrin and pus. ‘The inner surface of the pa-
rietal layer was studded with whitish nodules. Dr. Hoden-
pyl examined the specimen and reported that the new-
growth was made up of small spheroidal, epithelioid, and
giant cells. Examination of the kidneys revealed the
presence of nephritis.
Dr. Hopenpy. said that it was important in these
cases to note the condition of the bronchial and medias-
tinal glands. Weigert had lately made the assertion that
the so-called tuberculosis of the pericardium was always
primarily a tuberculosis of the mediastinal glands.
Dr. Hodenpy! then presented two specimens of
TUBERCULAR PLEURISY AND PERICARDITIS.
The first specimen was from a man thirty-four years of
age, who had been exposed four months before his death
to cold and wet. He developed a cough, and then
began to suffer from dyspnoea and loss of appetite.
Physical examination revealed a pleuritic effusion on the
right side. The patient was tapped several times, a large
amount of bloody serum being drawn off each time. At
the autopsy the pericardium was found completely ad-
herent and thickened.
The second specimen was one apparently of primary
tuberculosis of the pleura, with secondary affection of the
pericardium. In this case the bronchial glands were ex-
amined and found to be tuberculous. On microscopical
examination the sections. showed almost the same appear-
ances as those seen in Dr. McHale’s case. The tuber-
cles were somewhat cheesy, and contained large numbers
of giant cells.
Dr. WILLIAM P. NORTHRUP presented a specimen of
ADHERENT PERICARDIUM
with dilatation and hypertrophy of the heart.
‘The patient was a male child, aged thirteen months.
His only illness was double otorrhoea, so far as recorded.
He was cross and fretful by seasons. Never had any
contagious disease, unless possibly measles. Two days
before death his respirations became rapid—6o per
minute ; the pulse was 160, while his temperature remained
99°. One day before death temperature was 100”, the
extremities were cold, and the child screamed, apparently
from pain, and seemed to be dying. He died without
convulsions.
248
On autopsy, the body was found well nourished ; brain
normal. The heart was enlarged; weight 5 oz. 5 dr.
The pericardium everywhere was adherent by loose bands
which allowed moderate movement of the adjacent peri-
cardial layers. ‘The auricles and ventricles were dilated,
and their walls were hypertrophied. ‘The valves were
normal, and the foramen ovale was closed. The great
vessels were normal. The lungs were congested, œde-
matous, and flabby. The bronchial glands were moder-
ately enlarged and dusky. Kidney, cortex pale ; marking
indistinct. ‘
Dr. R. S. Freeman had looked up the literature of
adherent pericardium in young children and had found
the following cases reported. ŒE. Cerf’ reported forty-
three cases of pericardial adhesion ; of these the youngest
was eight years of age. Samuel Wilks’ reported six cases
in early life ; the youngest was nine years of age. A few
cases in very early infancy are on record. A case was
reported in Vienna where retraction over the apex was no
ticed on the eighth day, and at the autopsy fresh adhesions
were found. Bednor found adhesions in a child of three
months. Billard ° makes the following note on the autopsy
of a child, aged two days. ‘There were “firm adhesions
between layers of pericardium, producing belief that they
were the product of former pericarditis developed during
evolution of fœtus.” ‘This condition in a new-born child
is also reported by Huetner.
Dr. Northrup presented a second specimen showing
ABSENCE OF THE SEPTUM AURICULORUM,
dilatation and hypertrophy of the heart, and acute exu-
dative nephritis in a child aged thirteen and a half
months. The child had always been “ miserable” and
irritable, but never sick. ‘There was no history of scarlet
fever or diphtheria, and the child was not a blue child.
On autopsy the heart was found very large, its common
auricle being distended with dark clot, the walls of the
auricle and ventricles were thickened. ‘The ventricles
were empty. There was a thin, membranous, crescentic
rudiment, the only attempt at aseptum auriculorum. ‘The
lungs were moderately congested, uniformly ; no consoli-
dation, no bronchitis ; slight cedema.
_ Kidneys enlarged, cortex thickened, pale, markings
varying from moderately distinct to indistinct and obliter-
ated. The pyramids were congested, and in them and
about their bases were masses of hemorrhage, and within
the hemorrhagic masses pale spots. ‘The striations and
mottlings were found, under the microscope, to be formed
of alternating masses of pus and hemorrhage.
also hyaline casts and drops of cast matter within the
tubes ; also necrosis of the epithelium of many convoluted
tubes. The urine from the bladder showed pus only.
Other organs normal.
Four other specimens were presented, showing hernia in
children. One of these specimens was of double congen-
ital inguinal hernia. On the right side the czecum and a
few inches of the ileum were in the sac. On the left side
the sac wasempty. The opening easily admitted the end
of the little finger.
Dr. ARMSTRONG asked what was the experience of the
members present in regard to the frequency of a patent
foramen ovale. He had found it so often that he had al-
most ceased to look upon it as a rarity.
THE PRESIDENT had seen it a number of times, and in
many cases there had been no symptoms during life lead-
ing to a suspicion of the condition.
Dr. FERGUSON said that some three years ago he had
presented before the Society a series of specimens of
patent foramen ovale. In every instance, however, there
was a valve-like arrangement which effectually closed the
opening in the septum, one part lapping over the other so
that no direct opening existed. ‘There was no cyanosis or
1 Bauer: Ziemssen, Handb. d. Spec. Path., vol. vi.
2 Guy’s Hospital Reports, vol. xvi., pp. 196-208.
3 Billard: Diseases of Infants, p. 251. Philadelphia, 1850.
THE MEDICAL RECORD.
There were |
[August 31, 1889
other symptom during life pointing to the presence of an
incomplete septum.
Dr. ARMSTRONG said that in one of the cases of patent
foramen ovale which he had seen there were four segments
to the valve of the pulmonary artery. He had seen this
condition several times.
Dr. H. S. STEARNS presented a specimen of
TUMOR OF THE DURA MATER.
The tumor was of rather large size, and examination
showed it.to be a sarcoma. No extensive clinical history
had been obtained, but it was stated that the man had been
paralyzed a short time before death.
Dr. J. West ROOSEVELT presented some corrosion
specimens, with remarks (see p. 237) upon
SIMPLE METHODS FOR MAKING CORROSION PREPARATIONS
SHOWING THE GROSS ANATOMY OF LARGE VISCERA.
Dr. FREEBORN exhibited a corrosion specimen, show-
ing the terminal air-cells in the lung, which he had made
several years ago. The injection material was celloidin.
It was mounted in glycerine jelly, which the speaker
thought was a very good medium for the celloidin. He
had used ninety-eight per cent. alcohol to soften the cel-
loidin and render it less brittle.
Dr. H. M. Biccs presented a specimen of
PATENT DUCTUS ARTERIOSUS.
The patient was a young man about twenty years of age,
who was in Dr. Janeway’s service at Bellevue Hospital,
under treatment for pulmonary tuberculosis. There was
a loud murmur heard in the second intercostal space on
the left side, accompanied with a very marked thrill. A
diagnosis of pulmonic stenosis was made. ‘The patient
had but little dyspnoea and no cyanosis. After death the
lesions of chronic venous congestion were found, and
there was seen to be a patent ductus arteriosus.
Dr. Biggs also showed a specimen of very pro-
nounced
INTERSTITIAL MYOCARDITIS,
removed from the body of a man sixty years of age, who
was under treatment for what was supposed to be asthma.
He dropped dead one day while crossing the ward in the
hospital. At the autopsy there was found to be advanced
disease in the smaller arteries, and very marked myocar-
ditis. There was commencing cardiac dilatation, and at
one point the wall of the heart was exceedingly thin.
There were also found one or two small calcareous plates
on the tricuspid valve.
Dr. FRANK FERGUSON presented a specimen of
MILIARY ANEURISM
removed from a person who had died of cerebral apoplexy
and also one of
PACHYMENINGITIS HAMORRHAGICA
occurring in a man sixty years of age, who was supposed
at the time of his death to be suffering from ordinary
apoplexy.
A third specimen was one of
GIANT-CELL SARCOMA OF THE TONGUE.
It was removed by operation from a man aged forty years,
who was thought, by some of the physicians who saw him,
to be suffering from syphilitic ulceration of the tongue.
The lesion began as a small ulcerated surface which grad-
ually increased in depth, its edges becoming thicker, with-
out any noticeable increase in area. Dr. Ferguson, when
he first saw the case, made a diagnosis of epithelioma,
and removed the growth. The lesion returned, however,
with great rapidity. ‘The glands also became enlarged,
and upon removal were found to be sarcomatous.
Dr. Ferguson then presented a specimen showing
INTERSTITIAL MYOCARDITIS.
The patient was a boatman, thirty-nine years of age, of
good family history, who had always been well up to within
August 31, 1889]
four months of his admission to the hospital. ‘Then he
began to suffer somewhat from dyspnoea, and this gradu-
ally grew worse until his death, which occurred six days
after his entrance into the hospital. At the autopsy there
was found to be an aneurism of the aorta which pressed
upon the trachea, and the heart muscle was inflamed.
The coronary arteries were perfectly normal, but the
pneumogastric nerve was pressed upon by the aneurism,
and it was to this that the speaker thought the myocar.
ditis was in great measure due.
A fifth specimen was one apparently of
DOUBLE BLADDER.
It was removed from the body of a man who had given
no symptoms of bladder trouble during life. The two
portions of the bladder were connected by a very small
opening. ‘The second bladder was as large as the normal
viscus, and was so situated that it made no pressure upon
either of the ureters.
Dr. Biccs asked whether there were any stricture of
the urethra, for the specimen looked to him like a dis-
tended ureter due to retention of urine, and not like an
Ordinary diverticulum of the bladder.
Dr. FERGUSON replied that there was no stricture, and
the prostate was not enlarged. He had never seen a case
of diverticulum from pressure of the retained urine in
which there was such a small opening.
Dr. RoosEvELT did not think that Dr. Ferguson’s ex-
planation of the occurrence of myocarditis was needed in
the present instance. ‘There was certainly disease of
many of the vessels in the body, notwithstanding that the
coronary arteries appeared to be normal, and it seemed
hardly necessary to invoke the stretching of the pneumo-
gastric nerve in explanation of the phenomenon. ‘The
pneumogastric nerve is often found to be pulled upon in
cases in which no myocarditis is present. He asked what
was the condition of the 1
Dr. FERGUSON replied that the lungs presented the or-
dinary appearances seen in these organs in heart disease.
In all the cases of aneurism that he had examined he had
never seen a single one with interstitial myocarditis. He
did not deny that the condition of the aorta in this case
might have had something to do with the production of
the myocarditis, but as to the coronary arteries, they were
perfectly normal.
Dr. Biccs asked if Dr. Ferguson had ever before seen
a giant-cell sarcoma arising from the tongue or in any
tissue so far removed from bone.
Dr. FERGUSON said that he never had. In this case
the tumor commenced apparently in the mucous mem-
brane of the tongue. When he first saw it, it was about
the size of a bean. The giant cells were not reproduced,
and the glands in the neck presented the appearances of
a typical spindle-cell sarcoma.
Dr. Biacs said that he had recently seen a tubercular
ulcer of the tongue in which there were very large and
typical giant cells. In this case the lungs were tubercu-
lous. Such a case as that reported by Dr. Ferguson must
be extremely rare.
The Society then went into executive session.
Stated Meeting, May 8, 1889.
Wn. P. NorTHRuP, M.D., PRESIDENT, IN THE CHAIR.
Dr. H. P. Loomis presented a specimen showing
CONGENITAL NARROWING OF THE COLON,
with extensive dilatation above the constricted portion.
It was removed from the body of a woman, thirty-four
years of age, who died at Bellevue Hospital, after a three
weeks’ sickness, from acute tubercular phthisis. The con-
dition of the intestine was not suspected during life.
On opening the abdominal cavity the colon, as far as
the splenic flexure, was seen to be enormously distended
with gas. From a point just below the beginning of the
descending portion of the colon to the anus, the intestine
THE MEDICAL RECORD.
249 -
was collapsed, and in size not as large as a normal ileum.
A careful examination of the abdominal contents showed
nothing abnormal ; there was no evidence of peritonitis,
no bands of connective tissue, no adhesions, no new-
growths, and no twisting of the intestine. On raising the
small intestines the descending colon was seen to narrow
in a funnel-shaped manner until, about four inches below
the splenic flexure, it had reached about half its normal
size.
Just below the funnel-shaped constriction was found a
round, soft, faecal mass, and scattered throughout the rest
of the descending colon and the rectum similar masses
were observed. On removing the intestines and making a
careful examination, the colon was found perfectly normal,
except that the lower portion of the colon and rectum
were atrophied. Nothing was found within the intestine
except fæces. Dr. Loomis said that he could account for
the condition only by considering it congenital. ‘The ab-
sence of any apparent cause for the condition, and the
fact that the diminution in size was gradual and uniform,
seemed to bear out this assumption.
Dr. Loomis also presented a second specimen, showing
A DIVERTICULUM FROM THE LOWER PORTION OF THE
ILEUM.
The diverticulum was found at a distance of about twenty
inches from the ileo-czcal valve, and was of about the
same diameter as the ileum, and eight inches in length.
It presented all the appearances of the normal intestine,
as regarded both its mucous membrane and muscular coat.
In one case of this kind that the speaker had seen, the
patient had died of typhoid fever, and the intestinal lesions
of this disease were found in the diverticulum.
Dr. J. C. PETERS said that quite a number of cases of
intestinal diverticula would be found recorded in the first
volume of the “ Transactions” of the Society.
THE PRESIDENT said that in making autopsies on chil-
dren he had often seen the upper portion of the colon
enormously distended, while the lower part would be empty
and contracted. He had never found any satisfactory ex-
planation of this condition, but the specimen presented by
Dr. Loomis reminded him of it. He asked how soon
after death the autopsy was made.
Dr. PRUDDEN said that in cases in which the lower
portion of the colon is thrown out of use by reason of a-
stricture, there is very apt to be atrophy of the unused
part. In such cases, however, there are some symptoms
pointing to the condition present.
Dr. Loomis said that the autopsy was made some
twelve to eighteen hours after death. When he first saw
the case it looked as though there were a constricting
band, but none was found on examining the specimen
more closely. ‘The woman was sick in the hospital for
three weeks before her death, but she presented no symp-
toms whatever indicative of any intestinal abnormality.
Dr. H. J. BOLDT presented a specimen of
ADENOMA OF THE OVARY.
The patient, a woman in middle life, had suffered from
pain about two years. Microscopical examination of the
enlarged gland shows it to be in a state of adenomatous
degeneration.
A second specimen was one of
FIBRO-MYOMA OF THE UTERUS,
It was impossible to enucleate the tumor, and in conse-
quence the uterus was removed with it by the supra-vaginal
method, and intra-peritoneal treatment of the stump was
carried out.
GONORRHCEAL SALPINGITIS.
The specimen was removed from a woman who had
been infected with gonorrhoea by her husband six months
previously. Two months after the beginning of the
trouble the left tube was found to be enlarged. No bene-
fit was derived from the treatment employed, and the in-
tense pain incapacitated her from attending to her house-
250
hold duties. Examination showed the uterus to be
embedded in a mass of exudation. On opening the abdo-
men the tube was enucleated with great difficulty from
the perimetric adhesions. The tube was enlarged, but
apparently contained no pus, and on cutting into it before
removal none escaped. ‘The enlargement seemed to be
due to interstitial inflammation.
The tube was, however, removed, because in case of sutur-
ing the wound the lumen might be permanently occluded,
or, in the event of the sutures giving way, some of the
products of gonorrhceal inflammation might escape into
the peritoneal cavity. The opposite ovary was also dis-
eased, having on its surface some small cysts; these were
excised after Schroeder’s method, which would allow the
patient to continue in her generative functions. The
three cases above reported made a good recovery.
In addition, Dr. Boldt said he desired to mention an-
oiher case of rupture of a pyo-salpinx, successfully oper-
ated upon by his colleague, Dr. Von Ramdohr, a few
hours after occurrence of the rupture, which took place
during the night, necessitating operation at 3 a.M. His
patient also made a good recovery.
LYMPH NODES AND LYMPH NODULES.
Dr. T. M. PRUDDEN referred to the new nomenclature
in regard to the so-called lymphatic glands, and said that
the Society might do much to promote its general adop-
tion if the individual members would employ it. The so-
called lymphatic glands are not glands at all, and should
be called lymph nodes. There are other collections of
lymph tissue, scattered about in various organs, which dif-
fer from the nodes in their small size, and in the fact that
they are not distinct one from another and surrounded by
a capsule, as are the nodes. ‘These should be called
lymph nodules. Then the term gland could be used
where it belonged, and much confusion mignt be avoided.
It was also a misnomer to apply the term solitary and ag-
minated follicles to the collections of lymph tissue in the
intestine. He hoped that the members of the Society
would help along by the influence of their example the
general adoption of this correct nomenclature.
The Society then went into executive session.
ENUCLEATION OF THE EYEBALL BY A NEW METHOD.—
Dr. George M. Hamilton, of Ashland, Pa., writes: “ In
THE MEpIcAL ReEcorD of May 11, 1889, I notice an
article, credited to Zhe Lancet, which gives the details of
a method of enucleating the eyeball, as practised by Dr.
Coppez, of St. John’s Hospital, Brussels. It is one of the
best methods in use; far simpler, as he claims, than those
of Bonnet and Tillaux, both in regard to the instruments
used and the manner of after-treatment, but it is by no
means a new one. Dr. Biddle, of the State Hospital,
Ashland, Pa., has been enucleating by this method for the
last two or three years. The article says: ‘ The patient
having been anesthetized, and the eyelids separated by a
speculum, a thread is passed transversely through the
comea by means of a curved needle; the ends of the
thread are knotted and the loop held in the left hand. By
traction on the loop the eye is drawn slightly forward, and
with a curved scissors the conjunctiva is divided close to
the corneal edge. The subconjunctival tissue is then torn
through, and the tendons of the recti muscles come into
view and are divided ; next the oblique muscles, and
finally the optic nerve.’ This is almost identical with the
operation performed here as far back as 1886. In order
to more fully expose the insertions of the muscles, Dr.
Biddle prefers to raise these structures with a blunt hook.
‘This enables him to divide the tendons evenly, and get a
better surface for an artificial eye. ‘The danger of having
the eye become flaccid, by the escape of contents of
anterior chamber, can be reduced to a minimum by using
a proportionately small needle and large thread, and in-
troducing the needle at the corneo-sclerotic junction.”
THE MEDICAL RECORD.
[August 31, 1889
New Zustrunents.
A SPECULUM FOR APPLYING CAUSTICS TO
THE DEEP STRUCTURES OF THE NASAL
CAVITIES.
By J. HERBERT CLAIBORNE, Jr., M.D.,
NEW YORK.
THE accompanying cut represents a nasal speculum which
I have had constructed for the purpose of making appli-
cations of caustics to the deep structures of the nose.
It will be seen that the
instrument is a modi
fication of Simrock’s
speculum. In front
are two flanges for sup-
port by the index-finger
and thumb when the
instrument is inserted.
There are two sizes of
the instrument. The
larger measures one inch and seven-eighths from tip to
base. The diameter of the canal at the base is about
six-eighths of an inch in height, and four-eighths of an
inch in breadth. ‘The edges of the truncated part of the
cone are rounded, so that the mucous membrane may not
be wounded when the instrument is inserted in the nose.
The rounding of the edges is not correctly shown in the
cut. The smaller speculum, while of the same length as
the larger, just fits within it. In the case of very narrow
nasal canals the horizontal diameter of the instrument
can be diminished. ‘The instruments are made of bright
metal, but one of hard rubber can be used when the
actual or galvano-cautery is employed. The manner of
introducing it is as follows: The barrel having been
greased with vaseline, the point of the nose is raised by
the thumb of the disengaged hand; the thumb of the
other hand is placed over the aperture at the base of the
instrument, while the index and middle are hooked be-
hind the flanges. The instrument is then pushed gently
in, till, if need be, the whole barrel is sheathed in the
nasal cavity. I find this instrument of peculiar value in
making applications to the posterior tips of the inferior
turbinated bones. Many surgeons use large aural specula
for making applications, whether of fire or chemical caus-
tics, to the deep structures of the nose. ‘The use of these
aural specula for the nose is attended by pain, even un-
der the use of cocaine, and personal discomfort experi-
enced from their use has suggested to me the instrument,
the cut of which is herewith presented.
The instruments are made by Meyrowitz Brothers.
PATHOLOGICAL INFERIORITY OF THE LEFT SIDE OF THE
Human Bopy.—When a unilateral lesion attacks any of
the double organs of the human body, the left organ is
more frequently affected than the night. ‘Thus, obliterat-
ing arteritis attacks the left Sylvian artery, tuberculous
infiltration occurs in the left apex, pneumonia in the left
lung ; calculous nephritis, or cyst of the kidney, attacks
the left kidney ; ovaritis and ovarian hyperzesthesia are ob-
served in the left ovary; orchitis affects the left testicle,
etc. M. Henry Duchenne tries to explain this fact by the
greater activity of the right side of the body and the rela-
tive passive condition of the left side, which contains the
heart. The mechanical activity of the right side deter-
mines nutritive activity. The mechanical passivity of the
left side produces a kind of physiological mealiness, a
pathological predisposition. Dr. Duchenne considers
that the law of atavism may also explain the physiological
inferiority of the left side of the body, for in ancient
times, when hand-to-hand fights were always occurring,
the activity of the right side of the body was constantly
called into play.— Medical Recorder.
a EES
August 31, 1889]
Army and Hany ews.
Official List of Changes in the Stations and Duties of Cfi-
cers serving in the Medical Department, United States
Army, from August 18, to August 24, 1889.
BaILy, JosEPH C., Lieutenant-Colonel and Surgeon,
Medical Director 'Teadquarters Department of Texas,
San Antonio, Tex. Granted leave of absence for one
month. S. O. 54, Headquarters Department of Texas,
August 17, 1889.
Brown, Harney E., Major and Surgeon. Died at
Jackson Barracks, New Orleans, La., August 20, 1889.
Pope, BENJAMIN F., Major and Surgeon. Granted
leave of absence for one month, with permission to apply
through Division Headquarters for an extension of two
months. Par. 7, S. O. 54, Department of Texas, August
17, 1889.
Official List of Changes in the Medical Corps of the United
States Navy for the week ending August 24, 1889.
SCOFIELD, W. K., Medical Inspector. Detached from
the Lancaster.
HIBBETT, C. T., Passed Assistant Surgeon.
from the Lancaster.
Wuite, C. H., Medical Inspector.
Pensacola.
HESLER, F. A., Passed Assistant Surgeon.
the Pensacola.
Curtis, L. W., Passed Assistant Surgeon.
the New Hampshire.
Jones, W. H., Surgeon. Detached from the Pensacola,
and placed on waiting orders.
WEDEKIND, L. von, Assistant Surgeon. Detached
from the New Hampshire, and ordered to the Pensacola.
Detached
Ordered to the
Ordered to
Ordered to
edict Items.
CONTAGIOUS DISEASES—WEEKLY STATEMENT. — Re-
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending August 24, 1889:
| Cases. | Deaths.
Typhus fever
WeKGN aa pos eww Ma eese scene E fe) o
Typhoid fever sisse rrurcioirieineie arent wiris | 72 15
Scarlet LEVER yes igs oy e4 EREET 33 I
Cerebro-spinal meningitis.............cccseceeces 2 2
Measles Wiis ka a vecike tees e ese Ch awa itnereads 16 3
Diphtheria sc iicscenGaraseonse ates EENAA EE 71 12
Small POK scssisigiorcwosiers choad seeder owas wad CETE oO o
Yelow levet. oieee owas was ene dei Neee i EAD o) o
el i a E E ne E iues x l. o o
A SPECIMEN ARMY MEDICAL BOARD EXAMINATION.—
Arithmetic.—Time, forty-five minutes. 1. æ. Multiply
17$ by 13.37. 6 Divide 44 by 24. 2. Define propor-
tion in arithmetic. 3. If four grammes of morphia cost
forty cents, what is the price per apothecaries’ ounce and
per avoirdupois ounce? 4. A owes B $1,000, to be paid
in twelve days, and $500, to be paid in three months. If
settled by one payment, when should this be made? 5.
What is the cube root of .08769? 6. What is the air
space of a ward 30 feet long, 18 feet feet wide, walls 13.5
feet in height, with six round columns 18 inches in dia-
meter? 7. How can you ascertain the width of a river
which you are unable to cross? 8. a. How is the value
of an angle expressed? 4. Name and illustrate by dia-
grams the principal forms of triangles. Geography.—
Time, forty-five minutes. 1. Mention the sources and
THE MEDICAL RECORD.
251
principal tributaries of the Missouri River. 2. Tell what
you know of the physical geography of the peninsula of
Florida. 3. What strait separates Asia and North Am-
erica? What portions of land do the Straits of Magellan
separate? 4. Explain the cause of the trade-winds. 5.
Where and what is Samoa? 6. What are the principal
mountain ranges of Europe, and where is each situated ?
7. How is the State of Kentucky bounded? History and
Literature.—Time, one hour. 1. What was the object of
the crusades, and what the date [approximately] of the
first? 2. What led to the earlier Arctic expeditions? 3.
What were the most important decisive battles of the war of
1861—65, and who commanded the opposing armies? 4.
Who were the allies at the battle of Waterloo? 5. What
are the principal works of Chaucer, and in what century
did he live? 6. Mention two or three of the early Italian
authors and their principal works? 7. Who was Haw-
thorne and what did he write? Who wrote “ Evangeline?”
What did Prescott write? 8. What city was the scene of
Homer’s “ Iliad,” and where was it situated? Chemistry.—
Time, one hour. 1. State the law of multiple propor-
tions. 2. What is ozone and what are its properties ?
3. Give the names and symbols of the non-metallic ele-
ments. 4. How is chlorine usually obtained in a free
state? 5. What is the composition of phenol, and from
what source is it obtained? 6. What is the source of the
essential oils, and what are the chemical and physical
properties? 7. What are the properties of hydrocyanic
acid, and by what tests is it recognized? PAysics.—Time,
one hour. 1. In what direction is the pressure of the at-
mosphere most exerted? 2. What is the lowest point
[Fahrenheit] registered by the mercurial thermometer ? 3.
Why is the light of a Bunsen burner non-luminous? 4.
How do you determine the number of vibrations per second
necessary to produce a given musical tone? 5. What
do you understand by the emission theory of light, and
what by the undulatory theory? 6. Mention and define
one or more of the heat units. 7. Explain the construc-
tion and uses of the electro-magnet. ygiene.—Time, two
hours and a half. 1. What are the advantages and disadvan-
tages of stoves as a means of heating ? 2. What means would
you adopt to prevent the spread of scarlet fever, and what to
prevent the spread of typhoid? Give your reasons in each
case. 3. What diseases have been most influenced by the con-
struction of sewers in towns? 4. What is the proportion of
CO’ in the atmosphere of a sleeping apartment when a
“ close ” odor from organic matter begins to be percepti-
ble? 5. What disinfectants would you use during an
epidemic of cholera, and how would you use them? 6.
Mention some easy methods of testing the purity of milk.
7. What is the source of ammonia in impure water, and
what is the most reliable test of its presence? 8. What
is, under ordinary circumstances, a proper temperature
for a sick-room or hospital ward? 9g. What is the effect
of alcohol on the excretion of pulmonary carbon dioxide ?
ro. Mention the death-rate of one or more of the princi-
pal cities in this country and in Europe. Anatomy and
Phystology.—Time, three hours and a half. 1. Describe
the surgical anatomy of the axillary artery, giving its
origin, course, and relations in the different parts of its
course : enumerate its branches and state their course
and ultimate distribution. 2. State the parts cut through
in a circular amputation at the middle of the thigh. 3.
Name the arteries establishing the anastomoses around
the knee-joint after ligature of the femoral artery. 4.
Give the origin, relations, branches, and their final distn-
butions, of the seventh cranial nerve, and state its func-
tions. 5. Name the viscera: 1, covered by peritoneum ;
2, partially invested by peritoneum; and 3, state what vis-
cera have no peritoneal investment. PAysiology.—t.
Mention the different kinds of cartilage that exist in the
human body ; describe the peculiarities of structure that
distinguish each variety, and state the purposes which
each answers and where found. 2. What are the princi-
pal sources and modes of production of animal heat?
Mention the circumstances causing variations in tempera-
252
ture of the human body ; ; aad state how the average tem-
perature of the body is maintained and regulated. 3.
By what means is the eye adjusted to distinct vision at
different distances? 4. What are the functions of the
sympathetic nervous system? Name the ganglia compos-
ing it, and state the location of each. 5. What is the
total amount of the excreta, estimated as carbon and
nitrogen, daily eliminated from thè human body? and
what amount and proportions of dry food are daily re-
quired for a healthy adult man of average height and
weight? Materia Medica and Therapeutics —Time, two
hours and a half. 1. Give the source and composition
of nux vomica, mention its preparations and doses of
each ; describe its physiological actions in (a) small, (4)
full, and (¢) toxic doses, and state the therapeutical in-
dication for its use. 2. Give the officinal preparations
of antimony, with doses of each ; state the physiological
actions of its principal salt, in (a) small, (4) larger, and (¢)
tonic doses, and mention the therapeutical indications for
its use. 3. What is the active principle of calabar bean ?”
State its physiological actions and mention the therapeuti-
cal indications for its use. 4. What is the source and
composition of colchicum ? Mention its preparations and
doses of each ; give its physiological actions and state the
therapeutical indications for its use. 5. Name the fifteen
officinal alkaloids. 6. State the principles upon which
counter-irntants act, and mention the therapeutical indi-
cations for their use. Practice and Pathology.—Time,
three hours and a half. 1. Give an account of the etio-
logy and clinical history of diphtheria. 2. What are the
symptoms of acute peritonitis? 3. Give the etiology of
dilatation of the heart. 4. What are the principal
causes of epilepsy? 5. Describe the treatment of ty-
phoid fever. 6. How should you treat a case of delirium
tremens? Give prescriptions in full. 7. Give an account
of the pathology of tuberculosis. 8. Give an account of
the pathology of Asiatic cholera. 9. Define eczema.
10. What are the principal diseases dependent on changes
in the spinal cord? Surgery.—Time, three hours and a
half. 1. What is the theory upon which antiseptic treat-
ment in surgery is based, and how do the agents used
modify the processes of inflammation? 2. Compare the
effects of the principal agents used for producing general
anesthesia. 3. How is dislocation of the head of the
femur on the dorsum ilii usually caused? What are its
characteristic signs, and what is the rationale of its treat-
ment by manipulation? 4. What are the causes, predis-
posing and exciting, of erysipelas? What circumstances
influence prognosis? How would you treat a severe
case? 5. What evidence would lead you to believe that
the lung had been wounded in a penetrating wound of
thorax, and how would you treat such a case? 6. In a
case of gunshot fracture involving the ankle-joint what
conditions liable to be present would influence your de-
cision as to operative or conservative treatment? 7. Ex-
plain causation of organic stricture of urethra. What are
its most frequent situations, and how does situation
modify treatment? What diseased conditions may result
from untreated urethral stricture? 8. What is the pathol-
ogy of trachomatous conjunctivitis and its results when
unrelieved ? How would you treat a case? Obstetrics
and Diseases of Women and Children.—Time, two hours
and a half. 1. What symptoms indicate the existence of
placenta przevia, and how would you treat such a com-
plication occurring in labor? 2. What complications
may arise in labor from abnormal conditions of the funis ?
What considerations guide you as to time of tying the
funis? 3. Mention the chief conditions with which an
ovarian tumor may be confounded and how a diagnosis is
to be made. 4. What do you understand by subinvolu.
tion of the uterus? What are its causes and what its ef-
fects? 5. How would you diagnose a case of spasmodic
catarrhal laryngitis from one of membranous laryngitis
before expulsion of membrane? How would you treat a
case of membranous laryngitis? 6. What is the pathology
of essential infantile paralysis? What groups of muscles
THE MEDICAL RECORD.
[August 3 31, 1889
are most liable to be affected p What permanent results
may be produced ?
MATERNAL IMPRESSIONS.—Mr. Thomas Latham writes :
“ Some time in the year 1867 the wife of William Swin-
dells, a farmer, residing near the village of Marple, Cheshire,
England, gave birth to a child, she not having had one
previously for fifteen years, and being then fifty-three
years of age. ‘The child when born had neither fingers
nor thumb upon its right hand. Swindells and his wife
resided with his brothers and cousins in a small hamlet off
the main road. Some time before the birth of the child
a stranger passed along the narrow cross-road which in-
tersected the hamlet, and Mrs. S., glancing through the
door, observed that the stranger had neither fingers nor
thumb upon his right hand. Several of her relations also
noticed the man’s deformity as he passed the various
houses, which were all built closely upon the narrow road.
The double event of the birth of the child and its peculiar
deformity was the talk of the villagers for miles around.
I have myself often seen the child, which was a very
healthy one, in my youthful rambles about the neighbor-
hood. I could procure documentary evidence of the
above facts in Marple village now if necessary.”
THE Rasic COMEDY AT JARVILLE.—The commune of
Jarville, in Lorraine, near Nancy, has recently enjoyed a
hydrophobia scare of quite respectable proportions. ‘The
cause of all the commotion was a little black puppy,
about two months old, that belonged to the proprietress
of a public-house. The owner became ill, and, finding
the puppy rather troublesome, made it over to a friend,
who, in turn, transferred it to another, and so it passed
through several hands in a short time. One of its owners
was a drunken workman, who died from delirium tremens.
The report soon spread that the man died from hydro-
phobia. The original owner, who had suffered for some
time from cancer of the stomach, was so alarmed at this
report that she took to her bed, and soon after had a
final attack of hzmatemesis, to which she succumbed.
Rumor assigned hydrophobia as the cause of her death
also, and the town went wild. A large number of the in-
habitants went to Paris, to the Pasteur Institute, at the
expense of the commune, and after being inoculated re-
turned home with minds at rest, and now propose to cel-
ebrate their deliverance by a dal des enragés. Thus
ended what Dr. Linet, who chronicled the event, has
called the rabic comedy of Jarville.
A CoMPouND Liquorice PowDER.—Mr. J. H. Fisher,
in a paper recently read before the Pharmaceutical So-
ciety, said that he had some years ago prepared, at the
suggestion of a medical practitioner, a compound liquorice
powder which was in some respects an improvement on
the pharmacopceial powder ; it had a pleasanter taste,
tart rather than sweet; it was more easily miscible with
water, it was less liable to gripe ; it was, however, a some- `
what more powerful aperient, and hau some diuretic and
“ refrigerant” properties. ‘The formula is as follows:
Senna, 2 parts; liquorice powder, 2 parts ; fennel, 1 part ;
sublimed sulphur, 1 part; cream of tartar, 4 parts ; sugar,
2 parts.— British Medical Fournal.
CONSANGUINEOUS MARRIAGES,—A subscriber writes :
“« A short article in THE MEpDICAL RECORD, No. 24, of
June 15th, on ‘ Consanguineous Marriages,’ attracted my
attention. I would be grateful to you for the opinion of
authorities on this subject as to the likelihood of diseased
offspring or other injurious results from consanguineous
marriages, and hope you will make it convenient to give
space to this discussion in your journal.”
CHEAP MEDICAL SERVICES.—A medical association
has been formed in this city which advertises to furnish
medical attendance to its subscribers for forty cents a
month, and that all prescriptions for its subscnbers will be
filled by the leading pharmacists of the city for twenty
cents for each prescription. In all probability the ser-
vices and medicines are not even worth that.
The Medical Recc
A Weekly Journal of Medicine and S
AL LIBp,
PECTIC THE
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Poy a
—— — 1 ee aaa amaa aumaaÃħňõă
Vol. 36, No. ro
NEw
ee
Original Articles,
PARTIAL RESECTION OF THE HEAD OF
THE FIRST METATARSAL BONE FOR HAL-
LUX VALGUS.
A New METHOD OF AFIER-TREATMENT.
By GEORGE R. FOWLER, M.D.,
SURGRON TO THE M. E. HOSPITAL AND TO ST. MARY’S HOSPITAL, BROOKLYN, N. Y.
‘THE most important deformity of the toes, as well as the
most common, is that which is generally known as bunion,
or hallux valgus. It consists essentially of an external
deviation of the normal line of the great toe, or abducted
contracture of the latter. Instead of forming a contin-
uation in a nearly direct line of the first metatarsal bone,
the great toe forms more or less of an angle with the lat-
ter, and lies in a position to cross the other toes, passing
either above or below these, generally the latter.
The head of the metatarsal bone undergoes certain
changes, these being due to two causes. First, the dis-
placed phalanx, in its new position, produces increased
pressure upon the external aspect of the head of the meta-
tarsal bone, and, to a corresponding degree, lessens the
pressure otherwise exerted upon the internal aspect of the
same. The effect of this is to retard the growth of the
former, and favor the growth of the latter. Second, cer-
tain changes, due to periosteal irritation, are often seen
to be present. The first named results in a very decided
projection of the metatarsal head, and as time goes on
this may become more and more abnormally prominent,
until at last a well-marked exostosis marks the site of junc-
tion of the phalanx with the metatarsal bone. The car-
tilaginous covering of the head of the metatarsal bone
becomes more or less imperfect, and may disappear alto-
gether. This occurs particularly in those cases in which
the base of the phalanx becomes entirely displaced, and a
new articular surface is formed for it upon the external
lateral aspect of the metatarsal bone. Pressure upon the
projecting metatarsal head leads to a callosity at that
point, and not infrequently a bursa is developed in ad-
dition.
The disease is considered as being rather rare in young
individuals. Nevertheless, I am convinced that it is not
confined by any means to elderly persons. All three of
the cases treated in the manner about to be described, oc-
curred in the period of life between twenty and thirty
years. No station in life seems to giye immunity from
the affection. I have not observed the disease more fre-
quently among persons of a- rheumatic or gouty diathesis ;
this is to some extent significant when the fact is taken
into account that the latter is first apt to have its earliest
and most decided expression in the very articulation
under discussion.
I am inclined to attribute the occurrence of this de-
formity to the wearing of faulty-shaped shoes. Of all the
shoes worn, that which is probably the most mischievous
is the shape characterized by the pointed toe, with the
point on a line with the middle of the foot. Any shoe
which does not present a straight line upon its inner bor-
der tends to set up the initiatory changes which may re-
sult in the full development of this affection. Once the
toe is forced from its proper relation with the metatarsal
bone, the process of overgrowth of the internal portion of
the head of the latter commences; this, conjoined with
YORK, SEPTEMBER 7, 1889
the flexor proprius pollicis is brought into play.
arrest of development or absorption through pressure
upon the external portion of the head, leads to a rapid in-
crease of the deformity. If the shoe be narrow at the
site of the base of the toes, in addition to the pointed
shape above alluded to, the pressure upon the projecting
portion of the articulation will lead to the development
of a callosity, and in some instances to a bursa. In-
flammatory processes and their sequele may supervene in
the latter, and it not infrequently happens that patients
present themselves to the surgeon having one or more
fistulous openings leading down to a suppurating bursal
sac at the site of a hallux valgus.
There is another factor in the etiology of this deformity
which should not be lost sight of. I refer to the influences
exerted by a retraction of the proper extensor of the great
toe, combined with the presence of an internal lateral liga-
ment whose structure has been altered by pressure, and
whose function of supporting the toe from undue abduction
during extreme extension is more or less interfered with.
It will be observed that the tendon of the extensor proprius
pollicis does not cross the metatarso-phalangeal articula-
tion on the line of the middle of the shaft of the phalanx,
but rather toward its outer side. In some instances I
have observed it lying in the slight hollow between the
first and second of the metatarso-phalangeal joints. As
the tendon passes forward from its point of emergence
underneath the annular ligament, it is placed quite in the
middle line of the dorsal surface of the foot for a part of
its course ; as it proceeds to its insertion in the last pha-
lanx it lies quite upon the middle line of the shaft of
the latter. The effect of this arrangement is to produce
a movement of abduction of the toe when the action of
‘This ab-
duction is opposed, in a voluntary manner, by the action of
the flexor longus pollicis, which, unlike its opposing mus-
cle, passes for almost its entire length along the middle
line of the metatarsal bone and the phalanges of the great
toe, and the abductor pollicis.’ When these are not
brought into play, the internal lateral ligament of the first
metatarso-phalangeal articulation becomes the principal,
and perhaps only, means of preventing the point of the
great toe from becoming abducted. Should undue press-
ure, by means of a tight shoe, interfere with the integrity
of the internal lateral ligament, and particularly if this be
accompanied with an unusual tendency to extension
caused by wearing high heels, a greater or less amount of
abduction of the great toe, or hallux valgus, will be the
result. ‘The greater the deviation of the great toe from
its normal line, the more the advantage gained by the ex-
tensor tendon is made manifest, until it almost appears as
if retraction of this tendon, and this alone, is responsible
for the deformity. But that this is a fallacy is proven by
the fact that tenotomy of this structure in advanced cases
does not result in restoration of the toe to its normal po-
sition.
Malgaigne was the first to call attention to the loss of
support resulting from an attenuation or weakening of
the internal lateral ligament, and considered this, to-
gether with muscular retraction or contraction, as being
the essential factors in the production of the deform-
! It should be borne in mind that, in the surgical sense, this muscle
is really an adductor. In the anatomical sense, the middle line of the
foot itself is taken as the point from which abduction, and toward
which adduction, takes place. Surgeons, however, select the median
line of the body itself for the point. Hence the seemingly paradoxi-
cal nature of the statement that the abductor pollicis muscle opposes
the abduction of the great toe.
254 THE
MEDICAL RECORD.
[September 7, 1889
ity. Nélaton expressed the opinion that hallux valgus
depended upon a contractured condition of the tendon
of the extensor proprius pollicis.
From the character and extent of the anatomical
changes present in hallux valgus, and the extreme sensitive-
ness developed in connection therewith, which almost ab-
solutely prohibits the application of orthopedic appliances
with the view of restoring the toe to its proper alignment,
the treatment of this affection by measures other than
operative is exceedingly unsatisfactory. Of the operative
means at our command may be mentioned, first, teno-
tomy of the tendon of the extensor proprius pollicis, with
or without section of the external lateral ligament of the
joint. ‘These procedures were much practised and
recommended by the older surgical writers, but have been
practically abandoned of late years, owing to the very un-
promising character of the final results obtained. Hüter,
of Gnefswald, proposed subperiosteal resection of the
head of the metatarsal bone, and in this he was followed
by the late Professor F. H. Hamilton, and A. Rose, of
New York. In a certain number of cases, particularly
those in which the joint has been invaded, and in which
suppuration and caries are present, this is the only opera-
tion practicable. The objection to it is, however, that it
shortens the inner margin of the foot unnecessarily, and by
removing the inner support of the anterior extremity of
the plantar arch, forces the weight of the body in walking
upon the heads of the metatarsal bones of the other toes.
These soon develop a painful condition, due to the
crowding against the sole of the shoe. As before stated,
this method of operating should be reserved for cases in
which the joint has been invaded as a result of a suppurat-
ing bunion, or where caries has attacked the articulation.
A cuneiform osteotomy of the metatarsal bone was sug-
gested and practised by Barker, an English surgeon. It
is based upon a similar operation performed for the res-
toration of the symmetry of the limb in cases of genu-
valgum. I have experience: with this method in but a
single case, and in that the result was far from satis-
factory, for reasons to be alluded to further on. I do
not think that this operation is destined to become a very
popular one among surgeons.
The proposal to perform a partial resection, or to
simply remove the overgrowth, or exostosis, of the internal
portion of the articular head of the metatarsal bone, made
by Reverdin, promises, in proper hands, and with rigid
antisepsis and careful after-treatment, to be the operation
above all others best calculated to achieve final favorable
results. This procedure, however, like those of Barker and
Hüter, is open to the objection that, in cases in which
they have been heretofore carried out, the incision from
which the joint is attacked has been made upon the inner
side of the foot, directly opposite to the articulation. As
a result of this, strictures are involved in the wound that
are the site of a callosity or a bursa, or both, and the
chances of failure in obtaining primary union in tissues of
this character are very great. This occurred in the only
case in which I attempted Barker’s operation, and a long,
tedious course of healing followed, accompanied by sep-
tic complications. Several attempts to follow the pro-
posal of Hüter resulted similarly. Another objection, the
validity of which is borne out by my experience in these
cases, resides in the fact that, from the hyperzsthesia de.
veloped at this portion of the foot during the course of
the disease, as well as the exposed location of the cicatrix,
the result of these operations, the pressure of a shoe is
not tolerated without considerable complaint on the
part of the patient. It has been asserted that the pain,
under these circumstances, is as great as before the opera-
tion.
Bearing these facts in mind, I had almost abandoned
operative procedures for the relief of hallux valgus, when
Petersen, of Kiel, published his article upon tuberculosis
of the first metatarso-phalangeal articulation.* This sur-
1 Langenbeck’s Archives fur Klinische Chirurgie, 1888.
geon proposed to attack the joint from its outer aspect, by
an incision made between the great and adjoining toe, and
extending through the entire thickness of that portion of
the foot. By this method he declared the joint to be
easily accessible, allowing the operator to thoroughly
identify all diseased structures, and permitting of the re-
tention of tissues not actually invaded by the tuberculous
process. I at once realized that this incision, applied
to the operation of hallux valgus, would do away
with the objections which had deterred me from further
-attempts to effect a cure of this condition by the older
methods. ‘The following comprises the history of the first
case thus operated upon, together with details of the steps
of the operation itself, and a new plan of after-treatment
designed to prevent relapse, and at the same time allow
the patient to pursue daily duties without the necessity
for the application of cumbersome apparatus, and the diffi-
culties inseparable from attempts to maintain the latter in
position.
On November 24, 1888, M. C. G , aged twenty-
five years, housewife by occupation, consulted me at the
M. E. Hospital for relief of an excessively
Le. painful hallux valgus on either foot, of four
» “* years’ standing. The deformity was very
“1 „g Well marked, as shown in Fig. 1, taken from
a tracing of the left foot. The patient be-
lieving the trouble to be due to rheumatism,
had been treated with liniments and rest,
and thus occasional temporary relief had
been obtained.
On the day following her admission I
performed the following operation: An in-
cision was made from a point upon the dor-
sum of the foot, somewhat below the level of
the head of the first metatarsal bone, and just
outside of that portion of the tendon of the extensor brevis
digitorum which goes to the great toe ; this was continued
to the bottom of the web between the first and great toes.
A similar incision was made on the plantar surface of the
foot, slightly to the outer side of the line of the tendon of
the flexor longus pollicis, The intervening parts were di-
vided through the whole thickness of the sole of the foot,
so as to join these two incisions. The great toe was then
strongly adducted, and the external lateral ligament divid
ed, opening the joint. After freeing the soft parts from
the neck of the first metatarsal bone with the handle of a
scalpel, the phalanx was completely displaced. ‘The great
toe was adducted still further, until its inner border lay
along the inner border of the foot, its point looking directly
backward ; the head and neck of the first metatarsal bone,
together with a large exostosis constituting
the “bunion,” were thus freely exposed.
The latter, together with the inner half of }#
the articular surface of the former, were f
sawn off by an oblique cut, as shown by the
dotted line, Fig. 2. The toe was then re-
placed in its normal position, and drainage
provided for by a tube in the bottom of the
gap. The soft parts were sutured; dress-
ings of sublimate gauze and paper wool,
and a splint, were applied to retain the toe in
a straight position. The other foot was op-
erated upon in the same manner. Union of
FIG. 1.
Fic. 2.
the wound in the left foot was somewhat delayed by the
occurrence of slight suppuration. In three weeks, how-
ever, the patient could walk comfortably, but was kept
under observation until the end of the sixth week, when
she was discharged from the hospital cured.
During the patient’s sojourn in the hospital it was con-
sidered only necessary, in order to maintain the toe in its
proper relations, to keep a straight splint of thin wood,
well padded, applied to the inner border of each foot, to
which the great toe was securely fastened. When, how-
ever, she was allowed to walk, and was about to be dis-
charged, it became apparent that some retentive apparatus,
less cumbersome in character than the latter, would be
September 7, 1889]
necessary in order to facilitate free locomotion, and at
the same time guard against the possibility of a relapse of
the hallux valgus.
To accomplish this the following device was resorted
to: In the first place, a stocking of rather more than or-
dinary width was chosen, and
a double line of stitching run
at the site of the interspace
of the great and adjoining
toes; by cutting accurately
between the lines of stitching,
a separate cot or receptacle
was provided for the great
toe, similar to the thumb
portion of a mitten. Fig. 3
shows the stocking so arranged, drawn upon the foot. A
shoe was then made, with a separate compartment located
upon its inner border, and corresponding to the
point at which the great toe should rest. In
selecting a last for this shoe, care should be ex-
ercised in order to secure the so-called “ com-
mon-sense ” shape, /.¢., that which presents a
straight inner edge of the foot (Fig. 4). The
partition separating the compartment for the
great toe from the balance of the front of the
shoe, is made of two thicknesses of calfskin,
and is secured in place in the following manner :
The last is split, as >
shown in Fig. 5, and
the pieces of calfskin
from which the parti-
tion is to be formed are placed in
position in the slot, a sufficient
projection being left to pass
through a slit in what is to be the
inside sole of the shoe, in which latter location it is secured
while still upon the last. ‘The shoe and welt are then
lasted in the ordinary manner, the reflected upper edges
of the partition being stitched to the toe portion of the
upper, and the shoe being
arranged, in order to fa-
cilitate putting it on prop-
-) erly, to lace as low down
+) as the site of the partition,
which latter may be only
just sufficiently. deep to
get a firm hold upon the
toe, say about one-third
the depth of the inter-
digital space. Fig. 6 shows the shoe, with one side of
the upper cut away, in order to show the partition.’
It is now nine months since the operation, and
the patient declares that they are the most
comfortable months she has enjoyed within cy
her recollection. ‘The partitioned shoe and f}} F
glove-stocking give her not the slightest incon- }
venience. She walks several miles upon a }
stretch, whereas, prior to the operation, it was
only by the most painful hobbling she was \$
enabled to perform her household duties. \'
Fig. 7 shows the present condition of her
foot and the line of union of the wound.
The advantages of this method of operat-
ing are: ist. Facility of reaching the artic-
ulation and determining the exact patholog-
ical changes present, and thereby determining
the necessity or otherwise of removing the
entire or only a portion of the articular extremity of the
metatarsal bone. 2d. The incision is made through healthy
structures, thereby, barring some error in the aseptic tech-
FIG. 3.
FIG. 4.
FIG. 5.
Fic. 6.
Fic, 7.
1 The partition which is to occupy the interdigital space is unnec-
essarily deep in the drawing. If too deep, as the foot settles forward
in the shoe as the result of wear, the bottom of the space will crowd
against it, and produce discomfort I am indebted to Mr. O'Gorman,
the skilful maker of foot-wear, of Court Street, Brooklyn, for the in-
telligent manner in which my plan of arranging this partitioned shoe
has been carried out.
THE MEDICAL RECORD.
255
nique, insuring an uninterrupted and rapid course of heal-
ing. 3d. The external lateral ligament is divided, thus
eliminating this as a possible hindrance to the reduction of
the deformity. 4th. It renders practicable Reverdin’s pro-
posal to remove the exostosis when it exists ; this latter
being the best operation for the purpose of effecting a cure
of hallux valgus. Plastic exudation or an organized blood-
clot at once fills up the space made by the removal of the
exostosis ; this is not interfered with in its separative prog-
ress by possible infection through a wound from without,
and adapts itself to the new location at once. 5th. If
contracture of the extensor hallucis exists to an extent
sufficient to prevent easy reduction, section of this tendon
may be done through the same opening. 6th. It does
not interfere with the attachments of the abductor pollicis,
thereby favoring relapse from this cause. 7th. The re-
sultant cicatrix is so situated as to be out of harm’s way
when the patient resumes the use of shoes. Hüters op-
eration, as well as. that of section of the shaft of the met-
atarsal bone to facilitate reduction, may also be performed
through the same wound.
Not among the least of the advantages of Reverdin’s
proposal to remove the existing exostoses in these cases, is
that which relates to the preservation of the entire length
of the metatarsal bone. ‘This will be realized when it is
remembered that the most important of the three points
of support of the arch of the foot is formed by the head
of these bones, and its preservation, whenever possible, is
of the greatest importance. For this reason I prefer to so
treat the deformity, where the conditions, as found when
the articulation is exposed, will admit of it. ‘Three cases
have been treated by me in this manner, and the uniform
success thus far achieved has been most flattering.
In a fourth case, one of the best-marked deformities of
this kind I ever saw, and for the relief of which the pa-
tient had come to the hospital from a long distance with
the expressed determination of having the member ampu-
tated, I found, upon exposing the head of the metatarsal
bone, that no exostosis existed. A thick callosity and
bursa, covering the stretched capsule and attenuated in-
ternal lateral ligament, occupied the site of the junction
of the phalanx with the metatarsal bone. ‘The articular
cartilage was still intact, save here and there it was trav-
ersed by narrow, irregular grooves, giving the head of the
bone a “ worm-eaten ” appearance. ‘This is the only case
coming under my observation having a distinct rheumatic
history. and it partook of the character of an arthritis de-
formans. It was a question with me whether or not to
remove the head of the bone, after Hiiter, in this instance ;
but I finally decided to do so, and the immediate out-
come of the case was all that could be desired. Sufficient
time has not yet elapsed to enable me to judge of the
functional result.
In a subsequent cage of this character I would advise
that partial section of the shaft of the metatarsal bone,
through Petersen’s incision, and just above its head, be
made ; a fracture at this point is then produced. ‘The
lower fragment can be placed at such an angle to the up-
per as to insure a proper alignment of the toe when
brought into position. Or Barkers operation of cunei-
form osteotomy may be done at this point. For all of
these operations I consider the best instrument for mak-
ing section of the bone, where the parts may be thoroughly
cleared, to be a thin-bladed, fine-toothed saw.
STRYCHNINE IN THE ALCOHOL Hasit.—Dr. F. W. All-
wright calls attention, in Zhe Lancet of May 25, 1889, to
the value of hypodermic injections of strychnine in dipso-
mania. He uses a solution of one grain in two hundred
drops of water, giving of this five minims by one injection
in the twenty-four hours. Hygienic and moral forces are
also invoked in the management of his cases. He reports
nine cases cured (?) in from ten days to three weeks. ‘The
drug causes, he says, a positive loathing for alcoholic
drinks.
256
THE MEDICAL RECORD.
[September 7, 1889
A CASE OF TRICUSPID STENOSIS, ASSOCI-
ATED WITH AORTIC AND MITRAL LE-
SIONS.
By C. M. HAY, M.D.,
ASSISTANT PHYSICIAN TO THE STATE INSANE ASYLUM, MORRIS PLAINS, N. J.;
MEMBER OF THE MEDICO-LEGAL SOCIETY OF NEW YORK.
Tuis rare form of cardiac lesion was found post mortem
in a case admitted to my wards in this institution a short
time ago, and the history, as far as can be obtained, is as
follows :
Mary A. McW , aged thirty-five, single, and by oc-
cupation a silk weaver. She was admitted April 25, 18869,
and had been suffering with acute mania for three months
prior to admission. ‘These areall the facts I have been
able to obtain of her previous history, and nothing could
be ascertained of her family history. When admitted
patient was much emaciated, unusually small in stature,
and weighed about ninety pounds. She was wildly de-
lirious, and her language and actions were typical of acute
delirious mania. ‘The condition of the woman made ex-
amination difficult, but it was noticed that she was slightly
cyanosed all over the body, the coloration being most
marked in face and extremities. The conjunctive were
injected, but otherwise clear. In addition to the cyanosis,
the skin was abnormally pigmented, and this was also
most noticeable over the face and extremities. Physical
examination the following day revealed normal lungs,
some enlargement of hepatic and splenic dulness, and
marked cardiac murmurs. ‘The urine was scanty and
high-colored, and on examination contained great excess
of urates, a few red blood corpuscles, no casts, and no ap-
preciable amount of albumen. The cardiac symptoms
observed during repeated examinations may be detailed as
follows: On inspection thorax was of normal contour.
There was diffuse pulsation in the praecordia, extending
over the epigastrium across to the right nipple line, and
along the cervical vessels. ‘Ihe hearts action was seen
to be very irregular. Fora time the systole would be
strong and transmit very distinct waves in the directions
named, while, on account of the extreme emaciation, the
heart could almost be outlined. After a minute or more
of such action, the heart would suddenly begin to beat so
rapidly that its pulsations could not be counted, and the
adjacent tissues of the thorax presented an excited tremor.
This usually lasted fosa longer period of time than the
slower and stronger contractions, but this alternation of
rhythm was always observed. No distinct apex-beat could
be felt, but the strongest impulses occurred in the fifth
and sixth intercostal spaces in the parasternal line. There
was a very coarse systolic thrill. Cardial dulness was
somewhat increased in all directions. A double aortic
and a double mitral murmur were heard, but a careful ex-
amination was impossible in the case. The murmurs
were extremely loud ; the systolic portions whistling and
rather musical, and heard at any point over the thorax;
while the diastolic or presystolic portions were almost
equally high-pitched and shrill. ‘The first murmur would
frequently be broken by a pause, and when the heart’s ac-
tion became rapid and more irregular the confused mass
of shrill notes, mingled with lower-pitched vibrations, de-
fies description. Pulse very small, weak, irregular; at
times not felt. ‘The woman continued in acute mania,
and the cyanosis grew gradually more marked during the
two weeks following her admission. She then failed more
rapidly, and on the seventeenth day became jaundiced,
with a rise of temperature amounting to 102° F. On the
nineteenth day there was marked jaundice, no fever, and
the tip of the nose was perfectly black. On the twen-
tieth day the nose became swollen and blebs formed ; the
cyanosis was much increased, and there was no pulse at
either wrist, while the signs of a large przecordial effusion
were evident. The existing dyspnoea became extreme,
and the patient died on the twenty-first day after admission.
At no time was there any cedema of the tissue other than
in the nose (which was gangrenous before death); and,
other than the pericordial effusion, no dropsy.
Post-mortem. This was performed six hours after
death. Body extremely emaciated ; nose and part of both
cheeks swollen, black, and the cuticle was easily detached.
No cedema elsewhere. l
Brain.—Skull-cap of normal thickness. The dura
mater was very adherent to it. There was considerable
fluid in the arachnoid spaces, and the pia mater was
opaque, thickened, and œdematous, the veins being espe -
cially well filled everywhere. On section of the brain sub-
stance the puncta vasculosa were unduly prominent, and
the gray and white matter appeared equally congested.
No other gross lesions were found.
Lungs.—The lungs were much congested, posteriorly
présenting cedema and hypostasis. On section the lung
structure seemed normal. Slight pleural adhesions at
both apices. The stomach and intestines, with the uterus
and tubes, were normal. The kidneys were enlarged,
much congested, but capsule not adherent, and section
showing their structure not perceptibly diseased.
Liver and Spleen.—The liver and spleen were both en-
larged considerably, and both were markedly congested.
In addition, the liver was curiously marked with grayish-
white patches. ‘The capsule was not adherent, however,
over those, and section gave negative results.
Heart.—The pericardium was found filled with clear
serum, the sac itself being normal. ‘The arch of the aorta
and great veins were of normal size and distribution. On
opening the right heart white clots were found in the au-
ricle and ventricle. ‘The heart weighed thirteen ounces.
The left ventricle was hypertrophied, while the wall of the
right ventricle seemed unusually thin, and as the cavity of
the ventricle was not enlarged the wall seemed actually
atrophied. The muscular substance was normal, as was
also the coronary arteries in their position, distnbution,
and walls. ‘The aortic valves were fused together and
formed a hard fibrous ring, into which the tip of the little
finger could not be inserted. ‘The united valves formed a
cone with its apex toward the aorta. The endocardium
was opaque and thickened from the aortic ring to the base
of the anterior mitral segment, and also for one inch down
over the interventricular septum. At the mitral orifice
the valves, with their immediate attachments, had coa-
lesced to form a cone pointing into the ventricle, with a
narrow elliptical opening about one and a half centimetre
in length by a half centimetre in width, and the little fin-
ger could just be inserted into it up to the first joint.
The mitral papillary muscles were much hypertrophied
and were directly attached to the edges of this opening,
while the chordz tendinez were obliterated, having appar-
ently united with each other and the valves to form the
stenosis described. The left ventricle was not dilated,
while the left auricle was much enlarged with thickened
walls and dilated cavity.
The tricuspid orifice was markedly stenosed ; the first
two fingers could just with difficulty be inserted up to the
first joint, and on examination only two valves could be
found. ‘These two were very much thickened and adher-
ent to one another at their bases, and they were drawn
considerably into the right ventricle from contraction of
the chordz tendinez and papillary muscles. Where the
edges of the two apparent valves met upon the side oppo-
site the septum, there was a considerable thickening and
fusion of the valve-tissues, and it seemed as if the missing
valve had been chiefly involved in the pathological pro-
cess, and had been nearly obliterated, only leaving a rem-
nant of its tissue at the right juncture of the two remaining
valves. But after a very careful examination of the spec-
imen, I confess that I am unable to decide whether this
was really so or whether the valve was not congenitally
absent, while the two valves seen simply underwent sub-
sequent sclerotic changes. ‘The condition, as seen, resem-
bled very strongly a small mitral onfice, with much thick-
ened valves and contracted ring. The right ventricle, as
has been stated, was not dilated, nor were its walls hyper-
trophied, but, on the contrary, seemed atrophied. The
right auricle was very much hypertrophied and dilated,
September 7, 1889]
THE MEDICAL
257
RECORD.
ee Prat
the cavity being fully twice the normal size. It will be
noted that both auricles were hypertrophied and dilated
very much, while the ventricular cavities were normal in
size, and the wall of the left ventricle was only moderately
thickened. The pulmonary orifice, artery, and valves were
normal. The aortic intima, for a distance of one inch
from the valves, was thickened, but there were no calca-
reous deposits here or in any of the other lesions.
This case is interesting from the extent and situation of
the lesions, the peculiar changes at the tricuspid orifice,
and the symptoms observed during life, including the pro-
gressive cyanosis for such a long period of time, the acute
maniacal mental condition for three and a half months prior
to death, and the absence of cedema and dropsy, other
than pericardial. The post mortem examination, as stated,
revealed considerable venous congestion, and cedema of
the brain and its membranes. The great infrequency of
disease of the right auricula-ventricular valves may be seen
from the fact that, from 1851 to 1870, the post-mortem
records of St. Mary’s Hospital, London, gave but fourteen
cases, and in all but one case the result was incompetency
(Reynold’s “System of Medicine,” edition 1880, p. 658).
Dr. Bedford Fenwick (Zancet, January 22, 1881, p. 137)
States that, since 1825, only forty-six cases of tricuspid
stenosis have been recorded, and he concludes from a
study of them that the greater number were due to changes
after birth, while in all of the reported cases the mitral
onfice was similarly affected, in nearly all the stenosis be-
ing greater at the mitral than at the right auriculo-ventric-
ular orifice.
_Dr. C. Hilton Fagge* says: “ Indeed, although tricus-
pid stenosis in moderate degree is common enough when
mitral stenosis is considerable or extreme, I am not
aware that it is ever clinically met with apart from such
an association ;” while Roberts, “ Practice of Medicine,”
says: “ This condition is a mere curiosity, if it ever exists,
or might possibly be due to endocarditis during intra-
uterine life.”
_Dr. Hallam has recorded a case* in which the tricus-
pid onfice admitted only the tip of a forefinger.
In the frequently quoted case of Professor Gairdner, in
which a diagnosis was made during life, the stenosis was
caused by the pressure of a tumor growing from the auri-
cle, and pressing upon the valve-segments.
_ Bramwell * states that acquired (non-congenital) tricus-
pid stenosis is far more common in females than in
males, and also that, when the lesion is limited to the valves
and ring, it is probably acquired, the congenital form be-
ing usually attended by other congenital defects of the
heart and vessels. In this case, in the right heart the
jesion was limited to the valves and their immediate at-
tachments, and did not involve the endocardium of the
right ventricle or auricle ; while in the left ventricle the
endocardium around both the aortic and mitral orifices
was considerably thickened. The universal coincidence
of mitral and tricuspid stenosis in cases of the latter af-
fection is also illustrated in this case, while the superad-
dition of such extreme aortic narrowing adds much inter-
est to the specimen. It would seem as if the stenosis of
the mitral and tricuspid valves in part compensated the
aortic lesion and distributed the work of the heart more
evenly upon its chambers, and mainly upon the auricles,
as shown by the marked hypertrophy and subsequent dil-
atation as seen post mortem. ‘The fact of actual gangrene
occurring-in the nose before death certainly exemplifies
the very slow failure of circulation, and the gradually in-
creasing venous engorgement and peripheral stasis ; while
the absence of pulse at the wrist for several days pre-
vious is fully accounted for by the condition of the aortic
valves, together with the coincident pericardial effusion
and rapid failure of cardial power. The very marked
cyanosis which the patient exhibited on admission, and
which intensified. until death, must have been due partly
* Reync d's System of Medicine, p. 729.
2 Edinburgh Medical Journal, 1864, vol. x., p. 271.
2 DiseAses of the Heart, p. 540.
to the tricuspid lesion, which both tended to overfill the
general venous circulation, and also prevented a sufficient
amount of blood access to the lungs, so that the periph-
eral arterial capillaries both received an insufficient
amount of arterial blood, while the venous capillaries suf-
fered an increasing stasis. ‘The chronicity of this con-
dition is evidenced by the deeply pigmented condition of
the skin.
—
A SUCCESSFUL AND CONVENIENT METHOD
OF TREATING PUERPERAL ECLAMPSIA.
By RICHARD COLE NEWTON, M.D.,
LATE CAPTAIN AND ASSISTANT SURGEON, U. S&S, A.
In this paper no discussion of the still unsettled question
of the etiology of puerperal convulsions will be entered
upon. I wish merely to discuss the principal methods of
treatment and to lay before the profession a plan of treat-
ment which has so far in this neighborhood served its pur-
pose well.
It can scarcely be denied that eclampsia has hitherto
constituted a part of the odia medicaiia, and that its
treatment has not reflected much glory upon our art.
Notwithstanding our utmost care in examining the urine
of pregnant women, and our improved prophylaxis, a
number of cases will occur in any obstetric practice.
Moreover, either from accident or design, the urine of
women about to lie in is not always sent to the doctor for
examination. Add to these the small number of cases
(percentage not yet determined) in which eclampsia oc-
curs without ascertainable change in the urine, and the
cases in which the patient may be attended by a midwife
or other ignorant person, and in which a competent phy-
sician is only called when the woman is already in con-
vulsions, and it is evident that anyone of us must hold
himself in momentary readiness to treat eclampsia; with
the assurance that his failure to save the patient will be
widely known and pretty generally condemned, whereas
his success will redound to his individual credit and will
increase the prestige of our art.
Let us briefly review the more recent literature of our
subject. That the disease is a frequent and dangerous
one is well known. Professor Parvin, in a recent paper,’
says that ninety-four deaths from eclampsia in about one
hundred thousand labor cases were reported to the Phila-
delphia Board of Health in five years. He assumes that
these ninety-four fatal cases were a third of the cases of
eclampsia that occurred in Philadelphia in the period
mentioned, which would give approximately one case
of convulsions to every three hundred and thirty-three de-
liveries, and the high death-rate of thirty-three and one
third per centum. Professor ‘Thomas, in his lectures in
my student days, gave the provortion of eclamptic
cases as one to every four hundred and eighty-five preg-
nancies and the death-rate at from twenty-five to thirty
per centum. ‘The generally accepted figures are in close
accord with Professor ‘Thomas’, #.¢., one case of eclampsia
to every five hundred pregnancies and a mortality rate of
thirty per centum. ‘The number of cases of albuminuria
in pregnancy seems, according to recent observers, to be
much greater than was formerly supposed. However,
with this aspect of the subject we will not at this time
concern ourselves.
Now, from twenty-five to thirty per cent. of death isa
high mortality rate from any acute disease ; higher, prob-
ably, than that of any other acute disease that afflicts the
good people of this latitude and longitude. It is not to
be wondered at that childbed convulsions are intensely
dreaded by the profession and the laity.
Much has been written on this important subject and
considerable progress has been made in unravelling the
mysteries which surround the still somewhat obscure
questions of its etiology and therapy. l
As to. the principal modes of treatment, I think we
! Hirst’s American System of Obstetrics, vol. ii., p. 75.
258
may justly say that they are four in number: 1, Chloro-
form to control the spasms, often combined with other medi-
cation, as, ¢.g., drastic carthartics ; 2, morphine, hypoder-
matically ; 3, venesection ; and, 4, the induction of labor.
Probably a fifth, viz., the administration of veratrum
viride, should be added. Of course, there are many and
various ways of treating eclampsia, but I think that a
large majority of physiciansin these days place their chief
reliance upon one of the means mentioned in our list.
There has always seemed to be a disposition to adopt one
method to quiet the spasms, and to supplement its action
by another, to alter or eliminate the morbific material
from the system. If chloroform is given, cathartics, su-
dorifics, or diuretics seem to follow. If the patient be bled,
she seems to be also subjected to hot baths or purging.
Doubtless, if labor is to be brought on, the spasms are
meanwhile controlled by chloroform, etc. It is this dual
indication which, I believe (with our present light), it is
necessary to follow out if we wish to successfully cope
with eclampsia.
A few years ago pilocarpine was brought forward as
the best and most scientific drug with which to combat
this disease. I understand that it is now recommended
to the students in the Harvard University Medical School
as decidedly our best means of treatment. Still, a num-
ber of cases in which jaborandi or its alkaloid have failed
have been reported. And as the drug so often acts un-
certainly in general medicine it seems doubtful whether
it will ever be looked upon with general favor in eclamp-
sia.
Professor Parvin * speaks of chloral with some favor ;
and there seems little doubt that the fearless exhibition of
this drug has, in a number of reported cases, given excellent
results. Professor Byford praises colchicum in eclampsia.”
Oxygen has been tried and spoken well of.’ Of course,
galvanism has not been left without a champion.‘
Not to take up too much space with the consideration
of these lesser known remedies, let us confine our remarks
to the five principal methods of treatment mentioned
above.
First, chloroform is no doubt the most widely known
of the remedies in eclampsia. A short list of the distin-
guished men who have advocated the drug would com-
prise some of the brightest names in medicine. It would,
therefore, be out of place for me to cry down this valu-
able and potent agent ; neither is it necessary here to go
into a detailed discussion of its merits. An unsurmount-
able objection to its use is the amount of time which the
physician must give to one patient if he uses chloroform
for eclampsia. Professor Thomas used to say that, to be
effectual, the remedy must be kept up for from twenty-
four to forty-eight hours. As no conscientious physician
would like to intrust the administration of chloroform to
a nurse, he must, in case he gives it in puerperal convul-
sions, remain at the bedside for one or two whole days
and nights, and maybe longer.
In may cases this must be impracticable, and it can
never be convenient to oneself nor just to one’s other pa-
tients. Had the treatment by chloroform been generally
satisfactory, so many substitutes for it would not have
been brought forward.
As to morphine in eclampsia, two or three cases which
have occurred in this neighborhood tend to confirm the
common impression of its danger. Certain promising
young matrons, although fully brought under the influence
of this drug, lost their lives ; and two of our practitioners
have told me that, although once strongly in favor of
morphine in the convulsions of childbed, they have now
abandoned its use. In the literature of the subject many
diverse opinions prevail. Professor Byford * strongly con-
demns it. Rosenthal’ says that the opiate treatment gives
good results, especially after delivery. Professor ‘Thoinas
1 Op. cit. a Theory and Practice of Obstetrics, p. 448.
3 THE MEDICAL RECORD, August 8, 1885.
4 Ibid., August 9, 1879.
® Diseases of the Nervous System.
$ Op. cit.
THE MEDICAL RECORD.
[September 7, 1889
would seem to agree with Rosenthal. A wniter in the
Pacific Medical and Surgical Journal recommends _one
and one-half grair of morphine hypodermatically, and
says that he is convinced that twice the quantity might be
administered once. Almost the latest reference’ to the
treatment of this disease, that has met my eye, states that
Veit, after using other methods, has been led to rely upon
morphine. His initial dose is three-fifths of a grain hypoder-
matically, followed by half as much when required. He
adds: “ It is generally necessary to give from one and one-
fifth to three grains in from four to seven hours.
For the renal complications hot baths followed by packs
are best ; pilocarpine favors pulmonary cedema.
Theoretically these large doses of morphine must do
harm by locking up the secretions. It would seem that
such therapy is on a par with the conduct of a person
who, after discovering a fire on his premises, should take
great care to exclude the firemen by locking his door and
throwing away the key. ‘This view receives strength
from the fact that after delivery the secretions (markedly
that of the kidneys) rapidly re-establish themselves, and
that morphine can then be borne. However, in Galobin’s
tables * only eight per cent. of the women seized with con-
vulsions post-partum died; so that any treatment would
have to be very bad to show a high mortality rate in such
cases. ?
Furthermore, the doses of morphine recommended in
eclampsia are, to say the least, startling to a quiet mind.
The question of bleeding has received a great deal of
attention. Formerly it seems to have been nearly uni-
versally practised, and it has powerful advocates to-day.
Dr. Michener and others published ° a brochure four or
five years ago, containing forty-four cases of eclampsia,
all that they could collect that had occurred in their
county (Chester County, Pa.). They unreservedly ad-
vocated venesection. In the Medical and Chirurgical
Faculty of Maryland * several speakers were enthusiastic
in favor of bleeding in these cases.
A Dr. Darvon, of New York State,” stated in a medical
meeting that he and his father had successfully bled their
eclamptic patients for ninety-two years. Professor Thomas
advised it in a few sthenic subjects with great vascular
tension and plethora. Professor Parvin’ speaks more
favorably of venesection in selected cases than of any
other one method. Professor Thomas,’ however, modi-
fied his advocacy of this procedure by stating that phle.
botomy is a method inferior to chloroform, more unreli-
able, and dangerous. I presume that he still holds this
view. Professor C. Braun ° gave up venesection years ago,
and quotes other authorities who have done likewise. At
best, with our modern ideas, bleeding is revolting and
frightful to the patient if conscious, and certainly to the
friends. It removes some of the vital fluid from a pa-
tient who, if she comes out of her spasms, has probably a
long convalescence before her. Neither is it always effi-
cacious ; a number of failures having been reported in
cases of convulsions treated by bleeding. It might tide
the patient over some uncontrollable spasms, especially
where there seemed to be sufficient vascular tension to
threaten apoplexy. Although this latter contingency is
mentioned by Trousseau, its occurrence must be quite
rare.
The induction of premature labor as a means of curing
or preventing eclampsia seems to be growing in favor
among the profession in this country. At a meeting of
the American Association of Obstetricians and Gynecolo-
gists held in Washington in September, 1888, the con-
sensus of opinion seemed to be wellnigh unanimous in
favor of this method of treatment.
Professor Thomas used to say that for the purposes
1 American Journal of the Medical Sciences, January, 1889, p. 103.
2 Hirst's American System of Obstetrics.
3 Reviewed in THE MEDICAL RECORD, November 22, 1884.
4THE MEDICAL RECORD, May 15, 1886.
6 Ibid., November 22, 1884.
7 Lectures on Obstetrics.
* Braun: On Puerperal Convulsions,
6 Op. cit.
September 7, 1889]
THE MEDICAL RECORD.
259
of treatment he divided his pregnant patients who
showed albumen in the urine into three classes—slight,
medium, and grave. In the latter class he always advised
that labor be brought on at the eighth month of gestation.
A vumber of cases are reported, some successful and
others not. One writer ’ saved four out of six women in
whom he produced premature labor.
The induction of premature labor, or of abortion, is al-
ways a grave undertaking. Perhaps we are apt to lose
sight of its gravity. Nature ever resents this interference
with her laws. She will, and frequently does, terminate a
gestation whenever such a course seems to be indicated
for the welfare of the mother, as, for example, in uterine
displacements, fevers, cholera, etc, and also where the
foetus if viable would not probably ever develop into a
healthy child, as, for example, in syphilis, scurvy, Bright's
disease, etc. The well-known comparative immunity of
pregnant and lying-in women from epidemic and endemic
diseases, their almost miraculous recoveries from post-
partum hemorrhages, complicated labors, etc., all point to
the peculiar and fostering care with which nature regards
her pregnant daughters. Just in proportion as extaordi-
nary safeguards are thrown about those women who fulfil
the law of their nature and do their share toward propa-
gating the race, just so far does nature resent our interfer-
ence with gestation. It is no light matter to bring on
labor under any circumstances. Witness the high mor-
tality rates in criminal abortions, no matter how skilfully
these comparatively simple operations may be performed.
Witness the broken health and lifetime of suffering which
so often follow. Any clown can bring on a miscarriage,
but no human agency can repair the damage he will prob-
ably inflict upon the unfortunate woman. Professor Mc
Lane used to tell us that he would rather any one of his
patients would have two babies at term than abort once.
Professor Braun * quaintly obser¥es that he has frequently
seen premature labor brought on for hyperemesis fatal,
but he has never seen hyperemesis fatal.
My friend Dr. Love, of Montclair, tried bleeding in his
eclamptic cases. His success was but indifferent. He
then tried the induction of labor, and declares that the
latter method was worse than the former, since by bleed-
ing he did save some cases, whereas when he brought on
labor he lost nearly every case that he had.
Leaving the consideration of the veratrum viride treat-
ment for a moment, I think that I have indicated that
every means so far generally employed to combat this ter-
rific disorder has frequently failed. So far as I know, it
is not claimed that the mortality rate for any large num-
ber of cases has been kept below twenty-five per centum
by any mode of treatment. Dr. Breus * reports twenty-
two cases treated with hot baths, with a mortality of only
two (ten per cent.). Dr. C. Braun reports sixteen cases
successfully treated with chloroform and acids. Nitro-
glycerine has proved a valuable adjuvant in a few re-
ported cases. Now, as the mortality has not apparently
been greatly altered by the various (and sometimes totally
different) modes of treatment in vogue, it seems fair to
assume that a large percentage of cases would recover
without treatment. Galobin ‘ gives some interesting fig-
ures, as follows : j
Average mortality at Guy’s Charity, 25 per cent.
Of those attacked before labor, 50 per cent. perished.
Of those attacked during labor, 25 per cent. perished.
Of those attacked after labor, 8 per cent. perished.
Professor Braun remarks, in his excellent monograph,
that of those seized with convulsions before labor few re-
covered.
Charpentier ° gives some figures showing the mortality
as influenced by the number of seizures :
Of 45 women who had from 1 to 10 convulsions, 25 per cent. died.
te I 664 10 to 20 (A) 33 +6 46
1 THE MEDICAL RECORD, April 1, 1872.
2 Epitome of Braithwaite’s Retrospect, June. 1882, p. 255.
3 THE MEDICAL RECORD, August 15, 1885.
+ American System of Obstetrics.
ê Ibid.
There would appear to be a wide and only partially
cultivated field of study before us in puerperal copvul-
sions. However, let us hasten on and take up our last
division of the treatment, viz., that by veratrum viride.
This drug has enjoyed a checkered career since it was
so boldly thrust upon the profession by Dr. Norwood in
1850. Good authorities seem to be still disputing about
its value in pneumonia. In some other diseases, as, e.g.,
diarrhoea and dysentery, its value does not seem to have
been as yet well studied. Professor Fordyce Barker is
said to have suggested its use in eclampsia forty years ago.
Since that day it has never seemed to lack a champion as
our best treatment in this disease. Various Brooklyn
physicians have spoken highly of it, and I fancy that it is
gradually gaining ground. I notice that it is favorably
mentioned in the last “ Year Book of Treatment,” and in
Hirst’s “ American System of Obstetrics ” (just published).
However, the profession at large do not yet seem to trust
this remedy, which is now suffering unmerited obloquy—
the natural result of undue praise.
Twenty-eight years ago Dr. Cutler, of Jersey City,
stated in the New Jersey Academy of Medicine that he
had been in practice twenty-five years, and that during
that time he had seen on an average eight cases of puer-
peral convulsions a year, in his own practice and in con-
sultation, and that he had never lost a case, and that in
treating this complaint he relied upon veratrum viride.
Dr. Love was present and heard these remarks. Shortly
afterward the late Dr. Isaac Nichols, of Newark, called
the doctor’s attention to benzoic acid, and suggested its
use in the albuminuria of pregnancy. My friend put the
hints dropped by these older men (at that time eminent in
this State) together, and concluded to treat his next case
of eclampsia with veratrum viride and benzoic acid.
This was many years ago, and Dr. Love has seen no
reason to alter his treatment. He has had in all twenty-
three cases and he reports twenty-three recoveries. __
In the stirring up of dry bones and scattering of ancient
records which moving one’s office after many years’ oc-
cupancy causes, the notes of these individual cases were
lost or mislaid. But a dozen or more of the women are
now residing in this neighborhood, and can be seen and
interviewed. Case No. 23 has occurred since this writing
was begun. She isa primipara, twenty-three years of age.
Her urine was highly albuminuric on April 3oth. In
spite of treatment, by May 15th her water had diminished
to less than five ounces per diem. It resembled pea-soup
in appearance, and when boiled with nitric acid it
promptly solidified. She then fell into convulsions and
had six in twenty-four hours. During this time she re-
mained totally unconscious. As it was difficult to make
her swallow, and as the veratrum viride exhibited per orem
was vomited, eight minims of Norwood’s tincture were
given hypodermatically, which also produced emesis.
This amount was, however, injected under the skin every
hour until five or six doses had been given. The benzoic
acid was also given every four hours. I saw this patient
afterward myself, and made frequent examinations of the
urine. Microscopically, tube-casts and renal] epithelium
were noted. About three weeks after the convulsions
labor came on of itself and a child was born, which lived
a month and died in convulsions. The mother made a
good recovery. O
Dr. Love says that, in his experience, within twenty-one
days after the first spasm labor will come on, and that the
foetus is generally dead. l
Only two children in his twenty-three cases survived.
In the case just given he tried nitro-glycerine as a help to
eliminate the materies morbi, but had to give it up on
account of the headache it caused.
His plan of treatment has been as follows: Give three
drops of Norwood’s tincture (a freshly prepared portion)
and repeat in an hour; then two drops every hour or two
until the patient experiences a cord-like feeling in the
neck. If the nurse be not sufficiently intelligent or con-
$cientious, the physician must give the veratrum viride
260
— eee -= -—
himself. The benzoic acid is given in the following pre-
scription, which is taken from Ellis’ “ Formulary,” and is
No. 120 in that collection of recipes :
B. Acidi benzoici .....ses.sescosesssoseoo 3
Potass:. bicarb:.4ccucce perrot er haries
Spts. ether nitesges roses ieke r eepe n Sate fl. 3j.
Sptsy MeENGETEN 2. 66:54:66 < aig cee sateen oe fl. 3 ij
Syr. limonis...... cece .cccccccs q. s. ad fil. 3 vj.
M. Sig.: 3ss. q. 4 hrs.
This must be mixed with some care, but any competent
pharmacist can do it. It forms a rather unpleasant dose.
All I claim for Dr. Love is a happy and partly original
combination of well-known remedies. No one else has,
so far as I know, reported twenty-three successful cases
without a break. Professor Braun’s sixteen cases, treated
with chloroform and acids, is the next best showing that
I have found. Dr. Staples, of Dubuque,’ reported uni-
form success for nine years with veratrum viride and ac-
onite hypodermatically. Number of recoveries not stated.
Under Dr. Love’s treatment the infants can scarcely be
said to flourish. Under any treatment it appears that
one-half of them die; and of those born alive, as ‘Tyler
Smith points out, a number will die of convulsions (Dr.
Smith calls them uremic convulsions). If, then, there is
more probability that the child will die than live, we
would hardly be justified in abandoning a course of treat-
ment promising the best chance for the mother’s life be-
cause some other may give a higher per centum of living
children. Löhlin’s, Winkel’s, and Heckers reported
cases* show that from seventy-seven to eighty-five per
cent. of the women were primipare ; and all the best au-
thorities agree in saying that a woman will probably not
suffer from eclampsia twice. Therefore, according to our
view, it is inexpedient and even reprehensible to weigh
the child’s chances for life against the mother’s when we
know that the latter, if she come out of her spasms, will
probably live to bear healthy children.
This plan of treatment is the result of nearly a lifetime
of thought and observation. In Dr. Love’s hands it has
not failed once in many years. It is convenient and
easy to administer, and absolutely harmless in competent
hands. it is freely offered to the profession with the
hope that it will be found as successful in other hands as
it has been in those of my esteemed friend, and that it
may prove another trusty weapon in our armamentarium.
MontTciair, N. J., August 6, 18&9.
THE TREATMENT OF PNEUMONIA BY TEPID
BATHS.’
By GEORGE N. KREIDER, A.B., M.D.,
SPRINGFIELD, ILL.
DurRInc the past few years much has been written about
the alarming mortality of pneumonia. Men whose wide
experience has extended over a long period of years affirm
that the death-rate is much higher under the present ac-
cepted modes of treatment: than it was forty years ago,
when the pathology of the disease was almost unknown.
It would hardly seem that our therapeutics of pneumonia
1s Commensurate with our knowledge of its etiology and
pathology. Some endeavor to explain this increased
death-rate by supposing that a change in the character of
the disease has occurred in the last half-century, while
others claim that the statistics are made more unfavor-
able by the fact that a larger number of poorly nourished
and dissipated persons are now treated in the large city
hospitals where these comparisons have been made.
Whatever may be the explanation, it remains true that the
mortality-rate is extremely, and I believe unnecessarily,
high. ‘The high mortality-rate of pneumonia and typhoid
fever in Amenica is the medical opprobrium of our coun-
! THE MEDICAL RECORD, February 21, 1880.
* American System of Obstetrics.
> A paper read at the Thirty-ninth Annual Meeting of the Illinois
State Medical Society.
THE MEDICAL RECORD.
[September 7, 1889
try. Dr. Osler says death in this disease is most fre-
quently due to high temperature and heart failure, and it
is against these very grave symptoms that our present
treatment is least effective. The same statement might
be made, and with equal truth, concerning typhoid fever.
The newer antipyretics antipyrin and antifebrin have their
place, and if used with proper precautions may render ma-
terial assistance ; but, used ina routine and indiscriminate
manner, they are capable of doing more harm than good.
They may enable us to reduce the height of the tempera-
ture, but are not lessening to any great extent the mortal-
ity of this disease. ‘Foo frequently they depress the
heart’s action and disturb the stomach, and thus cause
complications of the gravest nature by preventing the
patients’ taking a sufficient quantity of nourishment, and
by impeding the circulation of blood through the lungs.
After careful consideration, and influenced by the success-
ful use of the ice-coil in my practice, in the treatment of
typhoid and puerperal fever, I came to the conclusion
some time since that a change in my method of treating
pneumonia was desirable. Relying upon the statements
of well-known German authorities, 1 decided to make a
fair and impartial trial of tepid baths in grave cases. ‘The
employment of these means is so contrary to all our Ameri-
can teachings and traditions that it is only in the last six
months that I have gained sufficient courage to employ them.
So great is the fear of cold in the minds of both the laity
and the profession that it is doubtful whether I would
have been permitted to make the experiment earlier in
my professional career. For this reason the number of
cases which I am able to relate in support of my views is
not as great as would be desirable. However, I believe
that a careful clinical study of a few cases is quite as val-
uable in proving principles as tables embracing an indefi-
nite number can be. Modern investigation has certainly
proven that micro-organfsms of some kind, and not colds,
are the immediate cause of this disease, and in the light of
this discovery all mistaken prejudice against baths and
cold applications must fall to the ground. Pneumonia is
essentially a fever, which should be treated, as far as its
effects on the respiration, temperature, heart, and skin are
concerned, like any other fever. I do not pretend to say
that every case of pneumonia should be treated by baths.
Striimpell wisely says it is disadvantageous, if not inju-
rious, to give a patient baths if the disease is progressing
favorably, for almost every bath has some disagreeable
features which should be avoided if possible. Al these dis-
agreeable features vanish in a bad case. ‘The possibility of
the necessity for baths should be had in mind on assum-
ing charge of every case of pneumonia, and arrangements
made accordingly. A portable bath-tub should be in
storage from which it can be taken at a moment’s notice.
The dealer of whom I procure the tubs rents them out at
a reasonable figure, and is easy of access day and night.
A portable tub can be placed by the bedside and the’ pa-
tient lowered into it without the least physical exertion on
his part. ‘Ihe patient should be placed on a single bed-
stead, with low head- and foot-pieces, for convenience in
handling sponges and towels; dry sheets and blankets
should be on hand in abundance for use during and after
the bath. After the tub is once properly filled very little
more disturbance is necessary, since the water will retain
its heat for a long time and one or two buckets of hot
water will bring it to the required temperature. ‘The rea-
sons for resorting to the treatment should be fully ex-
plained to the relatives, and their hearty co-operation se-
cured. I have thus far found little opposition where this
treatment was proposed, and this was usually volunteered
by some officious neighbor whose medical attendant
“never did such a thing.” The physician himself must
superintend and assist in giving the baths. Especially is
this the case in children, whose expressions of fear will
often influence the parents to the detriment of the treat-
ment.
I have used baths in the treatment of six cases. All
have not been successful, but in none were any bad symp-
September 7, 1889]
toms caused by the bath; on the contrary, in every case
the patient came out of the tub refreshed and improved,
for the time at least. The first case treated was Mrs. F.
W.T , aged thirty-five, seen with Dr. Dresser in the
second week of puerperal fever, and with strength reduced
by that disease. She developed at this time catarrhal
pneumonia of the right lung, beginning with a severe chill,
pain in the side, and elevation of temperature, pulse, and
respiration. She was treated with antipyretics, stimulants,
and expectorants for six days, without very apparent bene-
fit. Matters had seemingly reached a critical point. The
pulse and temperature remained elevated, and little or no
material was raised from the lung. ‘There was coma vigil,
muttering delirium, and picking at the bedclothes. I
finally urged, as a last resort, the employment of a bath,
to which my colleague finally consented. To give it we
were obliged to carry the patient to another room and
immerse her in a stationary tub, which was only accessible
from one side. ‘This increased the labor of the treatment
a great deal, and minimized its benefits. The temperature
of the baths was 98° F. ; temperature of the patient, 103° F.
The bath was given at g P.M., and, the condition of the
patient being alarming, I remained all might an anxious
watcher at her bedside. My concern may be better im-
agined than described. I had, with many mental misgiv-
ings, urged a procedure which, until then, I believe I may
say, was unknown in the community, and severe condemna-
tion certainly awaited its failure. During the night some
encouraging symptoms appeared. She was bathed twice
the next day, each time with some slight benefit, but it
was not until a somewhat more prolonged bath was given,
on the following morning, that the rusty-colored sputa be-
gan to come away in any quantity. Four baths in all
were given. As showing the condition of the patient and
the value of baths, I may relate that her husband, an un-
usually well-posted clergyman, had cabled the patient’s
sister in London the news of her impending death. The
patient has fully recovered, a result which I think would
scarcely have been possible without the baths. One inter-
esting feature of this case is the comparatively low range of
the temperature. It never went above 103.5° F. The
fever was not entirely controlled by the baths, as it went to
as high a point after we had discontinued them as before ;
but their effect in loosening the exudation and stimulating
expectoration and the heart’s action was so marked as to
be beyond question. :
The second instance in which the baths were employed
was in the case of W. K , aged twenty-three, seen
with Dr. Walter Ryan, in the fifth day of the disease.
The temperature was nearly 105° F.; respirations, 64 ;
and pulse, 144. While on a drunken spree he had been
stricken with a severe type of the disease, and had been
treated with antipyretics and stimulants secundum artem
by Dr. Ryan. It was our opinion that death was inevitable
in a few hours, but, influenced by the brilliant success in
my first case, it was decided to give him the benefit of the
baths. They failed to rescue him, but not only did they
do no harm, but, we believe, sustained life thirty hours
longer than would have been possible without them.
The next case to which I successfully applied the treat-
ment by baths was Willie G——, aged ten. On the third
day of an attack of measles he developed pneumonia, and
it was only then that I was called to attend him. I found
his respirations 84 per minute, pulse above 160, blueness
of the lips, and temperature 104.8° F. I lost no time, after
informing the family of the gravity of the case, in preparing
to give him a bath. In default of a regular bath-tub,
and as I deemed an immediate bath imperative, we made
use of a large-sized wash-tubin which the boy seated him-
self, while myself and assistants poured the water over him.
He came out of the tub improved. Six hours later, find-
ing alarming symptoms again present, I put him in a second
bath. This completed the good effects of the first and
started him on the highway to recovery. Eighteen hours
after the first bath his respirations were 40; pulse, 126 ;
and temperature, 102° F. Rapid convalescence followed.
THE MEDICAL RECORD.
261
The fourth case is that of Mr. W. S——, aged twenty-
five, whom I was called to see at a coal-mining station ten
miles from the city. Finding pneumonia of the right lung
imminent, he was brought to the city by special train and
placed in St. John’s Hospital, where he soon developed
the disease in its most severe type. The temperature
reached the unusual figure of 106.2° F., and this despite
the employment of antipyretics and the ice-coil. When
it reached the highest point the unconscious patient was
placed in a bath at a temperature of 95° F., where he was
kept for ten minutes. ‘This procedure was repeated in
four hours. These two baths were sufficient to break the
force of the disease, and steady and rapid improvement
was noted from the time of their use. Expectoration,
which had ceased with the appearance of the bad symp-
toms, became again abundant, consciousness was regained,
and the heart’s action improved. This patient weighed
two hundred and eighteen pounds, but the labor of hand-
ling him was much less than was anticipated. The small
number of baths required was the more remarkable be-
cause of his development of adipose.
The fifth case is that of M. J——, aged seven, whom I
saw early in the disease, when there was probably little
more than congestion present. The symptoms of pain in
the side, distressing cough, and elevation of temperature
and pulse were great enough to call for active treatment.
Instead of giving the usual antipyretics I gave two tepid
baths, and was thus enabled to change this picture to one of
quietude and freedom from pain, and arapid convalescence.
The sixth case was that of L. D——, aged sixty-nine,
in which, unfortunately, the bath treatment was not given
until after severe symptoms of heart-failure had developed.
The effect of the bath was good for the time being, and
although the patient did not recover, the bath had nothing
whatever to do with the fatal result, which was due to
heart-failure. My only regret is that the treatment was
not instituted earlier in the case.
The results of my trial of this treatment, it will be seen,
give a mortality rate of thirty-three per cent. This is not
a very encouraging argument in its favor, but statistics in
so small a number of cases should not be used in that
way. Asa result of my clinical study of the use of baths,
I am prepared to indorse the statement of their good ef-
fects made by gentlemen high in authority and with a
large experience in their employment. My two patients
who died were already in extremis, and two of the cases
of recovery were calculated to give as severe a test of the
treatment as one is likely to encounter. The treatment
means work on the part of the medical attendant, and he
who prefers to write a prescription to using some physical
exertion had better remain an advocate of antipyretic
medication.
The conclusions I make in closing this very imperfect
presentation of the benefits of baths in pneumonia are :
1. They should only be given in those cases which are not
progressing favorably. 2. In severe cases nothing is cal-
culated to give so much relief to all bad symptoms. They
shorten the duration of the disease and of convalescence,
and reduce the mortality. Liebermeister says it has been
reduced in his hands from twenty-five to ten per cent.
3. Rules for selecting cases and administering baths can-
not be rigidly given. The thermometer is not always the
guide for their administration. Difficulty of respiration
and lack of secretion should lead to their employment, re-
gardless of the height of the mercury. 4. The tempera-
ture of the bath should be one hundred degrees or less,
depending on the severity of the case and the condition
of the patient. Baths of extremely low temperature I
have not found necessary as yet, but should not hesitate
to employ them if occasion should require. 5. Stimulants -
should be given just before entering and on coming out of
the bath-tub. ‘The patient should not exert himself in
the least. 6. The physician should himself superintend
and aid in giving the bath. ‘This rule could only be
broken by having trained nurses who are competent to
meet_the emergencies which might arise.
262
RECENT MEDICO-LEGAL CASES.
By HENRY H. RILEY, Ese.,
NEW YORK.
Some little time before this paragraph will be read, the
city of New York will have witnessed the unusual circum-
stance of the execution at one time by hanging of four
murderers.
These executions will take place after the long delays
and appeals permitted by the law of the State, so that
most persons have forgotten the crimes for which they will
suffer the extreme penalty of the law. Should there be
any bungling in the performance of the sad duty devolv-
ing upon the sheriff of the county, a new interest will be
given to the Electrical Execution law, which some people
are so earnestly trying to have set aside on the grounds
that it permits a “ cruel and unusual punishment,” forbid-
den by the constitution of the State.
It is difficult to see, however, why electricity should be
more cruel in its working than hanging, as sometimes car-
ried through. In a double execution occurring only a few
weeks since at Louisville, the papers give the following
horrible account of the mode of death: “Smart turned
round and probably died instantly, but Dilger slipped the
noose, the rope catching him over the chin at the lower
teeth. He was seemingly unhurt, and was drawn up by the
rope until his shoulders came through the trap, when the
deputies took him by the arms and pulled him upon the
scaffold. A new rope was brought into service, and when
the noose was adjusted Dilger asked, ‘ Whats the mat-
ter?’ When he was told he said, ‘ This shows I should
not die’ He placed himself upon the trap the second
time by making two hops. The drop was again sprung
-at 6.39 ; he was strangled to death.”
Considering the fact that there are so many hangings
where the condemned persons are slowly and painfully
-strangled to death, their necks not being broken by the
fall, it is very difficult to see how the advocates of this
‘mode of execution in place of electricity have much of an
advantage. It is true that no one can tell absolutely how
electricity will work until it has been tried, and the trial,
to give reliable information, must be upon a human being.
As to the probabilities of its action experts differ greatly,
as already shown in the testimony given before the referee
in the Kemmler case ; but there seems to be no uncertainty
about the opinion of the greatest electrician of the age,
Edison. His testimony was as follows :
“ Can an electric current be applied by artificial means,
in such a manner as to produce death in every case?”
“Yes.”
s“ Instantly ? ”
66 Yes.”
“ Painlessly ? ”
“ Yes.”
We have little fear that the murderer Kemmler will
escape through any sentimental fear that electricity will
not do its work, but the condition of the law in New
York State is such that, if the court should decide that
the use of electricity would be a “cruel and unusual ”
mode of punishment, he cannot be punished at all.
The knowledge of this probably makes his eloquent
counsel the more active in his efforts to have electrical
executions abandoned.
In North Carolina an action was recently brought
against the city of Asheville because of its neglect in fur-
nishing proper shelter for persons confined in its jails, but
the court held there was no liability. It seemed that
proper fires and bedclothing were not furnished the
prisoners during the winter weather, and the decision
was that the city was not liable if it had furnished the
supplies required by law. It seemed to be the inference
that the jailers might be personally responsible for the
neglect in caring for the prisoners.
The court said: “ We may safely say that neither cities
nor towns can be required, as a genera] rule, to answer
in damages for injuries to prisoners caused by the neglect
THE MEDICAL RECORD.
[September 7, 1889
of their respective jailers, policemen, or guards who may
have immediate charge and custody of them, and of
which the governing officials of the corporation had no
notice. We think that where window-glass in the window
of a police prison has been broken, and the bedclothing
furnished for its inmates has been destroyed, but the
governing officers of the town are not shown to have had
actual notice of the breaking or destruction, or to have
been negligent in omitting to provide for such oversight
of the prison, as would naturally be expected to give
them timely information of its condition, there is not
such a failure in discharging the duties of construction or
superintendence as to subject the corporation to liability.”
The State of Massachusetts has a strict law in regard
to Sabbath observance, and the courts construe it rigidly.
In a recent instance it would seem that a person sold
cigars, and the question was whether these could be
brought under the designation of “ drugs and medicines,”
which the law permits in Massachusetts, as elsewhere, to
be sold on Sunday. ‘The court listened patiently to the
argument, and then, in a long and convincing opinion,
pronounced the dictum that cigars were not medicines,
and that, therefore, the sale was unlawful on Sunday.
The Supreme Court of Montana has just decided that
the railroads cannot be compelled to pay for animals
killed by their trains, unless they are negligent, and in ab.
sence of a law requiring the companies to fence the tracks,
and a law to this effect has been declared unconstitutional.
The court holds that such legislation is on the line of that
attempted in Illinois, where a law was declared unconsti-
tutional which compelled railroads to pay the burial ex-
penses of all persons dying on, or killed by, their trains.
In this instance the court said that death might be caused
absolutely without any fault or negligence of the company,
and it was unjust to put a liability where such was the
case.
The California Supreme Court has declared that cities
in that State are not liable for persons injured by falling
into open sewers kept insufficiently guarded, where the
liability for such injuries is not expressly stated by statute.
One of the judges, who dissented from this opinion, said
that, if the law required the municipal authorities to keep
the streets in safe condition, this carried with it a liability
for injunes, even though no express provision. was made
by the law for compensation. ‘The latter view is probably
the prevailing one in most of the States.
The Georgia Supreme Court holds that it is within the
discretion of the trial court to require the plaintiff, suing
for a physical injury alleged to be permanent, to submit
to an examination by competent physicians to ascertain
the nature, extent, and probable duration of the injury, so
as to afford means of proving the same at the trial.
The judge cited with approbation the statement in
‘‘Thompson’s Trials,” as follows: “ In modern trials of
civil actions for physical injuries, the question has fre-
quently arisen whether the court has power to order an
inspection of the body of the plaintiff or person injured,
for the purpose of ascertaining the nature and extent of
the injuries. Some of the courts, carrying in their minds
no higher conception of a judicial trial than the concep-
tion of a combat in which each of the gladiators is per-
mitted, within certain limits, to deceive and trick the an-
tagonist and the umpire, have decided the right of the
defendant to have an order for such inspection.
“ Other courts, taking the more enlightened view that
the object of a judicial tnal is to enable the State to
establish and enforce justice between party and party,
have held that it is within the power of the trial-court, in
the exercise of a sound discretion in proper cases, upon
an application seasonably made, under proper safeguards
designed to preserve the nghts of both parties, to order
such an inspection, and to compel the plaintiff or injured
person to submit to it.
“ Another court has held that where a plaintiff in such
an action alleges that his injuries are of a permanent
character, the defendant is entitled, as a matter of right,
September 7, 1889]
THE MEDICAL RECORD.
263
Though the production of artificial anzesthesia during
to have the opinion of a surgeon based upon a personal
€xamination, unless there is already an abundance of ex-
pert evidence ; in which case the court, in its discretion,
may refuse to order an examination. Another court has
ruled that the trial-court may require the plaintiff in such
an action to submit to a medical examination, and dismiss
his action if he refuses to comply with the order.
“ This conclusion may be placed upon the higher ground
that, when a person appeals to the sovereign for justice he
impliedly consents to the doing of justice to the other
party, and impliedly agrees in advance to make any dis-
closure which is necessary to be made in order that justice
may be done.” It will readily occur to the reader that the
main ground of objection to the rule would be the danger
to which delicate and modest females might be exposed,
and in regard to this the judges say : “ There would be no
danger, we think, in this country, of an examination being
ordered needlessly, or where an improper shock to mod-
esty or feelings of delicacy would be likely. We decide
simply that the power exists, and that in each case it is to
be exercised or not according to the sound discretion of
the presiding judge.”
Clinical Pepartment.
ARTIFICIAL ANASSTHESIA DURING SLEEP.
By THEODORE POTTER, A.M., M.D.,
INDIANAPOLIS.
I was called at 9 P.M. on July 2d to see a case of
injury to the arm. The patient was a boy, aged eight,
rather delicate in appearance, timid, and of slight build,
but whose general health is good. ‘The injury had oc-
curred nearly two hours previously, and the swelling and
extreme pain prevented a thorough examination without
an anesthetic, which being given, fracture of the lower
end of the humerus was found, the internal epicondyle
being broken off.
Seven weeks before this the boy had received a severe
scalp-wound, during the suturing of which chloroform was
given. ‘This was a short time after a meal; he vomited
freely during and after the use of the anesthetic, and was
sick for some hours. He was therefore now much
frightened over, and dreaded, the idea of having to take
“ that nasty stuff again.”
Adjusting the arm in a comfortable position I left him
for about half an hour. When I returned with Dr. J. W.
Marsee, of this city, he was sound asleep.
At the solicitation of his family I made the attempt of
giving the anesthetic without waking him. ‘The experi-
periment was completely successful. The patient passed
directly from sleep into the artificial anesthesia, the only
signs of irritation being a slight holding of the breath, and
a few side-to-side movements of the head just before com-
plete anzsthesia was reached.
The dressing lasted twenty minutes ; the anesthetic was
then withdrawn, the patient passing into natural, quiet
sleep, without the slightest sign of disturbance. He did
not vomit during or after the chloroform, and experienced
no perceptible ill effects from it. ‘Three and one-half
hours afterward, at 2 a.M., he awoke, not having any
knowledge of what had occurred, and expressed surprise
that his arm had been dressed.
The anesthetic used was chloroform. It was given on
a small, thin handkerchief, gradually at first, and with very
free admixture of air, near an open window, and was as
gradually withdrawn. ‘The quantity used was exactly
three and one-half drachms. ‘The supervention of com-
plete anzesthesia was quite sharply marked by the change
to regular, deep, easy breathing, and full relaxation fol-
lowing slight ngidity of the muscles of the face and chest.
A plaster dressing was applied, completely immobilizing
the arm; there was thus the least possible irritation re-
maining after the withdrawal of the chloroform.
sleep 1s certainly a nice thing, if it can be successfully car-
ried out under such circumstances, the question is of
interest chiefly from a medico-legal stand-point.
The subject being under discussion in the local medical
society a few years ago, it was tested a number of times
by Dr. W. N. Wishard, then Superintendent of the Indian-
apolis City Hospital, the subjects being adults. In every
instance it failed; and failure has been the result in the
large maiority of instances in which it has been tried.
How rarely, then, must it be successful in the hands of ex-
cited, ‘bungling, incompetent persons who attempt it for
criminal purposes ?
A considerable number of successful cases is, however,
now on record ; and it is generally agreed that it is more
likely to succeed with children than with adults. The
two cases reported by Dr. Cluness’ were in children.
Dolbeau, in his report on the “ Employment of Chloroform
in Relation to the Perpetration of Crime,” * concludes that
children are less difficult to manage than adults. Wood *
makes the same statement.
In all the cases which the writer has been able to find,
chloroform was the agent used.
_ The subject is well summarized in Lyman’s work on
“ Artificial Anesthesia and Anesthetics.”* In none of
the cases related in this volume, nor in those which I have
been able to collect from other sources, with possibly one
exception, is it clearly stated whether or not the patient
continued to sleep after the chloroform was stopped. In
many it is stated or intimated that this condition did not fol-
low. Moreover, it is to be noted that in many of the re-
ported cases (all of those of Dolbeau) the subjects were
not suffering from any special irritation, such as an injury,
which would probably render the experiment more difficult.
The evidence in most of the supposed cases of the crim-
inal use of chloroform, such as occasionally come be-
fore the courts, or more frequently float through the
newspapers, is so incomplete or doubtful as to be of little
value. ‘This case, therefore, seems of interest as one
‘in which not only was artificial anesthesia produced dur-
ing sleep, but was followed uninterruptedly by sleep last-
ing a number of hours, and this in a person suffering
from a painful injury.
A CASE OF FECAL FISTULA—OPERATION—
RECOVERY.
By H. W. BOONE, M.D.,
SURGEON TO ST. LUKB’S HOSPITAL, SHANGHAI, CHINA ; PRESIDENT OF THE MEDI-
CAL MISSIONARY ASSOCIATION OF CHINA.
THIS patient comes in with the following history, furnished
by the doctor who first saw the case, November 1, 1888:
“« Nineteen days ago was seized with pain in inguinal re-
gion, which he said soon became general over the whole
abdomen. After his seizure there was for some days
more or less stercoraceous vomiting. On the sixteenth
day he says an oblong tumor, which had been observed in
the inguinal region, ulcerated through, and discharged
much fæces, pus, and fluid. After he was seen an enema
was given, which resulted: in the passage of a moderate
amount of very firm fæces. Some days after this the
bowels began to act spontaneously but irregularly. For
two months past he has passed one-half of his fæces by
anus, and one-half through the opening in inguinal region.”
Admitted to St. Luke’s Hospital, March 23, 1889, a
healthy-looking, fairly well-nourished lad of nineteen. He
has a small opening over the region of the cecum, from
which fairly well-formed fæces are passed. ‘There are the
marks of two sinuses, one running toward the scrotum
and one toward the median line, which are fully healed
up. ‘The opening of the fistula is too small to admit of
the passage of the little finger, and there appears to be a
1 Pacific Medical and Surgical Journal, June, 1874.
2 Annales d'Hygiène, 1874.
3 Materia Medica, 8th edition,
4 Wood’s Library, September, 1881.
264
THE MEDICAL RECORD:
[September 7, 1889
5 SSS
cavity between the skin and bowel which seems at times
to fill up, and then, after a free evacuation, to become
smaller. A probe, slightly curved, passes freely upward
and appears to be in a large cavity ; it can also be passed
directly downward for two inches, but not in any other
direction. The patient was carefully prepared for the
operation by bathing, the evacuation of the bowels, appro-
priate food, and the cleansing and disinfection of the parts.
On March 27th, at 10.45 A.M., chloroform was adminis-
tered by Dr. Reid, and with the kind assistance of Drs.
Jamieson and Deas, and Surgeon Kellard of H.M.S. Mu-
tine, I proceeded to operate. A free incision was. made
over the site of the lesion, and the parts were dissected
up, thus opening into a cavity which connected with the
cecum. A ragged irregular wound was found two inches
above the lower end of the czecum, nearly transverse in di-
rection, and one and three-quarters inch in length; the
mucous membrane was ragged and everted. On inser-
tion the finger passed up readily in the direction of the
ascending colon, also downward for nearly two inches.
With one finger in the gut, I then carefully freed the bowel
in this vicinity from some cicatricial attachments, removed
some shreds of areolar tissue, and then thoroughly cleansed
the parts with sponges wrung out of a warm two per cent.
solution of carbolic acid. I then put in a double row
of “ Lembert sutures” of fine silk, and closed the open-
ing, passing two stitches at either end of the line through
healthy tissues beyond the angles of the wound. The
edges of the wound having been thus inverted, and being
in close apposition, the parts were cleansed, a short india-
rubber drain-tube was inserted beneath the skin, and the
wound of incision was united with interrupted sutures of
catgut. Borated cotton was applied over the line of in-
cision, then Gamgee pads; a wide bandage was applied
round the body, with a spica inthe groin. The patient
bore the operation well. He was put to bed and allowed
nothing but one teaspoonful of weak hot tea from time to
time. On the evening í of the day of the operation his
temperature was 99.3° F.; on the next evening it was
normal, and continued so afterward. Slight chloro-
form nausea for twenty-four hours. At twenty-five hours
after the operation, began the injection of beef-juice per
rectum. After one day he objected so strongly to the use
of enemata, and to taking Valentine’s meat-juice by the
mouth, that I ordered three ounces of equal parts of milk
and rice-water to be given him, in spoonful doses, during
the day. Fourth day : Slight stain on dressings, which were
reinoved ; they were stained with pink serum, wound quite
healthy, no pain or tenderness ; fresh dressing applied ; rice-
water and milk, eight ounces. Sixth day: Enema, fol-
lowed by a small passage containing fæces; meat broth in
addition to milk and rice. Eighth day: Change dressings ;
wound healed except track of drain-tube, which was re.
moved. Ninth day: Minced meat and boiled fish with the
rice and milk. One-half ounce of salts in morning was fol-
lowed by two natural stools in the afternoon. Eleventh
day : Two natural motions without the use of any aperient.
After this time a regular and natural stool every day. On
the morning of the thirteenth day removed the third dress-
ing. Wound entirely healed ; a small pad of absorbent cot-
ton and a bandage were applied to keep his fingers from
the groin. On the seventeenth day allowed him to get
out of bed and sit in an arm-chair. April zoth: Returned
to his ordinary native diet, and walked about the hospital
yard. April 22d, twenty-six days after the operation, he is
perfectly well, and is discharged at his own request.
Remarks.—This young man had twice attempted sui
cide, and there is no doubt that his parerts, with true
oriental disregard for the sanctity of human life, were
quite willing to allow him to make away with himself.
His complete recovery seemed to them but little short of
a miracle. The man came to me in very good condition,
for his physician had kept the parts cleansed, healed up
the sinuses which had burrowed in the surrounding
region, and had put the parts into a healthy condition ;
while by careful attention to the general health of the pa-
tient he had put him in a good way to recover from the
results of an operation.
This is an example of a case where the operation was
an easy one, and there were no untoward complications.
My former cases were of fistulze, in which the small intes-
tine was involved, and where the two ends of the gut con-
nected with the artificial anus were resected and the cut
ends joined together by sutures, a much more dangerous
operation for the patient.
This case is reported as showing that it is not every
case of fecal fistula in which the operation for cure is
specially dangerous ; and that, while the modern plan of
cutting down and operating directly upon the injured por-
tion of bowel is the-best, in a certain proportion of cases
it is not attended with very great danger to the life of the
patient.
In this case the fecal fistula seems to have resulted
from some obstruction of the bowel, for we learn that he
had severe pain in the inguinal region; and after a few days
vomiting of stercoraceous matters. A fecal abscess was
then formed, which later on effected an opening through
the integument. There was ulceration of the czecum, but
nothing to show whether the appendix was or was not in-
volved in the inflammatory process. As the appendix
was completely shut off from the site of the injury, it was
deemed best to confine attention to the local lesion and
not to go exploring for undiscovered troubles. ‘The
bowel opened indirectly to the surface ; the skin-wound
was quite small, and the fistulous track was irregular ; there
was a cavity containing pus and fæces between the wall
of the abdomen and the bowel ; it is a variety known as
the sterco-purulent fistula. The method employed—of
utting in a double row of Lembert sutures, and of insert-
ing a couple of stitches beyond each angle of the wound—
seems to me the one which offers the greatest safety.
Two rows of stitches give greater security from yielding or
leakage than one ; the extra stitches at the corners of the
wound made sure that no openings were left at those
points. The very fine silk used would seem to be the
most reliable material for the sutures.
The wound never gave any trouble at all, and in less
than thirteen days it was entirely healed up. With our
modern style of operating and dressing, this is the result
which we have a nght to look for. Since giving up the
use of the spray, and then the general use of the irmgator
in all cases, I find more and more that perfect cleanliness
and dry dressings give me the best results, and that oper-
ations for laparotomy, the radical cure of hernia (so
called), and other operations go on to a cure with but little
if any untoward complications.
CASE OF IMPERFORATE ANUS.
By WILLIAM PERRIN NICOLSON, M.D.,
ATLANTA, GA.
On the morning of the 31st of July, 1889, I was called
hurriedly to see the child of Mr. Henry Denham, farmer,
with the statement that the child could not have an action
from the bowels on account of the absence of the anus.
Upon arrival I elicited the following history of the case :
The child was bom on the 2gth of July, and was delivered
by a midwife in the neighborhood. According to the usual
custom a dose of castor-oil was administered, and as this
had no effect the dose was repeated during the day. Fail-
ing the next morning to secure an action, a third dose was
administered. At this point a physician was called in and
made an examination, with the result of detecting the true.
nature of the trouble. I was called, and saw the child
about noon of the second day, and about forty-eight hours
after birth. There were evidences of distress in the face,
and I was told that he had been crying in great agony for
some time before.
Upon examination the anus appeared normal, but when
the buttocks were separated there was revealed a complete.
closure. ‘There was even the appearance of a small ex-
September 7, 1889]
ternal pile near the margin of the anus. The crying of
the child upon my efforts of examination caused the dis-
tended rectum to bulge out, showing that the gut was not
far away. |
The patient being held in the lap of the assistant, an in-
cision was made from the tip of the coccyx across the
anus, and soon after passing through the skin there was a
gush of gas, and then such a stream of meconium as
passed away I should never have believed possible in so
small a child. It continued for more than ten minutes to
ooze away in a constant, though somewhat intermitting
stream. Finally the opening was made large enough to
let my little finger pass into the rectum, and the patient
was left with instructions to the nurse to introduce the
finger twice daily for some time. I have since learned
that he is doing well. Cases of imperforate anus are suf-
ficiently rare to give them considerable interest, and this
belongs to the rarest class.
Progress of Medical Science.
MECHANICAL TREATMENT OF GLEET AND SEXUAL AS-
THENIA.—Dr. Szadek, of Kiev, has published a paper on
the treatment of gleet by the introduction into the urethra
of Beniqué’s curved tin bougies anointed with either
Unna’s salve (R. Olei cacao, 100 grammes ; cerz flave,
2.0 to 5.0; argenti nitrici, 1.0; balsami Peruviani, 2.0.
M. f. ung.) or Sperling’s (B. Lanolini, 20.0; cerz albæ,
4.0; argenti nitrici, 0.1 to 0.3. M. f. ung.). In nervous
or very sensitive subjects, in whom the insertion of the
bougies gives rise to pain and erection, a from three to five
per cent. solution of cocaine should be previously injected
into the urethra. During the first sitting the bougie is left
in situ not longer than for three to five minutes, but later
on the duration of the s¢ances is gradually increased up to
fifteen or even twenty minutes. ‘The sittings are repeated
every two or three days, except in very inveterate or atonic
cases, in which a daily introduction of the instrument is
advisable. As to the size of the latter, the author uses a
set from No. 18 to No. 30 Charriére, commencing with
the least irritating bougies and gradually ascending to
even larger ones. In relatively recent and mild cases he
usually employs Nos. 20, 21, and 22, while in more severe
and more protracted ones (which, by the way, constitute
a vast majority) he, following Professor Otis, passes by
degrees to No. 28, or even No. 30. In patients with
narrowed meatus, he enlarges the latter by means of a
bistoury or scissors. In such cases, where the lesions are
situated in the posterior division of the urethra, Dr.
Szadek introduces his bougies even as far backward as
the bladder. According to his experience, the deep in-
sertion, when practised with due caution and carefulness,
never causes any untoward accessary effects (such as
vesical or urethral irritation, etc.). In all, 30 cases of
neglected gleet were treated after the mechanical method.
In 3 of them, referring to unusually severe or old morbid
changes about the urethra, complicated with obstinate
vesical affection, the results were far from being satisfac-
tory ; but in the remaining 27 the treatment proved highly
successful. In 18 of the 27 complete cure ensued (and
that in 11 from the bougies alone, and in 7 from the
bougies and astringent means). In 9 a considerable im-
provement was obtained ; in fact, the only symptom left
was a scanty mucoid discharge recurring from time to
time. In relatively recent or mild cases, from four to six
sittings proved to be sufficient for effecting a cure. Ina
majority of cases, however, a one to two months’ course
was necessary for the purpose, while in some unusually
severe cases, where a relapse took place, another similar
course was to be repeated some months later. The same
method (in the shape of the insertion of Nos. 20 to 25)
gave also most gratifying results in eight cases of sexual
asthenia with spermatorrhoea and (incomplete) sexual im-
potence. Dr. Szadek arrives at the following general
THE MEDICAL RECORD.
265
conclusions: 1. The method under consideration proves
very useful (a) in many cases of neurasthenic irritation of
the urethral mucous membrane ; (4) in many cases of in-
veterate gleet, especially in those characterized by infiltra-
tion and other morbid changes in thesmucous membrane
and submucous tissues. 2. It proves beneficial, further,
in inveterate gleet of an atonic origin, or in that kept up
by local nervous disturbances. 3. In some cases, how-
ever, the mechanical treatment must be supplemented by .
a subsequent course of local astringent remedies. 4. The
method is free from any untoward accessary effects, pro-
vided it is practised with due precautions (including anti-
septics).— Zhe Provincial Medical Journal, June 1, 1889.
IRRIGATION OF THE PUERPERAL UTERUS.—Dr. Haynes
(American Journal of Obstetrics) concludes a discussion of
this subject thus: 1. Where intra-uterine irrigation is used
in the absence of sepsis, use no sublimate, but plain hot
water, or salt and water. 2. If the urine is albuminous
and scanty, use no mercury. 3. If the urine is slightly
albuminous and copious, or if the patient is profoundly
anzemic, do not use more than a pint of a solution of
1: 8,000. 4. Always use tartaric acid and sublimate tab-
lets or powders ; dissolve thoroughly in a small quantity
of water and mix carefully with a definite quantity of hot
water in a pitcher, from which pour into the irrigator.
5. Always use fountain-syringe, and for the uterus a
double tube, so as to insure the return of the solution.
If for any reason the fluid fails to run out as fast as it
flows in (if not through the reflex tube, by way of the
channels at its sides), shut off the flow. The irrigator
should not be raised more than three feet. 6. Precede
by copious irrigation with hot water to wash out blood, etc.,
which may form with sublimate adhesive albuminous com-
pounds, which may in time be absorbed. Follow by a
quart or two of hot water to insure the evacuation of all
the sublimate solution. 7. For the uterus use a solution
not stronger than 1: 8,000, and not more than a quart
daily. 8. For the vagina use a solution not stronger than
I : 4,000, and not more than a quart twice daily. Irnga-
tion used in the above way is, we believe, a practice al-
most devoid of danger. We have made more than one
hundred and seventy-five irrigations with the double tube
and fountain syringe, with no untoward results except in
two cases an unimportant rise of temperature, and in one
a severe but harmless chill, and even these slight accidents
we feel certain might have been avoided by greater care.
Yet irrigation of the puerperal uterus will always be a pro-
cedure requiring great care and judgment, and some skill.
Enough has been said to make it evident that our opinion
coincides with that of Credé and Fehling, that both vagi-
nal and uterine irrigation are attended with undoubted
dangers, and should never be employed in the puerperal
state unless to meet definite indications.
FISSURES OF THE TONGUE.—These obstinate and pain-
ful lesions are said to be speedily cured by applying the
following mixture five or six times daily :
B. Papayotine......cssecessccsee 2 parts.
Glycerin, aque... ...cceeeeoes 5A 10 ‘*
POSTURE IN THE ‘TREATMENT OF ‘lYMPANITES.—Mr.
Oxley, writing to Zhe Lancet concerning a case of ob-
stinate tympanites which had resisted all drug treatment,
says that instant relief was obtained by placing the patient
in the knee-elbow position. He advises a trial of this be-
fore resorting to puncture of the abdomen.
SALOL IN SCARLET FEvER.—Dr. G. J. Holmes, of New
Britain, Conn., in a recent brochure on scariet fever,
speaks very favorably of the action of salol, and states
his belief that the persistent and careful administration of
salol in proper doses, according to the age and general
condition of the patient, will, in many cases, reduce the
temperature, eliminate the poison, and cut short the dis-
ease.
266
THE MEDICAL RECORD.
[September 7, 1889
THE MEDICAL RECORD:
A Weekly Fournal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., EDITOR.
PROPRIETORS AND PUBLISHERS
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
New York, September 7, 1889.
A POSSIBLE CAUSE OF POST-PARTUM SHOCK.
THE subject of sudden collapse of the mother, shortly
after labor has come to an apparently successful end, is
one of so great difficulty and importance that any thought-
ful suggestion as to its cause or cure is welcomed by the
practitioner. In the Edinburgh Medical Journal, July,
1889, Dr. Ferguson, of Edinburgh, relates three cases—
one in his own practice—in which, he thinks, the extreme
and sudden prostration which occurred was caused by
pressure upon the ovary during the application of Credé’s
method of expression of the placenta. In the first case
the mother, a woman of very nervous temperament, was
delivered after an easy, rapid labor, without chloroform
or forceps, of her fourth child. As the doctor had not
arrived, the nurse, an unusually competent woman, thor-
oughly acquainted with Credé’s method, grasped the
uterus and firmly compressed it for half an hour, until
the doctor arrived. This kneading of the uterus gave the
patient great pain. The uterus contracted well without
hemorrhage. Soon after the expulsion of the placenta
the mother suddenly became unconscious, with imper-
ceptible pulse, and remained so for three hours. She
went through the death-struggles, and looked like a dying
person. ‘The pulse then gradually returned, and in half
an hour the patient could talk and take stimulants. She
recovered without further trouble.
In the second patient, a healthy young primipara, the
labor had been normal, except that from ngidity of the
external parts inertia threatened and low forceps were
used. After waiting a little while for the placenta, the
doctor put her half under anesthesia, and, failing to ex-
press by Crede’s method, which caused great pain, ex-
tracted the placenta by hand. Only a slight hemorrhage
occurred. Immediately after the extraction the patient
became cold, pale, pulseless, and gasping. She rallied
under injections of ether, etc., sank again, and finally re-
turned gradually to a normal condition, passing safely
through childbed.
The third case occurred in a healthy young primipara,
of nervous temperament. Labor proceeded naturally,
but at the end of the second stage a little chloroform
was given, and forceps were used on account of fatigue of
the patient. After delivery she awoke partially from the
anesthesia, and complained loudly of great pain when
the uterus was grasped, begging to be let alone. ‘The
pain made her sick and faint, and was worse each time
the uterus was compressed, becoming finally unbearable.
As the placenta was passing from the vulva the patient
became suddenly unconscious, after a period of restless-
ness and tossing. ‘The uterus was firmly contracted, and
there was no hemorrhage from cervix or vulva. There
was no perceptible pulse, no breathing, and the patient
seemed at the point of death. She remained in this con-
dition three hours, then gradually recovered.
In these three cases there had been no great difficulty
in labor, no excessive hemorrhage, no severe operation.
Eclampsia and heart disease were easily eliminated. In
each there were symptoms of syncope and shock ; uncon-
sciousness ; feeble, rapid, irregular pulse, sometimes im-
perceptible at the wrist ; dilated pupils ; shallow, irregular
breathing ; cold, clammy sweat ; vacant, torpid face, and
absolute insensibility to pain. In eight to twelve hours
they had completely recovered, feeling only a little ex-
hausted, and having some tenderness of the hypogastrium.
The patients after recovery had little or no recollection
of what had occurred during the attack. In two of the
cases the subsequent progress was normal ; in the third
there was persistent sleeplessness, leading to a prolonged
attack of melancholia, from which, however, the patient
recovered.
Dr. Ferguson thinks there can be no doubt that the
shock was, in each case, caused by squeezing one or both
of the enlarged, tender ovaries between the compressing
hand and the hard, contracted uterus. This accounts
both for the exquisite pain felt during compression and
for the subsequent serious collapse. He supports this
view by the observation that, during abdominal section for
removal of the ovaries and tubes, if the ovaries are
roughly handled or torn before the ligature has been
tied, the patient, though anesthetized, becomes generally
affected by shock, exhibiting dilated pupils, coldness of
extremities, clammy sweat, fluttering pulse, and irregular,
shallow respiration. These symptoms disappear after the
ligature is tied.
He goes on to show by quotations, and from personal
observation, that in a considerable proportion of cases the
uterus, during the third stage and after delivery, lies ob-
liquely in the pelvis, so that the ovaries, which cling
closely to its sides, lie the one in front of the transverse
line, the other behind it. The fingers which grasp the
uterus from behind may, in certain of these cases, very
easily squeeze the ovary which lies posteriorly. In our
attempts to grasp the uterus, also, we may, unintentionally,
twist it on its axis so as to bring the ovary where it may
be squeezed. When the patient lies on the left side the
hand naturally grasps the uterus in such a way that the
thumb in front is a little to the right, and the fingers be-
hind are a little to the left of the median line of the pel-
vis, and as the uterus is generally rotated to the right it is
grasped antero-posteriorly and the ovaries are avoided.
When the patient lies on the back this is not the case, the
rotated uterus being grasped obhquely and the ovaries en-
dangered. In most cases the compression required is
slight, and a woman of strong nerves will bear it, even when
the ovary is involved, without inconvenience. But where
pain is experienced during compression, or where consid-
erable force is required, the physician should take care to
find how the uterus lies before he applies pressure. Lat-
era] compression of the post-partum uterus should never
September 7, 1889]
THE MEDICAL RECORD.
267
be used except in cases requiring irrigation of its cavity,
when the Fallopian tubes should, if possible, be very
gently compressed, in order to prevent regurgitation of the
fluid through them into the peritoneal cavity.
Many of the attacks of syncope which occur immedi-
ately after the third stage, or during it, and which are as-
cribed to the very slight hemorrhage which has normally
occurred, ought to be put to the account of that energetic
and forcible kneading of the uterus and its adherent ova-
ries which an over-zealous accoucheur thinks necessary ot
prevent a more or less visionary post-partum hemor-
rhage.
MEDICAL JOURNALS AND THE NAMES THEY GO BY.
WE chronicled not long ago the birth of a medical journal
in St. Joseph, Mo., to which its sponsors had given the
rather extensive name of Zhe Western Medical ard Surgi-
cal Reporter, and we are pained to learn that the youngster
has not met with as cordial a welcome from all its con-
temporaries as it received from us. The cause of the
cold, or we might say hot, reception that it has en-
countered is to be found in the fact that its title resembles
closely that of several existing journals. Zhe Medical
and Surgical Reporter administers to it a not over-gentle
reproof, and Zhe Western Medical Reporter has cut short
the vacation of its fighting editor, and called him home
to sharpen his knife and clean his gun preparatory to a
busy season. The Cleveland journal with a similar name
has not yet been heard from, but he has been there before,
and probably will not care to say anything that will tend
to reopen old sores.
There is certainly no necessity for this copying of titles,
and it betrays a lamentable want of originality on the part
of the originators of these journals that they should be
forced to bestow borrowed names on their progeny. It
is also at times confusing, and may lead to the giving of
credit for good articles to the wrong journal. Neverthe-
less, we see no great crime in this appropriation of titles,
for no harm can thereby result to the older journals after
whom the younger ones are named. It is an evidence of
appreciation and sincere flattery, so why take offence at
it? THE MepicaL Recorp has several namesakes, but
it wishes them all well, and congratulates them upon the
enjoyment of so aristocratic an appellation.
For the sake of peace, however, and in order to pro-
mote a fraternal feeling among our contemporaries, we
would advise our young friend to change his name, and
start life with a designation that will be all and entirely his
own. We might, indeed, suggest a few names from which
he could select the one that pleased him most. In the
first place, the names of instruments furnish an inexhausti-
ble source from which appropriate titles may be drawn.
The Lancet and the Scalpel have been taken, but enough
remain to offer a rich choice. We have the bistoury, the
chain-saw, the forceps, the hypodermic syringe, the spec-
ulum, the catheter, and a host of others. ‘Then there are
other names relating more particularly to the avowed ob-
jects of the journal, such, for example, as the Occidental
Boomer, the Western College Puff, the Missouri Doctors’
Own, the Foe of the Atlantic, and many others. It
would be allowable also to imitate, though not to copy,
the title of some already existing periodical. ‘Thus, in-
stead of the name that it has so rashly chosen, it might be
called the Relator of Medical and Chirurgical Facts and
Fancies, or, in imitation of the Medical Waif, the St. Joe
Foundling.
We extend to our young contemporary, whatever name
he may be known by, the assurance of our most cordial
consideration.
TREATMENT OF HYDRARTHROSIS OF THE KNEE BY
SUBCUTANEOUS RUPTURE.
Oxe of the most troublesome of all forms of articular
dropsy to treat satisfactorily is chronic serous effusion of
the knee. Why this is so is not so easy to explain—pos-
sibly it is because the effusion in this joint is apt to be
greater than elsewhere, so that the lymphatics are unable
to receive it with sufficient rapidity. However this may
be, it is a fact that it is often impossible to disperse the
fluid without recourse to operation, and, despite the com-
parative safety of operations on the articulations as prac-
tised in our day, it is nevertheless better to avoid even a
puncture with an aspirator needle, if possible.
As a substitute for aspiration or a cutting operation in
cases of hydrarthrosis of the knee which have resisted
counter-irritation, pressure, etc., Dr. Georges Berne, of
Paris, proposes subcutaneous rupture of the synovial mem-
brane (éclatement), so as to promote the escape of the
fluid into the surrounding tissues (Z Union Médicale,
August 6, 1889): Examination of a knee-joint containing
much fluid shows that fluctuation is most apparent at the
upper and inner part, and if the joint be semiflexed the
distended synovial sac will form a very distinct promi-
nence in this situation. Dr. Berne’s plan is to render this
portion of the sac very tense by making upward pressure
over the joint with the palm of the hand, so that a con-
stricted neck is formed between the inner condyle of the
femur and the concave border of the hand. The sac
being thus rendered very tense, firm pressure is made
upon it by the thumb of the constricting hand, or it is
tapped somewhat sharply by the ulnar border of the fist
of the other hand. By this means the synovial membrane
is rent, and an escape of fluid takes place into the neigh-
boring cellular tissues, where absorption readily takes
place, owing to the abundant supply of lymphatics in
that region. Resorption of the fluid is further aided by
massage practised after rupture of the sac.
Dr. Berne has never seen any bad effects follow this
procedure, and he recommends it especially on account of
its safety and of its ease of execution. The method is,
however, applicable only to comparatively recent cases, in
which no marked thickening of the synovial membrane
has taken place, and in which no evidences of inflam-
matory action are present.
TUBERCULOUS INFECTION THROUGH EAR-RINGS.—A case
is related in the Wiener Medizinische Presse of a young
girl, fourteen years of age, of a perfectly healthy family,
who wore ear-rings left to her by a friend who had died
of pulmonary tuberculosis. Soon ulcers appeared on the
lobes of both ears, the cervical lymph-nodules became
swollen, and percussion revealed dulness at the apex of
the left lung. Tubercle bacilli were found in the ulcers
and in thesputa. It was presumed that the ear-rings were
the agents of infection.
268
Mews of the Geek.
THE AMERICAN ASSOCIATION FOR THE ADVANCEMENT
OF SCIENCE held its annual meeting in Toronto, com-
mencing August 28th. Professor Mendenhall, the Presi-
dent-elect, delivered an address of welcome. The first
paper in the Anthropological Section was by Mr. Garrick
Mallery, of Washington, and was entitled “ Israelite and
Indian—a Parallel of Culture in Planes of Culture.”
The general thought implied in the paper was an effort to
show that there is a strong similarity between the Indian
and Israelite races. An examination of the history of
both races would show that they are on parallel planes
of culture.
AN ACCIDENT IN A PHILADELPHIA HoOsPITAL.—A
painful accident, whereby several nurses were injured,
occurred last week in the Philadelphia Lying-in Charity
at Eleventh and Cherry Streets. Two strands of cable
attached to the elevator broke and the car fell from the
third floor to the basement. ‘The elevator contained five
nurses and the elevator boy, all of whom were more or
less injured.
FOUNDLINGS AS FREIGHT.—The Russian Minister of
the Interior has just issued an ordinance to all railway
officials prohibiting the further packing of small children
in baskets and forwarding them to the foundling-houses in
the great towns as hand-luggage. ‘The children were often
packed as many as eight in one basket. ‘The object of
shipping the poor waifs in this way was to avoid the pay-
ment of fare, as it appears that the rules of the Russian
railways always require payment for children of whatever
age they may be.
THE PRINCE OF WALES is reported to be suffering
from a mild attack of gout.
THE RIGHT TO PRACTISE MEDICINE IN BRITISH Co-
LuMBIA.—An odd state of affairs exists in regard to medi-
cal practice in British Columbia, according to a corre-
spondent of the Lancet, whereby Canadians as well as
Americans are discriminated against in favor of those
educated in Great Britain. It appears that during the
last session of the Local Parliament a number of medical
acts were consolidated, and among them an act of 1866
which was thought to have been repealed. Consequently,
as the law stands at present, only men with British diplo-
mas have the nght of practising in the province without
examination. All others, Canadians and Americans alike,
have to pass an examination, and have moreover to pay
a hundred dollars to the Provincial Medical Council.
LATE PREGNANCIES.—A correspondent writes for defi-
nite information regarding late pregnancies. Can any of
our subscribers give cases of fifty years of age and over?
TYPHOID FEVER ON A ‘I'RAINING-SHIP. — There is a
slight epidemic of typhoid fever on the United States
training-ship New Hampshire, and a number of cases at
the Newport Hospital. Investigations into the cause are
to be made by a board of naval surgeons.
THE USE oF CosMETIcs IN BERLIN.—Some statistical
fiend says, concerning the women of Berlin, that they use
every day over 400 pounds of face powder, 250 pounds of
rouge, 125 pounds of eyebrow-paint, 100 pounds of lip-
salve, and 50 pounds of cold cream.
THE MEDICAL RECORD.
[September 7, 1889
THE INTERNATIONAL PRISON CONGRESS will be held
in St. Petersburg in the summer of 1890. A prize of
$400 is offered by the conductors of the Prison Disci-
pline Review, for the best essay on the subject: “ What in
the most civilized nations has been the historical develop-
ment of the institutions relating to the correctional edu-
cation of minors who have been convicted of crimes at
common law, or who have been put in custody for idle-
ness and vagabondage, or with a view to paternal disci-
pline?” ‘The essays must be written in Russian or French,
and must be sent to “ The President of the Organizing
Committee of the Fourth International Prison Congress,
at St. Petersburg,” not later than May 15, 1890. ‘They
must be furnished with a motto, and accompanied by a
sealed letter containing the writers name and address.
TYPHOID FEVER IN Lonpon.—There has been some-
thing of a fever scare in the West-end in London, a num-
ber of cases of typhoid fever having occurred there during
the past few weeks. The disease was of a mild type, but
it was remarkably wide-spread, a number of cases appear-
ing almost simultaneously in different houses scattered
over a wide district. It is thought that milk was the
means of spreading the contagium.
ENGLISH PHYSICIANS IN SWITZERLAND.—The Swiss
Government has refused to allow foreign physicians to
practise in that country, and even forbids apothecaries to
dispense any prescription written by them. This action
is aimed more particularly at the English medical men
who have followed their patients to the Swiss resorts, and
have sought to obtain a practice among the English resi-
dents. The action of the Government is said to have been
taken at the instigation of Swiss physicians residing at the
popular health-resorts, and who did not relish the idea of
having the cream of their practice taken from them by
foreigners.
THE SIXTY-SECOND CONGRESS OF GERMAN PHYSICIANS
AND NATURALISTS will meet at Heidelberg on September
18th to 23d. Several foreign medical men have been in-
vited to take part in the proceedings of the Congress. |
Dr. ‘THomas Kinc CHAMBERS, of London, died in
that city on August 15th. He was honorary physician to
the Prince of Wales, but had not been in active practice
for a number of years. Dr. Chambers was the author of
several articles in Reynolds’ “ System of Medicine,” and
had also published several works on subjects relating
chiefly to diet and diseases of the digestive organs.
Dr. Joun T. Banks, of Dublin, has been created a
Knight Commander of the Order of the Bath.
THE SECOND ITALIAN CONGRESS OF INTERNAL MEDI-
CINE will be held in Rome on October 15thto 17th. The
chief subjects for discussion will be gout, nephritis, and
malaria.
A New TRrI-STATE MeEpical. ASSOCIATION.—A call
has been issued to the members of the medical profession
in Alabama, Georgia, and Tennessee, to meet in Chatta-
nooga on the third ‘Tuesday in October, for the purpose
of forming a Tri-State Medical Association. All will be
admitted to the meeting of the Association, but the mem-
bership will be restricted to graduates of regular medical
colleges in good standing. ‘This call is signed by com-
mittees from Jackson County, Ala., Medical Society ;
September 7, 1889] THE
MEDICAL RECORD.
269
Chattanooga, Tenn., Medical Society ; Cleveland, Tenn.,
Medical Society ; Cartersville, Ga., Medical Society ;
Dalton, Ga., Medical Society. The organization will be
independent of all other societies. It will be an associa-
tion of individual members of the profession of medicine,
and will be managed in the interest of medical progress.
The session will continue two days. Those desiring to
read papers or exhibit specimens are requested to notify
the secretary of the committee, Dr. F. T. Smith, of
Chattanooga, Tenn., at an early date.
THE ANATOMICAL SOCIETY OF GREAT BRITAIN held
its annual meeting on Thursday, August 15th, in Leeds.
Dr. Ambrose Birmingham succeeded, by following the
nerve-trunks, in ascertaining that an extra lumbar verte-
bra belonged to the sacrum and not to the dorsal region.
Drs. Griffiths and Oliver, having observed that the distri-
bution of herpes zoster seemed irreconcilable with current
accounts of the anatomy of the spinal nerves, were led to
investigate their anatomy. They showed that the dorsal
branches of the spinal nerves were distnbuted to the skin
very much lower than is supposed, and that they ran down-
ward for some distance in the substance of the muscles.
They also presented a series of specimens and frozen sec-
tions from the Leeds Museum, showing a patent parum-
bilical vein, an anomalous round ligament of the liver,
feet with six toes, frozen sections of the pelvis. Dr. R.
W. Reid also sent some rare specimens of cervical ribs,
a fifth lumbar vertebra with a suture in the neural arch be-
tween the upper and lower articular facets. Messrs.
Lockwood and Withers showed an unusual right aortic
arch, which, while showing the usual condition, had per-
sistence of a partof the second left arch, which gave
off the left subclavian artery. Professor Alexander Frazer
showed a series of photographs of anatomy, histology, and
embryology. He also described some bodies like Paci-
nian corpuscles, which he had found in the thyroid gland,
and in giving the details of his work on the spinal cords
of a number of rodents, said that he found that the
pyramidal tract ran in the posterior columns of the cord,
and not as others had descnbed.
INTERNATIONAL MEDICAL CONGRESS.—A further an-
nouncement concerning the Congress has been made.
Membership is limited to physicians and surgeons in reg-
ular standing. ‘The registration fee is twenty marks, and
each member will receive a copy of the Transactions.
The purpose of the Congress is purely scientific, and its
business will be transacted in sections. In the first sittings
of the various sections a president and a sufficient number
of honorary presidents will be elected, the latter to pre-
side alternately with the former. Owing to the difference
of languages, a sufficient number of secretaries will be
appointed from among the foreign members. ‘The general
sittings are intended for debates regarding the work and
general relations of the Congress, and for addresses and
communications of general interest. Such addresses are
to be delivered only on invitation of the Committee of
Organization. Proposals relating to the work of the
Congress must be made to the said committee before July
1, 1890. ‘The committee will decide whether they shall
be adopted or not. All discourses and communications
in the general and in the sectional meetings must be de-
livered to the secretaries in writing before the close of the
sitting. The Editing Committee will decide whether and
in what compass these writings are to be printed in the
Transactions. The official languages used at all meetings
will be German, English, and French. The by-laws and
programmes will be printed in all three languages. Intro-
ductory discourses in the sections are to be limited, as a
rule, to twenty minutes; in discussion only ten minutes
are allowed to each speaker. Students of medicine and
other persons of both sexes who are not physicians, but
feel interested in the debates, may attend the sittings on
permission being obtained from the president.
ACETOPHONE.—Acetophone, or methyl-phenyl-ketone,
which has been employed chiefly by some French physi-
cians as a hypnotic, has recently béen studied by Dr. S. S.
Kamenski (St. Petersburg Dissertations,” No.70, 1888-89)
in the laboratory. He finds that it lowers sensibility and
interferes with reflex action. Large and medium doses
produce a moderate amount of sleep. It quickens the
heart’s action, probably by stimulating the accelerator
nervous apparatus. It increases the irritability of the re-
spiratory centre, except in large doses, which may arrest
respiration altogether. It lowers the blood-pressure by
its action on the vaso-motor centre, and by weakening the
heart’s action. Medium and large doses lower the irrita-
bility of the brain, and even small doses have a similar
effect on that of the cord.— Lancet.
Younc MEDICAL STUDENTs.—A correspondent of the
Hospital Gazette, writes from Glasgow that the average
medical student seems to begin his work very early nowa-
days. Of the students who had completed their curricu-
lum here, several were compelled to wait a year for their
examination on account of their age, while no less than a
dozen who had just passed the final ‘ exam.” would not
be able to graduate for six months, until they should attain
their majority.
RECIPROCAL ‘TRANSFUSION IN TYPHOID FEVER.—A
writer in the British Medical Journal suggests the treat-
ment of typhoid fever by mutually transferring the blood
of a person with the disease and that of one who has al-
ready passed through an attack. He reasons that in this
way the bacilli will be destroyed by having no more
pabulum upon which to feed, while the healthy individual,
already enjoying an immunity, will not suffer. This
seems to be the season for queer notions in medicine.
THE DIAGNOSIS OF PERFORATION OF THE DRUM-MEM-
BRANE.—Dr. Spear proposes the following method for de-
tecting minute perforations of the drum-membrane :
While looking into the auditory canal in the ordinary
manner, with speculum and mirror, hold a piece of cold
glass close to the speculum, have the patient do the Val-
salva experiment, and if a perforation exists the vapor of
the breath will be condensed upon the glass and obscure
the view.— Boston Medical and Surgical Journal.
PROFESSOR V. BERGMANN, of Berlin, has recently re-
ceived from King Humbert the grand cross of the Italian
Order of the Crown. During the recent visit of the King
of Italy in Berlin, one of his officers was seriously injured
at a review, and was treated at the special request of Em-
peror William by v. Bergmann, and this decoration was
his reward for having brought the case to a successful is-
sue.
Society Reports,
BRITISH MEDICAL ASSOCIATION.
(Special Report for Tug Mepicat Recorp.)
Fifty-seventh Annual Meeting, held at Leeds, England,
August 13, 14, 15, and 16, 1889.
(Continued from page 246.)
THURSDAY, AUGUST I5TH—THIRD Day.
‘THE PRESIDENT said that a resolution had been adopted,
by the Section in Public Medicine, having for its object
an improvement in the public health service, which kad
been referred to the general body for approval. The
resolution was unanimously approved.
Mr. T. PRIpGIN TEALE then delivered the Address in
Surgery (see p. 232), taking for his subject
DETAIL IN SURGERY.
At the conclusion of the address a vote of thanks was
moved by Dr. Macewen, who said that he had learned a
great deal of surgery during his visit to Leeds. ‘The name
of Teale was one which was known throughout the surgi-
cal world, father and son having contnbuted largely to
surgical science. Mr. Teale’s accomplishments were not
confined to surgery, but included the most delicate opera-
tions upon the eye. He also devoted a considerable
amount of time to sanitary subjects, and had made himself
an authority on the economy of coal.
Dr. MITCHELL BANKS seconded the motion, remarking
that he should like to be able to express to Mr. Teale the
sentiments of respect and admiration with which they re-
garded him as the type of all that was best in British pro-
vincial surgery. It was given to some to excel in one
department of the profession, but to excel as an operating
surgeon, and to take rank as an oculist, and to be foremost
among the sanitary scientists of the country was given to
very few.
The resolution was adopted unanimously.
AN INQUIRY INTO THE MANAGEMENT OF MEDICAL CHAR-
ITIES.
THE PRESIDENT then gave notice of the following reso-
lution, which would be moved at the next session :
“hat this meeting of the British Medical Association
views with great pleasure the action of the Charity
Organization Society of London in presenting a petition
to the House of Lords praying for an inquiry into the
management of the metropolitan medical charities, and
earnestly hopes that the scope of the inquiry will be ex-
tended so as to include provincial hospitals and dispensa-
ries, with the view of obtaining as complete information
as is possible upon this important subject ; that a copy of
this resolution be forwarded to the Lord President of the
Privy Council, and that he be requested to receive a dep-
utation ; that the Council be requested to appoint a
special committee to deal with the question, and request
the Charity Organization Society of England to foim a
similar committee to act in conjunction with it.”
In the evening the members of the Association and of
the profession, of Leeds, met at a banquet which was
given in the Town Hall.
FRIDAY, AUGUST 16TH—FouRTH Day.
Sır JAMES CRICHTON-BROWNE delivered the Address
on Psychology, taking for his subject
THE HYGIENIC USES OF THE IMAGINATION.
A large part of the burden of caring for the insane fell
upon the general practitioner, for many of the mentally
afflicted were now treated privately instead of being cared
for in asylums. It was true that there were
EIGHTY-FOUR THOUSAND FOUR HUNDRED AND SEVEN IN-
MATES OF INSANE ASYLUMS
who were under the care of specialists, yet nearly all had
been consigned there on the evidence of medical men who
THE MEDICAL RECORD.
[September 7, 1889
were not specialists. A bill recently passed in Parlia-
ment, and now awaiting the royal assent, would in a
measure relieve medical men from much of the appre-
hension which they now felt in signing lunacy certificates,
but nothing could take away the sense of responsibility
which they must necessarily feel in thus depriving any
person of his freedom and entailing upon him sure op-
probrium as well as far-reaching disabilities. ‘The certi-
fication of insanity must, therefore, always remind the
general practitioner that psychology is a subject of especial
and practical interest to him. But it was not here alone
that medica] psychology came into prominence, for it met
the general practitioner at every turn, and in his daily
practice.
An address such as the present might emphasize the
psychical side of the union of mind with matter. The
researches of many physiologists led to materialism, but
mind was nut a mere exhalation of brain-substance.
Materialism was an error—confusing the objective with
the subjective. ‘To describe consciousness as a function
of the brain was erroneous. Volition, cognition, and feel-
ing were not functions of the brain. The real nature of
the relation between mind and matter was unthinkable.
Various theories had been suggested ; as, that the psychi-
cal relation of mind to the brain was that the mind acted
through the nervous system; that the brain and mind
were simply the reverse, one of another ; and that there
was a parallel between mental states and states of the
brain (theory of parallelism or concomitance). The lat-
ter view was that held by Herbert Spencer, ‘l'yndall, and
Hughlings Jackson. ‘The psychical centres had been
placed in the prefrontal lobes. Electrical stimulation of
these lobes in monkeys had led to the belief that they
were not motor. But the psychical centres could not be
pent up in any part of the brain. ‘Trousseau had related
the case of an officer whose frontal lobes had been pierced
by a bullet without any sensible loss of intellect, and he
had himself conversed with a man from whose right hem-
isphere Professor Horsley had taken a tumor the size of a
goose’s egg, and in whom he could detect no mental
defect.
Confining his remarks, then, to one of the mental facul-
ties, imagination, the speaker said that it had an applica-
tion in the treatment of disease which neither the general
practitioner nor the specialist could afford to neglect.
This psychic power was like a pioneer in anew country, for
IT OPENED UP NEW PATHWAYS IN THE BRAIN,
by means of which its different territories were brought
into closer and more ready communication. The brain,
without imagination, was like a country without railways,
in which locomotion was laborious and slow; and the
brain richly gifted with it was like one in which steam
and electricity had established easy and rapid communi-
cations. He would not stop to trace that development
of imagination which, resting upon intuitive beliefs and
historical facts, and stirred by the most earnest cravings
of our nature, mounted into faith and revealed to man
“the substance of things hoped for, the evidence of
things not seen.” Neither could he devote much of the
time at his disposal to those
EXCRESCENCES ON FAITH
known as Chnistian science and faith-healing, which had a
certain vogue at present, and fell legitimately within the
scope of medical inquiry. It was not to be gainsaid
that faith, even in its aborted or degenerated phases,
had a potent effect on the human organism, and was
capable of relieving and removing certain functional
disorders ; and credit might therefore be given to faith-
healing and Christian science for some of the cures
which they claimed. Their professors, like empirics of
all sorts, had wrought modern miracles on hypochon-
driacal men who had fallen into drivelling egotism ; on
hysterical girls who had entertained demons, not unawares ;
and on a few sincere but highly sensitive persons who
September 7, 1889]
could pass at a touch out of one allotropic state of the
nervous system into another. But the small good they
had done these had been more than counterbalanced by
the mischief they had wrought in encouraging imposture,
in postponing medical treatment where it was needed, and
in inducing in their adherents an attitude of mind that
was debilitating and conducive to the incursion of disease.
Before faith-healers and Christian scientists could claim a
hearing, they must learn how to make an accurate clinical
report, apprehend what induction really meant, and aban-
don the baseless assertions in which they at present dealt.
Only impatience and contempt came to the medical man
who perused their pretentious archives of cures in cases
in which disease was evidently simulated, in which it ran
its natural course, in which its existence was asserted, no
proof being given, or in which it was of a purely subjec-
tive character, and might or might not depart at the word
of command—such archives being, in one or two in-
stances, accompanied by minute directions as to how
post-office orders are to be forwarded. Let the faith-
healers and Christian scientists, he said, commence with
skin diseases—lure the acarus scabiei from its burrow
without the aid of sulphur, arrest lupus, and wipe out a
nzvus—and then their claims of power to cure internal.
diseases might be listened to with some respect. But it
was not of faith, or of this travesty on faith, that he had to
speak. ‘The subject of his remarks was simply imagina-
tion,
SECULAR IMAGINATION,
he might call it, which was one of the most effectual of
those psychical agencies by which the conditions of health
and of disease might be modified. He would consider
especially the hygienic uses of this mental faculty, though
a word might be said as to its scientific use as an instru-
ment of discovery in investigations of disease, both partic-
ular and general. Medical men had not merely to iden-
tify and catalogue the symptoms of disease, but they had
to trace them to their antecedents and true causes, and
this they could only do by invoking imagination’s help to
supply them with speculations and hypotheses, which were
not less essential to them in their work than the micro-
scope, test-tube, and clinical thermometer.
ALL TRUE SCIENCE RESTS ON IMAGININGS,
he said, and is nothing else than a body of established
truth which imagination has built up. Observed phenom-
ena had to be explained by unfolding their causes ; and
in medical inquiry a provisional guess was hazarded,
which was then put to the test by further observation and
experiment. Of course, such provisional guesses were
often wrong, and then had to be given up. But all the
truths of science had been provisional guesses to begin
with—working theories formulated hy the imagination,
and proved by the touchstone of experiment, and so
brought to a mathematical certainty.
The cultivation of the imagination was most important
to medical men, and they need not fear that they were
wasting their time when they turned aside now and then
from their pofessional tasks to ramble for a little in the
green pastures of literature. Imagination might be fully
trained for its professional duty, as it was exercised, in
conjunction with observation and judgment, in the scien-
tific sphere; but it would be braced, invigorated, and
have its resources multiplied by recreating occasionally
in its native air. Even if imaginative pursuits did not
strengthen the hands of medical men in grappling with
disease, or quicken their scientific vision, they would still
be commendable because of the refreshment they bring
to jaded brains. ‘To turn from the fatigue and anxieties
of practice into realms where rivalry was no more and
night-bells never rang, was to plunge into one of the most
soothing and depurative of
TIRED NATURE'S BATHS.
Members of the medical profession were, indeed, generally
THE MEDICAL RECORD.
271
and art more than any other class of professional men, ex-
cept, of course, artists and men of letters, and to an extent
that was remarkable, considering the engrossing claims
made on their time and the scant leisure they enjoyed.
Having referred to some of the contributions of medical
men to the department of imaginative work, the speaker
said that it was not as producers, but as consumers of
poetry and imaginative literature, that they derived from
them their restorative influence. It might be objected that
the imagination, if sometimes stimulating and restorative in
its influence, was often morbid in its tendencies, and that
its indulgence was to be guarded against by those who de-
sired to possess well-regulated minds. But the weak ves-
sels wrecked by imagination were really fewer than was
commonly supposed ; and he did not hesitate to say that
there were a dozen cases of
INSANITY CAUSED BY WANT OF IMAGINATION
for one caused by excess of it. Apathetic dulness and
torpor of mind were apt to deepen into dementia; and
those entirely given up to “the care of this life and the
deceitfulness of riches ” were more likely to be choked by
them than those who could surmount them, and breathe
the free and ample air of zsthetical emotion. A vulgar
error as to the nature of insanity had perhaps conduced to
exaggeration as to the dangers of imagination. Visitors
to asylums invariably expected to find growths of morbid
invention and belief, wild, tangled, and luxuriant as a trop-
ical forest, and left much disappointed by the barrenness
of the land, for the insane were the least imaginative of
beings. Idiocy was the absolute negation of imagination,
and insanity undermined and destroyed or enfeebled it
more or less; and, when they tried to drive out insanity,
the first thing they did was to invoke imagination’s aid, for
moral treatment consisted mainly in appeals to this faculty,
and fully acknowledged its hygienic uses.
THE FIRST RECORDED CURE OF MELANCHOLIA
was by the harp of David, and to-day in every lunatic hos-
pital worth the name persistent efforts were being made
by music, by pictures, by poetry and the drama, to stimu-
late the imagination, and thus “cleanse the stuffed bosom
of that perilous stuff that weighs upon the heart.” Like
every good gift, imagination might be prostituted and
abused, and in the history of art, literature, and the
drama, abundant proof might be found that it had been
made to pander to vice and folly. But when this had
been the case, it was not so much the imagination that
had been at fault as a certain pestiferous element that
had been infused into it. The records of crime, when
reported with prurient detail, and with a halo of romance
thrown round them, had sometimes a permanently perni-
cious effect, and tended to reproduce themselves.
MEN OF TASTE TURNED FROM SUCH GARBAGE WITH DISGUST,
but there were always sickly and partially depraved nat-
ures ready to be powerfully affected by strong impres-
sions of a criminal complexion. Sheer weakness and
vacuity or instability of temperament are the soils most
congenial to vicious and atrocious ideas. A highly and
widely cultivated imagination seems to increase physio-
logical resistance to morbid and profligate suggestions,
and also to pathogenic germs, for in plague and pestilence
those are most likely to escape who have varied mental re-
sources, can distract their minds and look beyond the mo-
ment, and those are most likely to succumb who give
themselves up to abject fear.
The speaker then referred to the
INCREASING PURITY OF ENGLISH LITERATURE,
which was so notiaeable at the present time, and pointed
out the absolute necessity that existed for the preserva-
tion of the literature for the young from any taint of im-
purity, since impressions made at this time were indelible
and would influence the whole future of the individual.
aware of this, and resorted to imaginative literature, music ' The study of statistics of public libraries had brought out
272
one fact that was most interesting to medical men. This
was that the call for works of fiction and volumes of poetry
was greatest in the spring, when nervous erethism existed,
and “a young man’s fancy lightly turns to thoughts of
love,” and was least pressing in autumn, when the nervous
system was comparatively quiescent. In concluding his
address, Sir James Crichton- Browne said that he had en-
deavored to unfold before his hearers some of the uses to
which imagination might be put by the medical man, and
he would only repeat now the assertion that imagination
must always receive primary consideration in a study of
mental hygiene.
After a vote of thanks had been extended to the
speaker, a number of resolutions were introduced, among
others, the following upon the
DISPOSAL OF TOWN-REFUSE,
presented by the Section in Public Medicine.
1. That this meeting hereby expresses its disapproval
of any system of middens, sewers, cesspits, dust-bins, etc.,
which involves the storage of filth or house-refuse in the
immediate neighborhood of dwellings.
2. That it further considers that in towns, villages, and
other populous places the sanitary authority should itself
undertake the removal of such refuse from each house-
hold at frequent, regular, and, in populous places, daily
intervals, at the public expense, without waiting for notice
to be given by the householder.
3. That it expresses its preference for small movable,
water-tight receptacles. for the collection of house-refuse
or other excreta, in order to fill the essential conditions
of preventing pollution of soil as well as air.
‘THE PRESIDENT then proposed a
VOTE OF THANKS
to the citizens of Leeds for the very handsome manner in
which the Association had been received and entertained.
After a vote of thanks to the President had also been
passed, the meeting was adjourned.
SECTION IN PUBLIC MEDICINE,
WEDNESDAY, AUGUST I14TH—First Day.
Dr. EDWARD BALLARD, President of the Section, opened
a discussion on
MEDICAL OFFICERS OF HEALTH.
He dwelt especially upon the requisites for an efficient
medical health-officer. In the first place, he should be
possessed of that kind of learning which should fit him to
deal with and to advise about disease as it affects the
community rather than as it affects the individual.
Since, however, communities are made up of individuals,
a knowledge of disease as it affects individuals is the basis
of the knowledge of disease as it affects communities, and
this is the reason why an officer of health, to be efficient,
must be a medical man “Nihil humanum a me alienum
puto ” is the motto which every practitioner of the art of
medicine appropriately adopts ; ‘“ Nihil mundanum a me
alienum puto ” should be the motto of every medical offi-
cer of health.
Secondly, he requires practical training under the direc-
tion of a good health-officer, just as the practising physi-
cian needs hospital training. Finally, they should be
possessed of tact, and this was of equal importance to the
rest, for without it the other qualifications would be prac-
tically useless. Health-officers had many things to con-
tend against, and their troubles were neither few nor
light, but their burden would press less heavily upon them
if they would seek consolation in scientific studies.
Nature is never unkind to such as in the proper way
seek to learn her secrets; she never disappoints, never
vexes, never discourages. To the medical officer of
health working in the baldest rural districts, as well as to
him who labors in the crowded town, she holds an open
THE MEDICAL RECORD.
[September 7, 1889
gate, and says, “Treasure is hidden here ; my servants
are contented and happy ; come and dig.”
Dr. C. E. J. GREENE was unable to be present, but
sent a paper upon some of the difficulties in the way of
an efficient carrying out of the sanitary officer’s duties.
He suggested that medical officers of health should pos-
sess a diploma in sanitary science, obtained by passing a
Government examination in analytical chemistry, botany,
geology, pathology, and sanitary engineering ; should hold
jurisdiction over a large area ; be appointed by and draw
their pay from Government, which pay should be sufficient
to support them without their engaging in any other occu-
pation ; should not engage in private practice ; and should
have the option of promotion to a better district after
some years’ service.
Dr. CALDWELL SMITH thought that
TOO MUCH ANALYTICAL CHEMISTRY
was required of medical officers. Although they should
know something of the subject, it was not necessary for
them to pass six months in an analytical laboratory, nor
did he think it advisable that they add the duties of a pub-
lic analyst to those of a health-officer.
_ Dr. LITTLEJOHN agreed with the last speaker as to the
unadvisability of combining the public analyst and the
health-officer in one person. He thought there should be
a rule forbidding medical officers of health from engaging
in private practice.
Several other speakers took part in the discussion.
Mr. J. B. JAMES read a paper advocating the appoint-
ment of
A CABINET MINISTER OF PUBLIC HEALTH.
Dr. GARROD spoke against
SENDING PATIENTS TO FOREIGN HEALTH-RESORTS.
He stated that a committee had been appointed by the
Royal Medical and Chirurgical Society for the purpose of
seeing what could be done at the different bathing places
in England, Wales, and Scotland in the treatment of cases
which now usually went abroad.
Mr. R. C. APPLETON contended that consumptives
were just as much benefited in going to some of the sea-
coast places in England as to the Continent. It has not
been proved that the climate of this country could not do
as much good as continental places ; hence he thought the
members of the Section should make a strong stand against
the practice of leading medical men who sent patients to
the Continent without any results superior to those which
were obtainable in our own country.
MILK AND TYPHOID FEVER
was the subject of a paper by Dr. ANDERSON, of Dundee.
He observed that in February, March, and April last, an
outbreak of typhoid fever occurred among the customers
of one particular dairy in Dundee, and the most searching
inquiries failed to find any trace of disease among the per-
sons handling the milk or in their households. He was
satisfied this milk did not acquire-infection from the human
subject. The sanitary inspector and himself examined the
teats and udders of all the cows which supplied the sus-
pected milk. On one of the cows they found an eruptive
disease on each of the four teats, presenting the appearance
of ringworm, level in the centre, the margin raised,
thickened, and excoriated, without scab or crust or infil-
tration of the base ; the eruption on the inner side of the
left hind teat being nearly circular, and about the size of
a shilling ; those on the other teats being apparently of
longer standing, and encircling the whole teat, so as to
present, not a circular eruption, but a raised, thickened,
freely excoriated edge. ‘There was no eruption on the
udder nor on the body. The cow appeared to be in per-
fect health, with a fine coat.
Dr. CALDWELL SMITH did not see that any causal rela-
tion between the eruption on the cow’s teats and the out-
break of typhoid had been proven.
September 7, 1889]
THE MEDICAL RECORD.
273
Dr. T. CHuURTON presented a communication entitled
INSANITARY HOUSES IN LEEDS,
in which he detailed the results of a systematic inquiry
into the sanitary state of the homes of hospital patients.
About one house in five was found to be in a decidedly
insanitary state. He thought that the inspection of the
dwellings where patients in hospital had lived was a mat-
ter of considerable importance, and should be more sys-
tematically made.
THURSDAY, AUGUST I5TH—SECOND Day.
Dr. PARSONS read a paper on
DISINFECTION WITH REFERENCE TO THE CONTROL OF EPI-
DEMICS.
By disinfection, he said, he meant the destroying of the
activity of that matter which, produced by a sick person
and receiv<d into the system of a healthy one, had the
power of causing in the latter a disease similar to that
from which the former was suffering. Modern research
had shown that certain diseases in men and animals were
undoubtedly caused by the presence in the system of
micro-organisms that were communicable by the inocula-
tion of such organisms. Of the pathogenic microbes the
most convenient for the purpose of testing disinfecting
agents was the bacillusanthracis. It formed, under certain
circumstances, spores which were exceedingly tenacious
of life; it could be cultivated, and was easily recognized
both by its microscopic character and its appearance
when growing, and if inoculated into animals it pro-
duced in them with certainty the disease known as an-
thrax. None of the ordinary infectious diseases of man-
kind were known to be caused by spore-bearing microbes,
though it was possible that small-pox, the contagium of
which was very tenacious of life, might turn out to be so ;
and so far as their present knowledge and experience went,
they might assume that means which would destroy the
spores of the bacillus anthracis might be relied on as effi-
cacious for their purpose, though it would not follow that
agents which did not destroy bacillus anthracis were there-
fore useless against the less resisting contagia of other
diseases.
The speaker then referred to various experiments to
determine the
BEST MEANS OF DISINFECTION.
It had been shown that steam would destroy the patho-
genic micro-organisms much more quickly and more surely
than dry heat. Carbolic acid and sulphurous acid gas
were efficacious to a certain extent in destroying the vi-
tality, or at least retarding the growth, of bacteria, but bi-
chloride of lime was the best disinfectant when it could
be employed. ‘The matters which might act as carriers of
_ Infection, and might thus require disinfection, were: 1.
The body of the patient, living or dead. 2. The dis-
charges given off from the body of the patient, and more
particularly those from the organs specially affected by
the disease. 3. The air, tainted by exhalations from the
sick, and the poison probably existing therein in the form
of suspended particles. 4. The clothes, bedding, and
other textile articles used by the sick. 5. Utensils of
various kinds used by the sick. 6. Articles of food, as
milk and water. 7. Walls, floors, etc., of dwellings oc-
cupied by the sick, especially dust and dirt lodging upon
the walls, and dirt accumulating in the cracks of the
floor. 8. Collections of filth, as sewage, especially in a
stagnant state, or deposited in or encrusting the sides of
foul drains, foul ground surfaces, and subsoil. It was not
of much use attempting to disinfect the intected air of
sick-rooms by chemical means, for active chemicals, if
present in sufficient quantity to be effective as disin-
fectants, would render the air irrespirable. It was easier
to get rid of it, and let its place be taken by fresh
air. The contagia of most infectious diseases appeared
to be destroyed when fully diluted by fresh air. The
poison of typhus fever was notably so, but that of
small-pox did not appear to be, and it had been proposed
that, instead of ventilating small-pox wards into the open
air, the air from them should be extracted through a flue
and burnt in a furnace. Or, he might suggest that a
steam-blast might be used to extract the air and disinfect
it at the same time. Of chemical disinfectants for the
disinfection of excreta, corrosive sublimate, probably, is
the most trustworthy and suitable for ordinary use.
For most cases of disinfection, either dry or moist, heat
could be used, but leather was destroyed by steam.
Books could be disinfected by means of dry heat, the
leaves being spread open. For
HOUSE DISINFECTION,
fumigation with sulphurous acid or chlorine gas, the latter
preferred, followed by thorough cleansing and scrubbing,
the removal of wall-paper and whitewashing, were to be rec-
ommended; but these processes, to be effectual, needed
to be carried out with more thoroughness than was often
done.
Dr. CALDWELL SMITH spoke of
THE NECESSITY OF ISOLATION
as well as disinfection. The latter was often very thor-
oughly carried out, while no attention at all in many cases
was paid to the former. He advocated the establishment
of cottage hospitals, in rural districts, as well as in towns,
and said that all cases of zymotic disease should be re-
moved to the hospital. It would be necessary, however,
to teach the public before the need for this strict isola-
tion would be realized.
Dr. W. Squire also referred to the great value of iso-
lation in the prevention of epidemics. ‘The disinfection
of premises, rooms, and clothes, which followed upon the
removal of the sick, often prevented other cases ansing
from the same source, while the removal of the patient
for the whole period of infection was a more efficient
safeguard against its spread than any amount of soap and
water or external disinfectant could possibly be. Both
means should be in force, but it was useless to give notice
of the presence of infection unless means of isolation
were provided and insisted on ; no method of disinfection
would succeed unless those who had been exposed to
+ infection were kept from mixing with others, at school or
elsewhere, until they were known to have escaped it, and
those who had been attacked were kept from mixing
with the susceptible until the infectious period was over.
The results of this system of isolation were very clearly
shown in the lessened mortality of scarlet fever during the
epidemic in 1887. In that year the disease in London
was less fatal than in many non-epidemic years, and so
completely was it arrested, that for the first time since
registration began, no autumnal increase of it occurred at
the end of the last year.
Dr. E. W. Hope cited several cases in which neglect
to isolate and disinfect had been followed by disastrous
results.
Dr. C. H. ALLFREY read a paper on
INFECTIOUS DISEASES IN HOTELS,
in which he gave an account of an outbreak of scarlatina,
which occurred while he was acting as resident physician
at the Grand Hotel, Grasse, and laid stress on the import-
ance of extreme caution in giving advice as to infection
from mild cases, holding that it was only safe to treat all
cases, however mild and whatever their stage, as equally
infectious, believing that infection depended more on the
susceptibility of the patient and on the degree and circum-
stances of the exposure, than on the severity or stage of
the infecting case. He expressed an opinion, that a second
outbreak which occurred in the hotel would have been
prevented altogether had the removal from the hotel of
the whole of the infected family been insisted upon. He
thought that the importance of adopting such a course
upon similar occasions should be impressed upon all hotel-
274 THE MEDICAL RECORD.
keepers. He advocated the formation of an association
of hotel-keepers, having for its principal objects (1) an
agreement to insist upon the removal from their hotels (as
soon as practicable and convenient with the safety of in-
dividuals) of all members of an infected family ; (2) an
agreement to require the signature of all visitors to a dec-
laration that none of the party had been suffering from,
or, to their knowledge, exposed to, infection within a cer-
tain period ; (3) the establishment of a register of sanitary
certified hotels. He warmly advocated the non-conceal-
ment of the occurrence of infectious cases, both as a mat-
ter of justice to the visitors and as a matter of policy to
the proprietors. He believed that visitors in a hotel
where the existence of infectious disease was known, and
where they could see what precautions were taken, and
. gauge the degree of danger, were safer than in chance
hotels, where cases of infectious disease might be con-
cealed. |
Dr. HuTcHINsOn stated that he had charge of the re-
cent outbreak of scarlet fever at Monte Carlo, and with
regard to the hotel arrangements he experienced exactly
the same difficulties as Dr. Allfrey had described. The
present mode of disinfecting rooms after scarlet fever was
absolutely useless, as was proved by a case which came
within his experience at Monte Carlo, where a young man,
after sleeping in a thoroughly disinfected room, occupied
three weeks previously by a patient, caught the fever and
died. They should have villas of isolation, and next year
he hoped that some institution of that kind would be pro-
vided at Monte Carlo for the reception of cases as they
arose at hotels.
Dr. LITTLEJOHN thought the villa system was imprac-
ticable, but favored the establishment of a hospital for
contagious diseases in every city. In Edinburgh there
was a hospital of this kind in which the well-to-do as well
as the poor sought care and treatment whenever they were
suffering from any contagious disease.
At the conclusion of the discussion the Section adopted
a set of resolutions embodying the suggestions made by
Dr. Allfrey.
Dr. GREENWOOD then read a paper upon the
DISPOSAL OF TOWN REFUSE,
in which he urged the necessity of covered wagons for the
removal of waste matters.
Dr. SLADE-KING said that combustion was the only
practicable method of safely disposing of house refuse.
Other papers were read dealing with the same subject
and suggesting better methods of disposing of waste mat-
ters than those now in use, and a committee was ap-
pointed to draw up resolutions expressing the views of the
Section on this point.
FRIDAY, AUGUST 16TH—THIRD Day.
Dr. GREENWOOD, on behalf of the committee appointed
to draft resolutions on the disposal of town refuse, re-
ported that a set of resolutions had been adopted and
would be presented to the general meeting of the Associa-
tion for approval.
Si J. T. ARLIDGE presented a communication en-
title
THE SOURCES OF LEAD-POISONING IN THE ARTS AND
MANUFACTURES.
This metal exerts its poisonous influence under three
forms, namely—1, lead in the solid form, as lead ore, as
metallic lead, and as an alloy ; 2, in the form of its salts,
whether in powder or solution; and 3, in a mixed form,
with oils and fluxes. In the form of ore it is productive
of plumbism among the miners and smelters, being in-
jurious to the former chiefly in the shape of dust, and to
the latter in that of vapor. It is, too, as a vapor that it
_ produces its noxious effects among the makers of the
oxides of lead in the process of calcination. In the case
of metallic lead, plumbism is a result among those who
frequently handle it, such as file cutters, makers of leaden
[September 7, 1889
pipes and of shot and lead foil, plumbers, and type-cast-
ers. In type it enters as an alloy, and as such at times
affects injuriously compositors. In the shape of an alloy
it proves mischievous with pewterers, the makers of soft
metallic capsules, and of inferior German silver or pinch-
beck. Further, metallic lead becomes indirectly the
cause of illness when employed to form utensils for the
storage or preparation of articles of food or of snuff and
tobacco, or in the construction of pipes for conducting or
drawing off fluids. But cases of poisoning are caused
more frequently by salts of lead, especially white and red
lead. The writer also referred to the accidental introduc-
tion of the metal, in articles of food or in drinking-water,
under conditions so well studied by sanitarians ; in porter,
beer, cider, and lemonade, or fruit juices, any of which
may have stood in contact with lead or itsalloys in the
form of pipes or capsules ; or in bottles carelessly cleaned
with shot ; in solid, but moist or deliquescent, food pre-
served in lead-foil, or so-called tin cans with soldered
joints; or in food cooked or salted in vessels on the sur-
face of which lead occurs as a glaze, or else which have
it enter into their structure. .
Dr. Arlidge then read a second paper, entitled
THE OBSERVATION AND RECORDING OF THE EFFECTS OF
OCCUPATION UPON HEALTH.
Among the causes of disease, he said, the effects of occu-
pation were not generally enough recognized, and, indeed,
they had not yet been sufficiently studied.
To establish the study of industrial disease upon a
sound - footing it was necessary to ascertain the numbers
engaged in a manufacture, the diseases occurring among
them for a series of years, the character of those diseases,
and the conditions of employment and the materials used
in performing it. The inquiries to be presented were,
therefore, of a four-fold character, viz., statistical, patho-
logical, technical, and sanitary.
Dr. SINCLAIR WHITE read a paper on the
CONTAMINATION OF DRINKING-WATER BY LEAD.
The measures which are of efficacy in preventing contam-
ination, or in removing lead already present, were of three
kinds. First, those in which lead piping and lead-lined
cisterns are replaced by other materials, such as wrought-
iron, tin, and glass-lined iron. ‘These are most applicable
in the case of new houses ; and wrought-iron piping might
be much more utilized than it is for this purpose. Sec-
ondly, removal of lead from the water. Nearly all forms
of charcoal filters will do this most effectually. ‘Thirdly,
treating the water before distribution so as to do away
with its solvent action. The last named is the most de-
sirable way of combating the evil, but it is the most diffi-
cult to carry out.
Dr. T. B. FarrcLoucu followed with a paper on the
same subject. He believed that much of the anzemia and
physical degeneration apparent in large towns was largely
due to the constant drinking of small quantities of lead,
the amount of lead palsy and lead colic being by no
means a true indication of the real amount of lead-poison-
ing in any district. Soft waters were those to be avoided,
and the water most fit for drinking purposes was spring
water, of sufficient hardness to prevent its taking up lead
under any circumstances. |
Dr. JEssop read a paper on
THE NUTRITIVE VALUE OF FOOD,
in which he pointed out the advantages resulting from
care in the preparation and cooking of various kinds of
food.
Mr. JoHNSON MARTIN presented a communication
upon
THE CARE OF LIVE STOCK AND ITS INFLUENCE UPON THE
FOOD-SUPPLY.
He said that cattle were not cared for as well now as
in former times. For example, the high embankments `
September 7, 1889]
THE MEDICAL RECORD.
275
which formed shelter from heat and cold for animals had
been and were still being taken down, causing pleuro-pneu-
monia and kindred diseases. It would be a great calam-
ity 1f owners and occupiers of farms did not at once
begin to provide better shelter and purer water for their
cattle. The impure water which many had to drink, and
the sewage which they had to trample in, increased the
virulence of foot-and-mouth disease. Swine-plague
would spread more and the disease be more virulent
where the animals were kept in a filthy state. Many
medical men were of opinion that tuberculosis was trans-
mitted from animals to man. ‘Tuberculous diseases and
diseases of the mouth and throat were, as a fact, increas-
ing, and it was certain that man was more secure from
disease when living on sound food than on that which
was unsound or diseased. The dnnking-water for a large
number of the cattle and sheep in England was now pol-
luted with sewage. The housing of cattle was also of
great importance. He had the authority of several prac-
tical butchers for stating that formerly very few cows in
England were found with diseased lungs and liver, and
that now very few cows of five or six years were free
from disease of the liver or lungs, or some part of the
body. This, in his opinion, was due to there being in-
sufficient shelter from heat and cold, together with an in-
sufficient supply of pure water.
After a vote of thanks to the President, the Section
then adjourned.
INTERNATIONAL CONGRESS OF DERMATOL-
OGY AND SYPHILOGRAPHY.
Held in Paris, France, August 5,6, 7, 8, 9, and 10, 1889.
(Special Report for Tug Mepicat Recorp.)
Dr. Ricorp, Honorary President, formally opened the
Congress in a few well-chosen words, and others followed
with addresses of welcome, after which the scientific work
was begun. ‘There were six subjects announced for dis-
cussion, to each of which it was determined that the fore-
noon of one day would be devoted, the afternoons being
occupjed in the reading and discussion of voluntary
communications.
DISCUSSION ON LICHEN.
Dr. Kaposi, of Vienna, said that the term lichen was
formerly used to denote any eruption of small papules,
and Hebra was the first to limit its application to a special
pathological condition, of which he recognized two forms,
called, respectively, lichen ruber and lichen scrofulosorum.
In 1877 the speaker pointed out that there were varieties
of lichen ruber, viz., lichen ruber planus of Wilson, and
the lichen of Hebra, which he had ventured to call lichen
acuminatus. These two forms may coexist in the same
person, but the latter may be found alone. It is always
fatal. The two forms, although apparently different, are
yet identical. The existence of lichen acuminatus has
been denied, but without justice. The disease does exist,
although it is very rare, and it should not be confounded
with the affection which the Americans, and with them
Unna, call by the same name, nor with the pityriasis rubra
of Hebra. Whether it was identical with the pityriasis
rubra pilaris of Devergie, the speaker confessed himself
unable to decide. .
Dr. JAMIESON, of Edinburgh, believed that lichen was
a disease, su? generis, and he accepted the classification
of Kaposi. He did not think that Kaposi’s lichen acumi-
natus was identical with Devergie’s pityriasis rubra pilaris.
The difference was plainly marked by the results of treat-
ment, for arsenic is of considerable efficacy in lichen but
useless in the pityriasis of Devergie. The latter affection
is accompanied by pityriasis capitis, which is not met
with in the lichen acuminatus of Hebra.
Dr. HALLOPEAU, of Paris, thought a mistake had been
made in grouping several distinct affections under the com-
mon designation lichen, which were related to each other
only in general appearance. The only disease to which
the term should be applied was the
LICHEN RUBER OF WILSON.
The speaker distinguished an acute and a chronic form,
and divided the latter into several varieties, such as planus,
acuminatus, obtusus, tuberosus, etc. A certain number
of cases reported as lichen ruber acuminatus belonged
really to the acute form of this disease. He did not be-
lieve in the existence of a lichen scrofulosorum, but re-
garded the affection called by that name as nothing but a
seborrhoea occurring in a scrofulous individual.
Dr. Hans Hesra, of Vienna, denied the identity of
Devergie’s pityriasis rubra pilaris and the lichen acumina-
tus of Hebra. The latter, he claimed, was a distinct dis-
ease, affecting the general system, accompanied by albu-
minuria, and terminating in death, while the former was a
much less serious affair. Anatomically, also, the two af-
fections differed. The
LESION OF LICHEN ACUMINATUS
took its origin in the derma and extended toward the sur-
face, but that of pityriasis pilaris travelled from the epi-
dermis to the derma. In the former disease there are also
lesions on the mucous membranes which are not present
in the other affection. Finally, a characteristic feature of
lichen acuminatus is the rapidity of its spread, involving,
as it does sometimes, the entire body within a month, or
even less time.
Dr. Boeck, of Christiania, agreed with the previous
speakers in believing these two affections to be distinct,
and said that their non-identity was clearly shown by the
appearance and characters of the lesions.
Dr. Unna, of Hamburg, also regarded the two affec-
tions as distinct, but there was some confusion in the
minds of the speakers which he wished to remove. ‘The
affection described by Kaposi as lichen ruber acuminatus
was by no means the same as that of Hebra. The latter
is a trophoneurosis, and he would prefer to call it neurotic
lichen. Kaposi’s affection was the same, in his opinion,
as that described by Devergie.
Dr. SCHWIMMER, of Buda-Pesth, said there were two
forms of lichen acuminatus, one mild (Wilson’s), and one
severe (Hebra’s). Unna’s assertion that lichen ruber
acuminatus was a trophoneurosis was a pure assumption.
Dr. LELOIR, of Lille, questioned whether it would not
be better, as had been proposed by Hardy, to do away
entirely with the lichen group, since the affections to
which this term was applied differed so widely from each
other.
Dr. BESNIER, of Paris, thought the term lichen ought
to be retained, and to be applied to the affection described
by Wilson as lichen planus. It seemed to have been
clearly shown by the discussion that the
PITYRIASIS RUBRA PILARIS
of Devergie was distinct from lichen acuminatus ; hence
dermatologists should recognize the distinction in future.
Under lichen he would recognize two forms—planus and
acuminatus—and the latter might be again subdivided
into several varieties. He could not accept Hebra’s
form, and believed that it had been confused with some
other disease, for there was no practitioner living who had
seen fourteen fatal cases of true lichen. The disease called
lichen ruber by the Americans was the pitynasis ruber
pilosa of the French. He thought further researches
were necessary before it would be possible to determine
the proper place of Unna’s lichen acuminatus. Lichen
scrofulosorum, so called, was not lichen at all, but was an
acne, or some other form of skin disease occurring in a
scrofulous individual.
Dr. NEUMANN, of Vienna, demurred to this last state-
ment, and maintained the existence of lichen scrofulo-
sorum.
Dr. DE Amicis, of Naples, was a believer in the neuro-
pathic nature of lichen.
276
Dk. Kaposi maintained that lichen scrofulosorum was
a distinct disease. He also protested against the pro-
posal to dismiss Hebra’s lichen, for he regarded it as a
type by itself.
Dr. VIDAL, of Paris, advocated a wider use of the
term lichen, and would have it embrace all papular affec-
tions, such as Wilson’s lichen simplex, prurigo, strophulus,
etc.
DISCUSSION ON PITYRIASIS RUBRA.
Dr. PÉTRINI, of Bucharest, in opening the discussion,
said that he regarded primary, generalized exfoliating
dermatitis, desquamative scarlatiniform erythema, and
Hebra’s pityriasis rubra as distinct affections. He had
observed a case of the last named disease for a period of
eight years, during all which time the character of the
eruption did not change in the slightest degree. ‘The
cause of the furfuraceous desquamation, falling of the
hair, etc., was to be found in the lesions of the arterioles,
even producing obliteration of the vessels. The disease
known as scarlatiniform erythema was quite rare. There
was never any danger of confounding this with a drug erup-
tion, for the latter never relapsed, unless upon renewed
administration of the medicament. Exfoliative dermatitis
Is susceptible of cure, although this usually requires some
time ; it should not be mistaken for the acute form of
Hebra’s pityriasis rubra.
_ Dr. Broca, of Paris, said that there were many affec-
tions of the skin characterized by a generalized redness,
and more or less abundant desquamation. ‘These have
been described under various names, but for the most
ok under that of pityriasis rubra. Besnier has called
them
ERYTHRODERMIES EXFOLIANTES.
These affections may be arranged under three heads with
several subdivisions. In the first group are (1) pityriasis
rubra pilaris (of Devergie), (2) pernicious lymphoderma
(of Kaposi), and (3) the generalized red and desquama
tive eruptions of artificial origin. In the second group
are, (1) the acute and generalized eruptions which occur
not infrequently in the course of an eczema, of a psoriasis,
or of a lichen planus, (2) Bazin’s “ herpétides exfoliatives.”
After all these have been disposed of there still remains a
group to which the generic name of pityriasis rubra may
be applied. This group comprises (1) desquamative scarla-
tiniform erythema, (2) exfoliative dermatitis, (3) chronic
dermatitis, (4) chronic pityriasis rubra (of Hebra), and
(5) subacute benign pityriasis rubra.
_ Dr. Crocker, of London, reported in full an interest-
ing case of supposed pityriasis rubra, and gave a summary
of twenty cases of the same affection.
Dr. JAMIESON, of Edinburgh, said that pityriasis rubra
of Hebra was but a stage of
GENERALIZED EXFOLIATIVE DERMATITIS.
‘This affection, which was often secondary to a pemphigus,
eczema, lichen, or psoriasis, presented itself in two forms
—one with small scales, the dry, and the other with large
scales, the moist. He was not yet ready to express any
decided opinion as to the relation between exfoliative
dermatitis and scarlatiniform erythema.
Dr. Unna, of Hamburg, said that cases often had the
appearance first of a psoriasis, and then later assumed
that of Hebra’s pityriasis rubra. Seborrhceic eczema
might also terminate in the same way. If the disease
were seen now for the first time, it might easily be taken
for Hebra’s pityriasis rubra. ‘There is an intense, uni-
form, deep-red color with marked desquamation, and ac-
companied by a sensation of burning. The patient has
repeated slight chills, loses strength and flesh, and finally
dies. He thought that this secondary pityriasis was related
to the pityriasis of Hebra, for both of them presented a
characteristic sebaceous odor. Recurring desquamative
erythema was, he held, merely a form of toxic dermatitis.
THE MEDICAL RECORD.
[September 7, 1889
Dr. SCHWIMMER, of Buda-Pesth, said there were
MANY DISEASES GROUPED UNDER THE NAME OF
PITYRIASIS RUBRA.
Everyone knew that an eczema might take on the char-
acters of dermatitis exfoliativa, but this was not pityriasis
rubra as defined by Hebra. This term ought to be re-
served for a specific affection, and should not be applied
indiscriminately to every eczema or psoriasis which might
assume a resemblance to it.
Dr. VIDAL, of Paris, related a case which began as a
seborrhoea of the scalp, face, and chest. The eruption,
at first discrete, became gradually generalized, and had
the peculiar sebaceous odor to which Unna had just re-
ferred. It then became scaly, the desquamative area in-
creased in extent, an abundant sero-purulent secretion
became established, and the patient finally died.
Dr. Kaposi, of Vienna, said that many diseases might
resemble at times the one under consideration, but they
were not it. One must have had a very large experience
in dermatology to have convinced himself from personal
observation that such a disease exists, and to be able to
recognize it as a specific entity. In the first place, the dis-
ease is of rare occurrence, and in the second place, the di-
agnostic points are not easily distinguished. ‘There are
many forms of dermatitis, following an eczema or a pso-
riasis, associated with uterine or renal disease, caused by
poisons or drugs, and the like, which may resemble this
disease. In the true pityriasis rubra of Hebra the desqua-
mation is fine, the skin preserves its suppleness, the red-
ness and burning are present from the first and persist
throughout, and the patient finally dies. If the patient re-
covered, that fact alone was sufficient to establish the in-
TOO
‘correctness of the diagnosis.
Dr. BESNIER, of Paris, in concluding the discussion,
said that it was now established that there was but one
form of pityriasis rubra, and that was the one which Hebra
had described—a disease clearly distinct from the various
forms of secondary exfoliating dermatitis. He wished, he
said, to settle the question as to priority, which had been
raised by certain dermatologists. It had been claimed
that Devergie had preceded Hebra in his descnption of
pityriasis rubra ; but this was incorrect, for Devergie had
evidently never seen the disease which Hebra called by
that name.
DISCUSSION ON PEMPHIGUS AND THE COMPLEX OR MUL-
TIFORM BULLOUS DERMATOSES.
Dr. NEUMANN, of Vienna, called attention to a vanety
of pemphigus which he had been the first to describe, and
to which he had given the name pemphigus vegetans. At
the onset of this disease the bullze are of the size of len-
tils. These rupture, and from their site arise whitish ele-
vations, which assume an irregular warly appearance, and
become surrounded by a zone of minute bullæ. These
excoriated -surfaces secrete a foul-smelling fluid, and be-
come covered with crusts. All parts of the body, even
the mucous membranes, may be the seat of this eruption.
When the buccal cavity is affected, the tongue becomes
swollen, fissures occur in the mucous membrane, and the
patient’s sufferings are intense. After the acute stage is
past, the tendency to verrucous growths diminishes, the
skin becomes pigmented, and exfoliates in large sheets.
The prognosis is grave. As to treatment, the continuous
bath gives the best results. ‘The diagnosis between this
affection and syphilis is often difficult.
Dr. CROCKER, of London, said that the description
given by the last speaker fitted exactly a case recently un-
der his own care. Hutchinson had reported some cases
which seemed to be of this nature, and Duhring had also
described a disease, under the name dermatitis herpeti-
formis, which he thought was the same as that of Neu-
mann.
Dr. Broca, of Paris, said that authors usually grouped
all the various forms of multiform bullous dermatoses
with pemphigus ; but among these was one with character-
September 7, 1889]
THE MEDICAL RECORD.
277
istics sufficiently pronounced to separate it from the rest
and to warrant one in regarding it as a distinct morbid
entity. ‘This was the
DERMATITIS HERPETIFORMIS OF DUHRING.
It had four cardinal features which were met with in
every case. ‘These were: 1. Polymorphism of the lesions
(erythema, vesicles, bull, etc.). 2. Painful phenomena
(smarting, burning, itching). 3. Chronicity, the eruptions
appearing in successive crops. 4. The good general con-
dition of the patient, notwithstanding the intensity of the
local lesions. Alongside of this affection, however, is a
class of painful polymorphous dermatoses which resem-
ble it in some points and differ from it in others. The
speaker had made an attempt to classify these forms of
dermatitis under four heads, viz., chronic, subacute, acute,
and relapsing of pregnancy. In the chronic form the le-
sions were polymorphous and appeared in successive crops,
their appearance often varying at different periods in the
same individual. ‘The subacute form permitted of two
subdivisions, one characterized by successive attacks sep-
arated by intervals of complete rest, and the other occur-
ring as a single attack made up of successive crops, almost
always overlapping each other, and extending over a pe-
riod of from twelve to eighteen months. In the typical
form of this variety the lesions are polymorphous, but
cases are occasionally observed in which there is but one
kind of lesion, papulo-vesicles, papulo-pustuies, or minute
bullz. In the acute form there may be but one attack,
or several successive ones, but their intensity and duration
are such as to warrant the designation of acute. ‘The
fourth form was the polymorphous painful relapsing der-
matitis of pregnancy, or herpes gestationis. As its name
indicated, it occurred only in pregnant women, either dur-
ing the course of gestation or in the week immediately
succeeding delivery. The speaker believed that this clas-
sification would be found useful in helping to bring some
order out of the confusion that now existed in respect to
this class of lesions.
Dr. SCHWIMMER, of Budapest, said that the disease to
which Duhring had given the name of dermatitis herpeti-
formis had formerly been known under various names,
such as vesicular erythema, bullous erythema, hydroa,
herpes iris, etc. He proposed to retain the names for
those affections, such as bullous or vesicular erythema,
which had already been well described, and to reserve the
designation dermatitis herpetiformis for that disease
which was characterized by successive crops of a general-
ized vesiculo-bullous, pruriginous lesion.
Dr. Brocg then read a letter from Dr. Duhring, who
was detained by illness from being present, in which he
described succinctly the four cardinal characteristics of
the disease under question as follows: 1, Marked poly-
morphism of the eruption; 2, constant painful phenom-
ena; 3, long duration of the eruption, varying from
several months to ten ortwenty yearsor more; 4, good
general condition of the patient despite the intensity of
the cutaneous eruption.
Dr. Kaposi denied that the affection described by
Duhring was a disease sui generis. Duhring himself, he
said, had taken away impetigo herpetiformis, which he had
first included under dermatitis herpetiformis, after Brocq
had pointed out that it was a distinct affection. In like
manner, he believed, the other diseases thus bunched to-
gether would come to be recognized as separate entities,
according as our methods of diagnosis were elaborated.
He had examined the case which had been exhibited by
Brocq as an example of the affection, and which had also
been examined by Duhring a short time before, and he
saw in it the symptoms of ordinary pemphigus—nothing
more. ‘lhe lesions of pemphigus were of a varied nature,
and he saw no reason for making a further distinction and
setting forth a new and distinct disease.
Dr. Unna agreed with Brocq, and believed that there
did exist a disease of a distinct clinical type characterized
by the four groups of symptoms just related, and which
was the dermatitis herpetiformis of Duhring. But since
THIS AFFECTION INCLUDES ALL THE FORMS OF HYDROA
(simple, subacute, grave, hereditary, and of pregnancy), it
might just as well be designated hydroa.
Dr. SCHWIMMER thought Kaposi was wrong in trying to
force all the bullous affections into the single group of
pemphigus. Confusion reigned here, and it was necessary
to infuse some order into this class of diseases.
Dr. Brocag, in summing up the argument in favor of
the existence of Duhring’s dermatitis, said that there cer-
tainly was a disease characterized by the four groups of
symptoms which he had detailed, and it ought not to be
confounded with pemphigus, nor with a number of other
bullous affections. What name was given to this syn-
drome: of symptoms was of minor importance; let it be
called dermatitis herpetiformis after Duhring, or hydroa
after Unna, the fact remained that it was a distinct dis-
ease. He himself preferred the designation, as being more
descriptive, though rather long, of chronic, pruriginous,
polymorphous dermatitis.
(To be continued.)
Correspondence.
THE ETIOLOGY OF RICKETS.
To THE EDITOR or Tue MenicaL Recorp,
Sir: A letter from Dr. Robert Lee, of London, was pub-
lished in a March number of THE MepicaL RECORD.
Dr. Lee states that he has the impression that rickets is a
rare disease in the United States, and expresses a wish to
learn the ideas of American physicians regarding the eti-
ology of rickets. He is of the opinion that rickets is pro-
duced by any disease in infancy which interferes with
respiration. In a late issue of THE MepIcAL RECORD
another letter appears from the same gentleman, in which
he expresses regret that there is a tendency (as shown by
a paper upon rickets, by Dr. Irving M. Snow) to explain
the views of others, and not to give the results of personal
observation. He also denies that there is evidence to
show that want of proper food is a cause of rickets, as it
is common among the children of the wealthy classes of
English society, whom he evidently supposes are properly
nourished.
My paper upon rickets, read before the alumni of the
Buffalo Medical College, was not written in answer to
Dr. Lee’s letter. Its object was to awaken the attention
of physicians to the frequency of rickets in America.
Thus I reported twenty-five cases found among fifty-eight
children under three years, from asylum and dispensary
service. I stated my belief that rickets is commonly due
to unsuitable diet, chiefly to a deficiency in fat. Every
physician knows that the correct proportion of fat is lack-
ing in artificial farinaceous food, or in diluted cow’s milk.
Most rachitic children are hand-fed, or, if suckled, receive
in addition some farinaceous food. ‘These views of the
causation of rickets are those of Dr. Cheadle, of London,
a physician to the great Ormond Street Hospital for Sick
Children, London. I endeavored to snow that rickety
children were excessively liable to pulmonary diseases and
to disorders of the gastro-intestinal tracts, and that a
bronchitis or an entero-colitis might often be regarded as
an intercurrent malady in a rachitic child.
Many continental and English authorities were cited,
who held that, with children dead of respiratory and diar-
rhoeal diseases, the enfeebled muscular power and disor-
dered digestive functions of rachitis were often the direct
cause of the fatal issue.
Now, as rickets is not commonly recognized in its early
stages in this country, the subject was treated at great
length, and I thought best to quote from the writings of
many eminent men. All of this Dr. Lee criticises, think-
278
ing the profession are sufficiently enlightened as to its
symptomatology, and evidently wishing that American
physicians may be able to prove that the precedent cause
of rickets is in disordered respiratory organs.
Of 13 rickety children examined by me in orphan asy-
lums, only 2 had ever suffered from any pulmonary dis-
ease. All of these were children who, at the time of
examination, were under no medical care, but were feeble.
and backward in development. Among 11 cases of rick-
ets seen at the Fitch Dispensary, in 6 there was no history
or present symptom of bronchitis or other pulmonary dis-
order, while 5 either had suffered or were afflicted with
bronchitis or pertussis. Another well-marked case of
rickets in an infant aged eight months showed no history of
bronchitis. It was suckled, and was also fed upon crack-
ers (biscuit) soaked in cow’s milk. ‘The child suffered
from colic and dyspepsia.
The farinaceous food was withdrawn, and a teaspoon-
ful of cream given three times a day. ‘The excessive
` sweating ceased, two teeth appeared in three weeks, and
the child grew strong and active. |
Thus I am unable to assist Dr. Lee in proving his
theory, that bronchitis, pneumonia, etc., usually precede
the development of rickets, and are to be regarded as the
precedent cause. Every experienced physician must con-
cede that a previously healthy child will often become
rickety during the course of bronchitis or whooping-cough,
yet there are many rachitic children who have never suf-
fered from cough or bronchitis.
Dr. Lee’s letter is most courteously worded, and if he
succeeds in awakening in the United States an interest,
either in the frequency or etiology of rickets, he will do
the profession a lasting service.
Irvinc M. Snow, M.D.
371 PORTER Avgnug, BUFFALO.
“THE PHYSICIAN SHOULD BE EITHER A
CHRISTIAN OR A PHILOSOPHER.”
To tHe Eviror or THe Mepicat RECORD.
Sır: When I read THE REcorp’s creed, “ The physician
should be either a Christian or a philosopher,” I embraced
it with devotion, and have, since then, chiefly looked to
it for my medical gospel. And when, after your late edi-
torial “ On Continence and Syphilis,” the d:zarre announce-
ments of Brown-Séquard were sprung upon an astonished
world, I patiently awaited the usual virile criticisms of
THE REcorD to purify and thoroughly sift these dogmas,
which seemed the emanations of an intellect once great,
but now in its decline.
But even Homer sometimes nods. It is presumed that
no one will call these views “Christian ;” as for being
philosophic, let us take the statement of Brown-Séquard
himself :
“It is known that well-organized men, especially from
twenty to thirty-five years of age, who remain absolutely
free from sexual intercourse, or any other causes of ex-
penditure of seminal fluid, are in a state of excitement, .
giving them a great, though abnormal, physical and men-
tal activity.”
Now, if we accept this simple statement without re-
garding the word “abnormal” as sub sudice—which, in
the light of the teachings of Carpenter, the physiologist,
Dr. S. D. Gross, Dr. William R. Gowers, Sir J. Paget, etc.,
we might fairly do—what father would not prefer for
his son the supposed dangers of “ abnormal physical and
mental activity” to syphilis, gonorrhoea, spermatorrhea,
and—worst of all—an unscathed career of sensuality ?
Brown-Séquard’s teachings ignore the duty and neces-
sity of self-restraint—at least they will be generally so
interpreted—and hence, coming from one who speaks
with authority, they are capable of doing great harm.
‘*Corruptio optimi pessima.”
The involuntary surroundings of vast numbers of men
for life, and of every man at certain periods, are such
THE MEDICAL RECORD.
EN
7, 1889
[September
that nothing but continence can prevent loss of self-re-
spect and the esteem of our fellow-men.
The fatal dogma that sexual intercourse is essential to
health, and that an involuntary emission from the sexual
organs, when within physiological limits, is noxious, is
the chief capital of the hordes of medical vampires, and
has ruined, and is still ruining, untold numbers of young
men.
True, it is hard for a man who is a “ good animal” to
always control his sexual appetite; it seems no less true
that no man is safe, either as to his own welfare or that
of those who are near and dear to him until, by the aid
of philosophy and religion, he has learned to climb up
from his mere animal nature and take refuge from the
illegitimate demands of passion in his moral and intellect-
ual being.
Carpenter says: “It is a general law, which pertains
alike to the vegetable and animal kingdoms, that the
development of the individual and the reproduction of
the species stand in an inverse ratio to each other.”
To the legitimate application of the new treatment no
one should object; but against encouraging mere sensu-
alism, from which the world now chiefly suffers, I think
every honorable physician should raise his voice and
wield his pen.
Young men should be guided by the counsels of Car-
penter, to keep their minds and bodies usefully employed,
and they will think much less about their sexual organs ;
and let them not be alarmed if an involuntary emission
occurs once in twelve or fourteen days, which seems just
as physiological, and no more injurious, than the analo-
gous flow from the female organs. ‘These words are
trite, but are necessary. It is every man’s duty to learn
this great lesson—to make obedient the beast within
him—and, having learned it, to teach it to others; once
thoroughly learned, “ the yoke is easy and the burden is
light.” Respectfully yours,
W. F. M.
[We have already expressed positive opinions on these
points, agreeing with our correspondent.—Ep. |
ENEMATA FOR INTESTINAL OB-
STRUCTION.
GASEOUS
To tue EDITOR or THe Mepicat Racorp.
SiR: In your issue of August 3d I see an article from
Dr. Dewitt C. Rodenhurst, reporting “a case of intestinal
obstruction” relieved by the use of gaseous enema. If
you will refer to page 155, August 6, 1887, of THE Rec-
ORD, you will see a case reported by myself, in which I
relieved a patient in the same way. Perhaps it is well
enough to call your attention to that portion of Dr. Ro-
denhurst’s article where he speaks of the method as in-
troduced by Dr. Senn, of Milwaukee, Wis. I do not
recollect having seen anywhere that Dr. Senn used the
treatment for removal of obstructions of intestine, though
I have within the past year seen where he used it for
diagnosing intestinal perforations. Since I first used
the method I have had occasion several times to use it
again for intussusception of bowel and fecal obstruction,
and have found it a valuable remedy, but not by any
means invariably successful. ‘There are several precau.
tions to be used in administering the gas, such as care in
not overdistending the bowel, and carefulness in using the
best chemicals, and not to inject air instead of the gas, as
I had the misfortune to do once, by omitting to turn the
stopcock attached to the gas-bag.
In corresponding with you after my report of the case
in August, 1887, you wrote, in speaking of the method,
that it was as “old as the hills,” which, in connection
with the recent reports of Dr. Brown-Séquard’s “ Elixir
of Youth,” leads me to exclaim that “there is nothing new
under the sun,” for on the farms and plantations where
sheep, hogs, and cattle were raised, the custom was at
stated times to castrate the male animals, and many times
September 7, 1889]
THE MEDICAL RECORD.
I have seen the negroes and other employees broil the
excised testes on the fire-coals in the lots where the ani-
mals were kept, and partake of same with much relish
and with many a jest as to its stimulating effect on the
functions, particulariy of the generative organs, and also
as to its increasing their strength to split rails and lift the
cotton-baskets. ‘The primitive mode of cooking the dish
was due to a delicacy in asking the female cooks to pre-
pare food fit only for the “ lords of creation.”
| Respectfully yours,
‘ W. P. COPELAND, M.D.
EUFAULA, ALA.
Rew Zustruments.
AN IMPROVED URETHROTOME.
By J. D. THOMAS, M.D.,
PxOFESSOR OF GENITO-URINARY AND VENEREAL DISHASES, WESTERN PENNSYLVA-
NIA MEDICAL COLLEGE, PITTSBURG.
ALTHOUGH the Otis urethrotome is recognized as possibly
the best instrument presented to the profession for sever-
ing strictures of large calibre, it has, in my experience,
A three faults : First, that after the knife or
blade is drawn forward and made to cut
the stricture, it has to be pushed back ;
second, it must be readjusted for each
stricture after the first is cut ; and, third,
owing to the fact that it opens on the
principle of a parallel ruler, the adjustment
is slightly altered after it is opened from
what it was when first set for the stricture.
The first objection is the most serious
one. Although it is intended, when the
blade is pushed back, that it shall traverse
the same line as was made by the forward
cut, in practice it does not do so, but goes
back along a new line; for the loose
character of the tissues of the penis makes
this unintentional cut unavoidable, and, as
the distal end of the blade is somewhat
dull, it makes in addition the cut a lacer-
ated one. The second objection is not
such a serious one, but the readjustment
takes time and necessitates needless and
hence injurious manipulation of the ure-
thra. ‘The third objection is a trivial one
—but an objection, notwithstanding.
With my improvement, which 1s here
displayed, these objections are all over-
come. The rod A slides to and fro in
the slot in the upper bar of the instrument.
The blade B is slid forward on top of this
Wem rod, and when the instrument is closed
i 1S) and ready for introduction into the ure-
thra, the blade is beyond the end of the
rod, down in the slot, and out of the way.
The urethrotome is then introduced to
the bottom of the penile urethra—to the
bulb—and opened, regardless of the loca-
tion of the stricture or strictures. The seat of strictures
having beeu previously located, the rod A is drawn for-
ward until its extremity is at the point of deepest stricture,
and fastened in place with the screw C ; then the blade B
is drawn forward, and when it arrives at the extremity of
the rod A it rides up on this and cuts the stricture. ‘The
rod is now released and drawn forward to the seat of the
next stricture, and again fixed with the thumb screw C.
When the rod is drawn forward the blade always drops
into the slot and is out of the way, so that it can be drawn
forward, and when it arrives at the rod it rides up on it and
cuts the next stricture. When there are more than two
strictures the same process is gone through with until all
strictures are cut—always cutting the deepest first.
It is not necessary to have any markings on the rod to
L OS WANWRHYO
indicate where the strictures are, for they can be located
for the blade by deducting the distance from the meatus
to the strictures from the length of the rod; eg., if a
stricture is at five inches, the rod being eleven inches, six
inches of the rod is left outside of the meatus, and when
the blade is drawn forward it rises exactly where we want
it to—at five inches.
The improved instrument has another advantage over
the original Otis—when the blade and rod are removed it
is easier cleaned. l
When introducing the rod or blade into the instrument,
if the thumb is placed at the point D, and a little press-
ure made, we utìlize a knack that will facilitate materially
the ease with which they slide in.
Having had some experience with the instrument, I find
it works admirably. S
To know that the blade has dropped into the slot it 1s
only necessary to draw the proximal end of the rod one
inch beyond the same end of the knife.
Army Hews.
Official List of Changes in the Stations and Duties of CM-
cers serving in the Medical Department, United States
Army, from August 25 to August 31, 1889.
‘TREMAINE, WILLIAM S., Major and Surgeon, now on
sick leave of absence at Buffalo, N. Y., by direction of the
acting Secretary of War will report in person to the com-
manding general of the Department of the Missouri for
assignment to temporary duty at the post of Fort Leaven-
worth, Kan. Par 4, S. O. 198, A. G. O., August 20, 1889.
PORTER, JosePH Y., Captain and Assistant Surgeon.
Resignation has been accepted by the President, to take
effect, August 29, 1889. Par. 11, S. O. 200, Headquar-
ters of the Army, A. G. O., August 29, 1889.
MATTH=zWS, WASHINGTON, Captain and Assistant Sur-
geon. Promoted to be Surgeon with rank of Major, July
10, 1889, vice ‘Town, promoted.
Ewinc, CHARLES B., Assistant Surgeon. July 5, 1889,
promoted to be Assistant Surgeon with rank of Captain,
after five years’ service, in accordance with act of June
23, 1874.
McCaw, WALTER D., Assistant Surgeon. August 20,
1889, promoted to be Assistant Surgeon with rank of
Captain, after five years’ service, in accordance with act
of June 23, 1874.
Medical Atems.
ConTacious DiseASES—WEEKLY STATEMENT.— Re-
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending August 31, 1889:
| Cases. | Deaths.
Typhus fever \icccee setone. sche sas tata 4 cages eee eves | o | o
Typhoid fever ...... 0.0... cc cee cece eee serres | I% | I6
Scarlet fever.. i... . ccc cece tee ewer ee eens | 16 I
Cerebro-spinal meningitis. .........seseseseseeseo | 2 2
Measles ici. o sting d-00% iens wid oa oe eee Ss RS al | 23 I
Diphtheria cc sissies s.. ueo soore ssncsosesseeceseseceno 80 23
Small-pox ..ccccscscccccsccccccccaccccsrsccee ove fe) o
Yellow fever......... O arcana eee ea | 0 o
Cholera rieri aan a E EEEE PE E o o
RECENT Stupies oF Two Hearr Tonics.—A series
of experimental studies upon the physiological action of
strophanthin has been recently made by Dr. Jacques
Popper, of Vienna; certain clinical observations upon
the therapeutic value of spartein have been made by
280
Dr. S. W. Lewaschen. The papers of both these gentle-
men have recently appeared in the Zeitschrift für kli-
nische Medicin, Bd. xvi., Hft. 1 and 2. Dr. Popper's first
series of experiments was made in order to determine the
influence of strophanthin upon arterial pressure. ‘They
resulted in showing a very constant and persistent increase
of this tension. This rapidly reached its maximum and
then gradually diminished, though it did not fall to nor-
mal. ‘The pulse was at the same time slowed. Another
series of experiments was made upon the blood-pressure
in the veins, with most interesting results. They showed
that the venous pressure became slightly diminished as a
rule, while that of the arteries was increased. ‘This phe-
nomenon is explained by the fact that the smaller arteries
are contracted and tense, shutting off some of the flow of
blood into the capillaries and veins, while the larger ar-
teries are dilated, tense, and full. The conditions are thus
united to a rapid emptying of the veins into the heart.
Experiments made to test the influence of strophanthin
upon the pressure in the aorta and pulmonary artery
showed that while the pressure in the former was increased
that in the latter was either diminished or very little
affected. The total result was to change the relations of
the pressure in the aorta to that in the pulmonary artery
from the normal of 5.9 to 1, to that of 8 to 1. Thus it
is shown that strophanthin increases the tonus of the arte-
rial system, but lessens absolutely or relatively that in the
systemic veins and in the pulmonary circulation. A series
of experiments were made in order to determine whether
the increase of the blood-pressure was due to a stimula-
tion of the vaso-constnictor nerves and contraction of the
arterial walls. The observations showed that strophanthin
does not act in this way, but rather that it causes increased
blood-pressure mainly by over-distending the arteries.
The action of strophanthin in slowing the heart-beat was
shown to be in part at least due to stimulation of the
vagus inhibitory apparatus. A clinical study of the ac-
tion of spartein upon the circulatory apparatus is of more
practical interest. Dr. S. W. Lewaschen, as the result
of his experiments, comes to the following conclusions :
Sulphate of spartein strengthens and regulates-the heart-
beat and slows it if itis too rapid. ‘This action is accom-
panied with increase of blood-pressure, increased flow of
urine, relief of oedema and dyspnoea. ‘The diuretic ac-
tion of spartein is only an indirect one, it has no specific
action on the renal epithelium. Spartein is a less powerful
heart tonic than digitalis, adonis, or strophanthus. This
is shown by the fact that in very severe forms of cardiac
degeneration and weakness spartein will not act, while the
other drugs do. ‘The tonic action of spartein, however,
may last for several days after its use has been suspended.
If spartein acts at all it acts rapidly, often within fifteen
minutes after its administration. The rapidity of its
action makes spartein a useful drug in cases of sudden
heart failure where the organ is not seriously diseased, as,
for example, in the acute fevers. The dose is from two to
five grains daily.
SHORT-HAND IN MEDICAL STUDY AND WorK.—A num-
ber of London physicians have started a movement for
the encouragement of the study of short-hand by medical
students or those professing to study medicine. A series
of examinations are to be held in October, and prizes
offered. A memorandum published in connection with
this movement says: ‘ ‘The physician is aided in a special
manner by the fulness of the notes of cases that can be
taken. ‘To him, in his effort to advance our knowledge
of medicine, and to all who cultivate the sciences that
rest on observation, short-hand is of peculiar value by in-
creasing, at least threefold, the amount of recorded ob-
servation, recorded while the phenomena are in progress.
The value of this increase, in fact, is scarcely to be meas-
ured. Short-hand must lessen the influence of imagination
in science, by increasing the amount of influence of def-
inite fact. In the observation of disease especially, in
which so much has frequently to be recorded in a short
THE MEDICAL RECORD.
` by the Scotch observer.
[September 7, 1889
time, the effect of its general use would soon be per-
ceptible in the greater exactness and minuteness of our
knowledge. Its influence extends, in the same manner,
to the processes of comparison and collation of facts, and,
indeed, to almost all the processes of work, up to actual
composition for the press.” Uniformity in the system of
short-hand is thought most desirable, and Pitman’s system
is recommended as being the one used by ninty-five per
cent. of short-hand writers. We have occasionally referred
to the subject of the advisability of learning short-hand,
and have uniformly discouraged any introduction of the
practice. ‘To learn it so that it will be really useful re-
quires a great deal of time which might be better spent.
The opportunities for its use after entering practice are
not frequent. Long-hand notes answer every purpose of
case-taking. Ifa person has a special taste and aptitude
for it, however, or if he plans to use it in reporting or
journalistic work, the case is different. We would add
that in this country, so far as we know, Munson’s sys-
tem is nearly as popular as P:tman’s, of which it is, how-
ever, only a modification.
POTATOES AS A SUBSTITUTE FOR LAPAROTOMY.—At a
meeting of the Imperial Society of Physicians in Vienna,
Dr. Salzer reported a communication from Dr. Cameron,
of Glasgow, upon the “ potato cure” first recommended
Dr. Cameron has used this plan
of treatment in several cases of ingestion of large foreign
bodies with gratifying success. Salzer has also had an
opportunity to try the potato cure in the case of a boy
who had swallowed a brass weight of twenty grammes.
Potatoes were fed to the child, cooked in a variety of
manners, so as to encourage his appetite. He took them
willingly. After five days the brass weight was compelled
to retreat, overwhelmed by the constant accessions of re-
enforcements from above, and passed out, leaving the po-
tatoes ın possession of the field. In the same manner he
treated the ingestion of a set of artificial teeth, while in
another case a scarf-pin proved no match for its farina-
ceous antagonist. Dr. Salzer believes that this form of
treatment will subserve a useful purpose in many cases in
which, up to now, gastrotomy appeared to be the only
form of relief available. He also advised the members
to place no trust in sauer-kraut, which has been recom-
mended for the same purpose. Dr. Hochenegg related
the case of a boy who had swallowed a nail 6 ctm. long,
in 1884, and had been treated by gastrotomy. He had
swallowed a similar nail two years later, when the potato
cure had proved successful. Dr. Billroth spoke of the
difficulty which exists in the removal of foreign bodies by -
laparotomy, and was strongly in favor of the potato cure.
—ZJnternational Journal of Surgery.
A SUBSTITUTE FOR ICHTHYOL is said to have been found
in thiol, a synthetically formed substance (Notes on New
Remedies). The latter is prepared in two forms, liquid
thiol, a forty per cent. sclution, and dried thiol, obtained
by carefully evaporating liquid thiol. Its odor is slightly
bituminous, and its taste bitter and astringent. Like most
of the new remedies produced in Germany, it 1s a patented
preparation.
HARD TO PLEasE.—Z/ndignant Physician: Man, what
have you done? You sent my patient the wrong prescrip-~
tion, and it killed him. Druggist (a calm man, accustomed
to abuse): Vell, vhat vas der madder mit you? Last veek
I send your odder patient der nghd berscription, and dot
killed him. How can somebody blease sooch a man ?
A STRANGE INDUSTRY.—Two companies exist in one
of the German cities, whose special business it is to man-
ufacture machinery and all the appurtenances for mak-
ing artificial unground coffee—pure Java in the berry.
A roasted meal of some kind, made cohesive with dextrine
and pressed in moulds, and afterward polished, is how it is
done. ‘Ihe artificial coffee is said to be a very good imi-
tation, and when mixed with the real article is not easily
picked out as false.— The Sanitary Inspector.
The Medical Record
A Weekly Journal of Medicine and Surgery
Vol. 36, No. Iri
Original Articles,
CHOLECYSTOTOMY.’
By NEIL MACPHATTER, M.D.,
CLEVELAND, O.
THE operation of cholecystotomy is not a new one.
Like many others it was described and anticipated by
several of the old surgeons. In looking up its history I
find that in the year 1618 it was performed by Johannes
Fabricius, who removed several gall-stones from the gall-
bladder. Later on Fabricius Haldiaus is thought to have
performed it. But it was not until the time of that very
clever surgeon, Petit, that the operation of cutting into
the gall-bladder and removing gall-stones was first es-
tablished upon anything like a scientific and surgical
basis. I read that this excellent surgeon described the
tumors of the gall-bladder, and the symptoms accoiapany-
lng them, as well as the operative proceedings, with so
much accuracy that his details could almost now be ac-
cepted. The ability of Petit was not, however, recog-
nized at the time ; but, upon the contrary, his teachings
upon this subject met with almost universal condem-
nation. From this time until a few years ago little or no
advancement was made, although several surgeons wrote
upon the subject, among them being Sharp, Brimfield,
Chopart, Morgagni, Haller, and others. Sebastian en-
deavored to establish an operation whereby the perito-
neum and gall-bladder were made to become adherent
before the incision into the gall-bladder was attempted.
Thudichum secured the gall-bladder to the abdominal
wound by sutures several days before cutting into it.
Bobbs, of Indianapolis, closed the incision in the bladder
by sewing it up and afterward suturing the abdominal in-
cision. ‘This was the condition of this operation when
Lawson Tait took it up and established it upon a firm
and satisfactory basis, having had fifty-two operations
with but two deaths, one of which cannot properly be at-
tributable to the operation itself, but rather to the extreme
condition to which the patient was reduced at the time of
operation.
The experiments made upon animals, and other investi-
gations that have from time to time been carried out,
fail to give us a proper idea of the function of the gall-
bladder. We are as yet groping in profound ignorance
on this point. The theory up to now advanced, that it is
a store-room for bile, cannot longer be accepted. A more
plausible one is that it secretes a mucous fluid which
mingles with the bile as it passes down the duct and
renders its passage more easy. Occasionally a small
quantity of bile is found in the gall-bladder, but this does
not take away from the argument. ‘This may be ac-
counted for by some temporary occlusion in the common
duct which would cause the bile to flow backward through
the cystic duct into the bladder.
For many years the profession have been investigating
the origin and cause of gall-stones. The theory ad-
vanced many years ago by Dr. Thudichum, that they arise
from deposits of cholesterin, which form about the minute
ramifications of the smaller ducts, is the one now gener-
ally accepted. Whatever be their cause, gall-stones do
not always form in the gall-bladder, as is almost univer-
1 Read before the Ontario Medical Association, June 6, 1889.
New YORK, SEPTEMBER 14, 1889
Whole No. 984
sally believed, but in the liver substance itself. They
there frequently give rise to suppuration and abscesses of:
large size. The samples which I now hand you in this
bottle were taken out of the liver tissue. It was necessary
to cut through the liver structure to the depth of over
an inch before they could be reached. I believe they
almost always have their origin in the liver, and pass
down the hepatic and cystic ducts to the bladder, where
they further develop and multiply. It is after they have
accumulated in the gallbladder, and there give rise to
serious symptoms that the great bulk of cases attract at-
tention and call for surgical relief. According to the
theory and teachings of Lawson Tait there are two va-
rieties of gall-stones. ‘These two varieties differ in their
history, symptoms, pathology, and treatment; they are
the solitary variety, when usually not more than one or
two stones of large size will be present, and the multiple
variety, when a large number of small stones of almost
uniform size will be found. Many hundreds are some-
times present, and from pressing and rubbing against one
another their surfaces become faceted in a characteristic
manner.
The large variety of stone has a distinct and character-
istic history, and a different line of symptoms, as compared
with the numerous kind. It is almost invariably of large
size, and grows very much like a urinary calculus. It
may remain for an indefinite length of time in the gall-
bladder without giving rise to any symptoms whatever, or
even suspicion of its being present there. It usually
makes its presence known by suddenly becoming lodged
in the beginning of the cystic duct. . From that moment,
by completely occluding the duct, the bile cannot enter the
gall-bladder. ‘The mucous fluid goes on developing until
it completely fills the bladder. When the stone becomes
lodged it cannot pacs down the duct, owing to its large
size. It therefore becomes impacted there, and may lead
to ulceration and suppuration, and may liberate itself in
one of the two following ways, either by setting up an
adhesion with some part of the intestine and establishing
a fistulous opening, or the fundus becoming attached to
the abdominal parietes and suppurating in an outward
direction. Many large stones have been known to pass
out in this manner. While this stone is lodged in the
‘duct the mucous secretion goes on increasing from day to
day, and gradually distends the bladder until it is some-
times enlarged to an enormous extent. ‘The operation,
when this distention is present, is much easier than when
the bladder is only of normal size, although a great diffi-
culty may arise in removing the impacted stone. It may
be necessary to chip it away in pieces, as I shall show
when discussing the treatment. The distinct characteris-
tic of this variety is the distention of the gall-bladder by
means of mucous fluid; so great does this enlargement
sometimes become as to make its diagnosis from other
cystic tumors, especially cystic enlargement of the right
kidney, difficult indeed. _
Clinically the multiple variety differs in its symptoms
and treatment from the solitary kind. Lawson Tait main-
tains that they differ also in their pathology. I do not
@are to have my opinion taken in preference to that of my
distinguished teacher, as he seldom gives expression to
an opinion without substantial grounds; yet I cannot
help thinking that there is no difference pathologically
between these two varieties. Whether my view on this
subject be correct, the two varieties, to my mind, are but
modifications of the same cause. It is well known, as I
282
have already stated, that gall-stones form in the liver tis-
sue itself. As a small stone passes down the ducts into
the bladder and there develops, the tendency is that its
coats chip off into small fragments which act as the nu-
clei for others. In this way these stones may go on de-
veloping and forming until a very large number be present.
Now, if from some cause or other the original or parent
stone does not chip its coats or break up into fragments
to form nuclei, but goes on individually developing, the
solitary variety, with its peculiar characteristic symptoms,
will be the result. An important matter that would seem
to bear this argument out is that the nucleus of the mul
tiple variety is altogether different from that of the solitary,
which usually cannot be found. ‘The gall-bladder is sel-
dom or never much enlarged in cases where patients are
suffering from multiple stones. ‘Ihe reason of this is that
they are nearly all sufficiently small to pass down the cys-
tic duct. Their uniformly small size is such as to facili-
tate this. ‘They are not lodged long in the cystic, and on
account of the common duct being shorter and wider, it
consequently follows that a stone that can pass down the
cystic will, with greater ease and speed, pass through the
common duct. It is for this reason that we seldom find
jaundice as an accompanying symptom of gall-stones.
Jaundice can only take place while the stone is passing
through the common duct, and as it is wider than the cys-
tic the stone is not lodged in it sufficiently long to give
rise to this symptom. ‘The symptoms accompanying the
presence of gall-stones are not constant, and may be quite
irregular. A large stone ora number of small stones may
be present, and yet give rise to no symptoms. Usually,
however, there will be a history of the patient having had
bihary colic, with its characteristic paroxysmal pains. The
stones may set up inflammation and suppuration, or may
become impacted or wedged in the cystic duct. ‘They
have been known to ulcerate through the bladder and set
up fatal peritonitis. When the impaction takes place in
the cystic duct the changes and symptoms will be of a lo-
cal character. When the hepatic or common duct is ob-
structed there will be present symptoms of jaundice, and
should this obstruction continue for any length of time,
general cholzmia will set in and reduce the patient’s
chances in an operation very materially. Frequently an
enlargement below the margin of the liver will be quite
readily detected. ‘The amount of enlargement that may
be present varies from the size of your fist to a large cys-
tic tumor, that may be mistaken for cystic enlargement of
the right kidney. It has before now been mistaken for
ovarian cyst. In all cases this enlargement will have its
commencement in the region of the gall-bladder. Very
frequently a rigid rectus muscle simulates the symptoms
of commencing enlargement of a gall-bladder, and I would
warn my readers to guard against this point.
I cannot agree with the statement of J. W. Taylor,
that the line of enlargement is usually in a diagonal line
from the fundus of the bladder to the umbilicus. I have
never yet witnessed this, but have invariably found, when
the enlargement is present, it is about two inches to the
tight of the umbilicus, and immediately below the normal
situation of the bladder. ‘The shape of this enlargement
will be round or pyriform, and will give a dull note on
percussion. In diagnosing, care is required to distinguish
between cystic enlargement of the right kidney, hydatids,
and malignant disease of the liver. ‘Ihe peculiar con-
dition of a gall-bladder being quite distended one day,
and upon examination a day or two following regaining
its normal size, may be owing to temporary occlusion
while a stone is passing through the cystic duct.
The operation for the relief of these conditions differs
somewhat in some of the details.
as I have already stated, the gall-bladder is usually dis-
tended, and the diagnosis is more certain. In the multi-
ple variety the bladder will be of normal size, more
difficult to find, and does not require to be emptied as the
other. The usual preliminary precautions are as essential
in the operation of cholecystotomy as in any other ab-
THE MEDICAL RECORD.
In the solitary variety,”
[September 14, 1889
dominal section. Therefore strict cleanliness of patient,
instrument, and surroundings is absolutely called for.
The patient is put in the ordinary position, as for ovari-
otomy, and the anesthetic given. When the enlargement
of the gall-bladder is so great as to be readily felt, the
proper incision is that directly over the tumor, vertically
downward. When no enlargement can be made out, the
incision should begin over the situation of the fundus of
the gall-bladder. ‘This is found directly beneath the tip
of tbe cartilage of the terth mb. ‘The various textures
are now cut through rapidly, until the peritoneum is
reached. If any hemorrhage be present, it is arrested by
sponges or forceps. Layer after layer is next held up be-
tween two pair of forceps, and gently divided, until an
opening into the peritoneum sufficient to admit the tip of
one finger is made. An exploration is now instituted.
If the gall-bladder is enlarged, and especially if cystic,
little or no difficulty will be experienced in finding it.
When it is of normal size it is sometimes difficult and
almost impossible to find. ‘The subsequent steps òf the
operation are much easier when the bladder is distended.
Generally the finger comes in contact with it immediately
beneath the opening. A curved trocar is now inserted
and the fluid drawn off. By this means the bladder can
be drawn out through the opening sufficiently far for the
subsequent steps of the operation. With a small scalpel
the opening into the bladder is made, beginning at the
side of the trocar. A flat sponge is placed below and
around the bladder, for the double purpose of keeping
back the intestine and absorbing any fluid or bile that
may chance to fall downward. ‘The opening thus made is
now held apart with forceps by an assistant, and it is ab-
solutely necessary that the assistant should be competent
to fulfil this most important and particular duty. Indeed,
it is as essential here that the assistant should be familiar
with his duties, and anticipate the wishes of the operator,
as it is for the surgeon to know how to operate. _IIl-judg-
ment or undue haste may be the means of disastrous re-
sults.
With the scoop or alligator forceps the stones can be
readily removed. When one is lodged in the cystic or
common duct, the operation becomes prolonged and
much more serious. ‘This complication may call out the
ingenuity of the surgeon to the utmost. If lodged in the
beginning of the cystic duct, it may be necessary to chip
it away in pieces. When in the common duct, Tait’s plan
of crushing it with muffled forceps may be tried.
When the stones are all removed the opening in the
bladder is to be stitched to the abdominal incision. The
sponge that has been left in the wound must first be re-
moved, and everything around the incision made perfectly
clean. Independent or continuous sutures may be used,
according to the inclination of the operator. If the con-
tinuous method be adopted, one thread will be all that is
necessary ; the needle, threaded with No. 2 Chinese
twist, being passed each time through cyst-wall, perito-
neum, parietes, and skin. When the whole circuit of
suturing is completed, the two ends of the thread are
drawn tightly and tied together. ‘The next step in the op-
eration is the introduction of a rubber tube. Rubber is
preferable to glass for this particular operation, as it bet-
ter adapts itself to the respiratory movements of the parts.
It should be fixed in position with a thread. ‘The only
dressing required is absorbent cotton wool, which may be
changed as required. As soon as union between the wall
of the gall-bladder and the abdominal incision has taken
place, the stitches can be removed. ‘The drainage-tube
may be left in longer if required. Usually a biliary fistula
is left, which generally heals up in the course of a few
weeks. Occasionally the fistula continues, and may re-
quire an operation to permanently close it.
This operation is one of the many recent triumphs of
surgery, and it is remarkable and gratifying to find pa-
tients who have been reduced to the lowest possible con-
dition of health gain rapidly in condition in the course of
a few weeks.
September 14, 1889]
NOTES ON EXALGINE.
By FREDERICK PETERSON, M.D.,
LECTURER ON NERVOUS AND MENTAL DISEASE AT THE NEW YORK FOLYCLINIC,
AT a meeting of the French Academy of Sciences, March
18, 1889, Drs. Dujardin-Beaumetz and G. Bardet pre-
sented a report upon the physiological ani therapeutic
action of orthomethylacetanilide (Gazette des Hépitaux,
April, 1889), a derivative of benzine, to which the name
exalgine was given by Brigonet, the chemist who prepared
it. It is very soluble in water containing a little alcohol,
somewhat so in warm water, but only slightly in cold
water. ‘They found it to act very energetically upon the
cerebro-spinal axis in animals, giving rise to phenomena
of impulsion, tremor, and paralysis of the respiratory mus-
cles. In non-toxic doses sensibility to pain disappeared,
but that to touch persisted; and a gradual but notable
fall of temperature took place. Compared to antipyrin,
there is a considerable similarity, but the effect of exal-
gine upon sensibility is more marked, and upon the ther-
mogenic centres less marked, than that of the former. In
therapeutic use exalgine gave rise to no rash, cyanosis, or
gastro-intestinal irmtation, such as have been noted in the
employment of antipyrin and acetanilide ; in one case only
was there slight erythema. ‘They treated all forms of
neuralgia with the new remedy, doses of twenty-five to
forty centigrammes being required for the analgesic effects.
The drug is eliminated by the urine. It modifies the
urinary secretion, and in diabetic polyuria diminishes the
daily amount of urine and the quantity of sugar. Com-
pared to antipyrin it seems to produce greater effects as
an analgesic in half the doses, according to these authors.
It has also to some degree antiseptic properties.
I have been testing the efficacy of the drug on private
patients, and on patients at the Polyclinic and Vanderbilt
clinics, as appropriate cases presented themselves, during
the last seven weeks. I have used it in the form of pills
containing two grains each, and in the form of a cordial,
each tablespoonful of which was equivalent to two and
one-half grains of the drug (both forms prepared by Mc-
Kesson & Robbins). Notes in some of the cases are
here appended :
Case I.—A. S——., female, aged twenty-four, suffering
from trigeminal neuralgia, upper two branches, and extend -
ing also over occipital region, several years’ duration. It
is proper to say that. many remedies had been tried una-
vallingly. ‘Two grains of exalgine was ordered every
three hours. She took nine doses without any relief of
pain, drowsiness, or apparently any effect. Aconitia and
quinine prescribed since have also failed to secure relief.
Case II.—K. G——, female, aged nineteen, for a
week or so had had cephalalgia, neuralgic in character,
over the whole of the right side of the head. She could
not sleep on account of the pain, and, as she expressed it,
“ was driven nearly crazy.” ‘There was good reason for
suspecting the case to be malarial, and quinine was ad-
ministered for some ten days, five grains three times daily,
without, however, any effect. She was then ordered ex-
algine pills, 4a gr. ij. every four hours. She took but
four doses, and reported complete cure.
Case III.—A. W , female, aged fifty, a paranoiac,
troubled excessively by pareesthesiz over the whole body,
which gave rise to the delusion that electricity was being
used upon her continually by her persecutors. Sleepless
much of the time because of these shooting pains and
prickling sensations. For two nights she took exalgine,
one dose only of two grains each night, and slept soundly,
the pains not recurring until morning
Case IV.—S. H. B——, male, aged fifty-two, supra-or-
bital neuralgia for three months. Pain much diminished
by exalgine, gr. ij. every four to six hours.
Case V.—S. D , female, aged thirty-six, occipital
neuralgia for two months past, of probable malarial origin.
Twenty grains of quinine daily for three days produced
no effect. Exalgine was ordered in two-grain doses every
THE MEDICAL RECORD.
283
four hours for several days. Patient stated that she felt
a sort of drowsiness, but the pain was not diminished in
the least. |
Case VI.—J. D , male, aged sixty, occipital and
supra-orbital neuralgia of some weeks’ duration. Was
treated with quinine and apparently cured. ‘The pain re-
turned, however. in three days, and quinine was employed
again without effect. Antifebrin was then used, and also
failed to relieve the pain. Exalgine was then given in
two-grain doses every four hours, and effectually banished
the pain for some days. On its subsequent return exal-
gine proved of no service, except to permit him to sleep
at night, although given in the same doses every two
hours. He complained of a singular feeling of numbness
all through his body after the use of the drug.
Case VII.—M. M-——, female, aged thirty-five, mor-
phine habit for three years, taken for a pain in the side.
The original cause of the pain was a fall several stories
down an elevator shaft. ‘The daily amount of morphine
taken for the pain is small, seldom more than three grains.
The disease seems now to be a morphine neuralgia. Ex-
algine pills were substituted for several days, two grains
every two or four hours. While she acknowledged some
relief of pain, other disagreeable effects were produced—
drowsiness, nausea, dilated pupils, and diarrhoea; pre-
viously there had been myosis and constipation. It is
probable that the pupils appeared dilated, merely because
of the relaxation of the ins from the cutting off of mor-
phine. Patient felt compelled to return to her favorite
habit, and as any quantity of morphine she may desire is
provided for her by an indulgent mother, there was no
obstacle to her so doing.
Case VIII.— M. A , female, aged sixty, brachial
neuntis. There was first a severe brachial neuralgia, with
a herpetic eruption over the whole extent of the median
nerve. After recovery of the herpes, there was intense
pain and tenderness along whole arm, particularly about
fingers and wrist, and with trophic changes in the skin
and muscles of those parts especially. For the ameliora-
tion of the pain exalgine was given first in pill form, later
in the form of the cordial exalginque, in doses of some two
grains each, every four to six hours. ‘The effect has been
excellent. The cordial seems the better form for admin-
istration in this case, and has been relied upon for three
weeks as an analgesic. No ill results have followed its
use.
In addition to these eight cases, of which notes are
given, exalgine was given experimentally in some twelve
cases of various forms of cephalalgia, in the two grain
doses several hours apart, and with benefit in about fifty
per cent. The doses, as is evident, have been minimal, and
where the analgesic quality of the remedy has not mani-
fested itself, it 1s probable that double or triple quantities
at one dose would have proven efficacious. Upon the
whole no bad effects were produced, except, possibly,
some in the case of morphine habit, and in certain of my
cases it was a decidedly useful medicament. ‘The doses
employed by the French physicians who introduced the
remedy were, as has been stated, from four to six grains,
and from my experience I should in most cases begin with
four-grain doses every two to four hours. With smaller
doses the analgesic effect may be uncertain in its develop-
ment.
201 WEST FIFTY-FOURTH STREET.
THE OwNER OF HunyaDi JANos.—David Andreas Sax-
lehener, owner of the Hunyadi Janos, who died recently,
was an uneducated but sharp-witted man. He was in the
clothing business at Budapest, when a peasantre marked
in his store that he had very bad luck in boring wells for
water on his farm, getting only an ill-smelling liquid that
he feared to use. Saxlehener procured a sample of the
water, had it analyzed, bought the peasant’s farm, and
became many times a millionnaire through the sale of the
water.— Medical and Surgical Reporter.
284
THE MEDICAL RECORD.
[September 14, 1889
UTERINE HEMORRHAGE AND LIGATION OF
THE UTERINE VESSELS AS A THERAPEUTIC
_ EXPEDIENT.
By JOHN A. MILLER, M.D.,
SALT LAKE CITY, UTAH.
LIGATION of the uterine vessels for uncontrollable hemor-
rhage, I believe, originated with the late Carl Schroeder,
of Berlin, accompanying or preceding his “ high amputa-
tion of the uterine cervix ;” at all events, I had never
heard of this surgical expedient before, nor have I seen
it referred to since in any of the medicals journals which
chanced to come into my hands. It was in 1884, when I
was a student in the Martin Clinic, that I witnessed Dr.
Martin precede his operation for the vaginal extirpation of
the uterus with a ligation of the uterine vessels, and that
he often removed the uterus without the loss of more than
half an ounce of blood was one of the most striking feat-
ures of his method of operating. In our country this
surgical resort is very little known, or at least noticed or
practised. Only a few weeks ago an estimable lady, and
mother of several children, bled to death, because the
hemorrhage from the uterus was beyond the control of
those remedies which are ordinarily employed in such
cases. In this case the bleeding was the result of an arti-
ficially induced abortion, which had been decided upon by
her medical advisers to check obstinate vomiting.
I can simply say that I have resorted to this surgical
expedient on three different occasions, where all else had
failed, and the results were immediate and all that could
be wished for ; and, had I not passed a ligature through
the lateral aspect of the fornix of the vagina, high up and
into the uterine tissue, the patients would all have died.
Uterine hemorrhage is a relative term ; to uterine dis-
eases it bears about the same significance as a cough does
to pulmonary affections. Hemorrhage of the uterus de-
pends on so many diversified pathological processes that
one cannot have an intelligent idea of the remedial re-
source in a given case until a thorough examination clears
up the relation of cause and effect ; so it is not my pur-
pose to enter into the etiology, but to outline a surgical
expedient which never can fail to arrest hemorrhage, no
matter what the cause, in the unimpregnated uterus.
To make the ‘subject thoroughly understood, I have
compiled the anatomy of the blood-supply of the uterus
in as few words as possible.
The arteries supplying the uterus, beginning from the
fundus down’ to the cervix, would be, first, the ovarian
arteries ; as these and the others are double, I can limit
myself to the description of one side. “The ovarian artery
arises from the aorta, and when it arrives at the pelvic
brim it passes inward between the two layers of perito-
neum, forming the broad ligament. The artery passes
beneath, on a lower plane than the Fallopian tubes and
ovaries, so that the small branches which supply the tubes
and ovaries from the ovarian run directly upward, while
the main ovarian, according to Hyrtel, runs tortuously to-
ward the upper angle of the womb, and there divides into
two branches, of which the upper supplies the fundus,
and the lower branch anastomoses at the side of the
womb, near the isthmus, with the uterine artery, which is
larger in calibre than the ovarian and arises from the in-
ternal iliac. 'This artery passes inward to the neck of the
womb ; here it ascends in a tortuous manner on the side
of the organ, and distributes small branches (the curling
arteries of the uterus) to the substance of the organ.
Near the isthmus there is a special branch of the uterine,
which joins its fellow of the opposite side, forming the
circular artery.
Now it will be interesting to notice that the indirect
blood-supply to the uterus, when the former branches are
ligated, must come from the vaginal arteries, which, anas-
tomosing, form the azygos vaginz, and that running up
joins the circular artery of the uterine. If we keep this
simple and clear picture of the blood-supply of the uterus
in our mind, we can at once see how easy and practicable it
is to cut off entirely the arterial supply of the womb. ‘This
is virtually done by Dr. Martin in the preliminary steps to
the vaginal extirpation of the uterus, and the result is in-
variably as above stated—no hemorrhage.
The ligation of the uterine vessels is neither difficult to
perform vor dangerous to the patient if ordinary skill
and care are employed.
The first step in the operation is to thoroughly disinfect
the vagina] canal by using a large quantity—two or three
gallons—of carbolized warm water of a two and one-
half per cent. solution.
‘The patient is then placed in the perineal lithotomy
position, and, by means of a bullet-forceps or some similar
instrument hooked into the vaginal portion of the cervix,
the womb is pulled down to the vulva. A Simon’s or
Sims’ speculum is used to open up and retract the poste-
rior commissure of the parts, while the assistants, who
are supporting the legs of the patient, by means of blunt
retractors retract the labia majora et minora; this latter
retraction is not always necessary. To an assistant is
also intrusted the bullet-forceps, and he at the same
time deflects the organ to the side opposite to that on
which you are about to pass the ligature. This will give
full scope for manipulation. With the index-finger the
operator now locates the body of the uterus, which it is
intended to include, or at least so much of it as will as-
sure the certainty that nothing. but broad ligament and
uterine tissue is insnared in the ligature, for it would not
be desirable to include the Fallopian tube, and decidedly
dangerous to stretch the intestines. From what has been
said on the distribution of the blood-vessels, it is obvious
that it is not necessary to carry the ligature too high up
or too far outward from the body of the womb to insnare
the vessels, and, by keeping close to the body of the
uterus, and not going higher than the upper end of the
middle third of the body, there is absolutely no danger of
wounding the intestines.
A strong curved needle, one and three-quarters of an
inch long, is armed with a strong double ligature ; the left
index-finger supports the tissues and the uterus, while
with the right hand the needle is passed near the cervix,
in front and toward its side, through the fornix of the
vagina, from before upward, backward, and downward, and
out through the fornix again, near its point of entrance.
This is then tied, and the other side is proceeded with in
a similar manner. After twenty-four hours both ligatures
may generally be removed, there being no further danger
from hemorrhage.
I will mention here that curved needles are not passed
by straight or direct pressure, it requires a curved or
circularly directed force, otherwise the needles will break.
A little practice with a curved needle on a piece of leather
will impart the necessary proficiency. To practise on
the patient is too late, and may result in failure.
In conclusion, I would like to suggest the ligation of
the uterine vessels for the cure of pathological processes
of a hypertrophic and inflammatory nature.
Heretofore great benefit has been derived from local
depletory measures like glycerine tampons, scarifications,
and hot irrigations; the results would be astonishing in
some instances where the disease is too obstinate to yield
to mild measures. ‘The congestion and swelling of the
uterus, incident to flexions, would also come under this
head, especially those cases whcre reposition of the organ
is made impossible from inflammatory adhesions. An
enlarged uterus might in that way be starved into smaller
proportions.
THE FIFTH INTERNATIONAL CONGRESS OF OTOLOGY
will be held in Florence in 1892. ‘The following sub-
jects for discussion are already announced : 1. The “ Patho-
logical Anatomy of Inflammation of the Middle Ear.”
2. “The Diagnosis of Cerebral Abscess caused by Ear Dis-
ease.” 3. ‘General Therapeutics of Ear Diseases.”
September 14, 1889]
THE USE OF THE TAMPON IN PREGNANCY.’
By GEORGE H. NOBLE, M.D.,
ATLANTA, GA.
Mr. PRESIDENT AND GENTLEMEN: This little paper is
presented to you with the hope that in it you will find
something of value to the practical man, as it treats of a
subject that has engaged a part of my attention for the
past eight years. During that time this treatment has
been applied to a number of cases, and demonstrated fully
to my mind the value of the method.
I desire more especially to call your attention to the
mode of treating old lacerations in the pregnant uterus ;
but, first, shall briefly mention some other conditions in
which it may be used with benefit.
My first applications of glycerine on cotton or wool, for
profuse and irritating vaginal discharges in pregnancy,
were made in 1881. In this way many troublesome and
almost intractable cases were relieved, especially when due
to turgescence of the pelvic blood-vessels. ‘The remedies
usually associated with it are palliatives or neutralizers of
the secretions.
Following close upon this, it was employed in some
instances of nausea and vomiting with very satisfactory
results. I was led to its use by the observation that in
some vascular disturbances of the pelvis reflex phenom-
ena were more pronounced and distressing. ‘This (unlike
Graily Hewitt) was attributed to the engorgement, and
not directly to flextons and versions. However, I endeav-
ored not only to relieve the engorgement, but also to cor-
rect the displacement ; as the relief of the former without
the latter was irrational and disappointing, though occa-
sionally it afforded some temporary relief with the uterus
in an abnormal position.
Its specific action I was unable to explain; but since
invoking the aid of Bretonneau’s theory I have assumed
that it augments the stretching of the uterine fibre by dis-
tention of the blood-vessels. Barnes anticipates me when
he says that “the immediate irritating cause we believe
to be due to stretching of the uterine fibre under the ex-
centric pressure of the growing evum, and to turgescence
of the uterine vessels. This turgescence receives a sudden
increment under the hydraulic pressure which takes place
on assuming the erect posture.”
Granting, then, that turgescence of the uterine blood-
vessels is an important etiological factor, the glycerine
dressing, through its detergent action and support afforded
the pelvic viscera, becomes a remedy most likely to meet
the demands of the treatment indicated. The combined
effect of the glycerine and the pressure promotes softening
of the cervix, thus enabling that portion of the uterus, so
susceptible to reflex neuroses, to stretch without demon-
stration of nervous phenomena.
The tampon can avail but little in retroflexions and re-
troversion of the gravid uterus, as it is far inferior to a
well-fitting pessary, unless tenderness is sufficient to pro-
hibit the use of the instrument. In this case the glycerine
treatment should be employed to pave the way for the
If the displacement is complicated by impaction suffi-
cient to render reduction impracticable, the glycerine may
reduce the swelling sufficiently to permit replacement of the
organ by carrying off the water in the engorged structures.
Spiegelburg used it for this purpose, recommending fre-
quent changes and the use of the T-bandage.
Impaction of the anteflexed uterus is so rare that some
authors doubt its existence. Just here it may be well to
mention that by impaction we do not mean a gravid uterus
of development just large enough to well fill the pelvis,
and requiring more or less skill in its reduction, but one
that has become so jammed in the true pelvis that it is
immovable without exerting force sufficient to endanger
the safety of the ovum.
_ Impaction may, however, occur with the anteflexed
1 Read before the Medical Association of Georgia, April 19, 1889.
THE MEDICAL RECORD.
285
uterus if there is contraction of the posterior ligaments by
parametritis and anterior adhesions to the fundus, thus
acutely anteflexing the uterus and fixing it in the anteverted
position. In that case the development would be down-
ward as well as upward, and it would most likely become
impacted if gestation progressed far enough, or unless the
adhesions give away.
A case of this kind presented herself to me with the
uterus acutely anteflexed and anteverted. The cervix was
drawn high up to the sacrum, while the fundus was en-
gaged beneath the pubic arch. ‘The impaction was ex-
treme, and correction impracticable without relieving the
swelling by the glycerine and light elastic pressure of the
wool, which accomplished the desired results.
Other cases may be relieved in the same way, though
they are apt to abort, or to be recognized before the de-
velopment reaches that point where the swelling alone is
sufficient to cause impaction.
Sacciform dilatation and hypertrophic elongation of
the cervix in pregnancy may be treated by the tampon
with a view of affording mechanical relief. Lusk recom-
mends it in the latter disease.
For prolapsus of the pregnant uterus I know of nothing
better. Here again the tampon has the indorsment of
Lusk, Spiegelburg, and others. It must be continued un-
til the uterus is large enough to remain above the pelvic
brim, and should then be gradually diminished.
In prolapsus of the vagina the tar ointment, one drachm
to one ounce of vaseline, is a most valuable remedy ap-
plied on a light tampon to the vaginal mucous membrane,
avoiding contact with the cervix. It shrivels the mucous
membrane equally as well as hot water, sometimes, I am
inclined to think, better, as the corrugations from the tar
seem to remain longer than those from the hot water,
when the patient is placed in the knee-elbow position.
Dysuria from pressure is one of the most common
troubles in pregnancy, and one of the easiest to relieve.
Often a few small pledgets of cotton with glycerine or
vaseline, under the base of the bladder, will give instant
relief. It is not always necessary, to take the weight off
the uterus, for a simple support to the base of the bladder
will often answer the purpose.
The Tampon in Lacerations of the Cervix of the Preg-
nant Uterus.—Perhaps there is no accident so common
in labor as laceration of the cervix, and certainly none
more prone to cause premature expulsion of the ovum in
subsequent pregnancies. l
The engorgement and swelling commonly found in lac-
eration of the cervix are greatly intensified in the gravid
uterus. The lips may swell until they virtually roll inside
out, adding increase to the irritation and turgescence of
the pelvic vessels. ‘These symptoms, conjoined with the
increased weight of the uterus and the softened condition
of the neck, constitute some of the principal elements re-
quiring consideration in the treatment. Swelling, ever-
sion, granulations with a tendency to oozing of blood, and
hemorrhages, are the most serious symptoms, for they are
almost always accompanied by pain and uterine contrac-
tions. ‘The vaginal portion may swell to more than three
inches in diameter, or even half fill the vagina, the extent
of which bears some proportionate relation to the gravity
of the case, but not to the extent of the laceration. I have
had the most aggravated symptoms with slight tears, and
have observed trivial disturbances from deep ruptures.
One of my cases, at the fourth month of gestation, had
slight prolapsus, with the cervix so swelled and everted that
it occupied at least half of the vagina. The finger passed
without resistance directly into the patulous canal, until
it came in contact with the membranes. The everted
surface was raw and granular, and bled freely on slight
friction with cotton. The laceration was unilateral, and
apparently an inch and a half deep. Uterine contractions
were frequent and forcible. Abortion seemed imminent,
but she was safely carried to term and delivered of a liv-
ing child. A pessary was applied before she was per-
mitted to leave the bed, as is my custom with patients
286
THE MEDICAL RECORD.
s
[September 14, 1889
who have been subject to displacement. When the pes-
sary was removed, six months afterward, J was very much
astonished to find that the laceration, instead of being an
inch and a half in length, was only a mere nick or fissure
in the side of the os.
The sagging usually found in the non-pregnant uterus
may become a prolapsus when pregnancy occurs, and ren-
der formidable a case that would ordinarily give but little
discomfort. When associated with a slight tear it may
cause more trouble than a rupture into the vaginal junc-
tion ; but when coupled with the latter, it is apt to be a
serious and delicate case to handle. Fortunately the
latter class of cases is in the minority ; though, if the true
status of affairs was known, it would probably prove to be
the cause of abortion in many cases that do not fall into
the hands of the physicians.
The objects to be accomplished in the treatment are :
rst. Correction of the displacement. which straightens
out the tortuous blood-vessels, and in this way relieves
obstructions to the flow of the blood (Emmet).
2d. The relief of turgescence, which is accomplished
by the detergent action of the glycerine.
3d. The support of the structures, which prevents re-
currence of the trouble; and,
4th. Softening of the cervix, which permits stretching of
the uterine fibre without nausea.
The application should be cautiously made, small pled-
gets of wool, often only a single one, well saturated with
glycerine, should be applied and increased gradually from
day to day, as the turgescence is relieved and tolerance
established, until a quantity sufficient to correct the dis-
placement or support the structures is employed. After
the uterus is developed sufficiently large to remain above
the true pelvis, the tampon should be reduced gradually
in order to avoid discomfort, and to observe whether or
not the vascular disturbances return. Some discoloration
of the mucous membrane and distention of the vessels
must be expected after the discontinuance of the dressings,
as it is a physiological condition of pregnancy, and should
be given consideration only when it goes beyond the bor-
der line and becomes pathological.
In that case a continuance of the treatment is indicated.
If the secretions are very profuse, the tar ointment or dry
tannic acid sprinkled in the lower part of the vagina will
be of great service in preventing expulsion of the wool.
Particularly is this useful in prolapsus and eversion of
vagina.
If there be great tenderness, glycerine in large capsules
has proven serviceable ; but a better thing is the glycerine
suppository. ‘These are soft and less liable to act as for-
eign bodies. ‘These I have used in several cases prepar-
atory to the wool-dressings, introducing them into the
vagina with the hips elevated, to prevent the escape of the
glycerine. However, there are but few cases that will not
bear the wool treatment from the start, unless it be those
with a tendency to bleed from fungi, or granulations of
the os. To the latter it is best to apply a thin layer of
glycerine-soaked cotton, to protect it from the hard wool
fibre, which will abrade or cut through the epithelium of
delicate mucous membrane. ‘To such cases the adminis-
tration of iodide of potassium is serviceable, either in con-
stitutional disease or in defective local nutrition.
If the symptoms are not serious nor the eversion ex-
treme, they may be relieved in a few weeks or months ;
but if, upon the other hand, the symptoms are grave and
the swelling and eversions very great, the treatment may
have to be continued until the case approaches near the
close of gestation. After shortening of the cervix has oc-
curred (in the latter months of pregnancy) it is not so liable
to become swelled and everted.
The longest time I have continued the treatment was
five months, ending in the seventh month of gestation.
This was in a delicate woman who, before coming into my
hands, had been subjected to numerous treatments for a
number of years. She had chyluria, hemorrhoids, and
other distressing symptoms. She was at the second month
of pregnancy, with the cervix greatly swelled and everted,
the os granular, the uterus slightly prolapsed. and the pel-
vic vessels distended. ‘The treatment relieved all these,
but had to be continued up to near the eighth month, as
an interruption was always followed by an indication of
relapse. The laceration was unilateral, and very slight in
extent.
Another case, who had had one premature labor and
one abortion, presented most alarming symptoms. The
swelling of the cervix was enormous, it half filled the va-
gina. ‘The os was raw and bleeding, the lacerations were
unilateral, and apparently an inch and a half deep, and the
uterus was prolapsed to the floor of the pelvis. Uterine
contractions were frequent, and abortion seemed actually
in progress. Yet she progressed favorably under the treat-
ment, which had to be be continued until the end of the
sixth month before it could be left off with safety. The
entire weight of the uterus was sustained by the dressing
until it was large enough to remain above the brim.
During the treatment of this case the patient was en-
tirely free of pain as long as the dressing remained in the
vagina, but as soon as it was expelled and the uterus al-
lowed to come down, the uterine contractions would re-
turn and continue until a fresh dressing was applied.
Now I cannot impress upon you too strongly the dis-
tinction between this treatment and the tamponing com-
monly and imperfectly done in gynecology. It is not the
hard packing used in the hemorrhages and other condi-
tions, but, at first, a simple pledget of wool intended as a
means of applying glycerine to the swelled and tender
structures. ‘Then, after it has accomplished some relief,
it is carefully increased as the improvement will permit,
until it has effected the desired results.
The pregnant uterus can be educated up to tolerance of
foreign matter in contact with the vaginal portion, espe-
cially if it isto be the means of relieving symptoms or dis-
ease more dangerous than the foreign body itself. ‘Taking
this view of the matter, the glycerine dressing, when used
with good judgment, is a safe’ and valuable treatment,
particularly for old lacerations in the pregnant uterus.
Summary of Cases.—Of sixteen retrodisplacements ten
had retroflexions; the réinaining six were simple versions.
Four were treated primarily with glycerine dressings to
pave the way for the pessary. Ten had pessaries applied
at once—thus all eventually were replaced by pessaries.
Of the ten retroflexions eight had lacerations, one of
which had been repaired, but hypermetropic elongation of
the portio media remained. The uterus was very soft and
flaccid, neither pessary nor cotton would keep it in place,
so as a last resort a flat, elastic stem-pessary was em-
ployed with success. One was treated conjointly with
vaginal pessary and small dressing, as the laceration caused
such extensive eversion that the pessary alone would not
answer the purpose.
Of twenty-two cases of profuse and irritating vaginal dis-
charges eighteen had some displacement ; seven, retro-
flexions, included in previous list ; one, anteflexion ; ten,
prolapses in various degrees. Of the eighteen, six had
lacerations. Of nineteen cases of laceration eight are
included in the ten cases of retroflexion, and six in the
list of profuse and irritating vaginal discharges. The re-
maining five were slight tears, with slight prolapses Or sag-
ging, more than is normally found in the early months of
pregnancy.
Of the nineteen cases of laceration, fourteen had bilat-
eral rupture, six of which extended into the vaginal junc-
tion ; five of these has a history of repeated abortions.
The lacerations in the remaining one occurred at the con-
finement of the preceding pregnancy.
One of the last five miscarried four weeks after dis-
continuing treatment, caused by ill-treatment from her
Eusband. Three cases with slight lacerations presented
alarming symptoms, but did not abort.
—_
1Jn a series of thirty-three. cases no unpleasant sy mptoms have ap-
peared, except a sense of fulness when the dressing was carelessly ap=
plied to a non-displaced uterus.
September 14, 1889]
SEVERE CASE OF INSOLATION; HISTORY,
TREATMENT, AND RECOVERY.
By R. ELLIS, M.D.,
PEEKSKILL, N. Y.
THE patient, a large, muscular man of forty-two, employed
in a sugar-house, felt indisposed the day before, but con-
tinued his work ; and, despite the advice of his friends,
persisted in going to work the next morning. He “ felt
bad all over,” yet kept on working in a very hot room
till, at 5 P.M., his fellow-workmen saw him fall forward on
his chest against an iron sugar-receiver.
His clothing was loosened, and water was poured over
his head until the arrival of the ambulance, which hastily
brought him to the hospital.
I found the man unconscious, face pale, hot, and
covered with profuse perspiration; respiration sighing
and very weak ; sphincters relaxed ; pulse, 160 ; and tem-
perature, by rectum, 109° F.
The patient, without being moved from bed, was
stripped, a rubber blanket placed under him, and ice-
water thrown from a height of four feet all over him ; tr.
digitalis, ™ x., and whiskey, Tl xx., were given hypoder-
mically, and the pulse and temperature taken every few
minutes. Great care was taken to disturb the patient as
little as possible ; the sphincters were so sensitive that the
introduction of the thermometer was followed by loose,
watery fzces.
5.30.—Pulse has responded very slightly to the stim.
ulants ; respirations still very feeble and sighing ; temper-
ature, 108.6° F. ; occasional involuntary passage of faeces.
6.00.— Pulse, 140, very weak and compressible ; tem-
perature, 108.2° F.; convulsive stage beginning ; face
slightly turgid.
6.15.—Convulsive stage well marked ; arms extended
and raised straight above head ; legs, fingers, and toes
flexed ; face very turgid ; jaws tightly locked on piece of
cork to prevent injury ; no attempts made to restrain pa-
tient ; loud sighing cry with every expiration.
6.30.—Pulse slightly better; temperature, 107° F. ;
legs and arms now extended ; body so stiff that patient
can be raised by heels and head ; occasionally an opis-
thotonic spasm comes over patient, lasting but a few
seconds, when body is rigidly extended again.
6.45.—Convulsive stage so severe that a hypodermic of
morphia, gr. 4, with atropine, 74, gr, was given, which
seemed to quiet patient greatly.
7.00.—Pulse, 120, feeble and occasionally intermitting ;
temperature, 106° F.; ice-water still continued, yet
stopped occasionally and entire body rubbed briskly to-
ward the heart with dry towels ; tr. digitalis, Ml x., hypo-
dermically.
7.30.—Pulse slightly stronger; temperature, 105° F. ;
ice-water and rubbing continued, body being red from the
rubbing ; fæces still passed involuntarily.
3.00.—Temperature, 103.6° F.; pulse, 110; ice-water
discontinued ; patient’s body dred and removed to ad-
jacent dry bed, care being taken to keep body horizontal
while being moved.
8.30.—Skin, though red, is still cold from effects of
the ice-water ; temperature, 103° F.; pulse, go, with ten
intermissions ; convulsive stage not marked, yet attempts
at flexion show body is still rigidly extended ; eyes now
open, with a look of intelligence ; does not answer ques-
tions.
g.0o.— Temperature, 103.4° F.; patient now covered
with towels squeezed out in ice-water ; ice-bag to head ;
temperature quickly fell below 103° F., only to rise again
when towels were removed. Interesting to notice that
the temperature is so much under the control of the
physician that the cold towels lowered the temperature
below 103° F. several times, only to rise again when the
towels were removed, till, finally, temperature remained at
102.8° F., great care having been taken to avoid too
sudden a fall from 109° F., especially when the tempera-
ture had fallen to 104° F.
THE MEDICAL RECORD.
287
g.15.—Patient covered with sheet and light blanket ;
temperature, 102.6° F. ; pulse, 80, with twenty intermis-
sions. ‘Ir. strophanthus, mM x., with whiskey, T, xx., were
given hypodermically. In five minutes there were but eight
intermissions, in fifteen minutes but four, pulse being much
stronger. Patient did not recognize his daughter, seemed
sleepy, and hence the light was turned down and quiet en-
joined.
10.00.— Temperature, 102.4° F. ; skin naturally warm ;
pulse, 100; looks frightened when touched, but seems
much relieved when he is reassuringly patted.
10.30.—Gave his name, and answered questions intel-
ligently, though with a very thick tongue.
11.30.—Patient has slept quietly, yet not deeply ; pulse,
go, no intermissions ; temperature, 102.2° F.
12.00.—Improved ; temperature, 102° F. ; pulse, go ;
ice-bag kept on head, and patient left with the nurse for
the night. |
8.00 a.M.— Very bright ; temperature, 99.5° F. ; pulse,
72, full and strong.
2. P.M.— Temperature normal; patient able to leave
hospital, only sequelæ being two swellings over pectoral
muscles, resulting from patient’s fall.
In conclusion, let it be said that—
First, every case is a law unto itself.
Second, every case should be treated immediately, even
while being carried home or to the hospital.
‘Third, the condition of the heart and temperature is
the basis for all treatment.
Fourth, do not reduce temperature too rapidly below
104° F.
Fifth, patient must be disturbed as little as possible,
and must not be left for a moment until he is either dead
or on the road to recovery.
Clinical Depariment.
REPORT OF A CASE OF TUBERCULOUS NE-
PHRITIS, WITH AUTOPSY.
By J. H. REILLY, M.D.,
FAIR HAVEN, VT.
I was called on April 11, 1888, to seeS. B——-, aged
seventeen, whose family history was very obscure, and
found her suffering from severe pain in the region of the
bladder. She stated that her trouble commenced about
two years previous by pain in the region of the bladder and
frequent micturitions, which afterward became very pain-
ful. This attack confined her to her room for about two
months. From this she recovered and became well enough
to attend school. Between the first attack and the pres-
ent one she had two acute attacks, running about the
same course as the first one. She had noticed a gradual
loss of strength since her first attack. She had no cough,
pain in the chest, night-sweats, nor any history of rheuma-
tism. Her last trouble commenced about two weeks:
previous to my seeing her. She complained principally
of frequent painful micturitions and constant pain in the
region of the bladder. I made a general examination
and found her much emaciated and very anemic. I
could not detect any abnormal condition of the lungs.
The area. of cardiac dulness was not increased, but a
systolic murmur could be heard over the aortic orifice,
which I attributed to her anzmic condition. ‘There was
no tenderness in the lumbar region, but palpating over
the region of the bladder caused great pain. There was
no abnormal condition of the urethra found. Œdema
was not present. ‘The urine which had accumulated in
the vessel showed a large quantity of pus. Thinking it a
case of chronic primary cystitis, I directed my treatment
to that organ. I tried to wash out the bladder with a
solution of biborate of soda, but the meatus, which was
excoriated, was very sensitive, and not having any cocaine
with me I didnot succeed. ‘The next day, after applying
288
to the meatus a ten per cent. solution of cocaine, I suc-
ceeded in passing the tube of the Davidson syringe into the
bladder, but that organ was so sensitive that it would not
tolerate over an ounce of the solution, and I also injected
into it two drachms of the solution of cocaine ; but the
whole procedure was so painful that I had to give up the
attempt. I prescribed for her a pill containing benzoate
of soda, 4 gr.; ergotin, 1 gr.; ext. of hyoscyamus, 1 gr.,
to be taken every three hours, and also a tonic of iron,
arsenic, and strychnine, and a diet consisting principally
of milk. An examination of the urine revealed at this
time a large percentage of albumen; the microscope
showed a large quantity of pus, epithelium, and phosphatic
crystals. I did not discover any casts at this time, but
three weeks later hyaline casts were present in abundance.
Her condition during the next month was somewhat im-
proved, but not to any great degree.
which was six weeks from the time I had seen her, the
vesical symptoms were more aggravated; gastric dis-
turbance had commenced, and a slight cough had de-
veloped, with pain over the apex of the right lung.
Hectic fever was also present, with evening exacerbations.
An examination of the lungs at this time revealed dulness
and moist rales over both apices and the left base. Later
on, tubal respiration could be heard, and the expectorated
matter from the lungs was purulent. From this time up
to the middle of August, when she died, her vesical pains
were very severe, and could only be partially controlled by
keeping her on large doses of morphine. The autopsy
showed that emaciation had reached an extreme degree.
Tubercular deposits were found~-all through both lungs
and pleura, which were firmly adherent in places. Noth-
ing abnormal was found about the heart. The liver was
in a healthy state. The right kidney was large and pale,
its capsule adherent. No tubercular deposits were found
through it. On opening the left kidney about an ounce
of pus was found in its pelvis, and a pyramidal-shaped
tubercular deposit had taken the place of each pyramid,
some of which had broken down in the centre, and the
cavities which were connected with the pelvis were also
filled with a greenish, purulent material. The ureter con-
nected with this kidney was about half an inch in di-
ameter, and its walls were very thick. The walls of the
bladder were very much hypertrophied ; its cavity was con-
tracted. At the opening of the left ureter there was a
large ulcer, probably produced by ichorous pus from the
kidneys. Its mucous surface throughout was congested
and roughened by elevations about the size of a pin’s head,
which I supposed were miliary tubercles. The perito-
neal glands were in a state of tuberculous degeneration.
. The mucous surface of the stomach was also congested.
The spleen was found in a normal state. ‘The brain was
not examined.
I think there can be little doubt as to which organ the
primary trouble originated in. From the fact that her
trouble dated back almost three years, and that pul-
monary symptoms manifested themselves only two months
before she died, I think it is safe to assert that the kid-
ney was the organ primarily affected, and that the deposit
in the lungs was secondary to it. ‘That the bladder was
the primary seat of the deposit I think we can exclude.
If this were the case, the probability is that instead of the
disease making its way up one ureter, it would be apt
to involve both. ‘There was also some doubt as to
whether the elevations I referred to as existing in the
bladder were tubercular or not. ‘There was no ulceration
in the bladder, only what was at the opening of the ure-
ter. Roberts, in his treatise on urinal diseases, states that
in primary tuberculous nephritis the urinary symptoms are
the most prominent from the commencement of the de-
posit until the termination of the disease, while second-
ary deposits rarely give rise to any distinct symptoms, and
that the deposits in secondary cases are minute, varying
in size from a pin’s head to a pea, and that they are scat-
tered over the surface and through the cortical substance
of the gland chiefly. In this case the cortical portion of
THE MEDICAL RECORD.
About June rst,
[September 14, 1889
the gland was free from the deposit. In fact, the deposit
was confined only to the secreting portion of the gland. —
Great stress is, by some observers, given to the variously
shaped epithelium cells found in the urine as a means of
differentiating diseases of the kidney from those of the
bladder. From the condition found at a late stage of the
disease this means of differentiating would lead to decep-
tion. Tubercular deposits taking the place of the tubules,
and the pelvis being devoid of epithelium, the urine could
only contain bladder epithelium, and, reasoning in this
way, our diagnosis would be referred to the bladder. Dr.
Schmidt, in a late article in THE MEDICAL RECORD, speaks
of palpation of the ureter as a means of diagnosing dis-
eases of this nature, and cites a case of secondary tuber-
culous nephritis in which he diagnosed the condition by
finding the tubercle bacillus, and by palpating the ureter,
and from other symptoms referable to the kidney. In his
case he could feel the ureter on the left side for about an
inch from the bladder, enlarged and tender.
Primary tuberculous nephritis, says Dr. Roberts, rarely
runs its entire course without the occurrence of tubercu-
lar deposits in other and unconnected parts of the body.
A CASE OF POISONING FROM OPIUM SMOK-
ING.
By JOSEPH COLLINS, M.D.,
NEW YORK.
Cases of opium-poisoning are, unfortunately, not among
the rarities. The unusual avenue of entrance of the drug
in this case, however, prompts me to report it. It will be
seen that the symptoms differ somewhat from those pro-
duced by opium when taken in the ordinary way.
‘The patient was a youth, twenty-one years of age, well
educated and refined, of a very nervous disposition, and
a descendant of a family in which the neurotic tendency
is well pronounced. He had been an “ opium fiend,” as
opium-smokers term themselves, for upward of three
years, and had suffered a previous but milder attack about
seventeen months before.
When first seen the patient was laying on the floor be-
side a smoking outfit, vainly endeavoring to cook a last
pill, which he knew would add to his danger. He was
very much emaciated, face haggard, and presenting the
characteristic sickly pale yellow look of the opium-smok-
ing habitué; eyes dull and expressionless, pupils con-
tracted ; respirations reduced to about 12 or 13 per minute ;
pulse feeble and rapid; intellect sluggish, although an-
swering rationally. From his companion I found that
he had been srnoking almost incessantly for the preceding
two or three days, averaging about one hundred and twenty
pills, of three to five grains each, in the twenty-four hours.
He had not partaken of food or stimulants during this
eriod, and was further weakened by an attack, of vomit-
ing and diarrhoea, which had set in a day or two previ-
ously.
The patient was put to bed, a drachm of brandy admin-
istered hypodermatically, coffee as much as the stomach
would allow, and further smoking interdicted. His symp-
toms, however, became aggravated, and the following
morning found his respirations reduced to 10 per minute ;
pulse, 130, and very weak, and the morale of the patient ex-
tremely bad. He complained of an indescribable gnawing
sensation in the stomach, and extreme restlessness ; could
not be retained in one position more than a few seconds ;
had hallucinations, and imagined that each minute was
an indefinite period ; his mind continually hurrying from
one subject to another that had engaged his atteution in
his previous career. Koumiss and brandy were given, as
much as the stomach would tolerate, and $y grain of
atropia hypodermatically every three hours, until the res-
pirations reached 16 per minute. The following night,
although his general condition was better, restlessness and
insomnia seemed to be aggravated. The ordinary hyp-
notics—as chloral and sulfonal—did not have the least
September 14, 1889]
effect in producing sleep, and as rest was now the most
important factor, I decided to administer one-half grain
morphia hypodermatically, which was done with the re-
sult of quieting him a very little. The succeeding day,
coffee, koumiss, and champagne were given in turn,
with the effect of bringing his respirations and pulse to
nearly a normal condition. The restlessness and uneasi-
ness of mind were influenced by the morphia when given
subcutaneously, and then only in a slight degree, although
doses averaging from one-half grain to two grammes were
administered.
After a continuance of this condition for three or four
days it was thought advisable to allow the patient to re-
turn to smoking small quantities again, as it was only
under promise that no attempt would be made to break
the habit that he consented to have any treatment what-
soever. An expert cooker was therefore obtained, and
the patient allowed six pills, of two grains each, at one
séance, not to be repeated more than three times a day.
This was about one-tenth of his former quantity. From
the first smoke he began to improve, and in a week’s time
his yui yan, as these poisonous symptoms are called, had
nearly disappeared, leaving his nervous system in a very
shattered condition.
There is an opinion abroad that opium-smoking is con-
fined almost entirely to Celestials. Unhappily this is not
the case. I have heard it estimated by a very well-in-
formed gentleman, himself a smoker, that there are be-
tween eight and ten thousand “fiends” in New York
City to-day; and to one who has not had intercourse
with this unfortunate class of people it is scarcely pos-
sible to picture their miserable existence. I have now
under treatment a lady, formerly an actress, who was
obliged to forsake her occupation, society, and its pleasures
and obligations, merely because it was impossible for her
to pass any two consecutive hours without resorting to
the solucing pipe.
No form of taking opium enslaves its victim so thor-
oughly as does that by the respiratory tract. ‘The will-
power and morale of the hadituds are entirely abrogated.
They will beg you to assist them to escape from its in-
thralment one moment, and forcibly resist you from mak-
ing any endeavors to help them the next.
I consider it next to impossible to cure any patient of
the habit without the aid of a well-regulated sanitarium
under the charge of a competent physician and attendants,
who can keep the patient under continual surveillance and
treatment; and then very rarely, I fear, except by the sub-
stitution of one form of slavery, although a milder one,
for another.
149 LEXINGTON AVENUR.
meer ma. o
A PECULIAR CASE OF TERTIARY SYPHILIS
OF THE THROAT.
By E. HARRISON GRIFFIN, M.D.,
ATTENDING SURGEON OF THROAT AND NOSE DEPARTMENT OF BELLEVUE HOSPITAL
OUT-DOOR POOR, NEW YORK.
On March 1, 1889, Mr. F—— came to consult me at
my office, complaining of a bad cough which kept him
awake during the night, and made his throat painful from
its incessant character during the day. He had been
under treatment for two months previous, taking cough-
sirups and morphine, and had been advised to eat rare
meat with cayenne pepper, and drink as much liquor as
he conveniently could. He was gradually growing worse
day by day.
An examination of his larynx had never been made
for this trouble. He had seen me once, two years pre-
vious, for a slight cough, which yielded quickly to treat-
ment, and rendered a second visit unnecessary. He came
with his wife, whom I was treating for a stenosis of the
nose of syphilitic origin. A thorough examination at
this time failed to reveal any syphilitic symptom.
THE MEDICAL RECORD.
289
Upon his second visit, two yedrs later, I found, while
examining his larynx, a deep ulceration and partial loss
of the epiglottis, with heavy ulceration of the true and
false cords, and ulceration in the sinus pyriformis.
I made my diagnosis, from the appearance of the ulcer-
ation and his past history, as syphilis of the larynx. He
gave the history of chancre, twenty-five years previous.
in the meantime he had been in good health—a little
rheumatism, a slight catarrh, but never any serious illness.
When he came to me he breathed with great difficulty,
and his appetite had completely gone. His cough was
incessant.
The history of the case and the appearance of the ul-
ceration could leave no doubt of the stage to which the
disease had progressed. I stopped all his previous treat-
ment, saw him daily at my office, and treated the parts
locally with Dobell’s solution, tannic acid in solution, co-
caine, voschano-oil spray, and the application of 1odoform
in powder over the ulceration. Internally I began with
the potassii iodidi, gr. xx., and gradually increased to a
drachm, three times a day, and had the hydrarg. oxidi
rubri rubbed in over his neck three times a day.
The patient’s stomach stood the doses of potassii iodidi
and did not revolt, neither was there any acne. At the
end of five days he complained of a slight pain in the
bowel, with a diarrhoea attended with a bloody discharge.
I thought this might be due to his inunctions of mercury,
and ordered a smaller quantity to be rubbed in. His
throat did not improve as rapidly as tertiary cases usually
do to doses of iodide. One day it was better, and the
next day it was worse. When I stopped the mercury his
pain was less severe in the bowel, but the healing process
of his throat was at a stand-still. I gradually decreased
his potassii iodidi, and at the end of ten days discontinued
it entirely, and put him under the one-thirty-second part
of a grain of hydrargyri bichloridi in solution three times
a day, and inside of a week was gratified to find my pa-
tient’s throat markedly improved. Once or twice I had
occasion to give him potassii iodidi in four-grain doses ;
but, as certain as I was to combine the iodide, I would
find the ulceration on the increase in a few days.
Among the large number of these cases that I have
been called to treat in private practice and in the Bellevue
Out-door Poor Throat Clinic, this is the only one I have
ever seen that yielded to hydrargyrum alone, and in which
potassii iodidi did absolutely harm. His wife was able at
one time to take one hundred grains three times a day,
and, in fact, it was only by this dose that I was able to
give her any relief from her symptoms.
The patient made a perfect recovery under the latter
treatment, and gained twenty pounds in weight. I have
heard since that the patient had been given up by his
previous attendant, who had diagnosed his trouble as con-
sumption of the lung.
An examination of the larynx is sometimes a very im-
portant factor in the cure of a case.
112 WEST Forty-rirru STREET.
TRADING IN PRACTICES.—A lawsuit in England re-
cently revealed a curious trade carried on by a young
physician named Hanna. Soon after obtaining his license
to practise, being then twenty-two years old, he bought a
practice at Bingley for £250, and sold it thirteen months
later for £650, though the purchaser does not appear to
have been altogether satisfied with the transaction. He
then went to St. Leonard’s and bought a practice there for
£185, but was not very successful in this venture and had
to sell out for £275. Then he turned to Coventry, and
bought the practice of Dr. Aitkens for £297, including
the furniture. Here he took a partner, who paid £500
for the privilege of sharing in a practice which was repre-
sented to be worth £950 per annum. Soon after this Dr.
Hanna became bankrupt in some unexplained way, and
when taken to court the history of these transactions
came out.
290
THE MEDICAL RECORD:
A Weekly Fournal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., EDITOR.
PROPRIETORS AND PUBLISHERS
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
——
New York, September 14, 1889.
‘SOME SUGGESTIONS CONCERNING NOMEN.
CLATURE.
LANGUAGE is intended to be the medium through which
ideas are expressed, and in order that it may fulfil this
purpose, it is of the utmost importance that the words
used should have a definite meaning, and one that is ex-
pressive of a certain idea. This is especially true in
science, and here, even more than elsewhere, the words of
‘the writer or speaker should be carefully selected, and
‘should be distinguished, as Dr. Pye-Smith has well said,
‘by clearness and conciseness. There are several terms in
‘medical nomenclature which are used in defiance of ‘this
axiom, and concerning which a few words may be useful.
One of these is the use of the word gland as applied in-
discriminately to any collection of tissue whatever. Most
authorities now employ the term strictly in the sense of a
secreting body, and apply the word nodes or nodules to
the enlargements occurring along the lymph-vessels, or
to the collections of lymph-tissue in the intestines and
elsewhere. This is a good distinction, and one that it
would be well if writers would observe generally, since it
tends toward the side of clearness and definite meaning.
There are two other points of medical nomenclature
referred to by Dr. Donald Macalister, in Zhe Practitioner
for August, 1889, concerning which the writer offers some
pertinent suggestions. The first of these is the distinction
between tubercular and tuberculous. By most writers
these two words are used synonymously, or rather inter-
changeably, without any attempt to separate them in
meaning. The author suggests that the adjective tuber-
cular be used only to denote a morphological appearance,
implying a condition in which small nodules are appar-
ent, being thus nearly synonymous with nodular. ‘The
term tuberculous he would employ solely as the adjec-
tive corresponding to the noun tuberculosis. Similarly,
he would use the terms tubercule and tubercle to denote
respectively the morphological cutaneous nodule and the
specific granulomatous nodule.
A second suggestion made by Dr. Macalister is con-
cerning the employment of the terms diphtheritic and
diphtherial. ‘The former word, he points out, is used in
two very distinct senses, as relating to one of the forms of
inflammation, or to the specific disease, diphtheria. ‘ Pa-
thologists,” he says, “classify the inflammations of the
mucous membranes as (1) catarrhal, characterized by a
morbid increase of secretion with desquamation; (2)
THE MEDICAL RECORD.
[September 14. 1889
a 1 aaaea aI Iam aaaaamammŘħŮŐ— ——
croupous or fibrinous, when there is an exudation from
the vessels which coagulates on the epithelial surface and
forms a separable false membrane ; and (3) diphtheritic,
when the exudation induces coagulative necrosis of the
mucous membrane, and the false membrane formed is
separable only as a slough. Necrosis and coagulation are
the essential features of diphtheritic inflammation, and it
may be due to various causes. The diphtherial virus,
when it affects the pharynx and neighboring parts, may,
according to its intensity and the state of the patient, set
up either catarrhal, croupous, or diphtheritic inflamma-
tion; it by no means always induces the latter form. On
the other hand, acute dysentery is often diphtheritic,
though it has nothing to do with diphtheria. The neuritis
of diphtherial paralysis is not a diphtheritic inflammation.
It would be impossible to make this latter statement in a
clear and concise form if the distinction here drawn were
not observed, and therefore I would propose that diph-
therial should refer to the specific disease diphtheria,
while diphtheritic is reserved for the variety of inflamma-
tion, whether it be induced by the poison of diphtheria
or not.”
It would be well, we think, were these distinctions ob-
served by writers on medicine, for they certainly are a
step toward that clearness and conciseness in language
which are so essential to a correct understanding of it.
AN AERIAL HOSPITAL.
THE value of high altitudes in the treatment of pulmonary
phthisis is generally recognized at the present day, though
unfortunately the number of sufferers who can avail them-
selves of this therapeutic measure always has been, and
always will be, limited. Only the favored few are so
situated that they can leave their occupations and can
afford the expenses inseparable from a long journey and a
prolonged stay in localities where the conditions are
favorable for arrest of tuberculous disease. Again, the
separation from home and friends is trying, and the de-
pressing influences of nostalgia are often sufficient to more
than counteract the benefits of climate and soil.
These drawbacks, however, are now to be done away
with, for an ingenious Frenchman, Dr. Riera by name, in-
spired doubtless by a climb to the topmost platform of
the Eiffel tower, has devised a means whereby high alti-
tudes may be brought, as it were, to everyone’s door, and
an elevation of one, two, or five thousand feet may be
reached in less time and with no more exertion than are
involved in a street-car mde of a dozen city blocks. The
accomplishment of this object is to be attained by means
of a captive balloon of large size, beneath which is sus-
pended a commodious hospital, provided with all the con-
veniences and luxuries of the best hotels on zerra firma.
The house can, of course, be raised or lowered to any
elevation desired. Communication with the ground may
be had by means of cars travelling upon the cables
attached to the balloon. By means of telephones the in-
mates of the hospital can converse with their friends, or
be entertained at evening concerts and lectures. The
library will contain a full set of Jules Verne’s works, and
will be free to all. ‘The opportunities for exercise would
necessarily be somewhat limited, but the roof of the house
could be used as a promenade, and the stronger and more
September 14, 1889]
adventuresome of the patients might climb dawn and up
the anchoring cables by way of getting up an appetite.
Among the therapeutic measures employed as adjuvants
to the high-altitude treatment, gaseous enemata would
doubtless be popular, for the balloon could be tapped at
- any time, and if the gas were returned after use there
would be no danger of reducing the level of the house.
We cannot refrain from extending our congratulations
both to the originator of this brilliant scheme and to the
many seekers after the hitherto unattainable which is now
within their grasp. It is thus that science triumphs over
all obstacles. Old age has been robbed of its terrors, and
now the consumptive can sit in his eyrie and laugh at the
bacillus of Koch.
A REPORT ON CIGARETTES.
Mr. WILLIs G. ‘TUCKER, analyst to the New York State
Board of Health, has sent in a report on the result of
his examination of various popular brands of cigarettes.
Statements are often made that cigarette tobacco is adul-
terated with opium or other agents, and that the
paper wrapper contains various injurious substances.
Careful analysis of tobacco and paper failed to reveal
any poisonous ingredients other than the tobacco itself ;
and the examination tended to show, what is probably
true, that most cigarettes contain pure tobacco and good
paper. ‘The evils of cigarette smoking are, as Mr. Tucker
States, due to the fact that cigarettes are cheap, conven-
lent, and can be used in large and excessive quantities,
that the smoke is usually inhaled, and that children and
immature persons so freely use them.
Mews of the GHeek.
Dr. HABERSHON, of London, died on August 22d.
He was author of a work, well-known in this country, on
diseases of the digestive organs.
SOME PERSONAL EXPERIMENTS WITH HANGING.—Àt
the recent Congress of Forensic Medicine in Paris, Dr.
Gosse, of Geneva, opened a discussion on hanging and
described experiments made upon himself. On two oc-
casions he had so far succeeded in hanging himself that
he entirely lost consciousness. He found often that the
cord did not squeeze the throat so as to stop the breathing.
‘The rope formed a sort of triangle which pressed on the
carotid, but not on the larynx. In that case death was
not painful, there was a buzzing sound in the head, and
unconsciousness at a very early stage. But if the rope
pressed on the throat, then the struggle for breath was very
painful. On carefully examining criminals after hanging,
it would be found that when convulsions occurred the
lungs were empty. If the victim could fill his lungs with
air before the rope tightened he would not suffer so much,
if at all. When a person was found hanged and there
were two marks showing that the rope had changed place,
this might be considered as a suspicious sign. It, in all
probability, meant that he had been hanged after having
been strangled. This he had noticed in the case of a
gendarme hanged on the Swiss frontier. ‘There were
two marks, so he made a more careful investigation, and
then perceived that the rope was too short for the gen-
THE MEDICAL RECORD.
29!
darme to have been able to hang himself. Ultimately,
what seemed a suicide was proved to be a murder.
SPONTANEOUS Cow-pox.— Dr. E. Morrison, of New-
ton, N. J., September 4, 1889, reports a case which he
believes to be one of original, or so-called spontaneous,
COW-pox.
THE CuicaGo Medical Journal and Examiner has sus-
pended publication.
ACCORDING to the Mew England Medical Monthly,
President Timothy Dwight, of Yale College, has secured
the title of “ LL.D.” for a homceopath to whom he felt
indebted for professional services. This homceopath is
furthermore said to have “ given public documentary evi-
dence of his small learning and less wit.”
A New MepicaL Co.iece.—The U. S. Grant Uni-
versity of Chattanooga, Tenn., has organized a medical
department which opens this fall.
TREPHINING THE LATERAL VENTRICLE.—In a case of
severe tubercular meningitis marked by coma, slow pulse,
Cheyne-Stokes respiration, fixed dilated pupils, and twitch-
ings in one arm, Professor von Bergmann trephined the
frontal bone and tapped the lateral ventricle. ‘The im-
mediate effects were excellent ; consciousness returned,
the pupils reacted to light, the pulse and respiration be-
came more natural, and all went well as long as the cere-
bro-spinal fluid continued to escape through the puncture.
But this drain ceased, the serious symptoms then recurred. -
and the child died.
AMERICAN ACADEMY OF MEDICINE.—Dr. Richard J.
Dunglison, secretary, announces that the annual meeting
of the Academy, for 1889, will be held at Chicago, Il.,
November 13th and 14th, being postponed to that date
by authority of the Council.
AN OFFICIAL INVESTIGATION OF ARTIFICIAL Foops.—
At the recent meeting of the Association for the Advance-
ment of Science, Dr. F. Hoffman, of this city, read a
paper on infant foods, in the course of which he stated
that the chemists of the United States Agricultural De-
partment were about to begin with the work of investigat-
ing the different artificial foods and infant foods now on
the market.
MEDICAL CONGRESS IN BRAz1L.—The second Brazilian
Congress of Medicine and Surgery will be held at Rio de
Janeiro, beginning on the 15th of this month. The meet-
ing will be presided over by Dr. Hilario de Gouvêa.
Among the subjects for discussion the following are of
general interest :—“ The Nature, Cause, and ‘Treatment
of Beri-beri,” “ Prophylaxis and ‘Treatment of Yellow
Fever,” “Prophylaxis and Treatment of Tuberculosis,”
“« Geographical Distribution, Symptomatology, Nature, and
Treatment of the Acute Spasm of the Œsophagus, which
is endemic in certain parts of Brazil,” “' The Nature of
Aivhum,” “ Elephantiasis Arabum,” etc.
Orris Root 1n AMERICA.—Florentine orris (iris flo-
rentina) is said to have been discovered in considerable
quantity growing in South Carolina.
THE ‘THIRD ANNUAL MEETING OF THE AMERICAN OR-
THOPEDIC ASSOCIATION will be held in the building of the
Boston Society of Natural History, at the corner of Boylston
and Berkeley Streets, on September 17, 18, and 19, 1889.
The following papers have been announced: Address by
292
the President, Dr. E. H. Bradford, on “ American Or-
thopedics ;” “Spondylitis after Typhoid Fever,” by Dr.
V. P. Gibney, of New York; “The Relation of the
Thoracic and Abdominal Walls to the Spinal Column,
considered with Reference to the Treatment of Anterior-
posterior Curvature,” by Dr. L. A. Weigel, Rochester (by
invitation) ; “ Psoas Contraction as a Symptom,” by Dr.
Dillon Brown, New York; ‘ Double Congenital Disloca-
tion of the Hip,” by Dr. Samuel Ketch, New York; “A
Case of Caries of the Ankle treated Conservatively,” by
Dr. C. C. Foster, Cambridge; “ A Report of Cases of
Caries of the Ankle treated by Excision (with exhibition
of patients),” by Dr. Charles L. Scudder. Boston (by in-
vitation) ; “ The Value of Motion in the ‘Treatment of
Hip Disease,” by Dr. W. R. Whitehead, Denver ; ‘ Rest
in the Treatment of Hip-joint Disease,” by Dr. De F.
Willard, Philadelphia; “Abscesses in Hip Disease,
their Prevention, Significance, and Treatment. A Clin-
ical Study,” by Drs. R. W. Lovett and J. E. Goldthwaite,
Boston; “ A General Discussion upon the Treatment of
Hip Disease,” by Drs. Shaffer, H. L. ‘Taylor, J. E. Moore,
Steele, De F. Willard, R. H. Sayre, Ridlon, Gibney, and
others ; “ An Experimental Study of Distraction of the
Hip-joint,” by Dr. E. G. Brackett; “An Analysis of
Twenty-one Cases of Hip Disease treated by the ‘Thomas
Splint,” by Mr. John H. Huddleston ; “ The ‘Treatment of
Pes Equino Varus,” by Dr. Henry Ling Taylor, New York ,
“Is Rotary Lateral Curvature of Rachitic Origin?” by
Dr. G. W. Ryan, Cincinnati ; “ A New Exercise in the
Treatment of Lateral Curvature of the Spine,” by Dr. A.
J. Steele, St. Louis; “The ‘Treatment by Portative Ap-
pliances of Ununited Fracture of the Thigh,” by Dr.
Newton M. Shaffer, New York; ‘Operations upon the
Spine for the Relief of Pressure Paralysis, with the report
of a case,” by Drs. Herbert L. Burrell and W. N. Bullard,
Boston (by invitation) ; “ A Case of Functional Torticol-
lis, probably due to defective eyesight (with exhibition of
patient),” by Dr. R. W. Lovett, Boston; “A Case of
Congenital Absence of Five Ribs, with resulting Deformi-
ties,” by Dr. Homer Gage, Worcester (by invitation) ;
“The After-treatment of Hip Disease,” by Dr. A. B.
Judson.
SAM JONES ON THE FAITH CurRE.—In a recent sermon
Sam Jones delivered himself as follows concerning the
faith-cure brethren: “TI’ll tell you where this faith cure
comes in. ‘There’s an old brother and sister who have
been taking all the nasty quack patent medicine on the
market for the last ten years. Somebody comes along
and prays over ’em, and they quit using the patent medi-
cines, and they are well again. ‘They say it was faith that
cured. It was faith. It was the faith which caused them
to quit taking old patent nostrums which cured them.”
AN INTERNATIONAL CONGRESS OF HyPNoTisM.—Paris
is congress-mad, and the number of so-called international
congresses held there during the exposition season is le-
gion. One of these was devoted to the study of hypno-
tism. ‘The objects of the meeting were to determine upon
a nomenclature for the new science, and also to collect
and record facts illustrating the therapeutic value of the
new method. Among the recommendations set forth by
the congress was, that all public exhibitions of hypnotism
siould be prohibited, that the exercise of this force as a
therapeutic measure should ,be placed under the same
THE MEDICAL RECORD.
N
[September 14, 1889
rules and restrictions that govern the praetice of medicine,
and that the study of hypnotism and its practical applica-
tion should form part of the regular medical curriculum
in the schools. The following is the somewhat clumsy
definition of the hypnotic state as formulated by one of
the essayists, M. Berheim: Hypnosis is a particular
psychic condition, susceptible of being induced, which in-
creases in varying degree the suggestibility of the patient,
that is to say, the aptitude of being influenced by an idea
accepted by the brain, and of realizing it.
EXAMINATIONS FOR THE MEDICAL CORPS OF THE
Army.—An Army Medical - Board will be convened in
New York City, N. Y., October 1, 1889, for the ex-
amination of such persons as may be properly invited to
present themselves before it as candidates for appointment
in the Medical Corps of the Army. Application for an
invitation should be addressed to the Secretary of War,
stating date and place of birth ; place and State of per-
manent residence, and accompanied by certificates, based
on personal acquaintance, from at least two persons of
repute, as to citizenship, character, and moral habits ;
testimonials as to professional standing, from the Profes-
sors of the Medical College from which the applicant grad-
uated, are also desirable. The candidate must be between
twenty-one and twenty-eight years of age, and a graduate
from a regular Medical College, evidence of which, his
diploma, must be submitted to the Board. Further in-
formation regarding the examinations and their nature
may be obtained by addressing the SurgeonGeneral-
United States Army, Washington, D. C.
A LATIN PeriopicaL.—Alongside of the Volapük en-
thusiasts there are a few men in this country, as well as in
Europe, who are working to reinstate Latin as the lan-
guage of science, if not of general communication between
the nations of the world. These may be encouraged to
learn that a periodical, written in chaste and elegant Latin,
has recently appeared in Aquila degli Abruzzi, in Italy.
It is edited by Carlo A. Ulnchs, a young Latin scholar of
considerable reputation, and is published semi-monthly.
Six numbers have already appeared, and the editor an-
nounces that the subscription-list is increasing in a very
satisfactory manner, and contains the names of many
scholars in Europe and America. The name of the
periodical is A/aude (Larks). It is a purely secular
journal, being filled with poems, stories, anecdotes, jokes,
and news. An effort is being made, it is said, to establish
a medical journal in Latin, but the success of such an un-
dertaking would seem to be very problematical at this time.
THE “ ANNALES DE LA TUBERCULOSE ” is the name of
a new journal recently established in Paris. It is to be
published bi-monthly, and, as its name implies, will be
devoted to a study ot tuberculosis in all its aspects.
THE BRITISH MEDICAL ASSOCIATION adjourned with-
out deciding upon any place of meeting for 1890. It was
supposed that London would invite the members to as-
emble there ; but there is a want of harmony among the
members of the medical profession in London just at this
time, so the invitation was not forthcoming. No other
place has expressed a desire for a visit from the Associz-
tion.
A New Source or Supp_y oF PopopHyLLuM.—lIt is
said that the May-apple grows in great abundance in the
September 14, 1889]
Himalaya mountains, and that it is very much richer in
podophyllin than the American plant, the amount of resin
which can be extracted from it being nearly three times
larger than that from the podophyllum of this country.
M. Pasteur has been created a baron by the Emperor
of Austria, for distinguished services.
Dr. J. J. SHANKS has resigned the superintendency of
the Flatbush Insane Asylum, and gone to Europe.
HOMCOPATHISTS IN AUSTRIA.—According to the most
recent official statistics in Austria, there are only 118
homeeopathists out of the whole number of medical men,
7,183, and only 44 of these profess to practise homceopa-
thy exclusively. ‘There are none at all in the Italian dis-
tricts, and only 19 in Vienna. The number also is said
to be steadily decreasing.— Medical Press.
SMALL-POX is said to predispose one who has suffesed
from it to contract tuberculosis.
THE Mott MEMORIAL LiBRARY.—One of the funniest
institutions in this city, says Zhe Sun, is the Mott Me-
morial Library. Dr. Valentine Mott left it behind him
because he could not conveniently carry it into another
world, and it has since been maintained as a public insti-
tution. It is strictly medical, chiefly surgical, almost en-
tirely confined to the period of twenty-five years ago. The
library and various busts and portraits of its original
owner are housed in a delightful old brick mansion in
Madison avenue. The books are carefully locked in
cases, and seldom consulted. The whole house is ex-
empt from taxation. Of course, it is wicked to tax a
free library. Meanwhile, however, the rooms in which
the unused library is situated are rented to various
organizations.
THE CORNER-STONE OF THE DELAWARE HOSPITAL,
in Wilmington, was laid August 18, 1889. The cost of
the grounds and building when completed will amount to
$20,000, $16,000 of which is in hand.
SuRGEON Harvey E. Brown, U. S. A., died August
zoth, at Jackson Barracks, near New Orleans. He was a
son of General Harvey Brown, of the regular army, and
born in New York. He graduated from the University
Medical College in 1858. He was surgeon of volunteers
from 1861 to 1863, and then became Assistant Surgeon,
U. S. A. ; became full Surgeon and Major in 1881. He
was the author of a valuable compilation and historical
sketch of the Medical Department of the Army from
1775 to 1873. He was identified with nearly every epi-
demic in the Gulf District for twenty-five years. His
final disease was lingering and painful, due to consump-
tion.
Jouns Hopkins UNIVERSITY RuINED.—The New York
Sun prints a long communication from Baltimore, describ-
ing the financial condition of the Johns Hupkins Univer-
sity, and claiming that it is now practically ruined. The
endowment was nearly all in Baltimore & Ohio R. R.
stock, which once paid ten per cent. dividend, but now
pays nothing. We note, however, that the University has
just received a legacy of over $100,000 by the will of
John W. McCoy.
VIRCHOW ON THE DARWINIAN THEORY OF THE ORIGIN
OF Man.—Professor Virchow, at the recent session of the
THE MEDICAL RECORD.
293
Anthropological Congress at Vienna, again attacked Dar-
win’s theory of the origin of man. ‘It is now,” he said,
“ twenty years since this doctrine of triumph has reached
us, that we had only to find the connecting link between
man and monkey to complete our history of race and va-
rieties ; but our labors since then have been fruitless in
discovering that important connection, the ‘ vormensch,’
or that particular ‘ pro-anthropos’ which would enlighten
our path. Since the promulgation of this theory many
stormy wars have been fought, but now we are inclined to
believe that every human race has come from a race of
human beings, and not from the monkey tribe at any
time.”
SuIcIDE OF Davip TiLDEN Brown.—Dr. David Tilden
Brown, Superintendent of Bloomingdale Asylum, from
1855 to 1875, committed suicide at his farm, at Batavia,
Ill., on September 5th. Dr. Brown was the victim of sen-
sational journalism. In 1875 a New York paper began a
bitter fight against the Bloomingdale management, because
of alleged outrages carried on there. This attack so af-
fected Dr. Brown that his health failed and his mind be-
came unbalanced. In this condition his wife took him
abroad for treatment. His insanity was of a mild form.
In an Edinburgh asylum a partial cure was brought about.
The doctor and his wife returned to America. In an
Illinois asylum, where Mrs. Brown secured a position as
matron, the cure was completed, and with what money he
had left Dr. Brown bought a small property in Batavia,
Ill., on which he has since lived happily. His son, Dr. F.
T. Brown, lives in this city. A few weeks ago, a New
York daily came out with a sensational account of Dr.
Brown’s history, and a statement that he, though believed
dead by all his friends, was alive. ‘The publicity given to
‘this story is said to have acted upon Dr. Brown’s sensitive
mind, and produced an attack of melancholia. Dr.
Brown was a man of fine attainments, a very popular man,
and an accomplished physician.
JUGULATING PNEUMONIA.—At the recent Therapeutical
Congress, in Paris, M. Petrescu, of Bukharest, claimed
that pneumonia could be aborted in its early stages by
giving large doses of digitalis, <. g., 4 to 8 grammes (3 j.
to 3 ij.) of the leaves in infusion, daily.
Dr. J. G. Jounsron, of Brooklyn, who was recently
arrested under charges of criminal assault, has been, we
are told, entirely exonerated.
IT IS STATED THAT MR. REGINALD HarRrIsON, F.R.C.S..
of Liverpool, who is well known as an authority and a
skilful operator in diseases of the urinary organs, is about
to take up his residence in London.
THE SECOND ITALIAN CONGRESS FOR INTERNAL
MEDICINE meets at Rome, October 15 to 18, 1889.
Among the subjects to be discussed are malarial infection,
nephnitis, and gout.
ORTHOMETHYLACETANILIDE is the name for exalgine,
found by Dujardin-Beaumetz to possess very marked
analgesic properties.
OVERHEAD ELECTRIC WIRES IN LoNnpDON.-—Attention
was called recently in Parliament to the danger from
overhead wires in London, and an effort is being made to
have them put underground.
294
THE MEDICAL RECORD.
[September 14, 1889
Society Reports,
BRITISH MEDICAL ASSOCIATION.
Fifty-seventh Annual Meeting, held at Leeds, England,
August 13, 14, 15, and 16, 1889.
(Special Report for THe Mupicat Recorp.)
(Continued from page 275.)
SECTION OF MEDICINE.
WEDNESDAY, AUGUST 14TH—FirsT Day.
Dr. Joun E. Eppison, of Leeds, delivered the
PRESIDENTS ADDRESS,
which consisted merely in a few words of welcome and a
brief sketch of the work proposed for the Section. He re-
marked that in his opinion it was wrong to so far divide
the study of medicine, and he much regretted the exces-
sive multiplication of sections. Thus medicine was split
up into sections of therapeutics and pathology, and there
seemed to be a tendency to make the medical section into
a mere place for the discussion of the symptomatology of
disease, a fatal error, he thought.
Dr. R. DouGLas PowELL, of London, then began the
work of the Section with a communication upon
THE CLINICAL ASPECTS OF CHRONIC TUBERCULOUS DISEASE
OF THE SEROUS MEMBRANES.
He said he would not enter into the detail of symptoms
before such an instructed audience, but merely give a few
general observations on tubercular diseases of serous
membranes in different regions of the body. Tubercular
disease was sometimes a primary affection in the pleura,
the joints, the cranium, and the peritoneum, and was
often localized in one serous membrane, so that the
symptoms produced were due to the presence of tubercle
in the It was said that in such cases the tubercle
bacillus effected an entry into the region from the outer
surroundings of the patient ; but he agreed with Mr. Bark-
er, who had observed that a certain state and condition
of the tissues seemed necessary for the appearance of
tuberculosis in any part. ‘Thus in children the cells of the
embryonic tissue were less resistant to the invasion of the
bacillus than those of adults in certain localities. ‘Thus
simple inflammatory disease of a joint might lead to the
invasion of the bacillus from lessened resistance. In
children of the ages between three and nine the tissues
were remarkably vulnerable ; but after the age of nine it
was rare to see tubercle in the joints. This period (three
to nine) was a period of great excitement. Tubercular
meningitis was rare in adult cases of consumption; thus
in 563 cases of that malady occurring in Brompton Hos-
pital, London, only 30 suffered from that form of it.
Tubercular meningitis as a chronic disease was so rare as
to be almost unknowr. It proved fatal sg rapidly that
it was not one of the instances of chronic tubercular dis-
ease of the serous membranes, so that he need say nothing
about that kind of affection of the serous membranes.
Pleurisy, he observed, was known to precede tuberculosis
in many cases, and it was often difficult in such circum-
stances to ascertain whether there might not be, simulta-
neously with the pleurisy, some deposit of tubercle in the
lungs. He mentioned a case of pleurisy which had been
under his care nine years previously, and which he had
brought before the notice of the International Medical
Congress in London. In this case he had drawn off the
serous fluid, and the patient was confined to bed for sixty
days, and left the hospital with a contracted left lung.
Last year, 1888, this patient had extensive tubercular dis-
ease of the same lung. In another case a girl, in 1885,
had been treated for pleurisy with effusion, and in 1888
she exhibited symptoms of phthisis pulmonalis of the left
apex, with many bacilli present in the sputum. In this
case there had probably been some consolidation of the
pleura previous to the occurrence of the pleurisy in 1885.
In the sputum there were lime salts present, and very
likely there had been some arrest in the progress of the
tuberculosis and deposit of lime salts around a small
cavity which was not recognized when the pleurisy was
present. He drew attention to the
DIAGNOSTIC POINTS
in ascertaining the presence of tubercle in such difficult
cases as this. Of such were slight hectic, slight cough,
and wasting of the body. Perhaps tubercular disease
might be found to exist in other organs. Dry pleurisy at
the apex of the lung was a very suspicious symptom, and
Dr. Burney Yeo had given interesting cases where such
dry pleurisy of the apices had existed without tuberculosis.
In some cases the sputum was tinged with blood. Then,
again, too little attention was often paid to slight rising
of the temperature in such cases. In some instances of
tubercle in the lungs the temperature might only nse to
99° F. in the evening ; but, if this continued, it was of very
great importance as a point in diagnosis. Then as to the
effusion, in most cases the fluid was perfectly pure. When
stained with blood this might lead to the suspicion of the
existence of tuberculosis or cancer. Setting aside cases
of pneumo-thorax, pus was rather the exception in such
cases of pleurisy than the rule. In twenty cases of pleu
ritic effusion in consumptive persons there was a total
absence of bacilli in the effusion. This was ascertained,
firstly, by microscopic observation ; next, from cultiva-
tions with the fluid, which proved fruitless; and, lastly,
from the results of inoculation of the lower animals with
the effusion, although the last of these processes had been
the most positive in its results in similar cases. Yet in
some of these cases the pleurze were found after death to
be studded all over with tubercles. In one case he had
seen, a gentleman had gone to Corfu, and while on that
island had experienced a chill while travelling. Shortly
after this the patient presented symptoms of softening of
the right base of the lung. ‘The temperature fluctuated in
this case, and it apparently was one of simple pleunsy ;
but it turned out to be a case of phthisis. In his case he
examined the effused fluid repeatedly for bacilli, but at
first found none, and it was only on the seventh examina-
tion that a few were seen. In another case of empyema
he had procured a drop of pus from the pleural membrane
itself, and this showed bacilli. He asked,
WHAT BECOMES OF CASES WHERE ABSORPTION TAKES
PLACE P
In such cases the tubercle became obsolescent, and the
prognosis depended upon the condition of the lung it-
self. With regard to the thickening of the pleura, a
hard, thick, cartilaginous pleura was not a concomitant
of tuberculosis. ‘These are the cases in which pneumo-
thorax occurs in phthisis pulmonalis. In the case of
tubercular peritonitis the diagnosis of the disease was
of great difficulty in the outset of the case. Friction
might sometimes be heard. ‘The pulse was quicker than
usual, and the temperature heightened, although it had a
lower range than in tubercular pleurisy. ‘Then there was
loss of flesh and sume ascitic effusion. This ascites might
in the female simulate ovarian dropsy. In one case which
he had seen the woman looked quite as if she was suffer-
ing from ovarian disease, but this was not the case. ‘Then
there was the case which had been published by Sir Spen-
cer Wells, in which there was a prominent abdomen, and
when the abdomen was opened the peritoneum was found
to be studded all over with tubercles. Sir Spencer Wells
stitched up the abdomen, and the patient recovered. This
was twenty-six years ago, and he had heard that the pa-
tient was alive.
Of thirty-eight cases collected in which the abdomen
had been opened in similar circumstances, sixteen of the
patients recovered their health. He was not sure whether
all of these were really tubercular peritonitis. In another
case cited by the author masses could be felt agglutinat-
September 14, 1889]
ing the intestines together, the tongue was glazed, and the
pulse quick. In another case, which proved fatal, there
was complete strangulation of a kauckle of intestine, and
Dr. Fenwick had noticed this cause of death in some
cases. Louis’ dictum, that when, in an adult, there was
tubercle in any organ of the body, there would also be
found to be tubercle in the lungs, was almost, but not
quite, true. The tendency of tubercular disease was to
produce fibroid degeneration in cases where pleuritic
effusion had existed for a lengthened period. The pelvic
portion of thc peritoneum was almost a separate sac, and
was Often entirely shut off from the general peritoneal
cavity. In his experience two cases of tubercular peri-
tonitis had been diagnosed as neurasthenia, and had
been treated by massage, which had proved fatal to the
patients. As a clinical phenomenon, it must be conceded
that tubercular peritonitis was not necessarily a fatal
disease. In the tunica vaginalis testis the appearances
were similar to those seen in pleurisy.
THE PROGNOSIS OF TUBERCULOSIS IN THE PLEURA AND
OTHER SEROUS MEMBRANES WAS NOT HOPELESS,
but, of course, very alarming. No drug we were ac-
quainted with had the power of curing tubercle ; neither
iodoform nor any any other antiseptic possessed such
power. Perhaps mercury, pushed to salivation, might
occasionally kill the bacillus; but all other parasiticides
were too feeble, so that all that could be done was to
strap the chest in pleurisy, or depend on other palliative
remedies. With regard to operations, great differences
existed as to the operative treatment to be employed in
joint tubercle, for while one surgeon would operate early.
and frequently in such cases, another would but rarely
operate, and when he did so would do it late on in the
disease. General tubercular disease in other organs
might be lighted up by the spread of the bacillus from
one organ. Effusion in other organs might be salutary in
cases of tuberculosis of the lungs. The idea of opening
the peritoneum in tubercular peritonitis would have been
looked upon with horror some years ago. But Mr.
Knowsley Thomson had twice operated inadvertently in
such cases of tubercular peritonitis, and had had no bad
results. ‘There were, of course, favorable cases, for it was
Impossible to remove the disease by operation, and the
successful cases were those which were not associated
with perforation of the bowels.
Dr. HANDFORD, of Leeds, agreed with Dr. Powell
that tubercle could not be cured by any drug. The
tubercle bacillus ran a very different course in different
animals. ‘The chief effort in therapeutics should be
directed toward improving the condition of the organ
affected with tuberculosis. He was by no means con-
vinced that all the cases where the peritoneum had been
opened by surgeons, and tuberculosis had been sail to
exist, were clearly cases of tubercular peritonitis. In
some cases called tubercular peritonitis no bacilli had
been found. He asked whether laparotomy was indicated
in cases where no effusion existed into the peritoneal
_ cavity. In suppurative peritonitis laparotomy might be
of service.
Dr. Burney Yeo said that it would be very important
in discussions if some proposition were defended and
attacked, as it would save time in sticking to the ques-
tion. As to tubercular disease of the pleura, this rarely
took place without the lung also being affected. Certain
cases of disease of the apex might occur, which were de-
pendent on rheumatic affections. Cases like these got
well, and often figured, he believed, among the cases of
cure of phthisis. Other cases existed with diseases of the
joints of rheumatic character, and iodine and iodide of
potassium cured them. A patient of his had some signs
of bronchial catarrh, but no symptoms of phthisis, z.e.,
neither emaciation, quick pulse, night-sweats, nor hectic.
She was considered to have phthisis by some, but neither
himself nor some other consultants took that view of the
case. He agreed with Dr. Powell that it was not very
THE MEDICAL RECORD.
295
good practice to remove the effusion in tubercular peri-
tonitis. He was in favor of antiseptics in the treatment
of such cases.
Dr. CHURTON said that he had had recently a case of
a man with tubercular peritonitis under his care, and who,
although not actively treated, had quite recovered. In
some cases where he had thought that the patient had
been cured, tubercle had afterward appeared in the lungs.
He asked whether in such cases the opening of the ab-
domen might not prove curative. As to diagnosis, he
considered that the presence of blood in the fluid drawn
off from a suspected case of tubercular effusion was not
of much value as a symptom of tuberculosis.
Dr. BROADBENT, of London, would say only one word
as to the effect of the incision of the abdomen in tuber-
cular peritonitis. He had not been fortunate enough to
see a cure effected by this operation in any case ; but in
all instances in which this operation had been performed
there had been some relief given to the patient. In one
instance great relief was given, and life considerably pro-
longed. ‘Tubercle, he observed, was a very vulnerable
neoplasm, and thus this operation might cause its disap
pearance in the organs.
Dr. C. G. Brown said that pleurisy of the base of the
lung was not infrequently followed by deposit of tu-
bercle in the apex of the lung. l
Dr. DryspaLe, of London, said that the opener of the
paper had alluded to the extreme vulnerability of children
from three to nine years of age with regard to the tubercle
bacillus in joints, and he would like to ask whether the
whole human race might not be considered as vulnerable
in like manner, if subcutaneous injection of tubercle ba-
cilli were effected. ‘This was his own belief, but he had
heard it doubted by most competent persons. He had
seen several cases where apparently innocent pleurisy with
effusion had, in a few years afterward, been followed by
phthisis pulmonalis, and cited the case of a gentleman,
aged fifty-seven, who caught cold, had pleurisy with abun-
dant effusion, from which he recovered, but three years
subsequently had phthisis pulmonalis and died of the dis-
ease. This was an instance of a part becoming vulner-
able to the bacillus because of an attack of inflammation.
He had never. detected the tubercle bacillus in pleuritic
effusions, even in consumptive patients. He saw but lit-
tle good in the proposal to operate in cases of tubercular
peritonitis, and was afraid that this was one of the cases
of the nimia diligentia medici which were to be avoided.
Dr. SaunpBy, of Birmingham, agreed that the bacillus
of tubercle could not be combated by germicides, and
hence
ANTISEPTIC TREATMENT WAS OF NO VALUE IN THE
TREATMENT OF CHRONIC TUBERCULOSIS OF SEROUS
MEMBRANES.
He was not in favor of incision in cases of tubercular per-
itonitis. As to the circumstances which favored the ap-
pearance of tuberculosis, he held with Professor Virchow
that these were of even greater importance than the pres-
ence of the bacillus tuberculosis. Predisposition was of
immense importance in the producing of phthisis pulmo-
nalis, and the human race were by no means all equally
vulnerable by tuberculosis.
Dr. DRESCHFIELD explained how it was that tubercle
became obsolescent. In his view the germs existing in
the part gradually exhausted all the material requisite for
their nutrition, and unless they were carried to another
part where there was fresh pabulum, they tended to die,
and then there was a deposit of lime salts in the cavity
left by the bacillus. | ;
Dr. Evpison thought that the good done by mercury
in syphilis was not by killing the bacilli, but by making
the blood antiseptic and incapable of nourishing the germ
of that disease. The reason why tubercle bacilli could
not be found in tubercular pleurisy was because we passed
the trocar into the fluid part. He strongly objected to
the vicious circle of therapeutic diagnosis which said that
296
because a disease was curable by mercury and iodide of
potassium, it was therefore clear that it was a case of
syphilis, etc. As to the question of incision into the per-
itoneal cavity and the discovery of the existence of tuber-
cular peritonitis by inspection, he felt inclined to ask
whether in all the cases where the peritoneum was opened
and tuberculosis diagnosed, the diagnosis had been clearly
made out.
Mr. Imuacu, of Liverpool, said that in some cases
where he had opened the abdomen he had discovered
tubercle in the ovary and in the peritoneum, and there
were cases in which he had operated in which he had
found the peritoneum studded with tubercle. In five
such cases he had expected to hear of the speedy death
of the patients, but this had not taken place, although he
had interrogated the friends of such patients for many
months after the operation. ‘The diagnosis of tubercular
peritonitis was extremely difficult. Washing out the ab-
dominal cavity with hot water was often of great service
in such cases.
Dr. Douctas PoweELL, in reply, said that antiseptics
were useful in pleuritic effusion when there was pus pres-
ent. Such antiseptics had, however, had no influence
on the bacillus tuberculosis. He was glad to hear Dr.
Broadbent say that incision was sometimes beneficial. As
to the remark made by Dr. Drysdale, that the whole hu-
man race were vulnerable to tubercle, this referred to
cases in which subcutaneous injections with a quantity of
bacilli were made, and these were not comparable with
ordinary cases of infection from a few bacilli. He be
lieved that all persons might be vulnerable in such circum-
stances as those uf inhalation of bacilli contained in spray
or in liquids which were subcutaneously injected. Dr.
Imlach’s cases were a great contribution to the subject.
Dr. CUTTER, of New York, exhibited a number of
lantern-slides of the blood of tuberculous patients, and
showed groups of yeast-cells which were contained in the
blood of such patients, and which, he said, were easily re-
movable by the removal of sugar from the diet of such
patients.
Dr. C. R. DRYSDALE, of London, read a paper on the
alleged
RARITY OF PHTHISIS PULMONALIS AMONG LONDON JEWS.
The author of the paper said that there had been for
some time past an idea entertained in London that con-
forming Jews in that city were far less liable to the inroads
of tuberculosis than the ordinary population of London.
This opinion had been entertained by Dr. Septimus Gib-
bon, and also by Dr. Maurice Davis and Dr. Behrend, cf
London, all of whom, experienced physicians, had spoken
as if the occurrence of consumption among London Jews
was excessively rare.. His own experience as physician to
the Metropolitan Free Hospital of London was also that
phthisis pulmonalis was comparatively infrequent among
the Jewish patients residing in the neighborhood of
Houndsditch and the Jewish quarters of the East End of
London. In order, however, to clear up this point he
had made inquiries of several London physicians practis-
ing among their own brethren, and had received com-
munications from Drs. Dyte, Kish, and Abraham Cohen,
in addition to similar letters from Dr. Maurice Davis and
Dr. Behrend. ‘This evidence was conflicting, for while
some of the older practitioners were very affirmative as to
the extreme rarity of consumption among London Jews,
the younger physicians admitted that phthisis was by no
means infrequently met with among them. Dr. Drysdale
had been permitted to witness the slaughtering of sheep
and oxen at the Deptford cattle market, and the way in
which such animals were inspected after death to ascer-
tain whether their flesh was free from impurities, or
KOSHER.
The organ most closely examined by Jewish inspectors
was the lungs, and the very smallest marks of pleurisy, or
pneumonia, or tuberculosis occurring in cattle and sheep
‘THE MEDICAL. RECORD.
[September 14, 1889
sufficed to cause the animal to be instantly rejected by the
inspectors, so that about one-third of all the animals ex-
amined were rejected as unfit to become the food of ortho-
dox London Jews. He heard, however, that perhaps not
once in one thousand or two thousand cases was tuber-
culosis detected among the cattle examined at the Dept-
ford cattle-market ; but still modern researches seemed
to have made it evident that the flesh of such animals
might spread tuberculosis among such persons as partook
of it. This was the cause assigned by Dr. Behrend and
other Jewish medical men for the comparative infrequency
of tuberculosis amorg conforming Jews. Dr. Drysdale’s
conclusions were: 1, That there seemed to be much evi-
dence that tuberculosis was rather rare in London among
Jews who eat only Kosher meat, although he thought the
rarity had been exaggerated ; 2, that tuberculosis in cattle
was an occasional cause of consumption in the human
race ; 3, that Jews probably escaped this form of contagion
to a great degree owing to the care taken by their inspec-
tors ; lastly, that it was important that such a system of
examination of animals offered for food should be made
by inspectors eithér appointed by municipalities or by
private companies for the supply of meat in our cities.
Dr. MACLAUREN, of Australia, said that in New South
Wales there were about five thousand Jews, and in three
years there had only been two deaths from tuberculosis
among that population ; whereas consumption was now
nearly as commonly met with in Australian cities among
the ordinary population as in the cities of Great Britain.
He was inclined to attribute this very great immunity of
the Jews in Australia from tuberculosis to their examina-
tion of the cattle used as food, many of which were af-
fected with tuberculosis in that country.
Dr. EppIsoN said that in Vienna there was a good «eal
of consumption among the Polish Jews attending hospital
in that city, and it would therefore be interesting to know
whether in cases where consumption was rarely met among
the Jews, as had been said, such Jews were more orthodox
and attended more to their religious traditions than such
Polish Jews did. In Leeds, where there was a colony of
Jews, he suspected that but little attention was paid by them
to the quality of the meat bought for consumption. In-
deed, such Jews purchased the very poorest parts of the
meat offered in the market, and consumption was not
infrequently met with among them in Leeds.
Dr. ACLAND, of London, said that he would gladly offer
Dr. Drysdale an opportunity of continuing his inquiries
in such cases at the Brompton Consumptive Hospital,
where there were patients of all classes suffering from
consumption. ‘The poor suffered much more from tuber-
culosis than the rich, and it would be interesting to ascer-
tain whether such Jews as contracted phthisis were more
lax in their attention to the rules of diet laid down in the
sacred books of their religion than those who escaped
from the disease.
SECTION OF SURGERY.
WEDNESDAY, AUGUST 14TH—FiRST Day.
Mr. Jessop, of Leeds, gave a short address on the
TREATMENT OF CANCER OF THE RECTUM,
introductory to the discussion announced to take place
on that subject. Mr. Jessop said that the treatment of
cancer of the rectum involved distrust of the past and
hope in the future. With regard to chian turpentine we
might now relegate it to its proper place on the back
shelves of the chemist’s shop. ‘Touching lightly on the
hygienic and medicinal treatment of cancer of the rectum,
Mr. Jessop remarked, among other things, that frequent
washing out of the rectum with simple water was useful
in many cases. Astringents were suitable in cases where
the anus and sphincter were implicated and the fæces
were liquefied. We should aim at obtaining simply a sin-
gle daily evacuation from the bowels. Coming then to
the consideration of operative procedures, he observed
September 14, 1889]
that they were of two kinds, viz. (1) operations for the
oblation of the disease, and (2) operations for diverting
the faeces, and thus dispensing with the rectum as the
channel] through which to evacuate them. ‘The former
class of operations must necessarily be confined to the
lower regions of the bowel; the latter were applicable to
all. He would pass by operations which consisted in
scraping the diseased surface and go on to consider
PROCTECTOMY.
This had only lately been forced into prominence by the
success of our German colleagues. It only remained to
determine in what cases it should be undertaken. In
performing the operation it was of importance to secure
proper drainage, to retain an efficient sphincter, and to
prevent subsequent cicatricial contraction. His own
cases were seven in number. Of these one died from
the operation, but the patient was a poor curate, greatly
reduced in health before being operated on, and he never
recovered from the collapse immediately following the
operation ; the disease extended round four-fifths of the
circumference of the gut, just above the anus. In the re
maining six life was extended for varying periods. Thus
one patient appeared well after twenty-one months, and
another after seventeen months, from the date of the op-
eration; while a third was unable to leave his room nine
months after the operation, owing to speedy return of the
disease. Proctectomy was a valuable means of prolonging
life and alleviating suffering. He had not himself re-
moved cancer from a higher part of the rectum than
could be reached by the finger inserted through the anus,
but he should be glad to hear the results of those who
had removed neoplasms from higher portions of the
bowel. He could not advise interference with cancer of
the anterior wall of the rectum when the urethra, bladder,
prostate, or uterus was involved. In performing the op-
eration the patient should be placed in the lithotomy po-
sition, Either the anus should be dilated or an incision
made into the rectum. He did not advise sutures to the
wound. It should be kept scrupulously clean, iodoform
dressings employed, and celluloid drainage-tubes used.
‘The rectum should subsequently be washed out every
eight hours with an antiseptic solution and an iodoform
suppository inserted. Proctectomy was an operation of
limited application in the present state of our knowledge.
He had never himself removed diseased portions of bowel
through an opening in the colon, but a previous diversion
of fæces (as effected by colotomy) was of advantage be-
fore undertaking an operation for the removal of diseased
portions of bowel and saved the patient considerable dis-
tress.
Mr. Jessop then passed on to consider
COLOTOMY.
Before asking to what extent it prolonged life, he would,
he said, ask how death ensued in cases of cancer of the
rectum? Of 102 patients he had seen, 17 had died from
complete obstruction of the bowel unrelieved by opera-
tion, 15 had died from obstruction in cases where left
lumbar colotomy had been performed, 3 had died from
hemorrhage, 5 from acute septiczemia, 2 from the impli-
cation of other organs, 9 had died after left lumbar colot-
omy without total obstruction having occurred, and 51
had died from exhaustion. In not one of the thirty-two
cases (31.4 per cent. of the whole number) in which death
occurred from obstruction was the disease within easy reach
of the finger passed into the bowel ; in most, it was quite
out of reach. In cancer of the lower half of the rectum
there was not much fear of complete blockage occurring ;
when the upper half of the rectum was involved the op-
posite was the case. Mr. Jessop then referred to some
cases of cancer of the rectum which had not been oper-
ated on, but which had survived several months (in one
case seventeen months, in another thirty-six) without com-
plete obstruction coming on. In cases of cancer in which
the upper movable part of the rectum was the seat of the
THE MEDICAL RECORD.
297
disease, we should, knowing as we did that blockage would
occur, make an opening in the colon above. Excluding
doubtful cases, the following were the results of 86 cases
of cancer of the rectum: In 52 cases no operation was
performed, and the average duration of life after the first
appearance of symptoms was seventeen months. In 34
cases left lumbar colotomy was performed, and the aver-
age duration of life was twenty-two months and a half from
the first symptoms. and fifty-three weeks from the date of
operation. Among patients who were advised to have an
operation, but who refused to submit to it, the average du-
ration of life was thirty-four weeks. ‘The average extension
of life due to operation was therefore nineteen weeks, but
we must admit that many of those cases in which operation
was declined were less severe. He concluded, therefore,
that colotomy did prolong life in cases of cancer of the
rectum. It was a question, from observing the compar-
ative sufferings of patients, whether it was advisable to
open the colon in cases where life was not directly imper-
illed. ‘The benefits of the operation were that it relieved
pain, diminished the constant desire to defecate, reduced
the incontinence of fæces, and enabled the patient to
have one motion in the twenty-four hours discharged with
ease. What kind of operation best met the condition of
the patient? Inguinal colotomy had been again consid-
ered since Mr. Herbert Allingham’s paper at the Dublin
meeting of the Association (1387). The disease had been
removed through a lumbar or inguinal opening. The
present choice, however, lay between proctectomy on the
one hand and some form of artificial anus on the other.
Mr. F. Marsu, of Birmingham, then exhibited a patient
on whom he had performed
MADELUNG'S OPERATION,
and subsequently excised the rectum. ‘The patient was a
man, twenty-eight years of age. ‘The colotomy was per-
formed on March 1st last, the excision of the rectum on
March 2gth, and the patient was discharged from hospital
on May 20th. In excising the rectum no vessel required
ligature. ‘The peritoneum was not opened, but formed
the upper boundary of the wound. The case was so suc-
cessful, said Mr. Marsh, that he had made up his mind
in future cases of cancer of the rectum to first perform an
inguinal colotomy and then excise the rectum.
Mr. MITCHELL Banks, of Liverpool, then spoke, and
said his experience of lumbar colotomy was confined to
twenty or thirty cases. He believed the mortality was due
chiefly to the condition prior to operation. He did not
think one site was preferable to another for an artificial
anus ; the distress of having one at all far outweighed
such considerations. In one lumbar operation he could
not find the colon at all, so he had opened the nearest
piece of small intestine. In cases of doubt it was a valu-
able plan to inflate the bowel with air by means of an or-
dinary Higginson’s syringe. He agreed with Mr. Jessop
as to the value of complete division of the bowel in pre-
venting the fecal matters from passing on beyond the ar-
tificial anus. Speaking generally as to the benefit of
operating in malignant disease of the rectum, he said that
no doubt where there was complete obstruction an opera-
tion was desirable, but in many cases the prolongation of
life for a few weeks or months, accompanied with suffering,
was not a very great benefit.
Mr. HARRISON Cripps said he had performed seventy
operations for rectal cancer, viz., thirty excisions and forty
colotomies. With regard to excision of the rectum we must
select our cases. He was aghast at the mortality (thirty to
forty per cent.) obtained by German surgeons. Such a mor-
tality should cause abandonment of the operation. Here,
where we selected the cases, the mortality was much less ;
if we did not select them, it would be as high. An oper-
ation which would be safe in the case of a middle-aged
man became dangerous in an old man broken down by
malignant disease. We should take care only to operate
in cases where there is no constitutional infection, as of
the glands or liver. Not more than four or five inches of
298
the bowel (as regarded height from the anus) could be
removed. ‘The growth could, in fact, be removed only
when it was so near the anus that the finger could feel
healthy mucous membrane above it. A movable condi-
tion of bowel was favorable to operation. If it were
fixed, he would not operate unless it were fixed on its
posterior wall only or on the ischio-rectal fossz. It was
unsafe and unwise to operate when the bowel was attached
to the uterus or the prostate. When the recto-vaginal
septum was involved he would not operate when the upper
part was involved, because in such cases Douglas’ pouch
was mostly drawn down and the peritoneum would be
opened. Kelsey’s tables in America showed a mortality
of twenty per cent. In his own thirty cases he had had
two deaths. In the remaining twenty-eight cases recur-
rence had taken place in most after varying periods of
time ; in three cases no recurrence at all had taken place.
‘The operation prolonged life and in comparative comfort.
Pain was removed—at any rate, for a time—and even
when the disease subsequently returned the pain was less
severe—possibly because the sentient nerves had been
largely removed. In operating, the best plan was to divide
the bowel freely behind. It should not be drawn down
and no sutures should be used. ‘The wound should be
plugged with lint, and a bougie be subsequently employed
to prevent contraction. Passing on to the
ADVANTAGES OF COLOTOMY,
he said these were twofold, the operation gave relief and
retarded the rate of growth of the malignant disease. In
cases of cancer of the rectum contraction would souner
or later occur. ‘There would be first constipation and
then diarrhoea, of which the cause was not the disease
itself but the accumulation above, from which a dribbling
away from time to time took place. ‘The case was sim-
ilar to the overflow which occurred from a distended blad-
der. Colotomy took away all these symptoms and gave
the patient comparative comfort. The operation should
be performed as soon as there were any symptoms of ob-
struction. ‘The mortality was in many cases not from the
operation but from the state of the patient. In his own
cases, forty in number, he had not had a single death from
the operation. He had formerly employed the lumbar
operation, but had lately discarded it for the inguinal op.
eration, influenced by Mr. Herbert Allingham’s advocacy
of the latter. ‘Ihe advantages of this were, firstly, that
the space in which to operate was larger; then there
was less difficulty in finding and identifying the bowel.
Sometimes the colon was abnormal and did not descend
in the left lumbar region at all; with the inguinal opera-
tion it would be easy to detect any abnormality. Mr.
Cripps remarked, in conclusion, on the advantage of early
examination in cases of rectal disease so as to establish
the diagnosis.
Mr. HERBERT ALLINGHAM said that for practical
purposes cases of rectal cancer might be divided into
three groups, viz.: 1, Cases in which the growths were
small, hard, and at the lower part of the rectum ; 2, cases
of large, ulcerating, crater-like masses ; 3, cases of disease
rapidly spreading and involving all the surrounding struct-
ures. He would perform excision only in the case of a
small, hard growth, freely movable, within three inches of
the anus, and when one could pass the finger freely above
it. A point was the rapidity with which the growth could
be removed. An operation for excision of the rectum
usually occupied forty-five minutes, but it could be done
in ten.
A PROLONGED OPERATION MEANT MORE SUBSEQUENT COL-
LAPSE,
because the patient was losing blood all the time of the
operation. It was better to operate rapidly and check
bleeding with hot spirit and water, putting in a few liga-
tures if needful. He did not approve of Mr. Cripps’
plan of completely isolating the bowel from surrounding
structures. It was best to avoid stitching down the bowel ;
THE MEDICAL RECORD.
[September 14, 1889
it was likely to cause cellulitis, and often one could not
bring down the mucous membrane to the skin. Colotomy,
when performed, ought to be done early, and the earlier
the better. As soon as there was frequent diarrhoea, pain,
and straining, it added to the comfort of the patient to
perform colotomy. In the inguinal operation it was a
good plan to make a good spur, so as to prevent the fæces
from passing on, which should render the operation use-
less. He thought the growth of the cancer was slower
when the fæces were cut off from it, and there was also
less pain.
‘Dr. Warp Cousins, of Southsea, said we must separate
the mortality from the immediate success. Many patients
came too late. If a patient lived a year after operation
he considered the operation. was a success; but one of his
patients had lived two and three-quarters, and another five
and a half years after lumbar colotomy. In the inguinal
operation there was the great advantage of having the
patient on his back ; there was also no difficulty in finding
the intestine. In lumbar colotomy the peritoneum was
generally opened, and a great disadvantage was the small
extent of bowel which was accessible.
Mr. VINCENT Jackson, of Wolverhampton, objected
tu the term “inguinal” as applied to anterior colotomy,
which had nothing to do with the groin. He suggested
the term
ILIAC COLOTOMY.
He thought the preceding speakers had minimized the
discomfort (from atresia ani) following ablation of the
rectum. ‘This was a reason for carefully considering the
operation of excision. For acute cases of obstruction he
advised the lumbar operation, but it was only in those
cases, or where the large bowel was so distended that
there was a difficulty in operating, that the front opera-
tion was not desirable.
Mr. BENNETT May, of Birmingham, said patients were
apt to postpone the operation of colotomy till too late.
In very acute forms of cancer it was hardly worth while
having colotomy performed except for acute obstruction.
It was best performed for chronic obstruction ; one of his
cases lived two and a half years after operation. Better
results had been attained since the inguinal operation,
which was easier, had been introduced and the operation
done earlier. He had had thirteen cases. He still pre-
ferred the lumbar operation in cases where the bowel was
much distended. In the inguinal operation, also, there
was liable to be excessive prolapse or excessive contrac-
tion. A moderate degree of prolapse acted as a “spur;”
he believed its degree depended upon the extent to which
the lumbar fascia was opened. Mr. May related a case
of colectomy in which the stitches gave way, and said he
should not again attempt to join together the divided
ends of bowel after removing the diseased portion, but
should bring both the divided ends out through the wound.
In the case he had just mentioned, although he had
operated early (the cancer having been accidentally dis-
covered after opening the abdomen to perform a different
operation), there were enlarged glands in the mesentery,
and considerable masses of cancer in the liver.
MR. JESSETT said there were few cases in which one
was justified in performing proctectomy, and even then
he would prefer to perform colotomy first, and then re-
move the rectum.
Mr. RUSHTON PARKER, of Liverpool, said excision of
the rectum was an Operation rarely advised, and the few
operations which had been done were due to individual
enterpnse. We could not always select our cases, for pa-
tients sometimes declined and sometimes sought opera-
tions ; but some of the unfavorable cases turned out well.
The disease should be low down to perform excision. He
had performed two operations, removing the diseased part
but leaving healthy bowel at the anus; both did well. He
demurred to the view that we should limit excision to
cases in which only the lower part of the rectum was in-
volved, and mentioned a case in which he had performed
September 14, 1889] THE
excision when the lower part of the growth was four inches
from the anus. Dr. Alexanders plan of incising the rec-
tum backward, and removing the coccyx, gave great access
to the rectum. By drawing down the lateral ligaments of
the rectum we drew down the rectum and could open it
several inches from the anus. In the case just mentioned
the growth extended along the bowel for five inches, and
his impression was that he divided the rectum about twelve
inches from the anus. As to colotomy, by attending to
diet, etc., patients could do a great deal to prevent ob-
struction from occurring, and thus obviate the necessity
for it.
Dr. INGLIS Parsons then spoke of the value of
ELECTRICITY IN CANCER OF THE RECTUM.
One electrode was passed through the diseased portion,
and another into the ischio-rectal fossa.
PROFESSOR ‘TREUDELENBERG spoke of the advantage of
operating not wholly by the knife, but partly by the fin-
gers. Where the cancer was fixed, colotomy was the
preferable operation, and the most convenient both to
the patient and the surgeon. Some patients might live for
twelve or thirteen years.
Mr. Lawford Knaggs and Mr. Stanmore Bishop having
also spoken, the President replied, and the discussion con-
cluded.
Mr. Mayo Rosson, of Leeds, then showed a patient on
whom he had successfully performed
CHOLECYSTENTEROSTOMY
for biliary fistula. The patient had had abdominal section
performed upon her three times. The first operation was for
pyosalpinx, and was performed five years ago. Eighteen
months ago the abdomen was again opened for acute pern-
tonitis, with pus in the gall-bladder. The bile finally came
away through the wound, anda biliary fistula resulted. From
thirty to forty ounces of bile daily escaped on to the sur-
face of the abdomen. ‘To remedy this condition the ab-
domen was opened again, and the gall-bladder attached
to the colon by a double row of sutures ; the onginal
Opening in the gall-bladder was then sutured. Mr. Rob
son said he could find no record of a case of biliary fistula
previously cured. An operation had been proposed by a
German surgeon for a case of obstruction of the common
duct, but it was not carried out. He employed Lembert’s
suture to attach the gall-bladder to the intestine, but the
opening in the gall-bladder was closed by a continuous
suture.
Dr. Eastes, of Folkestone, having narrated a case,
Mr. RuSHTON PARKER then read a paper on a case of
CEREBRAL TUMOR SUCCESSFULLY REMOVED.
The patient was a man, thirty-eight years of age, who suf-
fered from long-standing headaches and weakness of the
left arm and leg. ‘There was no optic neuritis. No re-
sults followed the administration of iodide of potassium.
It was not necessary to localize the tumor as there was a
puffy swelling in front of the right parietal eminence,
which was considered to indicate its position. ‘The opera-
tion was successful, and subsequent examination of the
growth convinced him that it was a gumma.
SECTION OF OBSTETRICS AND GYNECOLOGY.
WEDNESDAY, AUGUST 14TH—FIRST Day.
Dr. CHARLES J. CULLINGWORTH, President of the Sec-
tion, delivered the opening address, taking for his subject
THE APPLICATIONS OF ANTISEPTIC PRINCIPLES TO MID-
WIFERY PRACTICE.
His remarks were supplementary, he said, to an address
which he delivered at the opening of St. Thomas’ Hospi-
tal Medical School a year ago. Antiseptic cleanliness
does not consist merely in the use of some chemical dis-
infectant, important though that may be. But the very
fact that the use of certain chemicals forms an essential
MEDICAL RECORD.
299
part of the antiseptic method contributes to the danger of
trusting to them too implicitly to the exclusion of other
means of insuring surgical cleanliness. -The latter may
be subsidiary, but they are none the less of the greatest
importance.
FREQUENT VAGINAL EXAMINATIONS SHOULD BE AVOIDED,
especially during the first stage of labor, for they are un-
necessary after the diagnusis of the presentation has once
been made, and only expose the patient to the danger of.
infection. At the Dresden Lying-in Hospital, during the
years 1886—87, the number of cases admitted in whom, be-
cause of the very rapid progress of labor, or for any other
reason, no vaginal examination was made was 248. Of
these cases 242 made an absolutely normal recovery.
The remaining 6 had slight troubles of one sort or an-
other demanding their retention in the hospital for a few
days beyond the normal time, but among them all there
was not a single case of parametritis.
Another point of prime importance is
THE THOROUGH EMPTYING OF THE UTERUS
after labor or abortion. Retained matters offer a most
fruitful evil for the propagation of pathogenic micro-or-
ganisms which have once gained entrance. Although the
speaker did not believe in the possibility of self-infection,
yet he looked upon the retention of portions of membrana
placenta with as much apprehension as those who did so
believe. The secundines should, therefore, be carefully
examined after their expulsion, and if any part were found
missing no time should be lost in exploring the uterus in
order to remove it.
THE PATIENT SHOULD BE ALLOWED TO SIT UP IN BED.
This is contrary to the generally accepted teaching of the
present day, yet it is merely an application of the antisep-
tic principle of drainage to midwifery practice. In all
normal cases the speaker allowed his patients to sit up in
bed occasionally, for a few minutes at a time, on the
second or third day. This was in the line of practice rec-
ommended more than a century ago by Charles White,
of Manchester, but it was not carned to the full extent
of his recommendation.
Other points to which the speaker referred were the
immediate repair of all perineal lacerations of any magni-
tude, and the substitution of gauze-bags of sublimate wood-
wool in place of the traditional linen diaper.
THE CARE OF THE CHILD
was then dwelt upon at some length. Our zeal for the
safety and well-being of the mother should not, he said,
make us forgetful of the new-born infant. Antiseptic
principles could be usefully applied to the management
of the child in two ways, viz., in the prevention of ophthal-
mia and in the dressing of the remains of the umbilical
cord. In the
PREVENTION OF OPHTHALMIA NEONATORUM
the speaker recommended, in addition to the wiping of
the child’s eyes with a clean cloth as soon as the head was
born, and if possible before the eyes were opened, the ap-
plication of a solution of corrosive sublimate (1 in 3,000)
- by squeezing over each eye a saturated pledget of cotton
wool immediately after the first washing. Credé’s method
of dropping in a two per cent. solution of silver nitrate
need only be adopted in cases where the mother was
known to have suffered from a purulent vaginal discharge.
The report of a committee of the Ophthalmological So-
ciety showed that from thirty to forty per cent. of the in-
mates of blind institutions in Great Britain and Ireland
owed their blindness to purulent ophthalmia in their in-
fancy ; hence it was not unreasonable to infer that, by the
adoption of the means of prevention here suggested, the
amount of blindness at present existing might be dimin-
ished by one-third.
3Co
The second point in relation to the infant was
THE DRESSING OF THE REMAINS OF THE UMBILICAL CORD.
After the cord has been divided, the stump shrivels up
and is finally thrown off, leaving a small, raw surface,
analogous to the placental wound in the uterus of the
mother, which should be as rigorously protected from the
risk of septic infection.
The objects to be aimed at were to secure (1) the nor-
mal desiccation of the cord before its separation, and (2)
an aseptic condition of the wound left when separation
has taken place. The method recommended was, after
drying the surface of the cord, to powder it plentifully
with powdered starch, and wrap it in a square of antisep-
tic gauze. The umbilical wound should be dusted freely
with finely powdered boric acid, and covered with a pad
of dry absorbent wool.
In closing, Dr. Cullingwerth sketched out the work
which the Section had before it, and made an allusion to
THE COMBATIVENESS OF GYNECOLOGISTS.
It is true, he said, that the workers in this feld are some-
what combative, and sometimes perhaps even a little
wanting in forbearance toward those who differed with
them. The reason of this is partly beause the study of
gynecology is new, and men are still almost completely
in the dark as to the pathology of some of the most com-
mon affections to which women are liable. When gyne-
cologists know more, they will differ less. It is imperfec-
tion of knowledge that lies at the root of disputatious
differences of opinion.
Dr. BRaxTon Hicks read a paper or. the treatment of
PLACENTA PRAVIA.
He recommended that pregnancy be terminated as soon
as possible after the diagnosis of placenta praevia had
been made, and said that once treatment has been begun,
the patient should not be left until delivery has been ac-
complished. He formulated the following rules to serve
as a guide in the conduct of these cases :
If the os be expanded and the placenta marginal, rupt-
ure the membranes and wait to see if the head is soon
pushed into the os. If there be any slowness in this re-
spect, employ forceps or version. If the os be small, de-
tach the placenta from round the os, and if no further
bleeding occurs, we may wait an hour or two; but should
the os not expand, and if dilating bags are at hand, the
os may be dilated. If it appears that the forceps can be
admitted easily, they may be used; but if not, version by
the combined internal and external method should be em-
ployed, and the os plugged by the leg and breech of the
foetus. After this is done the case may be left to nature,
with gentle assistance, as in footling and breech cases.
If the os be small, and if we have neither forceps nor di-
lating bags, then combined version should be resorted to,
leaving the rest to nature, gently assisted. If, during any
of the above manceuvres, sharp bleeding should come on,
it is best to turn by the combined method in order to
plug by breech.
The after-treatment should be conducted according to
the modem antiseptic methods. Should oozing occur
after expulsion of the placenta, swab the lower part of
the uterus by styptics, and irrigate the uterus daily with
some antiseptic solution.
iodoform pessaries should be inserted into the vagina.
This is especially useful if the outlet of the uterus is
blocked by adherent clots.
Dr. Murpny, of Sunderland, said that it was exceed-
ingly hazardous to allow any case of placenta previa to
go untreated, and insisted that premature labor should be
induced as soon as it is ascertained that the placenta pre-
sents, after the seventh month of pregnancy, and even be-
fore this should bleeding be serious or frequently recur-
ring. He advised the constant presence of the medical
attendant during the whole period of labor. Labor
should be induced by Barnes’ bags, and then the question
THE MEDICAL RECORD.
If irrigation cannot be done, -
[September 14, 1889
must be decided how further to conde it. Generally
separation of the placenta, full dilatation of the os, and
bipolar version would give the best results. He submitted
a table of thirty-eight cases, with thirty-two consecutive
recoveries. Two, only, of the cases had resulted fatally.
Dr. LomER sent a letter, in which he advocated very
strongly the method proposed by Dr. Hicks. ‘The writer
had treated twenty-eight cases by the combined method
of turning, and had had but one death ‘Thirteen of the
children had been saved. After turning he made it a
practice to wait, and regarded the case as one of simple
foot-presentation.
TURN EARLY, BUT DO NOT EXTRACT,
was a maxim upon which he would lay special stress.
Should hemorrhage continue, he made some traction on
the foot so as to bring down the breech more firmly
against the parts from which the bleeding occurred. ‘The
object of his traction was, however, merely to make the
child act as a tampon, and was not meant to hasten de-
livery.
Dr. ROBERT BARNES began by saying that the treat
ment of placenta previa was a physiological proceeding,
and that the placenta, when it occupied the lower zone
of the uterus must be displaced. To do this the os must
be first dilated and the membranes should be ruptured.
For the purposes of dilatation he advocated the use of
the bags that went by his name. He was of the opinion
that detaching the placenta does not increase risk to
the child. Placenta previa, he pointed out, was a com-
plication that when once it occurred was liable to recur
in the same patient.
Dr. Ropert Harvey, of Bengal, drew attention to the
risk of the routine practice of rupturing the membranes,
as a fresh and fatal effusion of blood sometimes took the
place of the liquor amnii that had been evacuated.
Dr. Morr MADDEN described the old plan of plugging
the vagina after rupturing the membrane.
Dr. MuRDOCH CAMERON drew attention to the neces-
sity of using new dilating bags, as the india-rubber in old
ones was so liable to give way. In turning he is most
particular not to insert his hand into the uterus.
Dr. A. W. Jounstone, of Danville, U. S. A., read a
paper on
THE MECHANICS OF PUBERTY.
This, he explained, referred to the growth of sexual orna-
ments, showing that hair and feathers grow from the same
kind of texture as that which lines the body of the uterus.
Puberty is brought about, he said, by a general stimula-
tion of this lymphoid tissue, and that it is its “exhaus.
tion that causes the feebleness of old age, such as change
of life, and loss of permanent teeth, and senile alopecia.
He exhibited drawings showing that epithelial was re-
placed by cell growth of connective tissue. His view ex-
plained the source of repair for the monthly loss of endo-
metric epithelium, which is merely the lymph corpuscles
of the endometrium assuming the characters of epithe-
lium.
Dr. MORE MADDEN read a paper on
SOME POINTS IN THE TREATMENT OF UTERINE CANCER.
He thought that the disease was on the increase, and that
it originates in the cervix uteri. He therefore advised
timely removal of this portion. ‘The alterative, he said,
was the thermo-cautery, which was merely an improve-
ment on the escharotics formerly employed. He traced
the origin of the disease to pathological changes resulting
from partial lacerations which gave rise to inflammation,
and the first stage of cancer was, he thought, inflammatory.
In the cases that could be traced to their end he said
the disease was generally found to recur, but in fourteen
of Dr. Madden's cases of removal of the cervix the result
was satisfactory. He advises the cautious employment of
the curette as a means of diagnosis, and advocates early re-
moval of the intra-vaginal portion of the cervix, instead of
removing the whole uterus at a latter period.
September 14, 1889]
THE MEDICAL RECORD.
301
Dr. J. STUART NAIRNE then read a paper on
SOME PRACTICAL POINTS IN THE SURGICAL TREATMENT
OF CANCER OF THE UTERUS.
He first alluded to the symptoms of the disease, such as
hemorrhage, pain, and weight in the loins, the appearance
of a new-growth, the odor, etc. He referred to a series
of cases which had been operated on by removal of the
uterus at periods varying from eighteen to six months
ago. A case of the first-named date he regarded as safe,
and one of the last-named as hopeful, if there were no
signs of a return of the disease. Dr. Naime uses rectan-
gular dilators. He scoops out the uterus and excavates
till almost nothing but its peritoneal covering remains.
Much alleviation is the result of these operations, and,
even if nothing else was obtained, euthanasia was secured,
which alone was in such cases a consummation devoutly
to be wished for.
Dr. W. J. SINCLAIR, of Manchester, alluded to the great
mortality in cancer of the uterus. In operating in such
cases he now enucleates the organ, #.¢., he drags it down
and ties it bit by bit. He drew attention to the necessity
of diagnosing carefully between cancer and erosion. The
sharp spoon, he said, was an effectual means of effecting
a diagnosis. In the case of cancer the débris brought
away was unmistakable, and in cases of erosion nothing
but blood was taken out.
Dr. WILLIAM WALTER thought that 1f removal of the
disease by operative interference was had recourse to, the
whole uterus should be removed, just as you would remove
the whole of a breast attacked by cancer.
‘THE PRESIDENT thought the latest statistics of total ex-
tirpation of the uterus were encouraging, and said that
fifty-two cases had lately been operated on in this way
in Dresden without a death.
Dr. PETER Horrocks had seen a uterus removed for
suspected cancer which turned out to be merely chronic
endometritis. He regarded the German statistics as
doubtful.
Dr. RosBerT Barnes also thought these statistics unre-
liable, and said that many cases pronounced to be cancer
were really not cancerous.
THE PRESIDENT, in speaking of the use of powerful gal-
vanic currents, now recommended, narrated a case in
which the patient died under the operation as if struck
by lightning. esac
INTERNATIONAL CONGRESS OF DERMATOL-
OGY AND SYPHILOGRAPHY.
Held in Paris, France, August 5, 6, 7, 8,9, and to, 1889.
(Special Report for Toe Mgpicat Racorp.)
(Continued from page 277.)
DISCUSSION ON RINGWORM.
Dr. Butte, of Paris, related the method employed by
Quinquaud and himself in the treatment of tinea ton-
surans. Jt consisted simply in the application of a one
per cent. ointment of protochloride of iodine in lanoline.
Every second day the head is sprayed with warm water,
and then it is dried and rubbed for some time with this
ointment. It is possible by this means to cure ringworm
of the scalp within a few months without resorting to
epilation.
Dr. QuINQuAUD, of Paris, said that the method just re-
ferred to had produced excellent results in his hands.
Another plan was to cut the hair very short, shampoo the
head every morning, and then apply a lotion of biniodide
of mercury, 3 grains; bichloride of mercury, 15 grains ;
alcohol, 10 drachms; distilled water, 8 ounces. After
that the affected parts are scraped with a special form of
curette. At the end of a week, during which time this
process may have been repeated once or twice, the hairs
are pulled out. Epilation is accomplished much more
easily now, since the previous treatment has made the
hairs much less brittle. The scraping is repeated every
week or two, and in the intervals a plaster of the bin-
iodide and bichloride of mercury is applied. A cure is
thus obtained in three or four months. The children
usually bear the scraping very well.
Dr. BESNIER, of Paris, asked whether such vigorous
treatment did not occasion a pretty active dermatitis. He
had seen several cases of partial alopecia following a
dermatitis caused by too active treatment of ringworm of
the scalp. His plan was to cut the hair close, epilate
for some distance around the seat of disease, and then
apply borated vaseline. The head was washed every
morning with bran-water before the application of the
ointment.
Dr. QuINQuAUD replied that the lotion used by him
caused very little irritation. There was a little redness
observed for a day or two, but that was all. The plaster
usually brought out a few pustules, but they caused very
little inconvenience. It was well to stop all treatment
from time to time in order to avoid too much irritation,
but this was not always necessary, as the scalp usually
became quite tolerant after a few weeks.
Dr. BESNIER said that he would try this method on the
strength of Dr. Quinquaud’s recommendation. It should
be remembered, however, that this disease was very ir-
regular in its course. It sometimes lasted a year or two,
and might again disappear spontaneously in two or three
months. He recalled two cases which he had seen several
years ago. ‘The mother of the children asked him how
long the disease would last, and he had replied that it was
impossible to say. Six weeks later the children were
brought to him again, entirely healed, and the mother said
that they had been cured by Dr. Unna.
Dr. Unna, of Hamburg, said that he could not recall
what treatment he had employed in this particular in-
stance. But if the disease had disappeared so rapidly it
was a matter of spontaneous cure, and could not be
justly attributed to his treatment. He agreed with the
last speaker as to the irregularity in the course of a ring-
worm. He believed, however, that it was possible to
employ parasiticides which would attack the fungus with-
out destroying at the same time the tissue in which it
ew.
äi Dr. VIDAL, of Paris, said that it was an easy matter
to destroy the tricophyton when seated on the non-hairy
parts. Here it was superficial, and anything that would
remove the epidermis would remove also the parasite.
But when the tricophyton had penetrated into the hair-
follicles the matter was very different. Epilation was a
delusion, for if the hair was diseased it always broke off,
and only the healthy hairs could be extracted. He had
made some experiments to determine the nature of this
parasite, and had found that it was aérobic. ‘Therefore
if it could be deprived of oxygen it would perish. ‘This
could be accomplished by simply covering the part with
vaseline. He used an ointment of iodine in vaseline
(1-100), applied every day or every other day, and covered
it with gutta-percha tissue, and had obtained very good
results. A cure was effected in this way much more
speedily than when epilation was resorted to.
Dr. Hattopeau had employed a similar mode of
treatment, and was very well pleased with the results ob-
tained.
‘ Dr. DRYSDALE, of London, said that the disease was
very variable in point of severity and resistance to treat-
ment. He insisted on frequent washing of the affected
part, and then used applications of tincture of iodine.
Dr. Hans Hesra said that the disease under discus-
sion was uncommon in Vienna, and
BARBER’S ITCH
especially was very rare. He recommended the employ-
ment of a ten per cent. ointment of pyrogallic acid, by
means of which, he said, a complete cure could be ob-
tained in the course of three or four weeks.
Dr. BESNIER, in concluding the discussion, said the
302
geographical distribution of the parastic diseases of the
scalp afforded ground for much study, and its peculiarities
had yet to be satisfactorily explained. Favus, for exam-
ple, was never found among those residing in Paris
proper, but in its environs, in country districts, and even
in other large cities of France, such as Lyons, it was quite
frequently met with. On the other hand, ringworm of
the scalp, a very common affection in Paris, was com-
paratively rarely seen outside of the city. He spoke
rather despondently of the therapy of ringworm of the
hairy parts, and agreed with Unna in believing that a
cure was usually spontaneous rather than a direct result
of treatment.
DISCUSSION ON TERTIARY SYPHILIS,
including (1) the relative frequency of tertiary syphilis
and (2) the conditions favorable to its development.
Dr. NEUMANN, of Vienna, read a paper in which he
considered the principal conditions which favored the de-
velopment of tertiary symptoms. The chief of these was
a neglect of mercurial treatment. It was true that cases
were met with now and then which had been allowed to
go untreated, and yet escapcd all tertiary troubles; yet
these were exceptional. Even though there had been
some treatment, if this were not sufficiently active, nor
long enough continued, tertiary symptoms might show
themselves. Certain constitutional affections, such as
malaria, tuberculosis, or diabetes, were factors in causing
the apparition of tertiary phenomena, and so also were
any conditions, such as alcoholism, unhealthy surround-
ings, Old age, which tended to weaken the organism and
render it less able to resist disease of any kind. Tertiary
syphilis might, indeed, be seen in persons of good general
health, who had received proper treatment, but it was far
more common in those who had not been treated Its
occurrence was in nowise dependent upon the form or
virulence of the initial sore, or of the secondary manifes-
tations.
Dr. DryspaLE had found in his own experience that
the proportion of those who develop tertiary symptoms,
when not treated by mercury, is eight out of every hun-
dred. For several years he had not used mercury in the
treatment of syphilis, but had lately returned to it, as it
seemed to him to possess some real power in preventing
tertiary manifestations, although he could not agree with
Dr. Henry Lee that it was possible to cure syphilis abso-
lutely by means of calomel fumigations. He did not
believe that it was possible to form any prognosis from
the appearance of the initial lesion. Nor was age
a factor of any value in this regard, except that infants
suffered much more severely than others.
Dr. Mauriac, of Paris, said that little could be learned
from the appearance of the chancre concerning the future
course of the disease. A phagedenic sore was usually
followed by pretty severe secondary symptoms, but not
necessarily by any tertiary manifestations. ‘The propor-
tion of those who suffered from tertiary symptoms was
rather hard to determine, and as near an estimate as he
could make was that from eighty-five to ninety-five out of
every hundred escaped. ‘The time for the appearance of
tertiary phenomena was very variable and uncertain ; they
might come during the first year, or within a few months,
and their apparition might be delayed for forty or fifty
years. ‘I'he average period might be set down as from
the third to the sixth year. In some cases of visceral
syphilis the interval was very short. ‘The most common
tertiary manifestations were those of the skin, subcuta-
neous connective tissue, and mucous membranes, and of
the visceral forms of the disease the most important, by
far, was syphilitic disease of the nervous system.
Dr. FOURNIER, of Paris, in considering the time of ap-
pearance of the tertiary symptoms, said that he based his
statements upon an analysis of 2,595 cases occurring in
his own practice. According to these statistics the ter-
tiary phenomena appeared with greatest frequency from
the first to the third year after infection, the maximum
THE MEDICAL RECORD.
September 14, 1889
i
being in the third year. From the fourth to the twentieth
year it decreased gradually; between the twentieth and
thirtieth years few cases were found, and it was very rare,
although such cases did occur, for tertiary syphilis to
show itself for the first time over thirty years after infec-
tion. The other extreme was also uncommon, neverthe-
less the speaker had seen 129 cases in which the tertiary
manifestations were noted during the first year. As to
the lesions of this stage of syphilis, the nervous affections
predominated. Among his cases 1,085 were cases of
syphilis of the nervous system, or, excluding locomotor
ataxia (which was indirectly, if not directly, dependent
upon syphilis), the number was 681. The syphilitic poison
was therefore pre-eminently one acting upon the nervous
system.
Dr. Has.unp, of Copenhagen, presented the statistics
of 600 cases occurring in his own practice. Of these 444
had either not been treated at all or had been poorly
treated. In a very large proportion of cases the tertiary
symptoms appeared during the first twelve years after in-
fection. In point of frequency the cutaneous lesions held
the first rank, then came the nervous system, and after
that the bones and the internal organs. It had been as-
serted that tertiary phenomena were more common in
those cases in which the lesion was extragenital, but this
was due, he thought, simply to the fact that the true nat-
ure of such lesions was liable to pass undetected, and
consequently the patients were not treated properly.
Persons weakened by alcoholic or other excesses, or by
chronic malaria, were most apt to suffer from tertiary
lesions.
Dr. LELOIR, of Lille, thought the division of syphilis
into stages on a chronological basis was incorrect. It
was not the time of appearance, but the character, of the
lesion that was significant. ‘The characteristic peculiarity
of tertiary lesions was that they were essentially destructive
in their nature, whereas the so-called secondary phenom-
ena were not.
Dr. Vajpa, of Vienna, said that of 632 patients with
tertiary syphilis admitted to hospital in Vienna during the
years 1870-77, sixty-two per cent. were found not to have
had any treatment at all. ‘The average time of appear-
ance of the tertiary symptoms was three years and seven
months after infection for those not treated, and six years
and four months for those who had been treated during
the earlier stages.
Dr. ZamBaco Pacna, of Constantinople, said that in
his work on syphilis of the nervous system, published seven
years ago, he had called attention to the remarkable fre-
quency with which this part was attacked. His state-
ments met with considerable opposition at the time, and
he had been pleased to have them confirmed so fully by
Dr. Fournier in his remarks before the Congress.
DISCUSSION ON THE TREATMENT OF SYPHILIS.
Dr. McCALL ANDERSON, of Glasgow, said that anti-
syhilitic treatment should be begun as soon as the symp-
toms of the disease had declared themselves unmistakably,
but not before. The general health should be carefully
looked after, but the exhibition of tonics must not be al-
lowed to take the place of mercury and the iodides. It was
incorrect, he said, to assert that mercury is useful only in
the earlier stages, for it often produced the happiest re-
sults in tertiary syphilis, especially of the nervous system,
after the iodides had been tried without avail. ‘The mer-
curial treatment need not be interrupted unless the patient
gives evidences of hydrargyrism. He preferred inunc-
tions or injections, when practicable, to the exhibition of
the drug by the mouth. The treatment should be con-
tinued for a year after all symptoms have disappeared,
but even then it was not safe to pronounce the cure abso-
lute. He advised a mercurial course extending over three
or four months prior to the marriage of one who had
had syphilis.
Dr. LANGLEBERT, Jr., of Paris, said that the mercurial
treatment should be begun only on the appearance of the
September 14, 1889]
prodromes of the secondary stage (headache, fever, etc.),
and should be continued during the entire eruptive period.
He employed mercury only to combat the cutaneous and
mucous manifestations of syphilis, and never gave it in
the intervals of freedom, since he regarded the drug as
powerless to prevent any of the secondary or tertiary phe-
nomena, and of service only during the stage of evolution
of these symptoms. The iodides, on the other hand,
might be prescribed at any time, and were pre-eminently
the remedy for chronic syphilis. The average duration
of treatment by the iodides should be about three years,
and it should be begun only after the first eruption of the
secondary stage. ‘The mixed treatment may be preferable
during the first period of the tertiary manifestations, but
a cure in this stage can be obtained only by the use of
the iodides for a long period of time. Tonic remedies,
such as arsenic, iron, quinine, and sulphur, are of great
value, although of secondary importance in comparison
with mercury and the iodides.
Dr. Le oir, of Lille, read a paper, prepared by him-
self and Dr. TAVERNIER, on
MERCURIAL INJECTIONS
in the treatment of syphilis. ‘The authors had practised
1,573 injections during two years; the drugs employed
being calomel, yellow oxide of mercury, and gray oil. Of
these the calomel acted the most, and gray oil the least,
effectively. ‘The injections were of most service in the
secondary cutaneous lesions; but were of little or no use
in mucous patches. ‘Tertiary lesions uniformly resisted
their action, and could be controlled only by inunctions
and by local mercurial treatment. The disadvantages
of this method of treatment were so great that it could
seldom be employed in private practice. ‘The most im-
portant of the evil effects observed were: Local pain of
considerable intensity, lasting sometimes from one to nine
days, or longer ; paresis of the lower extremities ; head-
ache and vertigo; slight mercurialism; and a painful,
non-suppurating tumor at the site of the injection. One
curious fact, that was several times observed, was an erup
tion of mucous patches occurring four or five days after
an injection. ‘The injections ought not to be used in cases
of cerebral or spinal syphilis, and were serviceable only in
those cases of cutaneous syphilis in which a rapid cure uf
the eruption is especially desired. Relapses were very
common after treatment by injections.
Dr. JULLIEN, of Paris, had seen a number of cases of
DILATATION OF THE STOMACH IN TERTIARY SYPHILIS,
and he thought a knowledge of the existence of this trouble
was of considerable importance, for he believed it might
be the cause of many of the nervous symptoms commonly
attributed directly to the action of the syphilitic poison.
He advised that treatment be directed first to the dyspep-
sia in these cases, and said that oftentimes the h44dache,
vertigo, and mental troubles, which were thought to be
syphilitic in their nature, would then disappear. ‘The dil-
atation might be caused, he thought, by the drugs em-
ployed, especially the iodides, and he therefore regarded
these cases as specially suited to treatment by injections.
Dr. Dipay, of Lyons, was opposed to a continuous
course of treatment, and thought it better to give mercury
only during the presence of symptoms, for it was at this
time that the bacillus was most injurious in its effects, and
also most accessible to the action of parasiticides. The
advantages of employing antisyphilitic remedies in this
manner the speaker summarized as follows: 1, More
prompt curative effects are obtained ; 2, it will not be
necessary to give such large and harmful doses during a
fresh outbreak as it would be had the remedy been taken
continuously; 3, since the treatment is made to depend
directly upon the symptoms, the latter are more carefully
watched, and thus the physician obtains a better knowl-
edge of his case than he would otherwise have; 4, not
attnbuting any prophylactic power to the so-called specific
remedies, the physician will have made no promises to the
THE MEDICAL RECORD. 303
patient, and will therefore not be held sesponable when
fresh symptoms appear ; 5, a certain period of freedom from
all symptoms, while no remedies have been employed,
gives the patient a greater confidence in the permanence
of his cure than he would have had, had he been taking
medicine continuously.
Dr. SCHWIMMER, of Budapest, was decidedly opposed
to the plan advocated by Leloir, of waiting until unmis-
takable symptoms had developed before commencing
treatment. Syphilis was like any other disease, in that it
ought to be treated as soon as it was recognized, and it was
bad practice to wait until it had acquired its full develop-
ment before attacking it. The treatment should be varied,
he said, according to the race and climate, and it was not
reasonable to insist upon a rigid plan to be followed by
everybody everywhere. He had never seen any evil re-
sults follow the injection of calomel. He had before
recommended salicylate of mercury as preferable to the
bichloride, and he took occasion to refer again to its
superiority in the treatment of syphilis, though he did not
think it was as active as calomel employed hypodermically.
He had not had much success with the thymate of mer-
cury which had been recently recommended.
Dr. Neumann, of Vienna, began treatment as soon as
the first positive signs of the disease were manifest, and
continued it uninterruptedly long after the secondary
symptoms had disappeared. He preferred mercurial in-
unctions to injections.
Dr. Kaposi, of Vienna, was strongly opposed to injec-
tions, which he regarded as altogether unscientific. In
the case of a woman who had died in his service from
acute mercurial poisoning following two injections of gray
oil, an examination showed that a large part of the mer-
cury had not been absorbed. Thus, in a similar case, if
symptoms of hydrargyrism appeared, ıt would be impossi-
ble to withdraw the mercury at once, since there would
be a reservoir in the tissues at the sites of injection from
which absorption would be continually taking place. The
speaker preferred inunctions.
Dr. SCHÜSTER, of Aix-la-Chapelle, was opposed to the
injection of insoluble salts of mercury, which had never
given any good results in his hands.
Dr. CAsTELLo, of Madrid, began treatment immedi-
ately upon being sure of his diagnosis, and continued it
for some time after the disappearance of all symptoms.
Dr. Roso.imos, of Athens, said that cases were occa-
sionally met with in which mercury, administered in all
the different ways, failed to produce any effect. In such
cases injections were indicated. He believed that injec-
tions were more efficacious in preventing relapses than
were other methods of treatment. Abscesses might be
prevented by making the injections on the rounded parts
of the back, and the pain in this region was also less
marked.
Dr. PÉTRINI, of Bucharest, had lately made a pretty
extensive trial of tannate of mercury, and had been pleased
with its action. His plan was to begin treatment as soon
as the diagnosis had been made, commencing with one and
a half grain of tannate of mercury per diem, increasing it
at the end of ten days to three grains, and continuing the
treatment for twenty-five or thirty days. All his cases so
treated had done well, stomatitis being but rarely met
with.
Dr. Mauriac, of Paris, preferred to commence giving
mercury by the mouth, reserving inunctions and injections
for particular cases.
Dr. DE WATRASZEWSKI, of Warsaw, was opposed to in-
jections of mercurial salts, since they are apt to produce
considerable irritation locally, and if introduced into the
circulation may give rise to symptoms of acute poisoning,
or may be followed by serious pulmonary trouble. In
some experiments made upon cats, he found that either
gray oil or the yellow oxide of mercury, when introduced
into a vein, caused very extensive lobular hepatization,
the trouble being most marked when the yellow oxide was
used. The vaseline used to hold the mercurial in suspen-
pe
304
THE MEDICAL RECORD.
\
Sepienbi 14, 1889
sion had much to do with these evil effects, for when
mucilage was employed as the menstruum the pulmonary
troubles were much less marked. ‘This was due to the
fact that the mucilage mixed readily with the blood,
while the vaseline did not, and was carried to the lungs
holding suspended in it the mercury.
Dr. pu CASTEL, of Paris, was opposed to mercurial
injections, being unable to see that they possessed any
special advantages over other methods of administering
the drug, and fearing the effects upon the kidneys and
brain of mercury introduced so directly into the circula-
tion.
Dr. Baizer, of Paris, had never seen any injurious ef-
fects from injections of mercurial salts, and believed that
they were very useful in certain cases.
Dr. BERTORELLI, of Milan, said that he often had re-
course to calomel injections, and he had been surprised to
hear so much said against this method of treatment. It
was employed quite extensively in Italy.
Dr. BARTHELEMY, of Paris, looked upon injections as
most suitable in certain cases, especially in hospital prac-
tice, but it could be employed only exceptionally.
NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting, May 22, 1889.
WILiiaM P. NORTHRUP, M.D., PRESIDENT, IN THE CHAIR.
Dr. H. J. Botpr presented a specimen of
PERFORATION OF THE VERMIFORM APPENDIX.
The patient, nine years of age, had, according to the his-
tory given, always enjoyed good health until the night of
May 6th. He was seen early on the 7th, complaining
only of diarrhoea, and had some vomiting ; no pain. Ex-
amination, however, showed tenderness and tumefaction
in the right iliac fossa. The diagnosis of perityphlitis and
typhlitis was made. Ice-bags were applied, proper diet
ordered, etc. ‘The child had done very well under treat-
ment, and was thought to be out of danger, both tempera.
ture and pulse having reached a normal point by the roth.
About noon, though, the patient experienced a sudden
pain, radiating over the whole abdomen. When seen sev-
eral hours later he presented the characteristic picture of
one suffering from perforative peritonitis, the diagnosis of
which was made, and it was assumed that a perforation of
the appendix took place at the time when the pain was
felt. He then seemed in fair condition for operation, yet
by the time that preparations for such were made, col-
lapse was so marked that it was desisted from, and the
patient died a few hours subsequently. ‘The autopsy
showed the peritonitis to be very recent, and the perfora-
tion to be due to fecal concretions. The portion of ap-
pendix in the vicinity of the perforation was gangrenous.
The pelvis contained pus.
The interesting features are that apparently the case
was progressing so very favorably, and that it sank so rap-
idly after occurrence of the perforation. Although the his-
tory did not elicit any previous symptoms, yet the speaker
was confident that all these cases have had them, and they
were left unnoticed. ‘The majority of cases will go to a
favorable termination, without operative interference, by
proper treatment, consisting of rest, the ice-bag, and diet.
Medication is seldom required ; yet one should be on the
alert, when having such a patient in charge, to be ready for
operation should necessity require it.
Dr. Boldt had seen in the same patients several attacks
of perityphlitis and typhlitis in the course of two years,
and then finally a perforation of the appendix occur which
terminated fatally. Such cases are not unusual.
Dr. C. N. Dowp said that the case just related re-
called one that he saw about a year ago in one of the
house-staff of Roosevelt Hospital. He suffered for
about three weeks from symptoms of intestinal trouble,
and then signs of perityphlitis appeared. About a pint
of pus was found in the pelvis, and thete was complete
perforation. ‘The vermiform appendix was gangrenous,
and the appearances presented were as though there had
been a strangulation. .
Dr. VAN SANTVOORD said that Mr. Frederick Treves
had found evidence of previous inflammation of the ver-
miform appendix in about one-third of the autopsies
made by him. ‘This would seem to show that many peo-
ple have trouble in or near the vermiform appendix at
some period of their lives.
THE PRESIDENT asked Dr. Boldt what premonitory
symptoms he had observed.
Dr. BoLDT replied that there were occasional attacks
of pain lasting for four or five days, then passing away,
and recurring at intervals of a few days. Constipation
was also present.
Dr. S. T. ARMSTRONG asked whether the experience
of the members of the Society was in accord with that
of Mr. Treves. He had had only two cases of perityph-
litis in a hospital experience of eleven years, and it had
been rare in his experience to find evidences at autopsy
of past inflammation in the region of the vermiform ap-
pendix.
Dr. H. P. Loomis said that during the last four years
he had taken special note of the condition of the vermi-
form appendix in all autopsies made by him, and in only
a very small proportion of cases had he found evidences of
old trouble in that region.
‘THE PRESIDENT said that he had recently followed a
case of perityphlitis in a very young patient. There was
a tumor over the czcum, which subsequently passed away.
Pus was found on exploratory puncture. He was won-
dering whether they ought to be on the lookout for fut-
ure trouble in this case.
SUPPOSED ULCER OF THE BLADDER.
Dr. ARMSTRONG presented a bladder, removed from
the body of a man on whom suprapubic cystotomy had
been performed in the early part of last September. ‘The
patient was admitted to hospital for hematuria follow-
ing a gonorrhcea. An examination with the cystoscope
showed what was supposed to be an ulcer in the wall of
the bladder ; but when the bladder was opened by the su-
prapubic operation the spot was found not to be an ulcer
but simply a furrow in the mucous membrane. The
hemorrhage. came from the kidney.
Dr. Armstrong then presented a second specimen
showing
ANEURISM OF THE AORTA WITH EROSION OF THE TRACHEA.
The patient was admitted to the Marine Hospital with a
diagnosis of Bright’s disease and pulmonary tuberculosis.
He had had pneumonia four years ago, and dated his
present illness from that time. In March of this year he
was suddenly seized with a violent hemorrhage, and died
instantly. At the autopsy old pleuritic adhesions were
found. Arising from the ascending portion of the arch
of the aorta was a sac containing fibrin. It had produced
ulceration of the trachea, but the opening had been com-
pletely closed by a clot. A subsequent erosion of the
bronchus had caused the hemorrhage from which death
resulted. The aneurism had not been diagnosticated
during life. This was the second case of rupture of an
aneurism which had occurred in the hospital within six
months.
Dr. L. H. SAYRE presented a portion of a child’s tibia
and some slides for microscopical examination showing
the lesions of
RAREFYING OSTEITIS.
The specimens were removed by operation from the leg
of a child, nine years of age. ‘The child was born of
healthy parentage, at the seventh month. When three
years of age the patient sustained a fracture of the right
tibia, at the middle third, while he was being jumped on
the floor. The fragments united at a sharp angle, and
the bone was subsequently refractured, and an apparatus
September . 14, 1889]
THE MEDICAL RECORD.
395
making pressure over the seat of deformity was applied,
which caused ulceration at this point. The child was
brought to New York in order to have what was supposed
to be a lateral twisting of the tibia straightened. Exam-
ination revealed an enlargement of the leg in which there
was an obscure sense of fluctuation. An exploratory in-
cision was made over this enlarged part, and the bone was
found to be very much softened. A small piece was re-
moved with a trephine and presented the appearance of a
malignant growth. It was sent to a microscopist for ex-
amination, and the first report from him was that it was a
giant-cell sarcoma ; but just before the time set for opera
tion he made another report saying that he was not cer-
tain of its malignant character. Dr. Sayre excised the
tibia about ten days ago, and the child has done very well
since the operation. The speaker was of the opinion that
the case was one of osteomyelitis followed by rarefying
osteitis. He asked that the specimens be referred to the
Committee on Microscopy for examination.
Dr. Van GieEson, from this committee, subsequently
reported that the specimens showed the lesions of rarefy-
ing osteitis.
Dr. Van Gieson then demonstrated a
MEYNERT’S BASAL SECTION OF THE BRAIN,
and also presented a card specimen of empyema, in which
there was a heart-shaped
UNILOCULAR EMPYEMIC SAC,
weighing nine hundred and fifty grammes, filling the lower
right pleural cavity.
Dr. Wm. P. NoRTHRUP presented a specimen illustrat-
ing
SCORBUTUS IN AN INFANT.
The patient was a female child, eighteen months of age.
One month before death the right leg and knee became
swollen and tender. Temperature was 101° F. After two
days the symptoms disappeared.
Two weeks before death the child began to seem sick ;
her gums were swollen and blackened, and bled freely.
Two days later her left eyelid became black and swollen
—temperature still 101° F. One week before death her
pulse became 160 per minute, respirations 50, temperature
103° F.,and physical signs of pneumonia developed. At
this time her right eyelid showed ecchymosis, and there was
sarked swelling of the left thigh. During the remaining
days of life her passages became black and pasty ; the child
was very anemic, failed rapidly under symptoms of pneu-
monia, and died. No other ecchymoses were seen, and
no evidences of syphilis. Child was wet-nursed the first
sixteen months of life, but on account of impaired nutri-
tion was taken from the breast and was also given vege-
table acids.
For a full description of the cases of which this is a
typical example, see Eustace Smith’s “ Diseases of Chil-
dren.”
Autopsy.—Child well nourished. Left thigh symmetri-
cally enlarged and larger than right, though both seemed
disproportionately large. Left femur was normal at its
upper extremity, epiphysis, and end of shaft; but the
lower remaining portion was invested all about with a
layer of black clotted blood, having a uniform thickness
of 2 to 3 mm. This lay between the bone and its
periosteum. ‘The lower epiphysis was separated, and
the end of the shaft eroded and softened. A similar
dark layer, though less thick, separated the periosteum
from the right femur. Right and left tibize were sur-
rounded by a thin, dark, hemorrhagic zone beneath the
periosteum, and the shafts of these bones at their upper
ends and the lower end of the nght femur were congested
(as seen on section). The fibula and bones of the arms
and forearms not affected. Brain was normal. Lungs:
extensive pleuro-pneumonia of left side, lobar in character
—lower and upper lobes; right, extensive bronchitis
and scattered masses uf hepatization. No hemorrhage in
these organs, liver, spleen, nor kidneys.
Microscopic examination of the bone showed no syphi-
litic lesion to be present, and that the blood zone about
the shaft was extravasation, without signs of active inflam-
mation. ‘There was softening and disintegration, but no
suppuration in the cancellous bone-tissue. ‘There was
moderate congestion at the epiphyseal junctions ; in one
only was there softening and separation.
Dr. Northrup also presented a card specimen illus-
trating
DIPHTHERIA, GENERAL TUBERCULOSIS, AND PNEUMONIA.
At the autopsy the child was seen to be poorly nourished.
Extensive and abundant pseudo-membrane from the tip of
the nares to the beginning of the trachea, also in the cesoph-
agus and stomach. Mediastinal and bronchial lymnh-nodes
very much enlarged, many cheesy, some diffluent, some
containing discrete tubercles. Lungs thickly studded
with discrete miliary tubercles ; lower lobes consoli-
dated, recent hepatization. Liver, spleen, kidneys, con-
tained tubercles. Left kidney arrested in development,
about one-fourth its normal size, its companion being
correspondingly enlarged ; ureter dilated. No obstruc-
tion found, and no lesion to account for the arrested de-
velopment. Bladder normal.
Dr. VAN SANTVOORD said that Dr. Northrup’s case
recalled one of his own, presented to the Society Septem-
ber 27, 1882. It was that of a helpless idiot, stx
years of age, in whom extensive hemorrhage, with separa-
tion of both upper epiphyses, had occurred under the
periosteum of the upper halves of both humeri. ‘This
hemorrhage was apparently the immediate cause of death.
The case was regarded by him at the time as probably
traumatic. Reports that he had subsequently seen of
extensive subperiosteal hemorrhage with epiphyseal separa-
tions had been regarded by their recorders as scorbutic.
He had become convinced that his own case belonged
under that heading. In Dr. Northrup’s case the con-
dition of the gums seemed conclusive as to the existence
of scurvy.
Dr. G. C. FREEBORN presented a specimen of
COLLOID CARCINOMA OF THE GLUTEAL REGION.
The patient, a woman, aged sixty-seven, was admitted to the
New York Cancer Hospital, April 28, 1888, giving the
following history : About five years ago she fell backward
while alighting from a street-car, striking on her hip. No
bones were broken. She was under treatment for ten
weeks. ‘Two years after the fall a tumor was removed
from the region of the sacrum and pronounced sarcoma.
Four weeks after the operation she was seized with severe
pain over the site of the tumor, and shortly after she
noticed that the tumor was growing again. At the time
of her admission to the hospital a tumor was found in the
left gluteal region. It extended from a point five inches
posterior to the anterior inferior spine of the ilium, hori-
zontally, eleven inches to the region of the sacrum. ‘The
upper border corresponded to a line on the level of the
crest of the ilium, and measured, from above downward,
twelve inches. ‘There was an elastic feeling to the mass,
especially in the posterior portion near the median line.
The skin was adherent over the greater part of the tumor.
On June 2oth it was noticed that the tumor was grow-
ing into the pelvic cavity.
On July 23d the tumor had extended to the nght glu-
teal region, had encroached to a considerable extent on
the pelvic cavity. From this time to December 14th,
when the patient died, the tumor grew rapidly, both ex-
ternally and internally.
Autopsy.—A large, irregular-shaped mass is found occu-
pying the gluteal region ; it extends from a point one and
one-half inch above the crest of the ilium, downward, for
a distance of twelve inches. On the left side it is even
with the outer aspect of the thigh; on the right side it
extends downward on the outer aspect of the thigh, as an
irregular oval mass, as far as the middle third. Numerous
306
oval elevations of various sizes extend over the posterior
surface of the tumor.
On section through the median. line the cut surface
measures 23 ctm. in the vertical diameter, and 15 ctm. in
the anterio-posterior. ‘The tumor is found to be made up of
dense tissue in which numerous cyst-like cavities are found
filled with a gelatinous material. All the bones of the
sacrum up to the first vertebra are destroyed, though their
outlines can be made out in the tumor mass. The rec-
tum, uterus, and bladder are pushed well forward against
the pubes. The inguinal lymph nodes on both sides are
enlarged. No secondary deposits were found in any of
the organs.
Microscopical examination shows the new-growth to
be colloid carcinoma.
The Society then went into executive session.
Correspondence.
OUR PARIS LETTER.
(From our Special Correspondent.)
THE PREVENTION OF PHTHISIS—THE ACADEMY OF MEDI-
CINE ON THE CONTAGIOUSNESS OF TUBERCULOSIS—
THE DANGER OF MEAT AND MILK EXAGGERATED—EX-
TRA-UTERINE PREGNANCY—A FŒTUS IN THE ABDOMEN
FOR THIRTY-THREE YEARS-—FOUR CHILDREN AT A
BIRTH. l
PARIS, August 24, 1889.
Dr. VILLEMIN lately submitted to the Academy of Medi-
cine the instructions which were drawn up by the Stand-
ing Committee of the Congress for the Study of ‘Tubercu-
losis. It will be remembered that these instructions were
intended for the public, to enable it to know and be ca-
pable of protecting itself against the disease, which the re-
port says claims more victims in towns, and even in certain
rural districts, than any other disease. It is calculated that
about fifteen thousand, or more than one-fourth of the an-
nual mortality of Paris alone, is due to tuberculosis. Also,
that tuberculosis is a parasitic disease, virulent, contagious,
transmissible, caused by a microbe, the bacillus of Koch.
This microbe penetrates into the organism by the diges-
tive canal with food, by the air-passages with inspired air,
by the skin and mucous membranes, following sores, punct-
ures, wounds, and various kinds of ulceration. ‘The par-
asite of tuberculosis may be met with in the milk, muscles,
and blood of animals serving for the food of man. Raw
or underdone meat and blood, being capable of contain-
ing the living germ of tuberculosis, should be prohibited.
Milk, for the same reason, should only be consumed after
being boiled. The germ of tuberculosis is also capable
of transmission from the tuberculous to the healtny sub-
ject by sputa, pus, dried mucous discharges, and all ob-
jects laden with tuberculous dust. Measures should there-
fore be taken against the germs of the disease which would
be capable of preventing the propagation of the latter.
The above is only the summary of the document which
was submitted to the Academy, but where it did not meet
with much favor. It was severely criticised by Drs. Du-
jardin-Beaumetz, Germain Sée, Lancereaux, and others.
Dr. Dujardin-Beaumetz believes that phthisis is very com.
mon in the provinces. He considers that milk is much
less dangerous than it is said to be. For milk to give tu-
berculosis, it must have been drawn from cows the ud-
ders of which were diseased. Moreover, it must not be
forgotten that experiments by inoculation with milk or
meat are not comparable with the results of alimentation,
as in the latter case the normal gastric juice destroys or
profoundly alters the pathogenic bacilli. In any case, if
he would accept the recommendation of the milk being
boiled before use, he cannot admit the interdiction of the
use of raw or underdone meat, which are veritable medica-
ments ın many cases, and always form the basis of a tonic
alimentation. Dr. Daremberg does not believe that meat
THE MEDICAL RECORD.
could produce tuberculosis, as bacilli do not exist in the
muscular tissue.
Dr. Lancereaux is of opinion that it would be more
useful to instruct the public as to the simple rules of hy-
giene than to talk to them about the contagiousness of
tuberculosis, which is still a mooted point, except perhaps
in certain definite conditions; that it is inoculable there
can be no doubt, but it certainly is not contagious or in-
fectious as are measles, small-pox, etc. He, of course,
approves of the burning of the sputa of tuberculous sub-
jects, as, if allowed to become dry, particles floating in the
air may be inhaled by other persons, which would render
them tuberculous. Dr. Lancereaux insists upon avoiding
all depressing influences, as they act as predisposing causes
of the disease. ‘The two most powerful factors of tuber-
culosis are alcohol and deficiency of pure air, for it has
been ascertained that the bacillus of Koch cannot thrive
in pure air nor in a sound organism. Of ten alcoholic
subjects, eight die tuberculous, and the more crowded
are the inhabitants within a given space, the greater be-
come the number of phthisical subjects.
Owing to the idea of the excessive contagiousness of
tuberculosis being spread among the public, the people
have become so alarmed that they are beginning to look
upon phthisical subjects as persons to be avoided, which,
of course, must have a most disastrous effect upon the
patient, as well as upon his relations and friends. ‘Thisex-
clusion is quite unjustifiable, and would remind one of a
return to the practices of the middle ages, for the air ex-
pired by phthisical subjects docs not contain the bacillus
of Koch, as shown by repeated experiments. Moreover,
statistics have proved that persons in permanent contact
with phthisical subjects are not more frequently tubercu-
lous than others. In fact, it 1s only the sputa that may
be considered dangerous, but as regards meat and milk,
they should be left for what they are. In order to com-
pletely free them from the tuberculous principle, if they
contain any, the temperature to which they must be sub-
jected is not to ebullition, but to 110° C., and even to
180° C., which will simply lead to inanition. Dr. Sée
considers that milk is only dangerous when it is drawn
from cows affected with tuberculous mastitis. As for raw
meat, it does not determine tuberculosis. For several
years Dr. Sée has treated his chlorotic patients with raw
meat, and he has never seen that this treatment has pro-
duced a single case of this malady. It would be regret-
able to suppress this therapeutic means, which renders
immense service in the therapeutics of phthisis and other
maladies. According to the learned professor, tubercu-
losis is, after all, not so contagious as it is represented to
be, and that which is termed contagion among relations is
more frequently heredity. He would, therefore, not sim-
ply propose, as other speakers have done, to modify con-
siderably the instructions submitted to the Academy, but
he would suppress the whole document, that is to say, he
would have nothing published but simple rules of hygiene
applicable to all persons, and thus combat the idea of
contagion which has been so much exaggerated. He
would recommend the strict observance of cleanliness, the
destruction by fire, when this is possible, of the sputa of
phthisical subjects, and to prepare for them good physio-
logical food by the ordinary means of cooking. As Dr.
Villemin’s instructions have to be considerably modified,
the Academy of Medicine has appointed a commission
which is charged to propose new conclusions, which
should be independent of the instructions previously sub-
mitted. ‘This commission is composed of Drs. Cornil,
Dujardin-Beaumetz, Germain Sée, Verneuil, and Ville-
min.
A medical man commenting on the subject of the above
instructions expresses himself in the following pathetic
manner: “ Return, oh my masters, to a more normal ap-
preciation of facts, and when you draw up rules of
hygiene, quit for a moment your microscopes, which mag-
nify everything, even dangers.”
Professor Tarnier lately introduced to the Academy of
September 14, 1889]
Medicine a patient who is the subject of an extra-uterine
pregnancy dating as far back as 1856. At that period
pregnancy had reached the full term, the beats of the
foetal heart were distinctly heard, but the medical man
who was consulted on the occasion having diagnosed an
extra-uterine pregnancy, decided upon practising laparot-
omy, but before undertaking the operation Dr. Paul Du-
bois, the celebrated accoucheur was consulted, and
although symptoms of the death of the child had mani-
fested themselves, he did not see the necessity for imme-
diate intervention. In 1859 the patient had occasion to
consult M. Nélaton, who, after having established the
previous, diagnosis, refused to operate. Since that time
this woman had been lost sight of, when, a short time ago,
she consulted Dr. Tarnier, who, on examination found a
tumor in the sub-umbilical region, evidently constituted
by the presence of a child. This tumor was divided into
two parts, corresponding with the head and trunk, which
were distinctly felt. The patient is now sixty-six years of
age, and is in the enjoyment of comparatively good health,
as she suffers from nothing but a slight inconvenience
from the size of the tumor. The abdomen is so flabby that
the feet of the child are easily distinguished from the other
parts of the body.
At a subsequent meeting Dr. T'arnier related the case
of a woman who had just been delivered of four living
children: the first weighed at birth 1,900 grammes; the
second, 1,580 grammes ; the third, 2,100 grammes, and the
fourth, 1,580 grammes. She already had had twins at her
first confinement, at her second she had only one. Her
maternal grandfather was a twin-brother.
ELECTRICAL RESISTANCE OF THE HUMAN
BODY.
To Tue EDITOR or THe Mapicat Recorp.
Sir: A layman ventures to ask the freedom of your
columns in regard to the discussion on the subject of than-
atelectrists.
I have followed with some interest the different opinions
advanced by medical men, in this discussion, as to the
proper electrical resistance of the human body. Frankly,
is not this question one that requires the experimental
training and knowledge of the physicist rather than the
knowledge and training of the physician? Commenting
on a letter from Dr. Sachs, you state that “the methods
of testing human resistance are not difficult or complicat-
ed, and neither Jolly nor Gartner can be credited with any
superior and exclusive knowledge of the technique which
would enable them to obtain more certain results than
have experienced electricians like Edison.” I agree with
that part of the statement relative to Jolly and Gartner,
but with reference to Mr. Edison (for whose genius in
certain directions we all have a warm admiration) he
certainly is not familiar with the methods and use of in-
struments of precision in electrical measurements, and he
candidly describes his position as that of “ inventor,” and
in a manly way acknowledges his unfamiliarity with elec-
trical instruments of precision. The measurements of
human resistance made at Orange are entitled to just
about the same weight as the evidence on the certainty
of death given by the experiments on animals at Orange,
wherein those of the animals that did succumb (for some
the experimenters were unable to kill) were all immediately
dissected.
The statement that “ the methods of testing human re-
sistance are not difficult,” should not, bearing as it will the
weight of your authority, pass unchallenged. ‘The matter
of determining accurately the electrical resistance of a good
many objects (among them the human body) is just so diffi-
cult that notwithstanding all the means at hand in the finest
physical laboratories, these resistances are not yet deter-
mined with any degree of closeness. Maxwell, Helmholtz,
Mascart, Joubert, ‘Thomson, Von Webber, and Rayleigh
tell us that electrical resistance is a velocity, a length di-
THE MEDICAL RECORD.
397
vided by a time, and as such I have only to quote the ,
pertinent words of Professor Anthony,’ that “ the velocity
with which electricity passes over any given conductor is
not known, and that velocity depends upon a thousand
things.” It may surprise some of your readers to learn
that the old statements as to the velocity of electricity have
all gone by the board—and the man who now compares
the rate of transmission of nerve-sensation with the obso-
lescent 280,000 miles per second velocity of electricity
compares something with nothing.
Furthermore, physicists do not measure all electrical
resistances in the same way, #.¢., by a similar method.
One who would take a foot-rule to measure the circum-
ference of a circle would err less than the electrician who
would undertake to measure with a Wheatstone bridge
the resistance of the human body. There are many elec-
trical resistances wherein the employment of a Wheatstone
bridge gives unreliable results. ‘The internal resistance of
a battery (and this seems most fairly comparable with the
human body, since it is among the possibilities that the
heart possesses certain electrical properties *) is measured
by the voltameter method ; the insulation resistance of a
cable and all very high resistances, by the balistic galva-
nometer and standard-cell method, etc.
Nor does the fundamental law of Ohm stand as the
only law to be considered in determining human resistance.
In all this discussion not a word has appeared as to the
law of resistances in divided circuits, the very law that
seems most applicable to the case, for the human body, in
all probability, is a divided conductor, and in a divided
conductor the joint resistance is the product of the separ-
ate resistances divided by the sum of these resistances—a
very different quantity from the assumed simple resistance
of a certain portion of the body, which -may or not em-
brace the paths traversed by the current.
‘here are also heating effects, requiring careful deter-
minations of current-strength, resistance, and time; but,
without going further, it ought to be evident that the elec-
trical resistance of the human body is a very complex prob-
lem to determine, and one in which only very discordant
results can be obtained by the hasty application of primary
formule. Very respectfully,
ALEXANDER MCADIE, M.A.,
FrLLOw CLARK Umivaastry, WorcssTER, Mass.
e and Davy News.
Official List of Changes in the Stations and Duties of Cfi.
cers serving in the Medical Department, United States
Army, from September 1 to September 7, 1889.
By direction of the Secretary of War a board of medical
officers, to consist of Colonel Epwarp P. VALLuM, Sur-
geon ; Major Henry McELperry, Surgeon ; Major WASH-
INGTON MATTHEWS, Surgeon ; Captain JAMES C. MERRILL,
Assistant Surgeon, is constituted to meet in New York
City on the first day of October, 1889, or as soon there-
after as practicable, for the examination of Assistant Sur-
geons for promotion, and of candidates for admission
into the Medical Corps of the Army. ‘The board will be
governed in its proceedings by such instructions as it may
receive from the Surgeon-General. Par. 1, S. O. 203,
A. G. O., September 2, 1889.
Janeway, Joun H., Major and Surgeon. With the
approvai of the Secretary of War, leave of absence
granted, S. O. 52, July 29, 1889, Division of the Pa-
cific, is extended two months. Par. 1, S. O. 206, A. G. O.,
September 5, 1889.
CLEARY, F. J. A., Major and Surgeon. Leave of ab-
sence for two months, on surgeon’s certificate of disability,
is hereby granted. S. O. 59, Headquarters Division of
the Pacific, San Francisco, Cal., August 27, 1889.
1 Remarks at “Meeting of Electric Light. Association, August 14, 1889.
2 See Electrical Properties of the Human Heart, by Dr. H. D. Wal-
ler, THE MEDICAL RECORD, November 3, 1888,
308
EwinG, CHARLES B., Captain and Assistant Surgeon.
” Leave of absence for twenty-one days granted, to com-
mence on or about September 21, 1889, provided that at
that time the post-surgeon now on leave has returned to
duty. Par. 5, S. O. 201, Headquarters Division of the
Atlantic, Governor’s Island, N. Y., September 4, 1889.
BANISTER, W. B., First Lieutenant and Assistant Sur-
geon. Leave of absence for fifteen days is granted.
Par. 2, S. O. 82, Headquarters Department of Arizona,
Los Angeles, Cal., August 23, 1889.
By G. O. 69, A. G. O., August 31, 1889, the garri-
sons of Fort Laramie, Wyo., Fort Hays, Kan., and Fort
Lyon, Col., will be withdrawn, and the posts named will
be abandoned as soon as it can be done with due re-
gard to economy.
Official List of Changes in the Medical Corps of the United
States Navy for the week ending September 7, 1889.
Nash, F. S., Passed Assistant Surgeon. Detached from
the Dale and ordered to duty in the Bureau of Medicine
and Surgery.
RussELL, A. C. H., Passed Assistant Surgeon. Ordered
to Naval Hospital, Yokohama, per steamer of September
28th.
HaLL, C. H. H., Passed Assistant Surgeon. Detached
from Naval Hospital, Yokohama, on reporting of relief,
and to return home.
White, S. S., Assistant Surgeon. Detached from
Naval Hospital, New York, and ordered to the Minne-
sota.
STONE, E. P., Assistant Surgeon.
Minnesota, and to wait orders.
Bryant, P. H., Assistant Surgeon. Detached from the
Ajax, and ordered to Naval Hospital, Norfolk, Va. ,.
WENTWORTH, A. R., Assistant Surgeon. Detached
from Naval Hospital, Norfolk, Va., and to wait orders.
Detacned from the
Medical Items.
CONTAGIOUS DIsEASES—WEEKLY STATEMENT. — Re.
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending September 7, 1889:
Cases. | Deaths.
MY POUS Tevet void od seta eietech a aaa eeu twods |
Typhoid fever osiris sessrrensisidini erie waesans
% 80
ot
Scarlet fever...... PI Git do enw ote E SA ESE
Cerebro-spinal meningitis................+0cceeee
We aS ES iso ouisio 55 voi ea N wen die awe ates
Diphthériad cesi ene e a a eaaa aA
Small Pore 55e Geile san e a Vna wot |
Yellow fever, osdseor reces sasbueuawesdaleweaseus |
CHOC ag 5 ceca, TREERE ET NESTELE |
wn
00 OMS wm
=
COGAN nDwWMNO
CANCER AND AGE IN ANIMALS.— An instructive mono-
graph on tumors in the lower animals, by Dr. Plicque, ap-
peared recently in the Revue de Chirurgie. Among the
more interesting definite facts included in his paper are
the subject of melanosis and the relation of cancer to age.
Melanosis, so malignant in man, is far nearer the inno-
cent type of tumor in animals, especially in the horse. A
melanotic nodule on a spot subject to irritation by har-
ness sometimes disappears when the harness is adjusted
so as to rub the new-growth no longer. ‘The phenome-
non has even been observed after the growth has begun
tu ulcerate. Other tumors, especially sarcoma and car-
cinoma, are often more intensely malignant in animals,
especially the horse, than in man. Animals protected by
the resources of civilization, so as to live to an old age
rarely, if ever, met with in nature, are especially subject
THE MEDICAL RECORD.
[September 14, 1889
to cancer. Indeed, Dr. Plicque finds distinct evidence
that age is far more predisposing to cancer in beasts than
in man. Bouley, a French veterinary authority of experi-
ence, believes, on the ground of long observation, that
dogs are doomed to cancer if they live to old age and are
not killed by some acute pulmonary or gastro intestinal
affection. The cat, often cherished and kept alive when
old and miserable, is also very subject to cancer in age.
Statistics show that cancer is far more frequent in the
carnivora than in vegetable eaters. ‘This statement, as
Dr. Plicque is careful to explain, is liable to mislead the
pathologist ; indeed, it is a capital example of a statistical
doctrine eminently calculated to deceive the thoughtless.
For if we only note what animals are mentioned above in
this paragraph, the truth will become apparent. Old cats
‘and dogs, carnivorous animals, are kept alive through a
somewhat misguided philanthropy, or rather zoophily.
But an old horse is seldom favored in this doubtful way,
and cattle are killed, or ought to be killed, when they are
young and tender. The herbivora have little chance of
living long enough to have cancer.— The Lancet.
THE following interesting account of how a boy was
wounded in a very critical place, and the injury was
shrewdly diagnosticated and wisely treated by a medical
student, comes to us in the daily press. We suppress
only names. “ The boy, aged fourteen, had been fooling
with another lad, aged about sixteen, who was chasing
him with an open knife, and upon coming up with him,
gave him a cut about six inches long by one and one-half
inch deep, extending from a point opposite the upper
portion of the sanctum, diagonally across the left ham,
severing the glutacus maximus and exposing the glutacus
minimus. Mr. , a student at Medical College,
stitched the wound to the entire satisfaction of his father,
who witnessed his labors. Fourteen stitches were found
necessary to close the same.”—Boston Medical ana Sur-
gical Journal.
PIANOFORTE PRACTISING.—Professor Watzoldt, the di-
rector of the Elisabethschule (a girls’ school in Germany),
has addressed a most serious warning to parents and guar-
dians on one of the evils of the present system of teach-
ing girls. It is on the subject of what Wagner has con-
temptuously called Hammermusik. The professor begins
by pointing out that the terms “ musician” and “ piano-
forte-player ” are not at all convertible. Then he refers
to the illogical conduct of so many parents, who, for the:
sake of their children’s health, ask them to be excused
certain subjects of the school course, while they encourage
them in the most excessive exertions at the pianoforte.
Now, there is no subject which, if taught seriously, makes
such a demand upon the store of nervous energy of the
body as instrumental music. The brain, the eye, and the
hands are all exercised at once ; hence the frequent injury
to health in the case of girls who have not a strong con-
stitution. The professor has collected some statistics
which show that more than half the pupils are taught the
pianoforte, and that after their tenth year they spend twice
as much time daily at it as at their other home lessons.
Many girls complain of feeling tired, absent-minded, fidg-
ety, of headaches and sleeplessness ; and these complaints
grow worse as they grow older. In all cases where the
parents could be prevailed upon to diminish the hours of
pianoforte practice, or stop it altogether, a marked im-
provement in general health was the invariable result.
Herr Watzoldt, therefore, recommends (1) that pianoforte
instruction should not begin until the age of twelve ; (2)
that only girls of sound health, and who show some talent
for music, should be made to play.— Science.
Doctor: “ You see, wifey dear, I have pulled my pa-
tient through, after all! A very critical case, I can tell
you.” ‘Yes, dear hubby ; but then you are such an ex-
cellent physician! Ah! if I had only known you five
years earlier, I feel certain my first husband—my poor
Thomas—would have been saved ! ”— Æx.
The Medical Record
A Weekly Fournal of Medicine and Surgery
Vol. 36, No. x2
Original Articles,
THE EARLY DIAGNOSIS OF EXTRA-UTERINE
PREGNANCY.
By J. M. BALDY, M.D.,
PHILADELPHIA, PA.
THE subject of early diagnosis in extra-uterine gestation
is one of the utmost importance, and it is most necessary
that everything which is known on the subject be put be-
fore the profession at large in as clear and concise a
manner as is consistent with the facts in our possession.
This is particularly so, as on our being able or not to
make the diagnosis rests the treatment, in many cases, as
far as electricity is concerned.
Of late years much has been written on this subject, pro
and con. Among the most recent contributions is an
article in the July number of the American Journal of the
Medical Sciences, by Dr. J. C. Reeve. With many of the
propositions set forth by this writer I cannot agree, and
do not think the facts will uphold his statements. Many
of his errors can only be explained by the following words
quoted from his article : “ I fully recognize the fact that a
paper presented to an assemblage of practitioners should
be based largely upon personal experience, and that doc-
trine should be illustrated, or theory enforced. by the re-
cital of actual observations. I deplore, therefore, that I
have not clinical experience to lay before you.” I have
been extremely fortunate in being able to study this sub-
ject from a personal clinical and pathological stand-point,
and shall base my subsequent remarks on an experience
of some fifteen or more cases, on which I have either
operated, assisted others to operate, witnessed the opera-
tion, or examined the specimens shortly after death; in
all these cases I have previously been familiar with
the histories. In addition, I have seen a number of cases
diagnosed, by competent observers, as extra-uterine preg-
nancies, when no pregnancy whatever existed. I shall
try, as far as possible, to come up to the standard laid
down by Dr. Reeve, and “doctrine shall be illustrated,
and theory enforced, by the recital of actual observations.”
I take the paper of Dr. Reeve as a basis for my own,
simply because it well represents the opinions of those
who advocate that the early diagnosis of extra-uterine
pregnancy can, for the most part, always be made and
made with ease. Such, for instance, is the opinion of
Grandin, who states that “in this country the weight of
opinion certainly is that tubal pregnancy may ordinarily be
diagnosticated early, and of late years the number of in-
stances where this has been done have greatly decreased.”
Also of Janvrin, who stated at the Washington meeting of
the American Gynecological Society that the diagnosis of
extra-uterine pregnancy was easier than that of normal preg-
nancy ; and so with many others. My own experience,
in addition to a careful study of the experience of others,
as it has appeared in print, has convinced me that the fol-
lowing is the true position we must assume on this subject :
I. In a certain proportion of cases of extra-uterine
pregnancy, in the early stages, the diagnosis is easy and
unmistakable.
II. In a certain (quite large) proportion of cases suf-
ficient symptoms are present to more than warrant a diag-
nosis of extra-uterine pregnancy, such a pregnancy not
being present.
Whole No. 985
III. In a certain other proportion of cases the symp-
toms, until rupture has occurred, are entirely wanting, or
of such a dubious character as to in nowise warrant
such a diagnosis.
If these three propositions are correct, it is very ap-
parent that the natural deductions to follow are, that the
diagnosis of extra-uterine pregnancy in its early stages is of
such a doubtful and problematic nature that we are jus-
tified in saying it cannot be made. By that I mean
when we are most certain that such a pregnancy is present
it may not be; it may be present when we least suspect
it. In other words, the uncertainty is so great we can
never be certain.
Reeve says: ‘“ The symptoms which have been detailed
may be classified partly in reference to the order of their
occurrence, but especially as to their diagnostic value, as
follows :
“I. Suggestive-—a. The general and reflex symptoms of
pregnancy, especially if the pregnancy had occurred after
a considerable period of barrenness. 4. Disordered men-
struation, especially metrorrhagia, coincident with symp-
toms of pregnancy; gushes of blood, accompanied by
severe pelvic pains. ¢. Severe pain in the pelvis; attacks
of pelvic pain followed by tenderness in either iliac region,
and other symptoms of pelvic inflammation.
“II. Presumptive.—a. The existence of a tumor; this
tumor presenting the characteristics of a tense cyst, sen-
sitive to touch, actively pulsating; steady and regular
growth of the tumor to be observed. 4. The os uteri
patulous, the uterus displaced and empty.
“III. Certain.—a. Paroxysms of violent and over-
whelming pain in the pelvis, with general symptoms of
collapse. 4. Expulsion of the decidua.”
This classification of symptoms commonly associated
with this disease in the early stages, although not com-
plete, I am willing to accept, with the exception of “ par-
oxysms of violent and overwhelming pain in the pelvis,
with general symptoms of collapse.” Such symptoms
would put the case beyond the point of the present dis-
cussior. When the cyst has ruptured, no one will dispute
that the diagnosis can, in the vast majority of instances,
be made with certainty. These “ violent and overwhelm-
ing paroxysms of pain, with general symptoms of collapse,
always indicate rupture. This is so generally accepted as
a fact that I shall not attempt to prove it by citing cases.
With this exception, then, I am willing to allow Dr. Reeve’s
classification of symptoms to settle the question of the pos-
sibility of diagnosis before rupture or the extreme uncer-
tainty of such diagnosis.
I wish to make this explanation of the cases I have
seen. In every case there has been rupture more or less.
Often this rupture consisted simply of a teaspoonful or
so of black clots, and these were contained in the sac
itself. ‘They did not show themselves until the sac was
either torn loose from its adhesions, or was ruptured in
the manipulation. For all purposes of treatment, there-
fore, they were unruptured, and they are just such cases
as are picked for the electrical treatment. ‘They go in-
cidentally to prove Mr. Tait’s proposition, that the pe-
culiar paroxysmal pains of ectopic gestation always mean
more or less rupture. In every one of them pains had
occurred.
To prove my first proposition, that the diagnosis is at
times easy to make, I will mention a case in which I as-
sisted Dr. Montgomery, of Philadelphia, to operate. ‘The
doctor asked me to assist him with a laparotomy for extra-
310
— —
uterine pregnancy. The woman had general and reflex
symptoms of pregnancy; she had disordered menstrua-
tion, after missing a period, having previously been regu-
lar; she had rather characteristic pains, and had been
discharging blood from the vagina, together with shreds.
The uterus was found enlarged, with soft cervix, and a
tender pelvic mass to the side was plainly discernible.
The operation only verified the diagnosis. ‘The cyst was
unruptured, but contained a small quantity of blood-clots
in itself. The pregnancy was not more than seven or
eight weeks old. With the exception of one other case,
those cases I have seen, in which the diagnosis has been
as plain as this, had either ruptured into the abdominal
cavity, or into the broad ligament, and the diagnosis, in
which I concurred, was made in these, for the most part,
from the shock or collapse of the rupture. This was
notably so in a case on which I witnessed Dr. Goodell
operate, and in another one on which I operated myself.
My second proposition, that at times sufficient symptoms
are present which not only justify a diagnosis of extra-
uterine pregnancy, but compel such a diagnosis, is proven
by the following cases :
Mrs. X : General and reflex symptoms of preg-
nancy, such as swollen and painful breasts, containing
milk; morning nausea; enlarging abdomen; frequent
micturition ; constipation, etc.; had missed a period or
two; patient thought herself pregnant; had not been
pregnant for some years; irregular bleeding for a week
or twa; colicky pains in abdomen; passage of blood
and shreds per vagina. Examination showed a cystic
tumor to one side of the uterus, painful to the touch.
The patient was seen by Dr. J. Price and several other
gentlemen, all concurring with me in the diagnosis of un-
doubted extra-uterine pregnancy. Several days afterward
an operation disclosed an ovarian cyst as large as an
orange.
Mrs. Z——: General and reflex signs of pregnancy
almost as above ; not pregnant for years; missed a pe-
riod ; profuse bleeding, with clots and shreds ; severe pel-
vic pains of a colicky character. Examination disclosed
a pelvic mass to the side of the uterus, evidently a dis-
tended tube. A diagnosis of extra-uterine pregnancy was
made by Dr. Kyneth, several other gentlemen, and myself.
Operation in a few days, by Dr. Penrose, disclosed pyosal-
pinx. Any one reading the brief history of these two
cases must admit that the diagnosis was not only war-
ranted, but demanded. ‘They were both seen and diag
nosed by gentlemen who have had considerable experience
with this and other pelvic troubles, and who were per-
fectly familiar with the literature of the subject. The ob-
jection may be made, and in fact has been made, that the
shreds which were discharged should have been carefully
examined, and that the case should have been watched to
see if the cyst grew in size. My objection to waiting is,
that while we are watching and studying, the patient will
suddenly go into collapse and die from a rupture before
anything can be done for her. What we want is to make
a diagnosis when we see the case, not to wait and run all
the nsks of the question being settled by death. Where
the discharges can be, they should be examined. But
often we do not see the shreds, only having the patient’s
word for their presence. Such was the case with Mrs.
X—, and the woman was too sick to warrant any delay,
especially as the rest of the history was so clear. ‘The
shreds, or “ pieces of flesh,” having been passed the day be-
fore, there being none present at the time of the examina-
tion, it was not deemed worth the risk of even one day’s
delay. Even had they been found, and the examination
of them been negative, it would not have altered the diag-
nosis. ‘The criticism advanced by Dr. Kelly, when the
case of Mrs. X was reported, was that in a case of his
own the cyst had dimi.ished in size while under obser-
vation, and that this was a valuable symptom, and should
be looked for. In his case the foetus was dead and the
liquor amnii had become absorbed. ‘This would never
occur while the foetus lived, and therefore has nothing
THE MEDICAL RECORD.
[September 21, 1889
whatever to do with the question. Again, if the foetus
was dead, as the operation in his case proved it to be, ac-
cording to our electrical friends, the operation was un-
justifiable, for the reason that al] was then accomplished
which the most ardent electrician claims to aim at, viz.,
the death of the foetus. I could go outside of my own
experience and enlarge on this class of cases, if I wished;
but my second proposition is sufficiently proven by what I
have already given. A case I operated on only recently
will prove my third proposition, viz., that at times an
extra-uterine pregnancy is present and does not present
sufficient symptoms to warrant a diagnosis.
` Mrs. R——-, came to me complaining of abdominal and
pelvic pain. After giving a negative history, she was put on
the table and a diagnosis of pyosalpinx was made, and an
operation advised. One week later she sent for me, and I
found her lying on her bed ; she said she had been having
abdominal pains all week ; she arose from the bed in order
to obtain a letter she had received from her husband. While
on her feet she was seized witha colicky pain. As I
watched her the idea suddenly seized me that possibly
this might be extra-uterine pregnancy. I carefully exam-
ined her with this possibility in view. She had been bleed-
ing off and on for over two weeks ; the show was clear
blood, with never ashred or clot in it; she had not the
slightest general or reflex sign of pregnancy ; her husband
had been away for only three weeks or less, and she had
not missed a period, nor had she had a scant one; she
had been having children for the past six or eight years at
regular intervals. ‘The examination showed the uterus in
good position, and the cervix perfectly normal for a mul-
tipara. ‘There was a mass posterior, and apparently con-
tinuous with the cervix, so much so that had I not been
able to clearly feel the fundus anterior, I should have
thought it the fundus. The only symptoms, then, I had for
diagnosis were the bleeding and the pain. These symp-
toms are such constant and almost invariable companions
of all serious pelvic troubles, that without something more
to sustain the diagnosis it had manifestly to be given up.
Dr. Hamill made a most careful examination for me, and
could find nothing more than I had on which to base a
diagnosis ; in fact, hedid not think it a case of ectopic
gestation at all. Before beginning the operation the next
day, I remarked to the visitors that I was operating for
what I had thought to be a pyosalpinx ; that if it turned out
to be atubal pregnancy they must not say I had not at
least suspected that possibility ; that possibly I might find
nothing but an intra-uterine pregnancy (the continuation
of the softer mass posterior with the cervix making this
a possibility). My preference for the diagnosis of pyo-
salpinx was because of the negative symptoms for extra-
uterine pregnancy, and because the woman had been com-
plaining of pelvic pains for the past three or four years ;
had pain at her menses; painful coition and defecation.
She had been having more or less whites, and they had
suddenly become profuse, with itching about the vulva,
and painful micturition. She was in that state of life
when one would expect her husband to infect her with
gonorrhcea. ‘Taking it all for all, the indications were
clearly for pelvic inflammatory trouble, and against extra-
uterine pregnancy. It turned out to be a pregnancy of
the fimbriated end of the tube, with a small quantity (a
drachm or two) of black clots in the cyst itself.
Now here is a case in which the diagnosis of ectopic
gestation could not be reached, although a most careful
examination was made with that possibility in view.
These cases I present show some of the difficulties in the
way of a correct diagnosis, even in the hands of those
who are in the habit of seeing and handling such cases
frequently. What is a difficulty in the hands of the
specialist becomes oftentimes an impossibility in the
hands of the general practitioner, and where one constant-
ly used to dealing with pelvic and abdominal diseases may
at times suspect or stumble into a correct diagnosis, those
who have not the time to bear all these matters continu-
ally in mind, to the exclusion of almost everything else,
September 21, 1889]
must very frequently fail. At any rate, from my own ex-
perience I show clearly how extremely uncertain the
whole matter is, and what folly it is to say we can with
any degree of certainty make the correct diagnosis Be-
cause in sooth we can in certain cases make the diagnosis
and find it verified (for an unverified diagnosis is utterly
worthless), what right have we, in the face of such an ex-
perience, to say it can always be made? If we admit that
mistakes are and can be made, such as I have detailed,
then the whole subject becomes at once one of great un-
certainty, and my statement that the diagnosis cannot be
relied upon becomes justified. That such is the true
state of our present knowledge is proclaimed by the ma-
-jority of those with any real experience on the subject,
such, for instance, as Dr. Gaillard Thomas, who says, “ Need
I say how difficult such a diagnosis is at a period suffi-
ciently early to prevent rupture of a distended Fallopian
tube, which usually gives way before the fourth month of
gestation has far advanced? Even after foetal movements,
the foetal heart and the precious results of abdominal pal-
pation put themselves at our disposal, accurate diagnosis
is often far from easy. There are few pelvic condi-
tions which develop in the female, from phantom-tumor
to fecal impaction, which: I have not seen confounded
with ectopic gestation.” The advocates of the early diag-
nosis being drawn from the ranks of those who acknowl-
edge they have only such knowledge as they obtain from
the literature of the subject, or from those who make the
diagnosis, treat the disease with electricity, but never verify
it by either abdominal section or post-mortem examina-
tion. In other words, they only verify their diagnosis by
the so-called “ therapeutic test,” which Dr. Reeve com-
plains we, who differ from him in opinion, will not accept.
In view of the great uncertainty in our way of diagnosis,
€s shown by my own experience, and verified by the knife,
can any one blame us for not accepting such a test ?
INTUBATION IN CASES OF FOREIGN BODIES
IN THE AIR-PASSAGES; WITH REMARKS
CONCERNING FEEDING AFTER INTUBA-
TION.
By S. J. MELTZER, M.D.,
NEW YORK.
W.G , a boy, aged three years, while crying with
his mouth filled with food, was suddenly seized with a
choking spell. The mother, who was attracted by this
circumstance, supposing that food had become lodged in
the air-passage, turned the boy upon his head, slapped his
back, and finally administered syr. ipecac in sufficient
doses to provoke vomiting. The violent symptoms abated,
and the boy is said to have slept peacefully the following
_ night. In the morning, however, his voice appeared
hoarse, and his breathing in the course of the day became
more and more labored. I saw the child about 3 P.M.,
_ some twenty hours after the choking spell. The symp-
toms which presented themselves were those of a case of
croup in a tolerably advanced state ; and, indeed, without
the preceding history I would certainly have diagnosed it
as a case of croup. Having been unsuccessful in an at-
tempt to relieve the child by the endolaryngeal method, I
advised to consult a laryngologist. Upon my return, after
the lapse of three hours, I mec my colleague, who had
also fruitlessly endeavored to relieve by the laryngoscopical
method. He considered tracheotomy as the only means
out of the difficulty. The child, however, had at once to
be relieved, as its condition in the meanwhile became very
critical. The child lay comatose, its face intensely cy
anotic, pulse very feeble, frequent, and intermittent. The
supraclavicular and sternal contractions increased to their
utmost, and no air found access into the lungs. Many
difficulties presented themselves to the immediate perform-
ance of tracheotomy; I therefore conceived the idea of
trying intubation. With the assent of my colleagues
present, I introduced an O’Dwyer’s tube into the larynx,
THE MEDICAL RECORD.
311
and relief thereupon followed. ‘The child breathed freely,
the pulse improved, the cyanosis disappeared—in short,
the condition was nearly a normal one. I did not remove
the tube, but so wrapped the child in a blanket that it
could not free its hands and seize the thread. Small
pieces of cracked ice were alone given to the child, and a
constant watch upon the latter was ordered. The child
passed a good night, the peaceful slumber being only now
and then interrupted by coughing. Toward morning,
however, the watching grandmother loosened the blanket,
and fell asleep, whereupon the little patient, during a
coughing spell, seized the thread and pulled the tube out.
When I came I found the child breathing perfectly free,
without any sign of stenosis or dyspncea. Upon examining
the tube I discovered that it was half-filled with viscid
mucus, and that it contained, besides numerous small
particles, a comparatively large, pointed piece of a nut-
shell. Although the larynx did not cause any trouble, a
rise of temperature appeared the same day, which, as was
soon proven, proceeded from a fibrinous pneumonia.
The development and course of this illness was not of
sufficient importance to be reported in detail. There first
appeared symptoms of a pneumonic infiltration of the
entire lower lobe on the posterior surface of the left lung.
Five days later there also appeared a pneumonia of the
right side, posteriorly and inferiorly, but not so extensive
or severe as that of the left side. The temperature was
moderate, but slightly above 102° F. ; the general condi-
tion satisfactory, only a painful cough was present which
reminded one of pleurisy. In fact, the dulness was so
striking on the left side, even before the bronchial respi-
ration appeared, that I, in spite of the origin, carefully
looked out for the differennal diagnostic symptoms of
pleurisy and pneumonia before deciding upon the latter.
Over the dull areas fine crepitant rales and vesicular
breathing were present during the period before the ap-
pearance of the bronchial respiration ; the areas of dul-
ness remained unchanged in all positions. ‘The dulness
was not increased from above downward. ‘The vocal
fremitus was increased, that is, very pronounced, during
the first few days, before the pneumonia invaded the
right side. It is very probable that the infiltrated areas
lay superficially. The fever disappeared two weeks after
the beginning, and terminated by lysis. The dulness,
which outlasted for a long time the bronchial respiration,
disappeared gradually about three weeks later. Nothing
remained ; the child is perfectly well.
‘That we are here dealing with a foreign body ın the larynx
need not be further explained. The stenotic symptoms,
however, did certainly not originate from a direct obstruc-
tion of the glottis by the foreign body—the latter was too
small to cause this. It could, though, be conceived that
there were other small particles present, which were
coughed up and swallowed, and that the amount of these
might indeed have occluded the glottis. In a direct oc-
clusion, however, the first attack would not have passed
off, and the second deciding attack would not have been
developed relatively so slowly. tis much more probable
that the first choking spell was produced by a spasm of
the glottis, which was reflexly induced by the foreign
body, whereas the subsequent gradually developing steno-
sis was occasioned either by a submucous swelling or by
cedema of the glottis, which the irritation of the foreign
body resting in the larynx might have provoked. We
certainly find in literature mention of cases where foreign
bodies remain for a long time in the larynx without caus-
ing any reaction. Still, these particles lay chiefly in a ven-
tricle of Morgagni ; whereas our piece of nutshell, by the
nature of its pointed condition, might have been lodged
near the edge of a vocal cord, where, on account of its
frequent movements, the irritation must have been more
frequent and intense.
The removal of the foreign body from the larynx can
be explained in two ways; either that the body already
in the larynx lay embedded in viscid mucus, thence by
the introduction of the tube the body, with viscid mucus,
312
THE MEDICAL RECORD.
[September 21, 1889
became adherent to the lower end of the tube, and was
forced into the tube by coughing ; or that in pushing the
tube into the larynx the body fell down into the trachea,
and upon coughing was forced up into the tube.
The origin of the pneumonia in our case cannot be at-
tributed to the intubation. ‘The tube remained relatively
but a short time, and the child received nothing to drink
while the tube was in the larynx. It is much more prob-
able that the pneumonia originated from aspiration of
very small particles during the choking; we certainly
found a large number of these embedded in the mucus
besides the larger piece.
As far as I can review the literature, the present
attempt appears to be the first where intubation was per-
formed for the treatment of foreign bodies in the air-pas-
sages. Itis therefore appropriate to discuss how far intu-
bation may be brought into play in the cases mentioned.
Although this case terminated satisfactorily, it is yet ap-
parent that this method will not only be of no avail in
some cases, but will, on the other hand, work direct mis-
chief in many cases. If, for example, the foreign bodies
in the larynx be larger than the lumen of the tube appro-
priate for that particular case, then certainly intubation
will be useless ; it will, on the contrary, apparently do harm,
as the body will be pushed from the larynx into the
trachea, and the chance for the now expedient tracheotomy
will be greatly impaired, as there is more prospect of suc-
cess in tracheotomy to remove the foreign body when in
the larynx than when it is in the trachea. I shall there.
fore attempt to state the conditions under which intuba-
tion in cases of foreign bodies in the air-passages appears
permissible and advisable. Firstly, where we can with cer-
tainty assume that the foreign body lies in the trachea or in
abronchus. In this case there exists no contra-indication.
In all these cases intubation should be performed and de-
velopments awaited. If the foreign body be smaller than
the lumen of the tube, it will be dislodged by the severe
coughing attacks always present, in addition to which the
fluids which now and then flow down through the open
tube may also be of service in facilitating its removal. If
the foreign body be larger than the lumen, the success of
sracheotomy will not in any respect be impaired if com.
yelled to resort to it after the unsuccessful issue of intu-
bation. In cases where the body dwells in the larynx
the case is different. If the foreign body be sufficiently
large to occlude the glottis, and the first choking attack do
not pass off, then certainly tracheotomy should at once
be preferred, if there only exists a possibility of perform.
ing it. If, for some cause, such a possibility be not pres-
ent, then an attempt should be made to push the foreign
body into the trachea by means of intubation. ‘lhe trachea
is much wider than the larynx, and what fills the former
will allow the passage of air in the latter ; besides, the tube
lying in the larynx will prevent the foreign body from
again becoming wedged in it, so that by the intubation a
respite is gained for the possibility of a subsequent trache-
otomy. In cases where the body does not occlude the
larynx it is difficult to arrive at a conclusion. If the
stenosis has assumed a dangerous aspect, and if it be for
some reason not practical to perform tracheotomy at
once, as in our case, then we ought unhesitatingly to intu-
bate, and we may often avoid a subsequent tracheotomy,
as the case above described shows. But if the case is not
as yet very urgent, and tracheotomy can be performed
with as great facility as intubation, then, in my opinion, it
would be more rational to tracheotomize. If we cer-
tainly knew that the body could pass through the tube,
then, in my judgment, intubation would certainly be in-
dicated, with certain presumptions that the body would
again be coughed out. But we have no hint of what size
the foreign body may be, and it may possibly be larger
than the lumen of the tube, though it 1s not large enough
to obturate the rima glottidis. Should it be the case—
should the body be larger than the lumen—then we still
would not avoid tracheotomy ; but then the latter pre-
sents a more favorable prognosis for the removal of the
body if it be in the larynx than if it be in the trachea or
fallen down into a bronchus.
To the cases mentioned I would like to add the further
remark, that in a certain variety of foreign bodies in
the air-passages intubation is unconditionally indicated,
namely, where fluid deluges the lungs—the water, for
instance, in drowned people, pus from a retropharyngeal
abscess, blood in operations of the mouth, and especially
the blood in pulmonary hemorrhages. Death in the lat-
ter cases mostly does not ensue from loss of blood, but
from asphyxia, as the blood, which cannot escape rapidly
enough, deluges the whole respiratory surface. Cases
are cited in literature where tracheotomy under these
circumstances was the means of saving life. I do not
hesitate to state that in such cases intubation, to say the
least, will prove of as great avail as tracheotomy. If we
take notice what a large amount of fluid we may pour
directly into the trachea after an intubation, without per-
celving any threatening signs of asphyxia, we must con-
clude that the glottis alone is at fault if any fluid in the
trachea can provoke asphyxia, inasmuch as the glottis is
impelled to closure by the irritation of the fluid foreign
body, and thus is the escape of this fluid prevented. At
any rate we will not lose anything by intubating in such
cases.
As an addition to the preceding communication, I de-
sire to make a few remarks on a method of feeding after
intubation. As is known, the question of how the child
is to be fed, is, in the eyes of many, the weak point in the
method of intubation, on account of the danger of
‘“Schluckpneumonie.” I have explained in another place’
that the pneumonia can only be developed through active
expiration while the glottis is closed. A mere aspiration
cannot draw anything, even it be ever so small, into the
alveolz. If this theory be correct—and I hope soon to
be able to experimentally demonstrate its correctness—
we need not fear the “Schluckpneumonie” as long as
the tube remains in the larynx and prevents the closure
of the glottis; we must but cease with the feeding for
some time before the removal of the tube, and cleanse
the trachea with a mild antiseptic. But even without the
fear of ‘‘Schluckpneumonie ” the feeding after intubation
is very difficult, because most of the food makes its way
into the trachea, and but a small quantity into the cesopha-
gus, and, furthermore, the children stubbornly resist taking
food at all. To think of feeding by means of the cso.
phageal tube is in such cases the more natural, as this
method of feeding has already come into vogue in ordi-
nary cases of diphtheria.’ But the introduction of the
oesophageal tube through the mouth meets many difficulties
and induces vomiting, which we certainly should try to
avoid. Latterly, therefore, I have tried to overcome the
difficulties by introducing a soft catheter (silk or rubber)
into the stomach through the nose, and left there per-
manently. ‘Though my experience in its use is limited to
but two successful cases, I will briefly explain this method
(which I could not find described anywhere in literature)
so that others may try it. It gives promise of good results.
The outer end of the catheter was connected with rub-
ber tubing, which was knotted so as to prevent the out-
flowing of the fluid from the stomach, and to retain it
in situ it was fastened to the ear by a thread. The chil-
dren, both otherwise stubborn, made no attempt to seize
the tube. If nounshment was to be administered, a small
funnel was attached to the tube; if the nourishment at
times did not flow through, it was easily remedied by
blowing into it a little. As food there was used milk,
beef-tea, diluted wine, a little at a time, but frequently
even during sleep ; the child was never awakened by feed-
ing. Irto the mouth there was given only now and then
a 1 to 10,000 solution of bichlonde of mercury, in order
to moisten the mouth, to induce cough, and to cleanse
the trachea aseptically. Not a drop of this fluid entered
1S. J. Meltzer: Ueber die mechan. Verhdltnisse bei der Ent-
stehung der Pneumonie, Medicinische Monatshefte, 188. Heft Il.
2 Renvers: Therap. Monatshefte, 1889. Heft III.
served. If anything were injected into the empty nostril
the fluid would emerge from the other one, in which the
catheter was placed, so that the catheter is no obstacle in
the treatment of nasal diphtheria. In one of the children
the posterior nares were so completely occluded with
diphtheritic masses that I was compelled to bore through
the latter with a prostatic catheter before I could pass a
soft catheter through the pharynx. Both children, of
different families, had pronounced diphtheritic croup, all
the members of both families had had diphtheria, and, in
fact, several times, and among them there were types of a
severe nature. One of the two children had pronounced
croup twice within a short period and recovered. ‘The
other child died, but neither from croup, “ Schluckpneu-
monie,” nor anything connected with the intubation or
method of feeding. It was a four-year-old rachitic boy,
with a very severe septic nasal diphtheria, and an acute
nephritis ; he died of cardiac paralysis.
179 East One HUNDRED AND NINTH STRERT.
VAGINAL TAMPONAGE.
By CHARLES C. £REDIGKE, M.D.,
CHICAGO, ILL.
PRACTISING gynecologists have been and still are casting
about for a means to support the uterus and its adnexa,
by a ready, inexpensive, and practical process, the problem
always having been how to do this in the absence of a
fulcrum or point d'appui. ‘To their constant exertions
we owe the present elaborate process of tamponage.
This process discards a fulcrum by taking advantage of
elastic or resilient pressure, thus obtaining innumerable
points of support, without doing violence to anyone.
After having employed absorbent cotton, oakum, jute,
felt, etc., the writer thus far has obtained the best results by
the use of pure lamb’s-wool in loose felt-like sheets half an
inch thick, manufactured by Messrs. Seabury & John-
son, of New York. This was formed into spindles of
various lengths and thickness ; disks, rectangular, square,
wedge-shaped, and round and oval; cylinders, truncated
cones, etc., wrapped with moist carbolized gauze, then
loosely quilted and medicated as indications required.
After having treated patients thus from one to four
months, medication of these tampons could be dispensed
with in many cases, the engorgement, pelvic pain, etc.,
being removed by this process, aided powerfully by the
elastic abdominal supporter, transferring of the weight of
all the undergarments from the hips to the shoulders, and
restoring somewhat the natural security and tactile func-
tion of the foot by strenuously insisting on the wearing
of laced shoes with low, broad heels and roomy across
the toes. Considerable degrees of prolapse of the ante-
rior and posterior vaginal walls were thus removed, and-
this in many cases of lacerations of the perineum. Dur-
ing winter this process of tamponage need not be repeated
more often than once a week, z.e., in cases which by con
tinued treatment have reached a purely mechanical stage,
not complicated by any pronounced pathologic con-
ditions ; but during warm weather this will not do, for
the process has to be repeated twice. Yet few have the
patience, fewer the time, and still fewer the means to
keep this up, and, since “ possession is the death of love,”
therefore, after having ransacked the history of a process
from gray antiquity to the present time, and mastered its
principles and their practical application and execution,
its endless routine repetition becomes a labor or task, for
such patients then have practically passed out of the ap-
plication of tamponage as understood at present, and a
substitute becomes imperative—a substitute, not by a
hard or semi-solid pessary, for his experience compels the
writer to distinctly differ from the views of most practi-
tioners, who look upon tamponage as an appropriate pre
cursory procedure to the wearing of a pessary, but by a
313
simplified continuance of the same process, at once eff-
cient, inexpensive, clean, and of easy self-application.
It thus became a serious consideration to devise a tam-
pon possessing the advantages of a pessary with few, if
any, of its defects.
Comparative physiology teaches that the functions of
what we please to call the perineal body are unknown.
Civilization, which is not founded in nature, assigned to
it the function of support, but this is not proven ; for the
apex of acone or wedge cannot support anything, par-
ticularly when its base rests upon nothing, and compara-
tive anatomy shows that the vaginal formx is produced
only by an intussusceptio cervicis uteri into the lumen of
the vagina, induced by the assumption of the erect post-
ure, which intussusception disappears nearly if not quite
in the horizontal or genupectoral.
A cavity is thus produced which, if filled with plastic
material, would result in the formation of a body corre-
sponding in its general contour with that of a California
pear, the anterior surface of which would be rather flat as
compared with its more convex posterior and the small
end of which would join the body under a slight obtuse
angle.
In order, then, to permanently support this dome-like
roof of that cavity, with its eccentric pendant of the cer-
vix uteri and all other superimposed organs, the elastic
and self-adjusting resiliency of a collapsable rubber pouch
suggested itself.
Black sheet-rubber of the thickness of that employed
in the manufacture of inflated ring-pessaries was cut into
sections, according to patterns previously determined,
having curvilinear edges, to bring out the shape of a pear,
and united by welding and cementing uver an expansible
wire frame similar to that employed in Professor Otis’
urethrometer, which was then withdrawn at the small end,
when that too was united, closed, and perforated by a hole
punched into it of one millimetre in diameter. ‘The
cemented edges of the sections form ribs which, when the
air is pressed out of the balloon, exert a powerful ten-
dency to expand. ‘They, as well as the small end of the
balloon, effectually prevent shifting when :# stitu.
Well lubricated with carbolized petrolatum, it is rolled
up, and, according to previous instructions, the patient in-
troduces it while in the dorsal decubitus, and when the
small end is even with the orificio vaginz the patient
changes to the genupectoral without stepping on the floor.
The instrument is immediately drawn into the cavity,
to which it seeks to adapt itself. The patient is then told
to cough several times while maintaining this position
during five to ten minutes. l 7
There is next to no possibility of its changing position
when once in place, by walking up or down stairs, stoop-
ing, lifting, reaching up, etc. A perfect fit is indicated
when the patient, after having executed all these move-
ments, cannot tell that she is aware of the presence of a
foreign substance.
Active motion only tends to make it fit closer, by its
constant inclination to adjust itself to the continuously
changing lumen of the vaginal vault and ever-varying
pressure by the organs superimposed. _
‘The two thus far made were of necessity crude, expen-
sive, lacking workmanlike finish, and devised tentatively
for patients who were abundantly able and willing to pay.
They more than met the requirements of these cases, hav-
ing been worn constantly during the last five and three
months.
‘The first was a case of retroflexion, complicated with
displacement of the ovaries into the cul-de-sac of Doug-
las, laceration of the os and perinzeum, and prolapse of
the anterior and posterior vaginal walls, leucorrhcea, etc.
Twice a week the vagina was douched with two gallons
of hot water containing equal parts of sulphate of zinc
and alum in solution (one teaspoonful to a quart), the
lacerations of the os touched with liquid carbolic acid
ninety-five per cent., the fornix dusted with equal parts
of iodoform and tannin, a glycerinated, spindle-shaped,
314
quilted lamb’s-wool tampon placed into it so as to form a
horseshoe (patient in genupectoral and by means of a
Sims’), followed by a wedge-shaped quilted disk, charged
with powdered tannic acid, and a cylinder constricted in
the middle, charged with pulvis zinci oxidi comp.
As long as congestion lasted the glycerites were used
and changed every second week, such as the glycerite of
ammonio-ferric alum, acetate of aluminium, sulphate of
aluminium, of zinc, borax, acetate of lead, tannic acid,
and boric acid in the form of boroglyceride of fifty per
cent., prepared by melting eight troy ounces of boroglyc-
eride (as prepared by the Merrell. Chemical Co., of Cin-
cinnati), and adding glycerine enough to make sixteen
fluid ounces. The caustics to the os were also changed
to iodized phenol, to conduct the granulation so as to pre-
vent contraction and dipping in, the finishing touches be-
ing given with solid nitrate of silver—the disks and cyl-
inders (strings were not attached to them) being also
charged with the powders of these various agents accord-
ing to indications; acute inflammation of the external
parts, abrasions, etc., were relieved by the compound zinc
powder prepared of |
B. Zinci oxidi puri... .... 0. cee cee cece eee ee 3 vi.
Magnes. carb. pulv.,
AMY QU occa kee tea seee anaE «ed Bi,
Morph. sulph ....ee..oe Galsae- aia s'awed ewes 3i.
Misce bene.
Pure oxide of zinc possesses all the therapeutic proper-
ties here as well as subnitrate of bismuth, which is five
times more expensive.
The function of the mucosa of the generative tract be-
ing mainly that of secretion, ointments were not em-
ployed ; in fact, the writer has discarded them in the treat-
ment of all cases, having relegated their use to the lubnica-
tion of the digits and instruments, the polish of which they
prevent from tarnishing. When all these pathologic con-
ditions were removed, exclusive of the laceratio perinzi,
a soft-rubber stem, according to Professor A. R. Jack-
son, was introduced, followed by the collapsable rubber
tampon, the diameter of the body of which was one cen-
timetre larger than the cavity. It isremoved once a week
by the patient in the dorsal position, followed by a hot
alum-zinc douche through a fountain-syringe. The
patient has worm this now five months and enjoys
perfect health.
The other case was that of a nullipara, twenty-nine
years of age, married eight years, with hyperplasia of
the uterus, chronic endometritis and cervicitis, ovar-
algia, dysmenorrhcea, mennorrhagia, decided anteflexion,
and constant pelvic pain. After dilatation of the neck,
curetting, intra-uterine douches, iodized phenol, the
cervix was kept patent by a soft-rubber stem (exchanged
of late at the proper time for Dr. Outerbridge’s cervix
distentor to favor conception), the case went through the
same routine treatment, modified as indications required,
and now, after three months’ constant treatment, is prac-
tically a changed person with a fair chance of increasing
the population of the United States.
Its facility of self-application insures a longer period of
constant support, which is not otherwise attainable, yet
most indispensable in obtaining anything like permanence
of relief. The significance of this no one can appreciate
more than the - practising gynecologist, who more often
than any other sees his most elaborate efforts nullified and
frustrated by the passive resistance of his patient.
It would be much improved by adequate facilities for
construction, and the cost so reduced that those poor
women who need them most could be supplied without
charge at dispensaries, etc. ‘Ihe thickness of the ma-
terial employed, the form, length and breadth of the
instrument, its surface, length, width, thickness, number,
shape, and disposition of its ribs could then be varied ac-
cording to indications to be met. ‘The ribs form a most
integral part of it, which the intervening substance only
serves to maintain in their relative position. They may
be flat, fluted, little or not at all elevated above the sur-
THE MEDICAL RECORD.
[September 21, 1889
face, or they may stand out in relief, half-round, scrolled,
ridged, tapering above and below, and disposed lengthwise,
in a spiral, or horizontal. They act like so many con-
tinuous sutures in the tissue of the vaginal tract.
The inflated ring, the balloon and dumb-bell pessary
inflatable by a tube, are cumbersome to apply, want adapta-
tion, and are no improvement on the ancient hog’s bladder.
Mechanical niceties, such as the lever, ball and socket,
cradle, etc., as applied to pessaries, exist only in our im-
agination, but not when i” situ ; for, should they fit, they
do so only by crude pressure, the difference of density of
their substance as compared with that of the tissues being
so great that they becom> foreign bodies, and as such not
to be tolerated. They all presuppose but lack a fulcrum,
and to however few their points of impingement may be
reduced those points are not stationary. Indeed, such
contrivances find no nidus in the canal of the pelvis, the
diameters of anyone of the planes of which are not and
cannot be constant. Clinical experience and observation
teach that tamponage, even in its crudest manner, is far
superior to the most elaborately constructed pessary. ‘The
prognostic importance attached to lacerations of the os
and perinzum are shorn by it of much of their pathologic
significance, and their surgical treatment. becomes rather
a matter of personal choice than necessity, except in cases
complicated with vesico- or recto-vaginal fissures, degen-
eration, etc.
We thus obtain, while in the erect posture, to a con-
siderable extent the benefits to the organs produced by
the genupectoral, but be it repeated only then, when the
corset on the thorax is pulled down so that its lower edge
reaches midway between the crest of the ilium and the
great trochanter, the buttons on the boots replaced by
laces and the heels cut down, so that the centre of gravity
of the body is restored and the security of footing in-
creased by relieving the toes, which thus far have been
lying cheek by jowl, like kittens in a basket ; then, too,
our boulevards will not be graced so often by the painful
sight of ponderous dames waddling instead of walking for
an outing, blowing like whales under the burden of an ab-
dominal engorgement equivalent to an eight months’ ges-
tation.
445 THIRTY-SEVENTH STREST.
HEREDITY.
By J. T. SEARCY, M.D.,
TUSCALOOSA, ALA.
CERTAIN modes of motion, or habits of action, are ob-
servable belonging to every grade of animal. The modes
and habits always follow, in the life of the animal, a fixed
line of sequence, and are peculiar to the species.
For convenience these habits of action can be divided
into morphological and functional.
An animal begins, generally, from a minute genetic cell,
and gradually develops into the size and form of the
adult of the species. ‘The primitive starting-point is the
protoplasmic mass, which is called the nucleus of the cell.
This material appears “specialized” to perform a certain
routine of actions; or, it has the established habit of per-
forming certain specific modes of motion. ‘This is the
connecting inaterial between parent and offspring ; or, it
is the portion in the line of descent that breaks off from
the parent, and has the habit of continuing previous an-
cestral habits. Its specialization consists in this.
The morphological changes are cellular, and consist in
a proliferation and multiplication of new cells from the
original genetic cell. In embryonic and foetal life, these
cells are seen to assume shape and form by aggregation.
They collect in masses, some in one direction, some in an-
other, constituting eventually the different structures and
organs of the body. ‘The growth of the animal follows in
its specialized changes a method of development peculiar
to the species. The morphological process ends soon in
the development of a low grade of animal, but in one of
September 21, 1889]
a high grade the development runs through a long chapter
of changes, passing from a high to a higher complexity of
structure. Morphological changes indicate a habit of ac-
tion. ‘There are also established modes of motion, or
habits, in the functions of the several parts or organs.
The organs, the communities of associated cells, in their
aggregated capacity, exhibit also established methods ;
they indicate characteristic habits, always in accordance
with ancestral modes. ‘The morphology and the physi-
ology of the animal, comparatively speaking, is habitual.
A number of years before the hypothesis of evolution
was formulated to give an explanation to these methods
of life, several observers, Agassiz among the first, drew
attention to the fact that, in the embryonic and foetal de-
velopment of an animal of a high grade, its morphological
and functional actions in their.successive stages were an-
alogous to the successive grades of lower animals. The
new animai, in other words, beginning at the lowest cell-
form, in more or less accurate detail, repeated the ascend.
ing scale of animal life. Such phenomena are matters of
observation. No explanation was satisfactorily offered
for them until the hypothesis of evolution was applied to
them. This method of reasoning now permeates all
science. No naturalist of to-day can avoid it. The study
of physiology has to assume it.
Nothing is more simple, in explanation of the morpho-
logical and physiological habits of animals, than they are
repetitions of previous methods of action, of ancestral
modes. In other words, these habits of action have be-
come fixed methods by reason of a long course of repeti-
tions, extending, with occasional modifications, through
ages of ancestral life. The occasional modifications of
new adjustments are very few compared with the count-
less number of repetitions that have fixed the habits.
This is the modern view of heredity. It may be defined
to be the specialized property of the individual animal,
beginning in the changes witnessed in the genetic cell and
extending through those of its whole life, in which it re-
peats the modes of action of its ancestry. It does this
morphologically and physiologically. Heredity, for short,
is the habit of repetition.
Until recently the study of physiology has been very in-
complete. It only devoted its observations to the indi-
vidual. Science, in this particular, has made a very im-.
portant and valuable “ change of base.” It now considers
the actions of the living animal from a new stand-point.
The individual is not now considered a separate agent
distinct from others in the line, but is a part of the line of
descent. In his lineal aspect he is not separate at all.
There is no break in the continuance of his “ matter in
motion.” The genetic cell, it is true, separates from the
parent; but it is a segment, a portion of the lineal
structure branching off. The material continuity is com-
plete. Wherever the line breaks there is a complete ces-
sation, which never resumes. The mystery now disap-
pears. The physiological line of descent can now itself
be considered as an inaividual and considered as a whole.
A great deal of remodelling of philosophy has necessarily
been done since this view has been taken of life.
At this point, an inspection of the methods of re-
production is interesting and tends to confirm these views.
The lowest and simplest method of reproduction is by
segmentation, in which there is a simple partition of the
parent into two or more parts. l
A more complete method is by gemmation, in which
. the offspring begins as a bud from the body of the
parent.
The method which is the habit of most advanced ani-
mals is by genetic cells, exceedingly minute compared with
the size of the parent.
In essential particulars, these three methods are similar
processes, and the last two may be regarded as modifica-
tions of the first.
In the reproduction of animals there are two other
methods observable : one in which the parent animals are
sexed ; the other, in which they are not sexed.
THE MEDICAL RECORD.
315
In the non-sexed animals the offspring develops from a
single genetic cell. In the sexed animals the offspring be-
gins in the combination of two genetic cells.
A definition of the terms male and female among sexed
animals is well stated, when we designate the male as the
individual who has acquired the habit of not gestating his
own genetic cells, but turns them over to the female to
gestate in combination with her cells. The one does not
gestate; the other does.
Inasmuch as there are lower forms that singly develop
their genetic cells, we may suppose this was the original
method.
Gestation is in some cases a very short process, and
again, in many, the combination takes place outside the
body of the female. But still, for convenience, this defi-
nition is good, as it applies to all the higher animals, the
mammalia for instance ; the female gestates, and the male
does not. A better designation of the male is: he turns
over his genetic cell for combination with that of the fe-
male. He most generally seeks the female for that pur-
Offspring of sexed animals arise from a combination of
genetic cells. ‘The amalgamated cell is seen afterward to
exhibit a combination of the habits of action of its two
parental lines. ‘There isa combination of substances and a
combination of activities. Morphological and physiologi-
cal habits appear combined. Genetic cells from widely
separated species cannot combine successfully, because
their habits of action are not alike. Only when varieties
are nearly alike, the horse and the ass for instance, or the
bison and the cow, can a successful combination be ac-
complished.
The most advanced species are so decidedly sexed, their
genetic cells never develop singly. ‘The habit of com-
bination is too firmly established. There are, however,
some lower species that are sexed, the honey-bee for in-
stance, whose females do bear cells capable of single de-
velopment. l
In the human species there is no exception to these
general rules. The same kinds of “ habits of action ” are
observable. The offspring represents a combination of
ancestral traits. ‘The protoplasmic nuclei of the two
genetic cells are seen to commingle, and the amalgamated
cell follows a regular graded line of gradual development
until the organs and form of the adult are reached, when
we witness in all the modes of action a combination of the
ancestral lines ; we witness tendenċies to repetition, unless
diverted by unusual outside influences. It may not be an
exact repetition of those of the immediate parent, but in
atavism we witness the ancestral traits. The habit is repe-
tition, unless diverted. ‘This tendency shows itself in size,
shape, color, complexion, features, in the modes of mus-
cular motion, speech, voice, gait, and even in the most
recently evolved traits of intelligence and character. The
longest established habits are the most certain, those that
in ancestral modes have been most frequently repeated,
such as race or national characteristics.
Heredity, all through the animal kingdom, means the
habit of repetition.
THE DIURETIC ACTION OF SALIcyLic Acip.—Dr. Huber
claims to have had clinical demonstration of the diuretic
properties of salicylic acid. In twenty-five cases of rheu-
matism, he noted the quantitative augmentation of the
urinary secretion after the administration of the acid. He
found the quantity of urine to increase in the twenty-four
hours from five hundred to seven hundred grammes.
Similar results were noticed in cases of pleunsy. The
diuretic dose of salicylic acid was about ten grains every
three hours, till the quantity of forty-five grains per day
was administered. The diuresis augments from the first
day, and continues on the following days. Huber would
not advise the employment of this remedy in typhoid fever,
and still less in the course of nephritis ; in fact, he would
restrict its use to cases of simple pleuritic effusion.— Ga-
zette Hebdomadaire de Médecine.
316
THE MEDICAL RECORD.
[September 21, 1889
MATERNAL IMPRESSIONS.
By J. WETHERBY, M.D.,
ARLINGTON, KAN.
“ MINDS of great men do not run in the same channels.”
This seems to be true regarding maternal impressions, or
“ birth-marks,” as they are commonly called among the
laity. Although there is a great diversity of opinion in
regard to this subject among members of the medical pro-
fession, it is generally believed by the people at large.
Almost any grandmother with whom you may converse on
this subject will relate instances that have come under her
personal observation, that to her mind at least are un-
doubtedly birth-marks ; and to tell her that you do not
believe in such things as these would brand you forever as
an ignoramus in that old lady’s opinion.
The fact that the belief is so wide-spread, extending to
all nations and peoples, civilized or barbarous, ignorant or
educated, would of itself lead us to think that there must
be something in it, some foundation for such belief.
There are very few ideas which are almost universally
accepted by the world, as is the belief in mother’s marks,
that do not have some pretty sure foundation upon which
the superstructure is built. Of course there are many
beliefs or theories that are merely superstitions, and many
physicians relegate the theory of mother’s marks to this
class ; but very often these same superstitions, which are
looked upon as relics of the dark ages, are only perverted
facts. Again, because our grandmothers universally be-
lieved in some theory it does not follow that their theory
is correct, for it is often widely contrary to the truth ; but
the opinion of these old granddames is not always to be
lightly set aside, for they are frequently close observers,
and often arrive at very sensible conclusions.
The subject of maternal impressions has-interested me
very greatly of late, and Ihave watched the theories
and arguments pro and con that have been advanced
through the medium of our medical journals with both
pleasure and profit.
Some doctors profess a disbelief in the theory because
it cannot be scientifically proven ; but were we to accept
only that which is definitely and clearly understood, what
a set of doubting Thomases we would be! ‘The fact is
that most things in nature are mysterious, if we would but
admit it. We have our theories and many times are able
to prove them, if not correctly, at least satisfactorily ; but
often after one has been proven and accepted, and regarded
as a fixed fact, another rises up and demolishes our fair
structure, while we gaze with doubt and wonder upon the
ruins which the hand of progress and the fertility of man’s
brain have wrought. Even behind theories that have
come to be regarded as fixed facts there often comes to
our mind a ow and why that the most elaborate theory
does not reveal to us. Therefore we are forced to admit
that there is in all nature, even in its most simple parts, a
hidden something which no one except the all-wise Creator
can ever fully understand.
In no field of science do the remarks just made apply
with greater force than to the broad and ever-widening
field of physiology. Ideas are constantly changing.
Theories are advanced, accepted, and exploded. The
theories of our grandfathers, who were educated men in
their day, look, many of them, almost puerile to us; and
our grandchildren will look back pityingly at the wisdom
of the present generation.
Shall we, then, reject a theory or belief simply because
we do not understand its why and wherefore? Shall we,
like Thomas, disbelieve because we cannot see and be-
hold? Again, will our disbelief alter facts? We know
that many things are so, but why they are so we cannot
tell; yet if the fact appeals directly to our senses, we are
forced to believe it regardless of theory.
‘Then why should we, as physicians, believe there are no
such things as birth-marks just because we cannot, or at
least do not, understand their development or causation,
or the relation of the cause to the effect? Physicians
have said to me, “ It certainly does look as if it might be
a birth-mark ; but since neither the child’s vascular or
nervous system is connected with that of the mother, I
don’t see how the impression could have been conveyed
to the foetus, and I think it is only a coincidence.” Now,
the question is not how does this come about, but does it
come about at all ?
In the affirmative we have such men as Rokitansky,
Mitchell, Roth, E. Séguin, Foerster, Peacock, and many
others; while many equally good authorities are found
who are opposed to the theory. Byford, I think it is,
says that a woman’s occupation during her pregnancy
will have an influence upon the mind of her offspring.
On the other hand, a recent writer stated in an article
upon this subject that the child in utero is no more
under the influence of the mother’s emotions than is an
embryonic chick in the egg covered by the brooding hen.
He did not state, however, whether there was any differ-
ence between the egg in the hen before the shell was
formed and the egg in the nest, as regards its power of
receiving impressions. There is absolutely no analogy in
his comparison. Having said so much by way of intro-
duction, I wish to report the following cases which have
never been in priat before, and which, to my mind, are
genuine cases of maternal impressions.
Years ago, one of my aunts lay upon her death-bed, and
the relatives were all assembled to bid her a last good-by.
One of her aunts, who lived at a distance, did not arrive
until just before my aunt died ; and as she approached
the bedside the dying woman recognized her voice and
tried to greet her with a look of welcome, but so near to
death was she that only the nght eyelid obeyed the im-
pulse of the will, the left remaining almost closed, which
gave a peculiar expression to her countenance. It af-
fected the visiting woman very greatly, and was frequently
referred to by her fur weeks afterward. At the time of
the death-bed scene she was four months gone in preg-
nancy ; and when, five months later, her child was born,
there was the same degree of ptosis as was observed in
the case of the dying woman, the same eye being affected.
The eye was normal in every other respect.
Sceptics might say that the above case was only a coin-
cidence, there being many cases of congenital ptosis ; but
what follows ought to convince the most sceptical, as two
cases following each other so closely, in both of which
there had been strong mental emotions of a certain char-
acter, would hardly be mere “ coincidences.” When the
child just referred to was born, the mother recalled the
effect which her niece’s case had had upon her, and attrib-
uted the ptosis to it. It became the talk of the neigh-
borhood, and everyone was anxious to see the child.
Among the visitors was a distant relative of mine, who
was also enceinte. She did not think of her own con-
dition, and was surprised, when her son was born, to find
exactly the same defect there was in the first child.
To my mind these cases prove that birth-marks are pos-
sible, and that they do occur. Both of the children
have grown to manhood, and the ptosis is as marked to-
day as it was when they were born. Neither woman ex-
pected her child to be marked.
Another case was that of a woman four months preg-
nant, who spent the day with a family where there was a
child having convulsions, of which it died. Between the
convulsions the muscles, especially those of the eyes,
“ twitched all the time,” as she expressed it. She said the
case seemed to fascinate her. Many times during the.
day she resolved not to look at the chili again, and as
often found herself watching it. When her child was
born its eyes “ kept rolling all the time, and all its move-
ments were jerky.”
A case reported by the writer in THE MEDICAL RECORD
in 1888, was that of a woman who cared for some sheep
during her pregnancy, and when her child was born its head
was covered with a growth which seemed to be exactly like
lamb’s wool. She does not remember having been fright-
ened byasheep. ‘The child is now four years of age and is
September 21, 1889]
perfectly developed in all other respects. Her woolly head
gives her a very peculiar appearance. ‘There is no Afri-
can blood in either of the child’s parents. An interesting
feature of the case is, that the wool never gets long enough
to need cutting, and always falls out in the spring. I had
some of the wool subjected to a microscopic examination,
with the result that it showed the microscopic structure
of hair; “but,” the microscopist wrote me, “ that does
not interfere with the birth-mark theory, since the woman
had no conception of the microscopic appearance of wool,
and could only transmit to her offspring the impression as
it was conveyed to her.” Children are not marked with
the real object, but with the resemblance of the object.
A woman who was pregnant, was watching at the bed-
side of her dying husband. Her left hand was held in his
so tightly that it became painful. He died holding her
hand in this manner,.and when her child was born there
were only the merest traces of rudimentary fingers upon
its left hand. I do not know how far she was advanced
in pregnancy when the impression was made.
A friend of the writer kept a fine stallion, and a pony
stallion which he used as a “teaser.” A fine thorough-
bred mare, that had never been bred before, was covered
by the stallion, and three weeks later was brought back to
be tested as to whether she were with foal or not. Not
wishing to excite the stallion that had covered her unless
it were necessary, they used the “ teaser,” which she did
not take, and at which she became very angry, biting and
kicking at him viciously. In due time, and without being
covered again, she foaled, and the colt was marked ex-
actly like the teaser. ‘There were no marks upon either
the stallion or the mare, nor in their pedigree. ‘The stal-
lion got forty other colts that season, and none of the rest
was marked in any way. Stock-breeders have come to
recognize the fact of maternal impressions, and have done
away with the use of an inferior horse as a “teaser.”
Sometimes young mares are very difficult to get with
foal the first time, and a jack, which is generally a sure
getter, is used. Often the colts which are got by
thoroughbred stallions from the same mares afterward,
even to the third or fourth colt, bear strong characteristics
of the mule. ‘This is explained by breeders as being the
result of the stronger excitement and greater impress-
ibility of the young mare at the time of her being first
covered.
I could cite numerous other instances that are better
explained by the birth-mark theory than by any other, but
they are not well enough authenticated to exclude doubt.
Although I cannot explain the theory of birth-mark,
and do not attempt to, yet I am a firm believer in
maternal] impressions.
THE Mope oF ORIGIN OF HAMOGLOBINURIA.— M.
Lépine, in a recent communication, proposed the separa-
tion of cases of haemoglobinuria into two classes, viz. :
Those which depended on free hemoglobin in the blood,
and those of renal origin, depending on renal congestion
and rupture of vessels in the kidney. If there was slight
rupture of vessels in the glomeruli, and a few corpuscles
escaped into the capsule of Bowman, these were broken
up by the serous fluid which they found there, and their
components were passed with the urine. He illustrated
the possible local origin in the kidney without general ill-
health by an experiment on a healthy dog. A cannula
was introduced into each ureter, and one filled with steril-
ized water, the other with ammoniacal urine, the pressure
in the two being equal. ‘This condition was maintained
for three hours, and then the urine drawn off with the
cannulz. ‘That on the side of the water was normal, that
on the other side contained abundant hæmoglobin, but no
blood-corpuscles. Now, as ammoniacal urine preserves
any corpuscles that enter it, the inference would be that
the corpuscles in this case were not broken up in the gen-
eral circulation, but immediately before entering the renal
tubules.— Lyon Médical.
THE MEDICAL RECORD.
317
@linical Department.
AN OBSTETRICAL EYE-BANDAGE.
By GEORGE E. ABBOTT, M.D.,
NEW YORK.
DuRING the average confinement, at the end of the second
stage of labor, while the accoucheur is busy tying the cord
and afterward (with the assistance of the nurse) is at-
tending to the safe and neat completion of the third
stage, the baby is busily engaged in inoculating his eyes
with cultures of vernix caseosa,
etc., and often has such success
that, like many another scientist,
he, in due time, becomes blind to
everything else, but by no means
dumb.
To prevent this result I have
of late practised as follows: As
soon as the child is born, and
while I am waiting for the pulsa-
tions in the cord to cease, I give
the care of the uterus to the nurse
and carefully cleanse the face of
the baby with damp aseptic cloths,
and place over the eyes a narrow
bandage (about two inches wide
and a yard long), also damp and
aseptic, and secure it with a safety-pin, then cleanse the
baby’s hands, tie the cord, wrap the child in flannel, pro-
tected by a diaper, and let it care for itself with perfect
safety, until the nurse is ready to wash it.
Thus far I have had no ophthalmia neonatorum.
Of course this will not prevent all ophthalmia, es-
pecially those catarrhal forms due to bright light, cold,
smoke, dust, and gases, from ill ventilation ; but by its
use, those severe and distressing blennorrhceal forms of gon-
orrhceal, septic, and puerperal infection will, I believe,
be largely prevented.
19 EAST SIXTY-FIRST STREET.
CEREBRAL ABSCESS SUCCESSFULLY TREATED
BY TREPHINING.
By J. W. WRIGHT, M.D.,
BRIDGEPORT, CONN.
J. S——-, aged forty-one, habits intemperate, was admitted
to the Bridgeport Hospital, June 4, 1889, after having
served a term of six weeks at the jail for assault. While
there he had delirium tremens, and beat his head against
the cell walls, producing multiple abscesses, for which he
was brought to the hospital for treatment. The whole
scalp was infiltrated with pus. ‘Two openings already ex-
isted on the top of the head, and four more were made at
the most dependent portions of the abscess cavity, two on
the right and two on the left side of the head, and daily
syringed with a ;!,;, bichloride solution. Intense general
headache followed the dressings, lasting for some hours.
His temperature during the whole of his illness ranged
from 98° to 100° F. The abscesses healed kindly, and the
headaches became less severe. His skin was bronzed and
eyeballs yellow. About July 6th he complained of a feel-
ing of numbness and weakness in the right hand. On
examination I found the right leg, arm, and face paretic.
From this time he complained of a severe pain over the left
parietal bone, at intervals. ‘The paralysis continued about
the same, and for short periods he was aphasic until July
18th. By this time the scalp abscesses had nearly healed,
and the dressings had been removed. On this day he
seemed more stupid, but answered intelligently when
aroused. ‘The following day he was in a comatose state,
passing his fæces and urine incontinently ; the pupils were
contracted and irresponsive to light; the pulse was 48 to
50, and the respiration slow but regular.
318
On consultation it was thought besi to operate, in the
hope of finding an abscess in the region of the motor
centre of the arm. On July zoth the head having been
shaved, and the ordinary antiseptic precautions being taken,
the fissure of Rolando was mapped out by the rules laid
down by Lucas-Championniere, and a semilunar flap of
the skin and periosteum reflected ; an inch trephine was
then applied over the spot previously indicated by a small
drill hole through the skin, and the brain was exposed ;
the dura mater was now reflected, and an aspirating needle
was thrust into the substance of the brain. No pus ap-
pearing the needle was withdrawn and reintroduced a lit-
tle posterior and downward, when the barrel of the syringe
filled with pus—two drachms. ‘The blades of a dressing-
forceps failing to find the cavity, a straight, narrow- bladed
bistoury was introduced two inches, and the distal end of a
soft rubber cathether inserted, through which eight drachms
of pus were withdrawn and the cavity washed with water
(which had been boiled) until it ran clear. The drainage-
tube was left in, the flap stitched down, and the dressings
applied.
The following day he pulled out the drainage-tube dur-
ing the temporary absence of the nurse, and, holding it in
his hand when she returned, asked “if he had done any
harm?” Apparently not, for the wound has healed, the
paresis is disappearing, and he is able to sit up, eats with
a good relish and answers questions intelligently.
PLACENTA PRÆVIA CENTRALIS.
By CHARLES E. WILLIAMS, M.D.,
HOULTON, ME.
Mrs. Z—-—, aged nineteen, pregnant for the first time,
at eight months was seized with profuse hemorrhage on
Sunday, August 4th. ‘The hemorrhage continued with
intervals of remission until Tuesday morning, when the
physician who was in attendance asked for a consulta-
tion.
On my arrival I found the patient excessively weak
from loss of blood, with blue lips, sighing respiration, a
pulse of 120 and irregular. ‘The bedding was soaked with
blood and the vagina filled with clots. ‘There was the
baggy feel to the vaginal vault peculiar to placenta prævia,
the os was dilated so as to admit a finger, and efforts at
examination or movements of the patient excited flowing.
Failing in my efforts to introduce a Barnes bag, I firmly
tamponed the vagina and ordered stimulants and nour-
ishment.
Leaving the patient in the hands of the attending phy-
sician, I left to visit other cases. Returning after five
hours, I found that no hemorrhage had occurred. The
patient was weaker, however, with a pulse of 130. Re-
moving the tampon, I found the os dilated to the size of
a half-dollar. I partly introduced the hand within the
vagina and two fingers within the cervix, and making
counter-pressure externally, I swept the fingers about the
lower zone of the uterus, separating the placenta as I
proceeded and causing some hemorrhage ; working rapidly
and crowding down the uterus with the left hand, I finally
succeeded in reaching the placental edge on the right
side. ‘The distance reached by the fingers and subsequent
examination of the placenta, convinced me that it was a
case of central implantation.
Tearing through the bag of waters, the placenta retracted
to the left and the head presented at the cervix. Admin-
istering a little ergot the case was left to nature, and in
two hours I delivered the woman of a dead child.
Immediately after the birth of the child, the mother’s
pulse ran up to 160 and was hardly perceptible at the
wrist. There was sighing respiration, apparent uncon-
sciousness, and extreme faintness of the heart-sounds.
The body became cold and the case seemed almost hope-
less. Under hypodermics of brandy and external warmth,
after two hours of steady work, she began to rally; the
THE MEDICAL RECORD.
into a warm perspiration.
[September 21, 1889
pulse grew stronger and fell to 132, and she broke out
From that time on she has
made a slow but gradual recovery.
PRIMARY SYNCHRONOUS TRIPLE AMPUTA-
TION OF LEFT THIGH, RIGHT LEG, AND
RIGHT ARM, FOR RAILROAD INJURY.
By W. W. WILLIAMS, M.D.,
WICHITA, KAN.
Jounny S——, four years of age. On the afternoon of
May 3, 1889, I received telephone message to come to
stock-yards at once, that a boy had been run over by the
cars. On my arrival, I found the boy lying on the bed
with right arm torn off just below the elbow, and lying
near the bed. ‘The nght foot and ankle were crushed,
and the left leg below the knee had both bones broken,
and the flesh was crushed into a pulp almost to the ankle.
The bleeding had been checked by pieces of cord tied
around the limbs. I administered a hypodermic injection
of morphine and atropine, also some whiskey. He soon
rallied from the shock, and when reaction had taken
place, my assistants, Drs. Purdy, Fabrigue, Fordice, and
Van Nuys, of this city, having arrived, I amputated by
the circular method in the following order: right arm.
middle third ; right leg, middle third ; left thigh, middle
third.
The boy was put to bed and surrounded with bottles
of hot water; he rallied promptly from the anesthetic,
had a hypodermic injection of sulph. morphine and atro
pine at eleven o'clock at night, slept some, and took some
milk through the night. At eight o’clock the next morning
the temperature was 99° F. ; pulse, go. The boy had a ball
in his hand, and said he could play ball anyway, and
wanted milk. At twelve o'clock, noon, the temperature
and pulse were the same. At 7 P.M. I received a tele-
phone message to come at once, as the boy had a spasm,
and they thought he was dying. Dr. K. F. Purdy and I
arrived in a short time. ‘The patient was then resting,
with a pulse of 110, and temperature of 100° F. At nine
o'clock the next morning, his temperature was 102° F.;
pulse, 130. He could hardly be aroused, and continued in
this state until four o’clock the following morning, when he
expired. ‘The dressings were not soiled, and were sweet
and nice. No hemorrhage. I thought the prospect rather
good the first twenty-four hours. ‘The boy lived about
sixty hours after the operation. I think he died from
secondary shock or exhaustion. I only know of about
six cases of recovery after injuries requiring synchronous
triple amputations, and would like to know the mortality
after such operations. I think if we would report our
unsuccessful cases as well as the successful ones, we could
soon have an idea as to what the mortality may be.
VIPER-BITE TREATED BY ALCOHOL.
By JOHN B. HAWES, M.D.,
ASSISTANT SURGEON STKPHANS HOSPITAL, REICHENBERG, BOHEMIA.
In making my rounds of the wards on Sunday, the 7th
of July, my attention was attracted by a priest administer-
ing the last sacrament to a youth. The religious cere-
mony being ended, I proceeded to examine the patient, a
boy aged twelve, and found that twenty-four hours before,
while gathering whortleberries, barefooted, he had been
bitten by a viper in the toe. ‘lhe marks of the fangs were
plainly to be seen.
The boy was unconscious, pulseless, and cold. The
leg swollen to the hip and quite blue. A faint and very
rapid heart-beat, and a hurned and superficial respiration
showed plainly the desperate condition of the patient.
Hot claret and warm covering had been used against the
collapsed condition, but the patient vomited the claret
immediately. ‘The doctots, who had been in consultation,
September 21, 1889]
had informed the family that the boy must die, and at the
time of my visit the father and brother were waiting in
the corridor, expecting every moment to be informed that
the end had come.
I ordered a bottle of fine cognac at once, and at four
o'clock P.M., commenced giving teaspoonful doses of pure
brandy by pouring it well back on the tongue every five
minutes. Not until about six o’clock was any improve-
ment to be noticed, although the brandy was retained.
At this time, however, the pulse was to be felt, though it
was very faint.
This treatment was kept up, increasing the intervals
somewhat between the doses, until midnight, when the pa-
tient was conscious and the heart’s action improving.
After ordering tablespoonful doses of cognac to be given
every half-hour during the night, I returned home.
The next morning the visiting doctors were astonished
to find the boy not only alive but very drunk, the heart
working beautifully. He had taken in this time about
fifteen ounces of brandy. The leg had in the meantime
been rubbed every half-hour with camphor-water, and its
warmth and rosy spots here and there showed the renewed
circulation. ‘The brandy was discontinued and the ex-
ternal treatment kept up. Rubbing, however, caused
much pain, as the limb was extremely tender. Owing to
this fact, indeed, the patient could not be discharged until
the roth, twelve days after his admission, though he had
entirely recovered from the effects of the bite, as well as
of the brandy, by the fourth day.
The case has excited much interest here, and was pub-
lished in the Vienna and Prague, as well as the local, jour-
nals, as a novelty ; for, strange to say, the doctors here were
not familiar with the cowboy method of treating snake-
bites.
The interesting point in the case is that the alcohol
produced its effect at so late a stage, and that it caused
no vomiting.
Progress of Medical Science.
PUERPERAL INFECTION AND ERyYSIPELAS.— The in-
fectiousness of puerperal fever was first formally asserted
by Semmelweis, of Vienna, in 1849, but was not definitely
established until Pasteur turned his attention to it, in
1879. He showed conclusively that a certain variety of
micro-organism was invariably found in the tissues of
women who had succumbed to this malady. This micro-
organism, when injected beneath the skin of animals, gives
rise either to septicemia or pyæmia according to the
method of cultivation employed, and thus the identity of the
two forms of puerperal infection was demonstrated. The
streptococcus found in the tissues of the victims of puer-
peral disease was noticed to present a well-marked resem-
blance to the micro-organism obtained from erysipelas,
and clinical experience has long pointed to the existence
of a relationship between these two diseases. Within the
last three or four years M. Vidal has been enabled, by a
series of elaborate and carefully conducted experiments,
to show that the streptococcus of puerperal fever gives
rise to erysipelas in animals, and produces the same clini-
cal symptoms as the micro-organism obtained from ordi-
nary erysipelas. A very important point which has been
made clear is, that the same micro-organism may cause
maladies which differ from each other very materially
from a symptomatological point of view, according to the
method of inoculauion and the medium in which it multi-
plies.— The Medical Press.
TREPHINING OF THE PELVIS IN THE TREATMENT OF
SUPPURATIVE PsoitTis.—Dr. Gangolphe, of Lyons, advo-
cates trephining of the ilium in the treatment of suppura-
tive inflammation of the psoas muscle. This affection is
regarded as a very serious one, on account of the critical
condition of the patient in the majority of such cases, of
the extent of mischief, and of its possible extension to the
THE MEDICAL RECORD.
_-hip-joint.
319
Prompt release of the pus is the best means of
preventing a fatal issue. If the surgeon be guided by the
general practice, and wait until fluctuation be felt in the
lumbar or inguino crural region, he will certainly find that
the whole of the psoas muscle has then become disorgan-
ized, and possibly may favor by his delay perforation of the
hip-joint and secondary arthritis, which complication in-
variably leads to a fatal issue. Dr. Gangolphe claims that
the operation devised and performed by him presents no
difficulty, and is free from danger. ‘The ilium is per-
forated at a part three fingers’ breadths below the highest
point of the iliac crest, and five fingers’ breadths from the
antero superior spine. An incision about three inches in
length having been made through the skin and fascia
parallel to the course of the glutei, the fibres of these
muscles are separated by director and finger. A second
incision abous two and a half inches in length having been
made through the skin only, at right angles to the former,
in order to allow free exposure of the ilium at the seat of
operation, the periosteum is detached, and the whole
thickness of the bone removed by gouge and mallet, so
as to form an orifice of about the size of a two-franc piece.
The situation of this orifice, the author has found by aną-
tomical observations, corresponds in the horizontal decu-
bitus of the subject to the most dependent part of the
internal iliac fossa and also to the thinnest part of the
iium. Through this orifice the abscess cavity can be
readily drained and washed out by injected fluids. This
operation may be associated with the ordinary lumbar,
inguino-crural, or even posterior-crural incisions, accord-
ing to the circumstances, if the suppuration has extended
into any of these regions.— Revue de Chirurgie.
THE CHOICE OF SUTURES IN ABDOMINAL SECTION AND
THE CASAREAN OPERATION.—After carefully sterilizing
samples of carbolized gut, chromic gut, silk, and silkworm
gut, of similar thickness, Dr. Thomson made use of these
materials in the following manner: Rabbits, cats, and
dogs that had just given birth to young were selected,
and an incision was made in the cornu of the uterus on
each side, in each case. The incision was closed by
suture, different material being used on opposite cornua.
Sutures were also applied to the omentum and abdominal
wound, in order to ascertain if they were there subjects
to more or less rapid changes than the sutures in recently
pregnant uterine tissue. No difference could, however,
be detected in this respect. The animals subjected to
experiment were killed at different intervals of time, the
sutures being carefully inspected. The carbolized catgut
sutures were found to be very thin in the subjects killed
at the end of a week, and reduced to mere relics in the
neighborhood of the knots at the end of ten days. Chro-
mic gut remained absolutely unaltered, even at the ter-
mination of sixty-four days. ‘Ihe cut ends were more
or less covered in by membrane. Silk hgatures- were
found loosened, yet entire, at the end of fourteen days.
Nothing but scanty relics of this material remained at the
end of sixty-four days. At the termination of the same
period silkworm gut was found absolutely unchanged,
the still sharp-cut ends of the sutures made of this
material projecting freely into the peritoneal cavity.
Dr. Thomson concludes that silk is the best and safest
material for suture, particularly for the uterine wound in
Ceesarean section. Chromic and silkworm gut, as well as
silver, are bad materials, as they never undergo absorption ;
while, on the other hand, carbolized gut becomes absorbed
too early.— Zhe London Medical Recorder.
ONE DANGER IN THE ‘TREATMENT OF OBESITY.—In
a study of five cases of movable heart, Dr. Rumpf found
that three of them were justly attributable to attempts to
cure obesity.
To ARREST HEMATEMESIS.—Hot water, as hot as can
be drunk, is said to have been effectual in controlling sev-
eral cases of gastric hemorrhage.
320
THE MEDICAL RECORD:
A Weekly Fournal of Medicine and Surgery.
eee
GEORGE F. SHRADY, A.M., M.D., EDITOR.
poao
PROPRIETORS AND PUBLISHERS
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
New York, September 21, 1889.
THE DECAY OF OPHTHALMOLOGY.
Dr. Wits Van Hook has been lifting up his voice in
the North American Practitioner. He there asserts that
ophthalmology is sinking into hieroglyphic decadence.
Its records are no longer made in plain English, or even
technical English, but are condensed and crumpled into
cryptographic formulz, or compressed into lurid lines of
mystic, eye-straining, algebraic symbols. ‘There was a
time,” he writes, “when a general practitioner, of modest
attainment, yet industrious withal, might learn a little
about the eye. But now see to what an extent of endur-
ance must the aspirant’s patience be cultivated. For, be-
sides being a littérateur, a mathematician, a physicist, a
traveller, a linguist, a connoisseur in malt liquors, a
mechanic, an after-dinner speaker, and, in a word, a true
microcosm, the ideal ophthalmologist must have an ac-
curate knowledge of such a perversion of typography as
was never dreamed of by the scientific and philosophical
Benjamin Franklin, the patron deity of the compositor.
“ The ‘literature’ produced by these peculiarly educated
beings looks as if afflicted by some dire eruption of which
the pathology yet awaits elucidation. In the presence of
this typographical eruption and the anticipated omniscient
culture, the ordinary medical reader is pitifully lost in at-
tempting to follow the vagaries of the ophthalmographer.
For who, pray, but one inured to mental penance could
comprehend the impetuous wniter, carried on by a burst
of impassioned eloquence through the exciting details of a
case of ciliary spasm, when he concludes a glowing history
with the statement that ‘the spasm still exists, being
equal to —25 D. © —o.75cy axis 75°?’
“ These artificial and arbitrary hieroglyphics, thickly and
increasingly scattered through ophthalmological literature,
indicate a misdirected and mischievous energy, which, if
not turned into more profitable lines of action, will com-
pletely exclude from a knowledge of this branch of our
art that pariah of medicine, the general practitioner, un-
less he painfully and heroically masters its Volapiik.”
We sympathize with Dr. Van Hook, but we do not
think he has completed his indictment.
There was a time when the ophthalmologist, before
taking up his specialty, learned general medicine and
surgery. He walked the hospitals, he studied pathology
and physiology ; he interested himself in the general wel-
fare of the physician, and in the various economic and
scientific questions which arose.
Now the “ eye-man ” jumps from a three years’ course
THE MEDICAL RECORD.
[September 21, 1889
in a medical college to an eye-class in a dispensary, and
in a few years is a full-fledged ophthalmologist. ‘The spe-
cialty is thus being filled with men no doubt able and in-
genious, but utterly narrow in their medical knowledge,
and but little more in touch with the general line of med-
ical work than is the dentist or the chiropodist.
A WORD UPON THE REGULATION OF PROSTITUTION
AND SEXUAL HYGIENE.
THERE are still a good many sanitarians to whom pub-
lic health is a fetich before which they would sacrifice
every other social or economic interest. Some of these
enthusiasts would gladly serve the devil in order to reduce
the mortality-rate. When individuals of this class have
minds of a somewhat erotic tinge and have had perhaps
some severe blennorrhagic experiences in their youth, they
become intensely alarmed over the spread of syphilis and
begin to advocate the regulation of prostitution.
To such persons we would strongly recommend a re-
cent communication of Professor Aug. Forel, of Zurich,
to the Correspondensblatt fiir Schweizer Aerzte. Forel
embodies in his article a report by Dr. Nicolsky upon the
regulation of prostitution in Kiew. This report contains
the result of a careful study concerning the extent and
spread of syphilis and chancroid among prostitutes sub-
mitted to regular medical examinations during the years
1886 and 1887. It was found that, among the five hun- —
dred prostitutes of the city in question, about forty-three
per cent. had syphilis or soft chancre, or both, there being
six times more syphilis than soft chancre. In some houses
the percentage of chancre and chancroid was sixty-six per
cent., and there was found to be a yearly increase in these
diseases among the controlled prostitutes. A committee
of the Medical Society, under the direction of Professor
Stukowenkof, made a further report upon the subject of
prostitution and the spread of syphilis. ‘They advocated
the establishment of special hospitals and dispensanes for
the venereal diseases, so as to secure prompt and efficient
treatment of infected cases. They also recommended the
instruction of the laity, by lectures and pamphlets, as to the
dangers of syphilis. ‘They condemned as ineffective all
attempts to regulate prostitution by the State.
Professor Forel takes the above as a text for some very
vigorous and sensible words regarding masturbation and
prostitution. He, as an alienist, often met young neuras-
thenics and hypochrondriacs who had been prescribed for-
nication by their physicians. They had got some venereal
disease, but had not been cured of their nervous troubles,
for prostitution is no cure for onanism. There are, says
Forel, several types of onanism. ‘There is the imaginary
masturbator, who thinks he has abused himself, but who in
reality has rarely done so. ‘These are usually hereditary
psychopathic and hypochondriacal persons. ‘Then there are
persons with congenital sexual perversions, who masturbate
often and in some outlandish way corresponding to their
psychical abnormality. Again, there are those, and they are
many, who are simply led on by example, and who stop as
soon as they learn that it is unmanly and pernicious.
Fourth, there are those who, through early sexual excite-
ment or local irntation, are led to the habit; and finally,
there are those, the so-called “nothonanisten,” who have
no opportunities for natural sexual indulgence.
September 21, 1889]
~THE MEDICAL RECORD.
321
Forel asserts that onanism, except in early age and in
excess, 1S not seriously harmful. It should, of course, be
severely condemned and stopped, and the health of the
system allowed to depend upon nocturnal discharges.
There are, he says, no psychoses resulting from chastity,
but plenty that come from sexual excess and venereal
disease. Professor Forel joins most heartily in the view
of those physicians who, purely for physical and sanitary
reasons, teach that continence is the wisest and safest
course, and the surest preventive of venereal disease.
ALCOHOLISM, CRIME, AND INSANITY.
THE time must soon come when the question of the
proper method of dealing with the alcohol question will
become one for statesmen, rather than, as now, for fanatics
and politicians to consider. The facts and statistics re-
cently brought out at the Congress of Alcoholism in Paris,
illustrate this very well. One of the topics for discussion
was the relation of alcoholism to crime. Everyone knows
that excessive alcoholic indulgence leads to crime, but the
attempt was made to show a direct relation between the
two.
The following tables were given. In France the average
amount of alcohol consumed per capita was in
1873 Ay Seer eC ee oe a eT 2.72 litres.
1878782" occowers Oca oe a ca enee E 3:53 “
18S $87 orien hae ee eewaews wean sanes's 3-83 “
The increase of crime was from 172,000 to 195,000 ; the
increase of insanity from 37,000 to 52,000. In Belgium
the figures were :
1851... 606. 138 litres beer, 5 87 alcohol, 2.00 wine.
1871... .e6. 159 “' oe 7,66 “ 355 ‘
1881... 10o“ “{“ 975 “ 375 “
There was during this period almost a doubling in crime,
suicide, and insanity.
In Italy a similar increase of alcoholism, crime, and in-
sanity was shown.
In Norway, since 1844, the amount of alcoho! con-
sumed has gradually been reduced from ten litres per
inhabitant to four litres (in 1876), with a corresponding
decrease of crime.
The above figures are certainly very striking, and it is
particularly instructive to learn that the decrease of crime
and alcoholism in Norway has been due, not to prohibi-
tion, but to lessening the number of licenses, increasing the
tax on spirits, and the temporary depression in business.
It will not do, however, to trace all the increase of
crime and insanity to alcohol. In Bern, for example,
where there are only 4 saloons to 1,000 inhabitants, crimes
were more numerous than in Zurich, where the ratio is 12
to 1,000. Professor Vauderoy, of Liége, asserts that the
increase of the tax on spirits in Belgium has had but a
slight result; and Dr. Icovesco, of Roumania, asserted
that in a district in his country where a large number of
saloons were closed, alcoholism continued to increase.
Such exceptions must be borne in mind, but on the
whole it seems to be quite certain that a high tax or li-
cense, and a reduction in the number of saloons and total
amount of alcohol consumed, is followed by a diminution
in crime. |
The statistics of some of our own cities carry out this
view.
. MEDICINAL USE OF HYDROGEN PEROXIDE.
Ir is with pleasure that we peruse the new issue of
Sguibb’s Ephemeris for July, 1889, confident as we are
that whatever it tells us is in accord with the latest
scientific advances, and is the result of careful thought and
research. Among its articles is one by E. R. Squibb, on
“ Hydrogen Peroxide” (published also in Gaillards
Medical Fournal, March, 1889). This substance, which
is one of the most powerful, and at the same time the
least harmful, of all antiseptics and disinfectants, has
never come into general use, probably because it is so un-
handy and spoils so readily (Dr. Squibb thinks it js be-
cause it is so little known and so little understood). It is
made in large quantities by several large firms, but is used
chiefly in the preparation of secret remedies. Its prop-
erties have been known for a long time. It isa compound
of hydrogen and oxygen which is easily decomposed,
yielding water and nascent oxygen which quickly oxidizes
substances with which it is in contact. The mere appli-
cation of a solution of peroxide of hydrogen to certain
albuminoid substances 1s sufficient to liberate its oxygen,
which immediately coagulates the albuminoid substance
within its reach. Thus all sorts of virus, whether propa-
gative or not, are destroyed or, by coagulation, rendered
inert in its presence, just as when strong corrosive subli-
mate solutions are applied to them. ‘The undiluted
liquid peroxide is from its nature very unstable, and, on
slight disturbance, breaks up into water and oxygen with
almost explosive rapidity. Therefore, it is never made
nor used undiluted, but is always dissolved in water. The
“ peroxide of hydrogen” which is furnished to the phy-
sician is really a solution of the pure liquid in water to
which a little hydrochloric acid has been added, the acid
being necessary to prevent rapid decomposition of the
peroxide. A solution which will yield its own volume of
active (nascent) oxygen is called a one-volume solution.
The fifteen-volume solution (yielding fifteen times its
vojume of nascent oxygen) is that which is generally
supplied by the makers. It is put up in pint bottles, con-
taining about fifteen fluid ounces, sold at $9 a dozen.
It is colorless and nearly odorless, tastes slightly acid, and
leaves a slight, fleeting, not unpleasant after-impression.
Changes in this solution are indicated by the formation of
bubbles of gas, which rise through the liquid or adhere to
the sides of the bottle, and also by increased pressure
within the bottles. At or below 59° F. the solution does
not change for a long time. At 68° F. it does change,
sometimes very rapidly, giving off oxygen gas. ‘The solu-
tions, whether strong or dilute, should be kept cool, out-
side the window of the sick-room in winter, and on ice or
in ice-water in summer. The bottles in which the solu-
tions are contained must not be held in the hand for any
considerable time, as its warmth will cause decomposition.
It must not be kept in contact with metals, nor applied
by means of metal apparatus, as it not only ruins the in-
struments, but forms poisonous salts from the metal. It
does not attack hard rubber or glass. It is not necessary
to apply it as strong as when it comes from the maker.
The ordinary fifteen-volume solution sold is not injurious,
but it is stronger than necessary, and to use it undiluted
is wasteful. For the irrigation of a child’s nostrils,
pharynx, and mouth, a two-volume (made by adding two
ounces of the fifteen-volume solution to a pint of water)
Pai
322
THE MEDICAL RECORD.
[September 21, 1889
solution may be used every two or three hours, and any
part of this solution passing into the stomach will do good
rather than harm. Adults and children who can gargle—
especially in scarlatina and diphtheria—may use, as a
gargle and mouth-wash, a three-volume solution (three
ounces of the fifteen-volume solution to a pint of water).
For vaginal injections, as in cancer, etc., a thorough wash-
ing with the one-volume solution will often suffice, but it
may be necessary to increase the strength until the desired
effect is produced. When cloths wetted in a solution are
laid upon external sores they should be covered with oiled
silk. The methods for testing the activity of any solu-
tion are given in full, but need not be repeated here. Mr.
Charles Marchand, of No. ro West Fourth Street, New
York City, is referred to as one of the best makers and
furnishers of hydrogen peroxide. It is very necessary to
get a good article, as careless preparation and after-
handling may render it inactive. It is desirable that it
should be applied very early when used in diphtheria, be-
fore the deposits in the throat have caused disease of the
adjacent parts or of the general system.
THERAPEUTIC WORK AT THE PARIS EXPOSITION.
AMONG the most interesting of the various world’s con-
gresses now being held in Paris, was that on therapeutics
and materia medica. ‘Ihe occurrence of such a congress
is itself a matter of note, for heretofore attempts to bring
together medical men to discuss therapeutics alone’ have
not been very successful, and therapeutical societies have
always been failures. The work at Paris was to a con-
siderable extent, however, directed toward the question of
antiseptics and anti-microbian agents. One of the lead-
ing topics for discussion was that of “the antiseptics.
proper to each pathogenic microbe.” M. C. Paul con-
tributed the most important facts on this point. He gave
tables showing first the minimum amount of substances
sufficient to prevent putrefaction in a litre of beef-tea ;
the three most powerful agents were oxygenated water,
corrosive sublimate, and nitrate of silver. ‘he substances
which most surely destroyed cultures of the typhoid fever
bacillus were sublimate in proportions of 1 to 20,000,
sulphate of quinine, 1 to 800, and carbolic acid, 2 to
200. In the subsequent discussion, M. Petrescii, of
Bukharest, stated that, practically, in the treatment of
typhoid fever, he had found sulphide of carbon (sulfure
de carbon) and naphthol most effective, while M. Sem-
mola recommended sulphur in doses of 1 to 20 grammes
daily.
As to the tubercular bacillus, M. Paul gave the follow-
ing list of substances which he said sterilized cultures
completely: hydrofluosilicic acid, sal ammoniac (ammoni-
aque), fluosilicate of iron, or fluosilicate of soda, polysulfure
de potassium, and silicate of soda. From this list it
would look as though the silicate salts were especially an-
tagonistic to the phthisical process. In the discussion
upon this point M. Rueff gave an elaborate account of
his method of treating phthisis by pulverizations of bin-
iodide of mercury. He claimed that by it the patient re-
ceived into the lungs, at each treatment, 3 milligrammes
of biniodide, or sufficient to disinfect 80 grammes of
sputum. M. Rueff’s method has, however, been tried by
others with very little success.
News of the Weck.
DENOUNCING A Doctors’ Trust.—The Farmers’ Alli-
ance of Georgia is reported to have adopted the following
resolutions :
“ Whereas, We have been informed that some of
our physicians have gone into a comtbine, or organization
equivalent to a combine, that is detrimental to our inter-
ests ; therefore, be it
“ Resolved, That we publicly denounce any such organ-
ization, and also any physician who has or may hereafter
attach himself to that or any other similar organization ;
and we will not patronize any physician who belongs to
that society when we can do better.”
DARTMOUTH MEDICAL COLLEGE.—The plans for the
Hitchcock Memorial Hospital, at Hanover, N. H., nave
. been formally accepted. Work will be commenced in
season to complete the foundations this fall. The struct-
ure will be of brick, with Portland-stone trimmings ;
about two hundred feet long, with accommodations for
thirty patients. The estimated cost, exclusive of land, is
$50,000.
Raitway CasuaLTies.—In a late issue of the New
York Railroad Gazette is a report of the accidents which
occurred in the month of May, 1888, and chronicles 145
as having happened in thirty-one days. In the catastro-
phes of importance enough to be mentioned there were
43 deaths and 158 injuries. The nature of the accidents
is tabulated as follows:
Rear collisions: cic. pdn5 sees: oh iee eed ieee keinot 32
Butting collisions raresa seen Sees eee ne Veen w ws 27
Crossing and others. ............ccceveccceecccces 4
DeralmMents 2..6:5% 62 secd 6 eee esas aise CEREN 75
Unclassified. 2.5 ic da Sccna teeta eecoeswteesinnsneee 7
Total ..... E T E Mak eee A E 145
Passenger trains involved, 57.
This, we are told, is about an avérage month, and con-
sequently the railway monster requires the sacrifice of
about five hundred people yearly to satisfy his maw.
LonpDoN POST-GRADUATE CoursEs.— After a good deal
of discussion, a kind of post-graduate college has been es-
tablished in London, by members of the medical staffs of
Brompton Consumption Hospital, the Hospital for Sick
Children, the Hospital for Paralyzed and Epileptic, the
Moorfields Ophthalmic Hospital, and the Blackfriars Hos-
pital for Diseases of the Skin. No names of teachers are
mentioned in the advertisements.
QuAbRUPLETS.—Dr. J. E. Shore reports the birth of
four living children (Omaha Clinic). The mother is a
woman of forty and the father is sixty-six.
THE MISSISSIPPI VALLEY MEDICAL ASSOCIATION meets
next week (September 24th-—26th), at Evansville, Ind.
A New DISEASE-GERM WANTED.—The Vermont Mi-
croscopical Association has offered a prize of $250 for
the discovery of a new disease-germ. Information can
be obtained of C. Smith Boyton, M.D., Secretary of the
Association, Burlington, Vt.
PROGRESS OF MEDICAL EpucaTion.—The Iowa State
Board of Health has decided that Iowa medical colleges
September 21, 1889]
THE MEDICAL RECORD.
323
after 1891 must give a four years’ course, if they desire
their graduates to be admitted to practice within the
borders of the Commonwealth.— Zhe Medical Age.
BuT ONE MORE CONGRESS of interest to medical men is
to be held in Paris this year, viz.. the Congress of Hydrology
and Climatology. This meets on October 3d, under the
presidency of M. E. Renou. A Congress of Otology and
Laryngology was held during the past week, under the di-
rection of Dr. Duplay.
CARBONIC ACID IN PurTuisis.—Dr. Hugo Weber de-
scribes a novel way of treating consumption, in the Berlin.
klin. Wochenschrift, September 2, 1889. This consists
in administering to the patient a teaspoonful of bicarbo-
nate of soda before meals and following it with a glass of
water containing twelve drops of muriatic acid. ‘There
is generated about half a pint (270 cc.) of CO, which is
gradually absorbed and exhaled by the lungs. Weber re-
ports nine cases in some detail favorably affected by this
treatment.
DEATH FROM THE FAITH-CURE.—A young woman died
in Brooklyn on September 12th of typhoid fever. She had
been under charge of a faith-curer, and it is said persist-
ently refused to summon a physician, in which refusal she
was supported by others of her family. ‘The coroner held
an inquest and the jury brought in a verdict that the death
was due to typhoid fever, hastened by criminal neglect on
the part of the faith-curer, who was held for the grand
jury.
THE Brown-SEéquarD Injections.—Dr. Alex. Szikszay
has experimented with the Brown-Séquard testicular in-
jections upon a number of aged Budapestians, whose re-
turned vigor is celebrated in the Pest. med.-chir. Presse,
and thence, via the medium of the daily press, throughout
the land. Professor S. A. Rogers reports the results of
Injections in fifteen cases and states that they are “ satisfac-
tory” (Memphis Journal of Medical Sciences). Dr. Wins-
low Anderson reports the result of a careful trial on a
single case, an old man of seventy, upon whom seven in-
jections were made.
thirteen days, temperature increased from subnormal to
normal, muscular power slightly increased, constipation
ceased ; all of which, however, might easily have been the
result of mental stimulus. A Detroit chemist claims to
have found a stimulating substance in testicular juice, viz.,
“ spermine.”
THE SOUTHERN SURGICAL AND GYNECOLOGICAL Asso-
CIATION.—The next annual meeting of this Association will
be held in Nashville, Tenn., November 12, 13, and 14, 1889.
The following preliminary programme has been published :
“The President’s Annual Address,” by Hunter McGuire,
M.D., LL.D., Richmond, Va. ; “ Report of Gynecological
Work, with Especial Reference to Methods,” by R. B.
Maury, M.D., Memphis, Tenn. ; “ Direct Herniotomy,
with Cases,” by W. O. Roberts, M.D., Louisville, Ky. ;
“ Open Abdominal Treatment,” by B. E. Hadra, M.D.,
Galveston, Tex.; ‘The Abortive Treatment of Acute
Pelvic Inflammation,” by Virgil O. Hardon, M.D., At-
lanta, Ga. ; “ The Importance of Early ‘Treatment of In-
flammatory Affections of the Uterus,” by William C. Dab-
ney, University of Virginia ; “ The Relation of the Nerve
System to Reparative Surgery,” by Thomas O. Summers,
The patient gained three pounds in-
M.D., Jacksonville, Fla. ; “ Concerning the Causes of
Frequent Failure of Relief of Reflex Symptoms after
Trachelorrhaphy,” by W. F. Hyer, M.D., Meridian, Miss. ;
“ Cranial Surgery,” by DeSaussure Ford, M.D., Augusta,
Ga. ; “ The Treatment of Ectopic Pregnancy,” by W. H.
Wathen, M.D., Louisville, Ky. ; “ Laparotomy in Extra-
uterine Pregnancy,” by Waldo Briggs, M.D., St. Louis,
Mo. ; “ Epithelioma of the Penis, with the Report of a
Case,” by D. W. Yandell, M.D., Louisville, Ky. ; “ Lapa-
rotomy in Intestinal Obstruction,” by C. Kollock, M.D.,
Cheraw, S. C.; “An Experimental Study of Intestinal
Anastomosis,” by John D. S. Davis, M.D., Birmingham,
Ala. ; “ Operative Interference in Ascites,” by Hugh M.
Taylor, M.D., Richmond, Va. ; “ Observations Pertaining
to Pregnancy and Parturition,” by W. Duncan, M.D.,
Savannah, Ga.; ‘Puerperal Convulsions,” by John
Herbert Claiborne, M.D., Petersburg, Va. ; “Some Re-
marks upon Aneurisms, Relating more Especially to their
Surgical Treatment,” by F. T. Meriwether, M.D., Ashe-
ville, N. C.; “ Coccygodynia and its Treatment,” -by
Hunter P. Cooper, M.D., Atlanta, Ga. ; “ The Improved
Cæsarean Section versus Craniotomy,” by W. D. Haggard,
M.D., Nashville, Tenn. ; “ Conservative Surgery in In-
juries of the Foot,” by J. T. Wilson, M.D., Sherman, Tex. ;
“ Gunshot Fractures of the Femur,” by John Brownrigg,
M.D., Columbus, Miss. ; “ 'Tropho-neurosis as a Factor
in the Phenomena of Syphilis,” by G. Frank Lydston,
Chicago, Ill.; “'Trophic Changes following Nerve In-
jury in Fractures, with a Report of Two Cases,” by Will-
iam Perrin Nicholson, M.D., Atlanta, Ga. ; “ ‘Treatment
of Malignant Diseases of the Rectum,” by W. T. Briggs,
M.D., Nashville, 'Tenn. ; “ The Achievements of Modern
Surgery,” by J. Ewing Mears, M.D., Philadelphia, Pa. ;
‘The Treatment of the Pedicle in Suprapubic Hysterec:
tomy,” by William M. Polk, M.D., New York ; “ Abdom-
inal Surgery,” by Joseph Price, M.D., Philadelphia, Pa.
Several other papers have been promised, the titles of
which have not yet been announced.
Dr. Ernest LarLace, of New Orleans, has been
elected to the Chair of Pathology in the Medico-Chirurgical
College, Philadelphia. Dr. Samuel Wolfe, of Skippack,
Pa., will fill the Chair of Physiology in the same institution
for the coming year.
Dr. GEORGE J. Janeway, of New Brunswick, N. J., died
on Monday, the 16th inst., aged eighty-three. Dr. Jane-
way received his education at the University of Penn-
sylvania, graduating from its medical school in 1838. He
then went to Paris, where he studiedin the French schools
and hospitals. He returned to New York the next year.
In 1842 he moved to New Jersey, and five years later he
became a physician in New Brunswick. He was mayor
of the city one term—1869-71. Dr. Janeway had six
children, among them being Dr. Edward G. Janeway, of
this city.
THE ANNUAL MEETING OF THE AMERICAN RHINO-
LOGICAL ASSOCIATION will be postponed until October
g, 10, and 11, 1889, at which time it will be held at the
Palmer House, Chicago, Ill.
THE first International Congress of Physiologists was
opened at Basle, on September roth, and sat for three
days.
324
THE MEDICAL RECORI).
[September 21, 1889
Society Reports,
BRITISH MEDICAL ASSOCIATION.
Fifty-seventh Annual Meeting, held at Leeds, England,
August 13, 14, 15, and 16, 1889.
(Special Report for Toa MapicaL Recorp.)
(Continued from page 301.)
SECTION OF MEDICINE.
THURSDAY, AUGUST I5TH—SECOND Day.
Dr. Eppison, OF LEEDS, IN THE CHAIR.
Dr. Pavy, of London, opened a debate on the
PROGNOSIS OF ALBUMINURIA WITH SPECIAL REFERENCE
TO LIFE INSURANCE.
The author of the paper said that the title of his paper
had been chosen for him. ‘The traditional view was that
the presence of albumen in the urine was a reason for the
Instant rejection of candidates for life insurance. In for-
mer days, examination of the urine in patients had been
less common and routine than it now was. Brinton and
Sieveking dilated on the importance of examination of the
urine in all cases presenting themselves for insurance
policies. It had recently been found that albumen was
present in many cases when it was not suspected, and the
question had now been put, whether there might not be
cases of albuminuria which might not cause the rejection
of the applicant for such policies. Albuminuria some-
times occurred as a transient phenomenon. In forced
exercise, such transient albuminuria occurred—for in-
stance, in the case of the great pedestrian, Weston, who
passed albumen in his urine after a walk of one hundred
and fifty miles, which had greatly exhausted his powers.
For a short time his urine was found to contain albumen
and casts. Severe mental strain might produce transient
albuminuria, as also might cold baths. When not tran-
sient, albuminuria might be grouped under three heads :
when there was very little albumen, when a considerable
quantity was found, and, lastly, when albuminuria was
“cyclic,” że., existing only once in the twenty-four
hours. A careful survey of all the collateral circum-
stances must be made. Bnght’s disease often was hered-
itary, or ran in families. Gout and lead-poisoning were
likely to lead to some such affection. ‘Ihe other symp-
toms of the patient should be carefully attended to, such
as any unusual pallor, impairment of vision, high arterial
tension, want of appetite, or dislike to meat. The spe-
cific gravity of the urine would require attention, and a
microscopic examination of it would be necessary in dif-
ficult cases. When casts in abundance were found in the
urine such cases might be rejected as not fit candidates
for insurance; on the other hand, absence of casts was
not sufficient to show the patient to be a fit candidate.
In some cases, in the male, casts of the seminal tubules
and spermatozoa might be seen in the urine, which might
be taken for casts of the tubules of the kidney, when no
nephritis existed. Such were, in brief, the diagnostic
marks of Bright’s disease. In the first group, where only
traces of albumen were found, it was not clear that kid-
ney disease existed. Some tests for albumen were liable
to objections because fallacious. The granular kidney
was accompanied by very slight albuminuria. In the
second group, where a certain amount of albumen ex-
isted constantly, it was probable that many such cases got
perfectly well, and it was by no means invariably that the
existence of nephritis could be detected in such cases,
but a decidedly more than ordinary risk existed in these.
As to the group of “cyclic” albuminuria, in many such
cases there was no albumen found in the urine in the
morning, but the amount increased during the day, and
again, there might be none at night. As to admitting
such cases as candidates for life policies, there was a cer-
tain amount of reserve to be made; although if they
came as ordinary patients to the consultant, a greater de-
gree of optimism as to the prognosis might be indulged
in. Perhaps companies might come to admit such cases
at a somewhat higher premium. The usual form of albu-
men met with in ordinary nephritis was serum albumen,
but, in “cyclic” albuminuria, organic acids threw down
a precipitate of mucin, and some serum albumen was
precipitated by other mineral acids.
Dr. MAcutre said that there were two groups of cases
of albuminuria : the undoubtedly functional kind, and that
not clearly functional. One great diagnostic symptom in
this matter was the state of the pulse, and here the finger
showed more than the sphygmograph. In cases of heredi-
tary albuminuria there was a pulse of high tension. In
cases where there was albuminuria only in the middle of
the day and not in the morning, the pulse was that of low
arterial tension. Albumen in such cases might be found
in considerable quantities when exercise was taken. Hy-
aline casts were no signs of decided Bright's disease. Dr.
Broadbent had shown that there was often low arterial
tension in such cases, and the health was not seriously af-
fected. ‘The tension was never so high in similar cases
as it was in true Bright's disease ; and, three years ago, he
had shown that the albumen presentin such cases was
not that of the organic disease, the presence of globuline
alone indicated a less serious form of disease. But the
kind of albumen present was not always diagnostic of the
nature of the disease. ‘The patients with high tension
pulse should not be accepted as candidates for life in-
surance, whereas in the former group they might, he
thought, occasionally be accepted. :
Dr. Pye-SMITH said that there were cases where acetic
acid would cause aprecipitate of mucin. ‘The presence of
globuline in urine was of less importance, and in such
cases there might be no Bright’s disease present. But in
so far as a man passed albumen in his urine, he could not
be considered to be in a healthy, but in a diseased, condi-
tion. Even when casts are found in the urine, this was
not a certain indication of Bright’s disease. In mitral
disease, casts might be found in the urine without there
being any nephritis present. While Bright’s disease
might occur without casts, it might also exist with them,
and Dr. Mahommed had correctly said that Bright’s dis-
ease might be present although there was no albumen to
be found in the urine. With regard to albuminuria, its
presence should be considered, as hzemoptysis, a danger-
ous symptom. When albumen was found in the urine we
were entitled to indulge in hopes that it might not prove
of fatal prognosis, but it was advisable to remain in that
position and not to be risky in prognosis. In the case of
a private patient, he might be encouraged to take a cheer-
ful view; but, as officers of life insurance companies,
he held that it was difficult to distinguish between acci-
dental and permanent albuminuria. Lastly, as to the
tests, it was surely very important that when persons were
comparing different cases of albuminuria, they should
agree to use the same test, otherwise much confusion was
inevitable.
PROFESSOR GAIRDNER, of Glasgow, said that for many
years past he had been studying the question of albuminuria
as adviser to life insurance companies, and he was still un-
certain as to the existence of anything that could correctly
be styled physiological albuminuria. The word functional
was not objectionable ; but physiological albuminuria was
not allowable. When Weston passed albumen in his urine
when greatly fatigued, this could not be called a physi-
ological symptom, any more than if, in similar cases, he
had had an attack of bleeding from the nostrils. As
medical officer to companies, he considered always that
the occurrence of albuminuria was a danger signal. As
to the practical testing of urine, he considered that the old
test, heat and nitric acid, should be stuck to. He had
found that among the middle classes who applied for in-
surance policies, the occurrence of albuminuria was far
rarer than recent writings might lead one to expect. In-
deed, such a symptom was decidedly uncommon in appli-
September 21, 1889]
cants at his offices. If albumen were found to be present,
the medical adviser should ask to have plenty of time to
make up his mind ; and a good plan in such cases was to
ascertain who was the ordinary medical adviser of the pa-
tient, and to communicate with him and ascertain what
the history of the case had been, as far as it had come
under his notice. .
Dr. RABAGLIATE, of Bradford, said that ‘where there
was a mere trace of albumen, the prognosis might be con-
sidered to be good in albuminuria, and if the urine was of
specific gravity 1.020 or upward ; but where it was 1.010,
it indicated an advanced state of degeneration of the kid-
ney. The presence or absence of casts was of importance
in the prognosis, and the concomitance of gout, eczema,
or anorexia, were important guiding marks. The amount
of oxyluria also should be considered in coming to a con-
clusion. Supposing that a person with albumen in his
urine were admitted as candidate for hfe insurance, what
amount of premium should he pay? Dr. Saundby’s sta-
tistics showed that a very smal] number of persons died
yearly from urinary disease ; and he, Dr. Rabagliate, had
taken the statistics of the Scottish Widows Fund, and
found that eight per cent. of the deaths in that company
were due to such diseases, and half of these were due to
Bright’s disease. He had also done his best to get the
statistics of death from s::ch disease at Bradford, and had
found that about 3.4 per cent. of adult males died from
Bright’s disease in that city.
Dr. DRYSDALE, of London, said he thought it useless
to complicate the question of prognosis in albuminuria
with business transactions. It was quite difficult enough
without importing that element. The main fact now as-
certained was that, whereas, when Dr. Bright wrote his
work on * Albuminuria,” the prognosis of all cases of al-
buminuria was for many years looked upon as almost, if
not quite, fatal, but it was now known that hosts of
cases of albuminuria got quite well, and lived for an in-
definite number of years, and apparently without any de-
terioration of the health. If treated simply and without
heroic drug medication, too, even apparently hopeless
cases of albuminuria recovered. All this, however, gave
but little countenance to the idea that even occasional at-
tacks of albumen in the urine need be considered as of
little importance. He could not help regarding the pres-
ence of albumen in the urine of any person as a dangerous
symptom in all cases, just as attacks of hemoptysis were
always disquieting ; and, for his own part, he thought that
a person who had habitually or intermittently albuminuria
should make his will, if he had any property to leave, and
be prepared for any sudden illness, which might, of course,
be avoided by careful diet and hygiene. His experience
was that heat and nitric acid were the most practical tests
for albumen, and he thought it a mistake to import such
tests as acetic acid.
Dr. CRANSTON CHARLES had found albumen in the
urine of thirty-three per cent. of men examined between
the ages of eighteen and twenty-four ; and in the case of
students going up for examination he had found traces of
it in twenty-seven per cent. of the cases he had examined.
Anxiety might cause the presence of albumen in the urine.
In the case of a young lady, a patient of his, albumen was
found in the urine ; it was found that she laced herself
too tightly, and when this was abandoned she lost the al-
buminuria. Prolonged muscular exercise caused also the
presence of albumen in the urine. In some cases he had
examined, so long as arterial tension continued high there
was no albumen found. Peptones, serum albumen, and
globuline might be present in such cases. The tests he
made use of were cold nitric acid and picric acid.
Dr. Saunpsy, of Birmingham, said Dr. Drysdale had
remarked that albuminuria was once considered a neces-
sanly fatal symptom, and this was the real cause of the
present discussion. ‘The discussion on heart disease at
ighton had-done great service in clearing up the prog-
nosis of that disease, and so would this debate. ‘l'here
were many exceptions to the rule that albumen in the
THE MEDICAL RECORD.
Edinburgh, was too timid in his recommendations.
325
urine was to be looked on as of fatal prognosis. In some
cases albuminuria was innocent, and Dr. Pavy’s cases
of “ cyclical ” albuminuria were examples of this. There
were some cases which might be styled “ mechanical ” al-
buminuria. When the patients stood up there was albu-
men in the urine, which disappeared when they lay down
or were sitting. Insurance companies might safely accept
such cases ; but at present it was necessary to be careful
in advising them to do so. Gout, hereditary transmission,
frequent recurrent micturition, were evil points in the
prognosis of cases of albuminuria. If the urine deposited
casts in great quantity this was of bad prognosis. A med-
ical man examining for insurance companies had not time
enough for accurate judgment. Dr. Pollock’s work, re-
cently published, was too optimistic in its prognosis of al-
buminuria ; and, on the other hand, Professor Frank, of
Cases
presenting themselves with albuminuria to insurance com-
panies should be asked to return in six months. Unifor-
mity of tests should be insisted upon. He thought that
Dr. Rabaglia’s statistics were below the average, and it
was known that there were less deaths from Bright’s dis-
ease in Yorkshire than in other English counties.
Dr. Tyson, of Folkestone, thought the best test for
albuminuria was heat and nitric acid. There had recently
been great apprehension in the public mind concerning
the occurrence of albumen in the urine. There had been,
indeed, quite a panic among a certain number of persons
where there was no real cause for it. He, himself, had
found albumen in his urine for nine months, and had got
quite free from it, and from all disquieting symptoms.
Deaths from Bright’s disease were comparatively rare. He
was not at all unwell when he had had albuminuria ; and
he had had several similar cases where his patients had
been frightened by being told that they had albuminuria,
although otherwise in excellent health. In such cases
it was better for the patients to give up all attention to.
their urine. As to the prognosis in albuminuna, he ad-
mitted that it was to the older members of the profession
that we must apply for information on such subject, for
cases must be watched for many years before the correct
import of albuminuria could be judged of.
Dr. KAVANAGH remarked that teachers at medical
schools might perhaps examine the urine of all their
students, and see what became of those who had albumin-
uria in the course of twenty or thirty years ; medical men
could be very easily traced in after-life, and thus a prog-
nosis might be arrived at. A remarkable case of re-
covery from albuminuria existed in the person of a
distinguished lawyer in Scotland, aged eighty, who, when |
a youth, had been seen by Dr. Bright and given to under-
stand that he had a fatal disease, and was not likely to
live many months. And yet he got quite well, had a
laborious career, and rose to great eminence in his pro-
fession.
Dr. BARR, of Liverpool, said he had long thought that
in cases of albuminuria the amount of albumen passed was.
far too much attended to. He was accustomed to pay
greater attention to the quantity of urea passed ; and in-.
stead of paying attention to the kidneys in sûch cases, we
should direct our attention to the heart and the condition
of arterial tension existing. In granular kidney very little
albumen was passed ; but in such cases it would be found
that the patient was passing as much as 400 grains of
urea daily. He had always contended that in albumi-
nuria the heart was most often in fault.
Dr. Hay, of London, said that, with regard to Weston’s
case of transient albuminuria, the tracings showed that
while he was passing albumen he was exhibiting symptoms.
of high arterial tension.
Dr. HERRINGHAM pointed out the frequent relation-
ship of hzemato-globinuria with albuminuria, and cited
the case of an elderly gentleman who had exhibited
hemato-globinuria when coming back from a mountain
ascent.
Dr. GEORGE HARLEY, of London, said that the result
326 THE MEDICAL RECORD.
of the two and a half hours’ discussion which had taken
place was most valuable, and the British Medical Associ-
ation was useful as a place for mutual instruction, and
not for merely mutual admiration. He made it a rule,
in the examination of patients, to pay greatest attention
to the question of the specific gravity of the urine. It
was not the quantity of albumen in the urine that killed ;
it was the retention in the blood of excrementitious sub-
stances which proved fatal in Brights disease. ‘The
moment we had diseased kidneys we may get urzemia,
uric acid, and other poisons, all of which tended toward a
fatal result. Albuminuria with a urine of 1.015 was
curable. Albuminuria of pregnancy and caused by great
exertions, was a good prognosis. In such cases there was
simply congestion of the kidney. He considered that the
terms functional and physiological albuminuria were mis-
leading, just as neuralgia was misleading, and of no thera -
peutic importance. The kidney had no function in elim-
inating albumen. It was merely a filter. The specific
gravity of the urine was the important matter. ‘The
presence of albumen, whether temporary or permanent, was
not, per se, dangerous.
THE PRESIDENT read some conclusions which Dr. John-
son, of London, had forwarded to him. ‘These were,
that the presence of albumen in the urine is always
pathological ; the practice of testing the urine in all cases
had led to the discovery of many cases of albuminuria
that would otherwise have remained undiscovered. ‘To
talk of albuminuna as physiological was dangerous ; and
almost all such cases might be traced back to a pre-existing
causation in scarlet fever, cold, etc. On the one hand,
intermittent albuminuria was curable. In doubtful cases
the urine should be tested several times in the day, in
order to arrive at a conclusion as to the presence or
absence of albumen.
Dr. Eppison, of Leeds, was much gratified in hear-
ing the remark of Dr. George Harley, that it was not the
passing of albumen that was dangerous. It was to be re-
gretted that the discussion on the prognosis of albuminu-
ria had been mixed up with business transactions. A
clever chemist might find out some albumen in the urine,
when a physician would not find it, or care to find it.
Time was requisite to make up-the mind in doubtful
cases of albuminuria, and the patient should be asked to
return on some future occasion. He would be glad to
know more about the production of albuminuria in cases
of anxiety, as for instance, in positions like those he him-
self was occupying at that moment.
Dr. Pavy, of London, in reply, said that he fully recog-
nized that Weston’s albuminuria was a pathological symp-
tom. In great exertion there was doubtless incipient
disease of the kidneys. These cases were not compara-
ble with cases of cyclic albuminuria. The organic acids
precipitated one form of albumen. The term physiologi-
cal albuminuria was not tenable. It would be as sensible
to talk of physiological dyspepsia ; but the word func-
tional might be allowed. Something in the body was
functionally out of order. This need not be in the kid-
neys alone; it might be in the heart. It was not the
loss of albumen that was dangerous in albuminuria, but
the retention of the uric acid and excrementitious pro-
ducts.
Dr. Haic, of London, read a paper on
ALBUMINURIA.
He said that Professor Semmola had shown that the sub-
cutaneous injection of albumen in animals produced not
only serum albumen, but other albumens in the urine.
Albuminuria might exist without any disease of the kid-
neys ; and nephritis might be produced by the mechani-
cal passage of albumen through the kidneys. Deficiency
of activity of the skin was a frequent cause of albuminu-
ria; and many skin diseases when cured might cause
albuminuria. ‘The functions of the skin were greatly inter-
fered with in scarlatina, and hence the frequency of albu-
minuria in that fever. So too in cold bathing. It was
[September 21, 1889
probably, in such cases, the condition of the skin which
caused albuminuria, and not that of the heart. Semmola’s
views were definite. Cold, damp valleys tended to cause
Bright’s disease, and dry climates often effected a cure of
albuminuria. Deficient skin function was of utmost im-
portance in the pathology cf the disease. In some pa-
tients, when they were lying in bed, almost any kind of
treatment would suffice to ameliorate cases of albuminu-
ria; when these patients were up and taking exercise,
they were often enabled to do their work with comfort
under a milk diet, when any other diet would cause great
discomfort and increase the excretion of albumen. The
failure of the heart’s action did not account for those
cases where there was more albumen after meals. In
these circumstances there was more albumen in the blood,
and this caused the escape of it by the kidneys. It had
been found that hemoglobinuna had been produced by
freezing the fingers. Dyspepsia was often produced by
what had been styled an “uric acid storm.” Such were
Semmola’s views, which he, Dr. Haig, was anxious to
make known as widely as possible, as they seemed to him
to contain much truth.
Dr. SAuNDBY, of Birmingham, bore testimony to the
great interest of Dr. Haig’s former papers on uric acid,
and said that there were many points in this communica-
tion with which he was in accordance.
Dr. DRYSDALF, of London, said that he had on several
occasions met the learned professor Semmoia at the
meetings of International Medical Associations, and was
convinced that the views put forward by that author on
the causation of albuminuria contained many most im-
portant truths. The hints given by Dr. Haig with regard
to treatment, which were derived from Semmola’s views
as to the causation and pathology of albuminuria, such as
the importance of sending patients with Bnght’s djsease
to warm and dry climates, and feeding them on an easily
digestible or milk diet, were most valuable and were begin-
ning to be appreciated. ‘The main point, indeed, in the
treatment of Bright’s disease wis warmth, comfort, and
suitable diet. Purgatives and diuretics generally had
proved very injurious in his experience of acute and
chronic Bright’s disease.
Dr. P. MAGUIRE read a paper on
PRESYSTOLIC MURMUR WITHOUT MITRAL DISEASE.
The author brought forward two specimens to prove that
presystolic murmur may by caused by other circumstances
besides diseases of the mitral valve. In Case I. the patient
exhibited cardiac impulse in the sixth interspace, and two
murmurs were heard, a presystolic and a diastolic mur-
mur, with a few råles at basis of the lungs. There was no
pain. On October 14, 1888, the patient had an appear-
ance of cyanosis, and on listening the murmurs were heard
as usual by himself and Dr. Cheadle. The condition of
the lungs was impaired. The patient left hospital, but
returncd with an attack of anginal character from which
he died. The heart was found to be greatly enlarged.
The aortic valves were diseased, but there was no narrow-
ing of the mitral orifice. Great cedema of the lungs ex-
isted. In the second case, a patient entered St. Mary’s
Hospital in 1877, with diffused pulsation of the heart and
other evident symptoms of cardiac dilatation.. ‘There was
a diastolic murmur and also a presystolic murmur present.
The patient died and the heart was found to be very greatly
enlarged, weighing twenty-five and a half ounces. The left
oyifices were greatly dilated and the tricuspid valve dis-
eased. An aneurism of the coronary artery bulged into
the cavity of the auricle and caused the narrowing of the
orifice, which had given rise to the presystolic murmur.
Dr. Eddison, of Leeds, Dr. Acland, of London, Dr.
Saundby, of Birmingham, Dr. Drysdale, of London, and
Dr. Maguire, discussed this paper, and doubt appeared
to exist in the mind of some of the speakers, whether the
presystolic murmur in these cases was not connected with
the insufficiency existing in the aortic valves in both
cases.
—
September 21, 1889]
THE MEDICAL RECORD.
327
Dr. BouRNE HAR Ley, of London, read an abstract of
a paper on
THE TREATMENT OF ABSCESS OF THE LIVER.
The author observed that men were much more liable
to have abscess of the liver than women. When there was
‘an abscess in the liver it was apt to cause pyzemia, if not
treated by evacuaticn of the abscess, and hence as soon as
an abscess was known to exist it should be surgically
treated. A long trocar should be passed into the liver
from the right side, up to its hilt, until the end of it en-
tered the cavity of the abscess, which could then be
emptied through the cannula. As much as would come
away should be evacuated, and the cavity of the abscess
thoroughly emptied of pus. The trocar should always
be passed at the right side, and not from before backward.
Dr. Harley narrated cases in which a complete cure of
hectic and other alarming symptoms caused by abscess
of the liver had been effected by such surgical treatment.
The antiseptic used by himself in dressing the wounds of
the skin was a solution of boracic acid, ten grains to the
ounce of distilled water.
Dr. Eppison, of Leeds, asked whether there was not
some risk of escape of blood into the peritoneum in such
cases, where a vessel might be pierced by the trocar.
Dr. GeorGE Hartey said that it was the rarest cvent,
in the treatment of abscess of the liver by evacuation with
the trocar and cannula, to find any blood escaping from
the wound. Greatest care should be taken to pass the
trocar in from the right side, and not from the front of the
abdomen, as the latter method might prove fatal. When
such abscesses remained untreated the occurrence of
blood-poisoning was by no means uncommon.
SECTION IN OBSTETRICS AND GYNECOLOGY.
THURSDAY, AUGUST I5TH—SECOND Day.
Dr. HERMAN began the proceedings of this day by
reading a paper on corporeal endometritis, in which he
said that some persons almost refused to admit the ex-
istence of the affection. In many cases, he said, we had
nothing but inferences to guide us, but when these infer-
ences pointed in one particular direction, we were bound
to act on them. If the products of inflammation come
to us from the body of the uterus, we may infer the exe
istence of corporeal endometritis; but the pus which
exudes through the cervix may come from the tubes, and
not from the body of the uterus.
He recognized two forms of corporeal endometritis,
viz., the hypoplastic and the polypoid. In both the
uterus is enlarged and expanded. ‘The diseased surface
should be scraped with a curette, or caustics might be
employed. In the polypoid form, the blunt curette is the
one that should be used. ‘The polypoid growths are most
usually found in married women. The hypoplastic is met
with at all ages. The relation of corporeal endometritis
to cancer is very uncertain, and of the affection as arising
from gonorrheea very little is known. Endometritis is un-
doubtedly the result of specific fevers, as post-mortem re-
search has demonstrated its existence.
Acute endometritis is sometimes accompanied by severe
pain and fever, but when these are present in a marked
degree a more grave affection than endometritis may be
suspected.
In the treatment the chief indications were to look for
and remove the cause, when the disease would disappear,
whereas, if left to itself, it would spread to the tubes. Dr.
Herman drew attention to the different temperaments of
patients, and ‘said we must discriminate the symptoms of
the disease from what he called the symptoms of the
patients. He does not look upon this affection as due
to obstruction of the cervical canal, though local treat-
ment often alters the conditions which have induced the
disease. Active intra-uterine treatment, he thinks, is not
advisable in slight cases.
Dr. J. W. Byers opened the discussion on Dr. Her-
man’s paper by alluding to the treatment of endometritis,
which was chiefly by the use of caustics, or the curette.
The object of both is the same, viz., to remove diseased
growth, but caustics do not do this so quickly as the cu-
rette. Of the two forms of curette (sharp and blunt) Dr.
Byers preferred the sharp instrument, as it removes what
the blunt will often merely pass over. The curette must
be used with antiseptic precautions. He had generally
found corporeal endometritis most troublesome in nulli-
parous women, and in their case he had often been in-
clined to attribute the disease to gonorrhoeal infection.
Hemorrhage was not always a symptom of endometritis,
and the diagnosis between this disease and cancer was one
of great difficulty. Dr. Byers thought that Dr. Herman
“fought shy” of intra-uterine medication, which is most
useful and important.
Dr. RoutH thought that by means of Simpson’s instru-
ment for applying caustic to the interior of the uterus, we
can obtain some of the secretion at its fundus, and deter-
mine the nature of this secretion, which will materially
assist us in forming a diagnosis iu cases of endometritis.
In the treatment of this affection, Dr. Routh insisted on
the necessity of fully dilating the cervical canal in the
first place, and then in the use of powerful intra-uterine
Injections, being careful to see that they had free exit and
came away. From our knowledge of uterine innervation
and the sources from which the various uterine zones de-
rive their nerve-supp.y, he thought that we could diagnose
to a great extent the exact locality of intra-uterine in-
flammation. As regards the spread of gonorrhceal inflam-
mation to the tubes, he thought that any case of intense
vaginitis will affect the tubes independently of gonorrhoea.
Some say that when urethritis exists it is due to gonorrhcea.
Dr. Routh was not sure of this point, but he was satisfied
that in every case of urethritis there is affection of the
tubes. In the case of children who have suffered from
a vaginal discharge, corporeal endometritis does not follow
as a necessary consequence in after-life.
Dr. GraiLty Hewitt said that to understand fundal
endometritis we must go back to first principles and take
into consideration the fact that the alterations which occur
are dominated by the circulation. In other words, that
congestion precedes endometritis. The hypertrophy due
to menstruation is also of consequence in reference to
this consideration. Besides this, one cause of congestion
of the uterus is often found to be displacement of the
organ. Then the weakening of the circulation and local
circumstances augment this. As regards hypersecretion,
it must be remembered that the tubes themselves secrete,
and the question arises whence does the discharge come,
from the uterus or from the tubes ?
As regards the polypoidal variety, he mentioned the
case of an unmarried lady supposed to be suffering from
malignant disease of the interior of the uterus. ‘The os
was large and a soft mass could be felt by the finger, and
it was determined to remove the mucous membrane ; but
after the preliminary rest in bed before the operation, it
was found that when the patient was placed on the table
there was nothing to remove, as the hypertrophy of the
mucous lining was gone, although the uterus was enlarged
and acutely anteflexed. The speaker also insisted on the
necessity of enlarging the cervical canal before adopting
intra-uterine medication.
Mr. PripGIN TEALE said that, owing chiefly to the
labors of the Dublin gynecologists, we are now able to
deal with the interior of the uterus in a way we could not
venture on before. In dealing with the interior of the
organ we must begin by dilating the cervix, and as in dila-
tation of urethral stricture, so in dealing with the os uteri,
moderately rapid dilatation was advisable. We need not
now use tents for this purpose, their action is too slow.
In dealing with unmarried women, they should be exam-
ined under ether, in the lithotomy position, the os should
be dilated as directed above, when the curette may be
employed or medicaments applied to the interior of the
328
uterus. Success depends in a great measure on drawing
down and studying the os, and for this purpose Mr. Teale
exhibited a pair of forceps which he had found most
useful.
Dr. R. BELL, of Glasgow, thought corporeal endo-
metritis was a common disease, and that there was but
little difficulty in itsdiagnosis. One pathognomonic symp-
tom: was the great effect it produces on the nervous
system. When pus is discharged from the tubes, he
thought it had previously travelled to them by continuity
of tissue from the uterus. Corporeal endometritis was
not, hethought, spontaneously curable and, if not inter-
fered with, the interior of the uterus would go on gen-
erating pus ad infinitum. Dr. Bell alluded to some points
of apparent similarity in cases of corporeal endometritis
and of cancer.
Dr. More MADDEN in his remarks dwelt chiefly on the
treatment of this affection, and said that the present
means of rapid dilatation had done more than anything
else in helping us to treat these cases. Endometritis is
not limited, he thought, to any particular zone of the
uterus. He exhibited ergot largely, scraped the interior
of the uterus with a sharp curette, and washed it out with
warm water.
Dr. BRAITHWAITE thought that dilatation need not be
carried so far in endometritis as in dysmenorrheea.
Curetting was useful in chronic cases, but it must be re-
membered that it caused the uterus to bleed, which would
interfere with the application of medicaments.
Dr. HANDFIELD JONES deprecated excessive dilatation
of the cervical canal, and thought the dull curette a pref-
erable instrument to the sharp one for dealing with the in-
terior of the uterus.
Dr. A. Duke preferred the sharp curette, and laid
stress on keeping the cervical canal patulous.
Dr. WALKER thought uterine flexions played an impor-
tant part in these cases. The nervous condition present
was also important, and must not be overlooked. It
showed the necessity for general treatment. Discharges
from the vagina in children generally occurred among the
poor, and were due to a want of cleanliness, and also,
perhaps, to the child sitting on a cold stone.
Dr. MuRDOCK CAMERON thought that over-rapid dila-
tation of the cervical canal was not unattended with dan-
ger, owing to the risk of its causing cellulitis. He pre-
ferred the use of the dull curette, and advocated the em-
ployment, for the same purpose as a curette, of a metal
brush similar to that used for cleaning the interior of a
rifle-barrel. Carbolic acid and spirits of wine in equal
parts, he considered a useful intra-uterine medicament in
these cases.
Dr. Horrocks thought the diagnosis of corporeal endo-
metritis was difficult, owing to the insufficiency of our
knowledge of the process of inflammation. He alluded
to the frequent occurrence of endometnitis in women of
intemperate habits.
Dr. HANDFIELD JONES then read a paper on
CARDIAC INSUFFICIENCY IN ITS RELATION TO ABOR-
TION.
He said no great advance had been made of late in de-
ciding the question of the influence of the condition of the
heart on pregnancy. Stenosis of the mitral valve is said
to give rise to abortion, but he thought valvular disease
did not interfere materially with pregnancy. ‘There is a
normal hypertrophy of the heart in pregnancy, chiefly af-
fecting the left ventricle. If this ventricle is vigorous,
the blood-stream reaches and nourishes the enlarging
uterus. He said heart distress commenced generally
about the third month, and was very often due to the ab-
sence of the compensating hypertrophy he had just spoken
of. A feeble left ventricle gave rise to stagnation of
blood in the capillaries, which bulge and break, causing
extravasations of blood, which separate the ovum from the
uterus.
Dr. Murpock CAMERON exhibited drawings and read
THE MEDICAL RECORD.
[September 21, 1889
some most interesting notes on two cases in which he re-
cently performed
CAESAREAN SECTION
successfully in Glasgow.
Dr. ARTHUR ROBERTS read a paper on
CONCEALED ANTE-PARTUM HEMORRHAGE.
He mentioned some cases in his practice where pain,
faintness, and sickness were the chief evidences of the oc-
currence of this complication. The pain and sickness, he
suggested, might be due to the stretching or tearing of
the peritoneum. The prognosis in these cases is very
serious, and the treatment recommended is rupturing the -
membranes, and then waiting for nature to complete de-
livery.
FRIDAY, AUGUST 16TH— THIRD Day.
In the absence of Dr. W. S. Playfair, a written paper by
him was read by Mr. Wheelhouse, entitled
AN ESTIMATE OF THE VALUE OF ELECTRICITY IN GYNE-
COLOGY.
Dr. Playfair thinks hysterectomy is not a legitimate oper-
ation until electricity has been tried and has failed. The
spontaneous absorption of fibroid tumors was also alluded
to as having saved patients from hysterectomy. He also
drew attention to the hemostatic effects of electrolysis,
which is a strictly conservative operation. Membranous
dysmenorrhoea is also much benefited by electricity, and
the negative current is most beneficial in cases of inflam-
matory exudation which are of long standing and perfectly
chronic.
Dr. EPHRAIM CUTTER, of New York, gave some de-
tails of eighteen years’ work in the United States, in the
treatment of uterine fibroids by galvanism, and described
the method of operating ; and he also gave some statistics
of the treatment of uterine fibroids by food for the same
length of time.
Mr. Lawson Tarr criticised very freely Dr. Playfair’s
paper. He said that in two hundred and sixty-two cases
in which he had removed the uterine appendages, the
mortality was only 1.23 per cent. He thought Dr. Play-
fair’s statements too vague, and that there was no value to
be attached to any such statements unless the actual
number of cases which had been dealt with by electrolysis
and the results were given. This line of treatment should
first be tried in more superficial tumors, and its results
noted in such cases. He dealt in what he called the in-
trinsic and extrinsic causes of mortality; the former,
which were faults that it was in the power of the operator
to avoid, must be eliminated, and only the extrinsic taken
into consideration, and he thought that it will be proved
that the mortality in cases of hysterectomy would not
contrast unfavorably with that in cases treated by electro-
lysis. As regards one objection to the performance of
hysterectomy, viz., that it unsexed the patient, he said
that it must be borne in mind that the cases for which the
operation was performed also interfered with the pros-
pects of maternity.
Dr. Parsons said that as much accuracy should be
observed in laymg down treatment by electricity as is used
in defining treatment by the exhibition of quinine or opi-
um or mercury. He said we wanted assurance that the
so-called cases by electrolysis were complete.
Dr. IMLACH said that this was now the third occasion
on which treatment of fibroids by electricity had been
brought before the Association, without any reliable infor-
mation as to its beneficial results having been laid before
the meeting. |
Dr. Horrocks said that the electrical treatment of
fibroids was still sub judice, and as regards Mr. Lawson Tait’s
two hundred and sixty-two cases of hysterectomy with a
mortality of only 1.23 per cent., he would wish to ask how
many of the two hundred and sixty-two were now alive.
Fibroids, he said, are not necessarily fatal, and if the two
September 21, 1889]
hundred and sixty-two had not been operated on they
might probably be all alive now. ‘The constant current
he looked on in the light of a caustic, its energy dependent
on the number of cells used.
Dr. Byers said that if a Hindu surgeon had been lis-
tening to the discussion to-day, he would be puzzled how
to act. It must be remembered that different cases re-
quired different modes of treatment.
Dr. MuRDOCK CAMERON complained that sufficient
details had not been given, more particularly with regard
to the depth of the punctures in the treatment of fibroids
by galvanism.
Dr. BELL thought that Mr. Taits comments on Dr.
Playfair’s cases, which he (Mr. Tait) had not seen, were
somewhat unfair, and Dr. Bell welcomes the discussion of
any procedure, such as electrolysis, likely to do away
with more severe surgical treatment.
Dr. GRAILY HewıiTT said that we needed more facts
before coming to a conclusion. His experience of the
electrical treatment of fibroids had not been fortunate.
Dr. BRAITHWAITE used electricity in fibroid cases. He
thinks it produces absorption of the tumors, but it is not
applicable to every case, and there are difficulties in the
way of its use in hospital practice, particularly with out-
patients.
Drs. Routh and Madden continued the discussion on
Dr. Playfair’s paper and Mr. Lawson Tait’s criticisms
of it, and the President wound it up by saying, in reply to
Mr. ‘Tait’s suggestion of our first dealing with superficial
tumors, that he had tried electricity in the case of a very
large bronchocele. After five applications it began to
diminish considerably, and all difficulty of breathing,
which had been very urgent, disappeared. More facts
and statistics, he thinks, are needed to enable us to decide
on the relative merits of the different modes of treatment
of uterine fibroids.
SECTION IN SURGERY.
‘THURSDAY, AUGUST I5TH—SECOND Day.
Mr. Henry Morris read a paper on
SURGERY OF THE KIDNEYS.
The various ways in which calculi are embedded in the
kidney, he said, required special precautions while operat-
ing. Tubercle of the kidney might give rise to the same
tactile impressions as small calculi. ‘Tubercular disease
of the prostate gland was a source of fallacy in diagnosing
renal calculi. Nephrectomy was of very doubtful value
in advanced tubercular disease of the kidney. Lumbar
nephrectomy was the proper treatment for advanced hy-
dronephrosis and for large collections of fluid behind the
peritoneum, the result of lacerated kidney. In these cases,
nephrectomy, without previous incision and drainage,
should be more frequently resorted to than has been the
practice hitherto. Nephrorrhaphy for movable kidney was
often of great service. Finally, Mr. Morris said, the
changes which the perinephritic tissues undergo under
long-continued irritation sometimes rendered the search
for the kidney very tedious and difficult.
Mr. BENNETT May said he had operated for
STONE 1N THE KIDNEY
on fifteen patients—twelve males and three females. He
thought we might group cases according to the way in
which the stone was placed in the kidney. In at least
half the cases it was embedded in the cortex, away from
the pelvis, and was mostly of slow growth. Such calculi
were usually limestones, and occurred in young men.
Nearly all the patients had been bedridden for years be-
fore being operated on. A diagnostic sign was pain on
deep pressure under the last rib, accompanied by crystals
of oxalate of lime and uric acid in the urine. ‘Traces of
blood were passed in micturition, more after exercise.
The urine contained no pus. ‘These cases gave the best
results, because the patient was cured bv operation. In
THE MEDICAL RECORD.
329
several there was a narrow escape of the patient leaving
the table with the stone undetected. There was no hope
of finding the stone by palpation. He had used an acu-
puncture needle, passed in from the outer border of the
kidney, and particularly passing it from below upward.
A search should always be made for a second stone, which
existed in three of his cases. The other group of cases
comprised those in which the stone was in the pelvis of
the kidney. Pus in the urine was an early symptom, but
pain might be absent. The stone might be very small in-
deed, and give rise to symptoms of obstruction of the
ureter. He disapproved of nephrectomy in tuberculosis
of the kidney.
Dr. Newman, of Glasgow, said few cases of movable
kidney required operation. He usually treated them by
applying an elastic abdominal bandage, fitting accurately,
so that the pressure was equal over the entire abdomen.
In many cases the kidney became fixed and the adipose
tissue around it increased. In calculus we should oper-
ate early, before suppuration had occurred ; the operation
was then safe. ‘The aim of the surgeon should be to
bring out the points necessary to make a successful diag-
nosis. Catheterism of the ureter was useful, and facility
might be gained by practising on the dead body, in which it
was more difficult than in the living patient. It was also
useful as an aid to diagnosis to estimate the quantity of
blood pigment in the urine. Ina case of renal calculus
where a patient refused operation, we should treat the case
by perfect rest, in the hope that the calculus, if in the pel-
vis, might become encysted.
Mr. Lawson Tair, of Birmingham, said he had oper-
ated on seventy-five cases of kidney disease, with six
deaths. Four of his operations were exploratory incis-
ions; there were four nephrotomies (with one death),
twenty-one nephrectomies (with three deaths), and four
nephrorrhaphies. - In discussing the question of mortality
we must not mix up primary and secondary operations.
The mortality of ovariotomy had virtually disappeared
since early operation had become the rule; similarly,
many a kidney might be saved if early nephrotomy were |
performed instead of a late nephrectomy.
HE REGRETTED HIS OPERATIONS OF NEPHRORRHAPHY.
None of the patients had been benefited, and one had since
died under circumstances which might fairly be attributed
to the operation. He would himself have nothing further
to do with the operation of nephrorrhaphy. In operating
on the kidney he believed it was of no consequence what-
ever whether the peritoneum was opened or not. Re-
ferring to the uncertainty of diagnosis, he observed that
the proportion of mistakes in diagnosis was about the
same as in other abdominal cases—about ten per cent.
Tubercle of the kidney might possibly give rise to the
same tactile impressions as calculus, but as to this he
had no experience. Nephrectomy was of very doubtful
value in advanced tubercular disease. His treatment for
hydronephrosis was to open and drain it, and he would
remove no kidney till it had had a chance for repair. As
to lumbar nephrectomy being the proper treatment for ad-
vanced hydronephrosis, his own opinion was the exact
opposite. He also did not agree with Mr. Morris that
the changes which the perinephric tissues underwent
under long-continued irritation, sometimes rendered the
search for the kidney tedious, difficult, or even ineffectual ;
that was not yet his experience. :
Mr. Bruce CLarx said he had operated on seven cases
—on one twice over. In this case the kidney had a com-
plete mesentery. He found no stone, but sutured the
kidney to the body-wall. Pain was relieved for a time,
but returned. He operated again and incised the kidney.
Failing to find any stone he removed the kidney, and on
examining it after removal it was only after the most
careful and prolonged search that he found a small cal-
culus the size of the end of a pencil. One of his cases
died. Vomiting followed the operation and suppression
of urine (affecting both kidneys); at the post-mortem
330
suppuration was found in the peritoneum near the kidney.
He did not think nephrorrhaphy so useless an operation as
did Mr. Lawson Tait. He had had four cases, and be-
lieved that in cases of movable kidney pain would gener-
ally be relieved by passing sutures three-fourths of an
inch through the substance of the kidney and fixing the
kidney to the body-wall. In performing nephrectomy he
thought it a good plan, if removing the kidney from the
loin, to stitch the edge of the capsule to the skin. By so
doing, the wound was shut off from communication with
the ureter. It was, however, sometimes not possible to
stitch the capsule to the edges of the wound.
MR. KENDAL Franks, of Dublin, remarked that a cer-
tain amount of benefit did sometimes follow exposure of
the kidney, but it was generally only temporary.
REMOVAL OF THE KIDNEY
was a severe procedure ; it was far better to incise it, which
was not a formidable proceeding. It was better to search
for the calculus in the kidney while the kidney was still a
part of the patient’s body, than when it was on the dissect-
ing-table. With one modification (viz., making pressure
on the kidney when the patient was on his face), he
agreed with Dr. Newman that pain on pressure was a
valuable sign of calculus. Alternating pain, varying with
posture, was a sign of value. The wound in the loin
should be left freely open. In one case he plugged it
with gauze ; vomiting followed the operation and was
persistent, in spite of trying all the remedies he could
think of, until the plug was removed, when it ceased. In
many kidneys, small blood-clots formed which might form
the nuclei of future stones, unless they were washed out
by the flow of urine. He regarded excision of the kidney
in early scrofulous disease of the organ as a surgical pro-
cedure which should be adopted.
Mr. Lawrorp Knaccs, of Huddersfield, observed that
the passage of bloody urine after operation might suggest
congestion of the opposite kidney, but some of it might
come from the kidney which had been removed.
_ DR. Imtacn, of Liverpool, said he had removed the
kidney in hydronephrosis. In pyonephrosis the kidney
would not grow beyond a certain size, the pus being
limited by thickened and inflamed tissue.
‘THE PRESIDENT then called upon Mr. Morris to reply,
and asked him which method he adopted in performing
nephrectomy ?
Mr. Henry Morris then replied. In response to Mr.
Jessop’s query, he said ke adopted different methods of
nephrectomy in different cases. He was not in favor of
nephrectomy for malignant disease, but in dealing with
large malignant masses the anterior incision was the best.
He preferred Langenbeck’s incision at the outer edge of
the rectus. For calculus and tubercular disease he pre-
ferred the lumbar operation. He disagreed with Mr. Ben-
nett May about palpation being useless, and said that in
some cases the stone could easily be felt ; he agreed with him
as to the method of puncturing—in lines radiating from
the convex border of the kidney. In all his cases he had
tried rest, pads, etc., before operating, but he had not
tried the ring pad. He did not agree with Mr. Lawson
Tait that nephrorrhaphy was a useless operation. He would
freely incise before excising the kidney ; he did not do so
in his first case, but recommended it immediately after-
ward from his experience in that case. In hydronephro-
sis the kidney substance was almost or entirely destroyed.
He therefore advised removal of the kidney in such cases
and disagreed with Mr. Tait ; of course he would not re-
move the kidney without clear evidence of the other
kidney being present. When we knew a sinus would con-
tinue discharying, it was better to remove the kidney ; the
fluid discharged was of low specific gravity and was not
urine. He referred to the case of a patient whom he
tapped for hydronephrosis and let out two wash-hand
basins full of fluid and blood ; now (five years afterward)
there was a sinus remaining through which about twelve
ounces of fluid were discharged daily. The patient was
THE MEDICAL RECORD. |
[September 21, 1889
in good health and was not willing to submit to another
operation, but no doubt he would have been thank-
ful if his kidney had been removed at the former
operation, and his present inconvenience thereby avoided.
Mr. Bruce Clarke’s method of stitching the capsule to the
wound was good, but in cases where there had been in-
flammatory troubles it was difficult to shell out the kidney
without breaking through the fibrous capsule. Such a
procedure, also, was not practicable in hydronephrosis,
where we had little to deal with but a fibrous capsule
which collapsed immediately it was punctured.
MR. FREDERICK TREVES then opened a discussion on
THE SURGICAL TREATMENT OF TYPHLITIS.
Typhlitis, he said, was a localized form of peritonitis. If
it resulted in suppuration the pus might be encysted.
It differed from other localized forms of peritonitis in its
site and mode of causation. Numerous terms were at one
time used to describe various forms of the affection.
There was no reason tosuppose that primary inflammation
ever occurred, apart from catarrh or ulceration of the
mucous membrane. ‘The symptoms produced by catarrh
of the cecum were not those of typhlitis, but those of
colitis. Ulcer of the cecum would not produce symp-
toms of typhlitis until it had extended to the outer wall of
the czecum. Perforation of the cæcum was rare as a pri-
mary condition ; Fitz had recorded three cases. Abscesses
from cecal trouble were primarily intra-peritoneal ; the
czcum and appendix were entirely surrounded by perito-
neum. The milder varieties of typhlitis were usually
caused by peritonitis over the czecum ; the graver forms
by disease of the appendix. He had found that twenty-
five fatal cases had occurred in the London Hospital dur-
ing a period of several years. In one case a patient had
had fourteen attacks of typhlitis, and on exploration a
diseased appendix was found, but no pus. Fecal concre-
tions were present in the appendix in about half the cases.
Perforation was common, and was sometimes found without
any foreign body being discovered. ‘Typhlitis might occur
in very varying degrees. Firstly, there was the mild com-
mon form, which usually ended in resolution. This gen-
erally depended on fæcal lodgement in the cecum and a
stercoral ulcer formed. This form was more common in
males ; thirty-six per cent. of the patients were under
twenty, and only twenty-one per cent. over forty. ‘The
patients were usually constipated and the pain appeared
suddenly. There was seldom any rigor. The tumor
formed early and was large and doughy. Bladder troubles
were usually absent. ‘The second variety was severer and
led to suppuration. More than half the cases were over
twenty-one years of age. ‘There was often a history of
cold or injury. The pain was radiating, and associated
with tenesmus and troubles in micturition. The third
form was the familiar form of
RELAPSING TYPHLITIS.
The affection sometimes became more severe after each
attack ; it never led to suppuration. Cases of the first
mild form did very well under the recognized medical
treatment, viz., rest, opium, little fluid to drink, leeches,
fomentations, and the evacuation of the colon by means
of enemata. When suppuration occurred, or was expect-
ed, surgical measures were called for. It was seldom
necessary to make an incision before the fifth day, and it
was not advisable to do so unless there were urgent symp-
toms. In most cases an incision should be made only
after the first week. The abscess should be opened after
it became encysted, so as to avoid opening the general
peritoneal cavity ; this could hardly be done if it were in-
cised in thirty-six hours, as advised by some. He.did not
approve of the exploring needle for such cases. Deep-
seated pus, sufficient in amount to cause serious symptoms,
could be diagnosed hy other means, and careful incision
was preferable. The use of the needle was not free from
danger, though it was perhaps unfair to suggest that
suppuration was caused by it. But bloody pus had been
September, 21, 1889]
found in cases where the needle had been used repeated-
ly, and in some cases where no pus had been found by the
needle it had subsequently been found by incision.
PERHAPS THE NEEDLE WAS SAFE
in the hands of Dr. Bull, of New York, but if its use be-
came general we should have the opportunity of ascertain-
ing the effect of passing a needle, first through diseased
and suppurating tissues, and then into the iliac artery or
other organs. ‘The site for incision was in the iliac re-
gion, outside the deep epigastric artery—just above and
outside Poupart’s ligament. Some had recommended
scraping the abscess cavity with a spoon, also that foreign
bodies should be searched for. It had also been advised
that the diseased portion of intestine should be excised
and the ends united by a plastic operation. He consid-
ered that
SCRAPING WAS CRIMINAL.
Incision should be free and foreign bodies should be
searched for, but the less done to the appendix at the
time of operation the better. The state of the tissues was
not such as to favor a plastic operation, and he objected
to excising portions of the cecum; the fistula in the
cecum would do well in most cases if left alone, with rest
and a careful selection of food. The proper
TREATMENT FOR RELAPSING TYPHLITIS
was to remove the appendix. He had first urged this in
1887, and tnought no surgical procedure gave such good
results. We should operate between the attacks, when the
patient was well, and remove the diseased appendix. The
patient would recover from a simple abdominal operation
and have no recurrence of the typhlitis. ‘The condition
of the appendix varied. One patient had had fourteen
attacks, and had been in bed twelve months when the
operation was done. The peritoneal cavity must be
opened. ‘The appendix must be lightly clamped and
cut off. A double row of sutures should be placed in the
stump, which should be attached to any neighboring piece
of peritoneum. During the operation the general peri-
toneal cavity should be separated off from the site of op-
eration by sponges interposed. In some cases the appen-
dix could not be removed, in others there was danger
that the ureter might be removed under the impression
that it was the appendix.
Mr. BENNETT May commented unfavorably on the ad-
vice given by certain American surgeons, to operate within
a week unless recovery had taken place. We should en-
deavor, he said, to distinguish between perforative and
non-perforative cases. It was not easy to diagnose per-
forative cases. ‘The simpler the operation the better; a
drainage-tube should be employed. He had found con-
siderable trouble from hemorrhage.
Dr. EasrTEs related a case in which prompt relief was
afforded by opening posteriorly an abscess in the iliac re-
gion ; a glass drainage-tube was inserted. l
Mr. Lawford Knaggs, Dr. Beale, and the President
having spoken, Mr. Treves then replied. Commenting on
a case narrated by Dr. Beale, he said he thought that case
should have been operated on. There was no other
known diseased organ in connection with typhlitis but the
appendix. The latter was an obsolete organ, and the risk
of removing it was not to be compared with that of relaps-
ing typhlitis.
Mr. Mayo Rosson then read a paper in which he gave
an account of one hundred and eighty-eight consecutive
cases of
ABDOMINAL SECTION.
The peritoneum had been opened, he said, in every opera-
tion included in his list, from which he had excluded all
cases in which it had not been opened. He agreed with
Mr. Tait as to the difficulty of diagnosis, and the propor-
tion of cases (ten per cent.) in which mistakes were made.
He thought the motto of the surgeon should be, “ When in
doubt, operate.” His list included 61 cases of ovariotomy,
with only 2 deaths, and 56 consecutive recoveries. ‘Ihese
THE MEDICAL RECORD.
33!
wete all operated on in a general hospital, with the aid of
antiseptics. ‘The cases were not selected. He would
always operate on any case in which there was a chance
of doing any good. The largest amount of fluid removed
from any single cyst was ten and a half gallons. The
heart was pushed up and was beating in the second space.
The patient made a good recovery. ‘There were 14 cases
of abdominal section for fibroids, with 3 deaths, and 2 cases
of suprapubic hysterectomy (1 death). Seven operations
were exploratory, of which three terminated fatally. There
were six operations (all successful) for pelvic abscess. ‘The
abdomen was opened five—or, including one of the ex-
ploratory operations in which this condition was found,
six—times for tubercular peritonitis; all the patients re-
covered. Abdominal nephrectomy was performed in one
case; a large cyst was found, and the patient died from
acute mania in the third week. There were 2 cases (both
successful) of hepatotomy for hydatids; 11 of cholecys-
totomy, of which number all recovered but 1, in which
there was cancer of the pancreas. ‘There was one (success-
ful) case of cholecystenterostomy (patient shown on pre-
vious day). He had operated fourteen times for intestinal
obstruction, with four deaths. He believed most of the
deaths following operation in such cases were due to
shock, and he would never again spend a long time in
searching for the cause of obstruction, but, if it were not
soon evident, bring up a distended coil of intestine, attach
it to the edges of the wound, and open it twelve or four-
teen hours later. ‘There were 59 cases of hernia, of these
30 were cases in which herniotomy was performed for
strangulated hernia, and there were 24 recoveries, with 6
deaths ; 29 were cases in which the operation for radical
cure of hernia was performed, with only 1 death. There
were two cases of gastrostomy, with one death, and three
cases of abdominal section for perforating peritonitis, all
of which ended fatally.
FRIDAY, AUGUST 16TH—THIRD Day.
Mr. A. F. McGILL, of Leeds, opened a discussion on
THE TREATMENT OF RETENTION OF URINE FROM PROS-
TATIC ENLARGEMENT.
Mr. McGill remarked that in many of these cases self-
catheterization was the only treatment needed ; when
this failed, or was unavailable, further treatment was nec-
essary. Suprapubic prostatectomy was preferable to a
urethral or perineal operation. ‘The urethral operation
was unsatisfactory ; it was founded on faulty anatomy,
for in only 4 out of 24 cases he had tabulated was there
anything resembling a bar at the neck of the bladder.
The suprapubic operation was also more generally appli-
cable; in only 3 of the 24 cases in his table could the
perineal operation have been done. He considered
the suprapubic operation compared favorably with
others as regarded safety, but it was not possible to
show this from statistics ; many of his cases were in old
men. In performing the operation he thought the quan-
tity of water injected into the rectal bag should be smaller.
than that generally recommended ; from six to ten ounces
was usually sufficient. A catheter should be passed, and
left in until the finger entered the bladder. The bladder
should be irrigated with an antiseptic solution until the
latter came away clear. The prostate should, as far as
possible, be removed by enucleation with the fingers (a
manceuvre first practised by his colleague, Mr. Atkinson),
and not by cutting, though the middle lobe might be cut
through at its base after the mucous membrane had been
snipped through. Bleeding might be checked by irrigat-
ing the bladder with water so hot as to be unpleasantly
warm to the hand. Mr. McGill presented a table show-
ing the previous history, condition at time of operation,
date and nature of operation, subsequent history, and
final result of 24 cases, operatively treated by himself, or
one of his colleagues, at the Leeds Infirmary, from March
24, 1887, to July 11, 1889. In7 of these there were symp-
332
toms of stone, and lithotomy was combined with prosta-
tectomy ; calculi were found in all these cases—in one
case fifty small ones. Only one of these seven cases died,
and he was a man, aged seventy-three, who was admitted
for retention, and was in a very bad general condition ; at
the post-mortem many spots of commencing suppurative
nephritis were found in the right kidney. Of the six re-
maining cases, one was not traced, in one there was no
improvement since the operation, one continued well for
three months and then another calculus formed in the
bladder, and the other three (aged fifty-three, sixty-three,
and seventy, respectively) were doing well. In the 17
cases in which suprapubic prostatectomy was performed
without lithotomy, there were 3 deaths, viz., two within
twenty-four hours (one of these from hemorrhage), and one
four weeks after the operation. In the latter case the
kidneys were found to be granular, and there was a large
abscess in the retropubic space. ‘Two other patients
also died, but not from the operation, which was success-
ful. One of these died from pneumonia six weeks after
the operation; the other became insane and died ten
months after operation. In one case, owing to the excep-
tional hardness of the prostate, only a piece the size of a .
small pea could be removed, with difficulty. The wound
closed a month after operation, but the symptoms were not
relieved, so the wound was reopened and a permanent
fistula made. ‘The patient (aged seventy-two) was at pres-
ent confined to bed and wearing a suprapubic urinal of
Mr. Buckstone Brown’s pattern ; but the urine was so very
thick that it would hardly pass the pipe. One patient was
much relieved, but there remained a very small sinus
leading down to the bladder. One patient could not be
traced. In the remaining ten the results were good.
Seven of these cases were completely successful ; in the
other three there were occasional bladder troubles. Mr.
McGill remarked that fifty-four had been given as the
lowest age at which grave enlargement of the prostate was
met with, but one of his patients was only fifty-three. ‘This
was the first case in his table, and one in which both prosta-
tectomy and lithotomy had been performed ; the prostate
was the size of a large walnut, and surrounded the urethra
like a collar. ‘The credit of inaugurating-this operation of
prostatectomy was due to Dr. Belfield, of Chicago, who
first performed it in 1886.
MR. ATKINSON, of Leeds, supported Mr. McGill in the
views the latter had put forward. He had himself had
five cases (included in McGill’s table), with one death. In
the four cases which survived, the patients could not only
retain, but could also expel, their urine; they were not
only able to tolerate their condition, but were comfortable.
Mr. REGINALD Harrison, of Liverpool, said that in
many cases the irritation caused by an enlarged prostate
was far greater than that caused by a calculus or tumor
in the bladder. Cases in which there was enlarged pros-
tate might be divided into two classes: (1) those in which
obstruction was the leading symptom ; (2) those in which
there was, in addition, intense vesical obstruction. Mr.
McGill's operation gave the operator the advantage of
seeing what he was doing. ‘The early treatment of pros-
tatic obstruction was important. This was a subject
much neglected. Some years ago he had advised the use
of prostatic dilators similar to those employed for urethral
stricture. He referred to an instrument made at his sug-
gestion by Messrs. ‘liedemann, of New York, for exercis-
ing pressure upon any part of the prostatic ring. He had
also devised a prostatome, which had been made by
Messrs. Kroline & Sesemann.
Mr. Bruce CLARKE remarked the obstruction to the
flow of urine depended on two causes, viz., (1) on the
prostate extending down the urethra, and (2) on the pros-
tate obstructing the exit of urine from the bladder. He
agreed with Mr. McGill, that it was impossible to find out
the cause of obstruction by examination per rectum. He
had performed suprapubic prostatectomy in two cases.
In one case, which was complicated by the presence of a
stone in the bladder, the peritoneum was found to be at-
THE MEDICAL RECORD.
[September 21, 1889
tached to the bladder, and he performed the operation in
two stages.
Dr. Warp Cousins, of Southsea, said he had per-
formed two suprapubic operations for the relief of un-
nary obstruction. Both patients were old men, seventy-
eight years of age, and in both the obstruction was found
to be due to epithelioma, masses of which he enucleated
from the bladder with his fingers. ‘The patients lived two
or three weeks in perfect comfort. His chief experience
was in median cystotomy ; one patient, aged eighty, on
whom he had performed this operation, was still passing
a short tube by the perineum. He believed acute symp-
toms resulted from neglected chronic retention. The
catheter should be resorted to in time. ‘The necessity of
commencing catheter-life could be determined by injecting
water into the bladder and seeing how much would be re-
tained. There was a dodge in passing a prostatic cath-
eter. The surgeon should take one with a long beak,
pass it right down (the patient being at the edge of the
bed), withdraw it an inch, then turn it toward the nght or
left, depress the handle, and the point would usually jerk
into the bladder. When there was cystitis he would in-
ject a solution of boric acid—not more than two ounces ;
if pain were present he would add some cocaine.
Mr. JorDAN LLoyp, of Birmingham, said he could see,
from observing the specimens exhibited, that he had not
cut freely enough in his own operations. Patients could
not be got to use the catheter diligently and intelligently.
It was a fallacy to expect always to find an enlarged blad-
der in cases of retention; when the bladder was con-
tracted it would not enlarge, but no more urine would be
secreted. He had not himself been able to shell out
prostatic tissue with his fingers.
Mr. BENNETT May had not found the removal of
prostatic tissue easy, and had been much troubled by
hemorrhage.
PROFESSOR TRENDELENBERG spoke of the value of
placing the patient in an inverted lithotomy position—the
head and shoulders being lower than the pelvis. ‘The peri-
toneum was thus prevented from interfering with the
bladder, and the water-bag in the rectum was not neces-
sary. This position was also valuable in laparotomy.
Some weeks ago he had operated for vesico-vaginal fistula
by opening the bladder above the pubes ; the fistula was
high up and near the ureter, which might have been tied
if he had operated in the ordinary way. In opening the
bladder he made a transverse incision, which gave plenty
of room. Some photographs were handed round showing
how the interior of the bladder and the orifices of the
ureters were exposed to view.
Dr. HErN, of Darlington, spoke of draining the bladder
by the urethra, and said we should attempt to get primary
union of the suprapubic wound in the bladder.
Dr. MacewEn, of Glasgow, said that in one case he
had had to make a large wound in the bladder, and it had
healed in time extremely well.
Mr. McGILL then replied. He thought Mr. Harrison’s
plan of dilating the prostate one of doubtful value, and
he did not approve of the prostatome. With regard to
drainage by the urethra, he did not like to make a wound
at the neck of the bladder without providing for drainage.
PROFESSOR FRASER, of Dublin, then read a paper entitled
A METHOD BY WHICH THE HUMAN BODY, WITH ALL ITS
DETAILS OF STRUCTURE, HAS BEEN MADE PRACTICALLY
TRANSPARENT FOR OPERATIVE SURGICAL PURPOSES,
in which he described how, by means of a series of plates
he had prepared (from sections) and a system of measure-
ments, the exact position of any deep-seated organ could
be ascertained.
Mr. WILLIAM ADAMS then read a paper
ON THE SUCCESSFUL TREATMENT OF CASES OF CONGENITAL
_ DISPLACEMENT OF THE HIP-JOINT BY COMPLETE RECUM-
BENCY WITH EXTENSION FOR TWO YEARS.
Mr. Adams maintained that if the head of the bone could
be kept in the same situation for two years, the capsule |
September 21, 1889]
THE MEDICAL’ RECORD.
333
and the surrounding structures would adapt themselves to
their new position.
Dr. Orro KELLER read a paper on
TREPHINING IN A CASE OF ACTINOMYCOSIS OF BRAIN.
He had had, he said, two cases of actinomycosis. In one,
there were first thoracic and then cerebral symptoms.
The patient (a man aged forty) was operated on, and the
masses of actinomycosis removed, trephining being em-
ployed to remove the cerebral mass. The patient made
a good recovery from the operation, but six weeks after-
ward some weakness of the left arm remained. At the
end of a year Graefe’s symptom was present, and vomiting
returned. ‘Trephining was again performed, but the pa-
tient died. Dr. Keller said he had not been able to find
any similar case on record.
Correspondence.
DETERMINATION OF SEX.
To THe Epiror or THe Mepicat RECORD.
Sir: In reading the widely differing theories of medical
men, and men not medical, as to the factors which de-
termine sex in the fœtus, one cannot fail to be struck
with the fact that the question is in a deplorable muddle.
We may be inclined to laugh at the Hippocratic idea of
tying up the right or left testicle, before intercourse, ac-
cording to the sex desired; but there is evidently very
little more sense in many of the modern theories.
While one claims that the result of procreation before
midnight will be a boy, and after midnight a girl—another
that it depends on the relative ages or vigor of the par-
ents—and another that it depends on the menstrual period
occurring before or after intercourse—it becomes pretty
clear that the exact determining causes are not clear to
the medical profession.
Still another theory has been advanced (I believe first
by a layman), to the effect that, if at the time of copula-
tion the preponderance of amatory desire was by the
father the child would be a female, and vice versa.
This last theory is not even mentioned by medical
writers, who yet give great prominence to those above.
Without being understood as holding to this theory un-
tested, I wish to ask, Why the silence of the medical
profession in regard to it? Is it any more absurd, or less
likely to be correct than any of the others? I think
every candid seeker after truth is compelled to admit
that it is as likely correct as any yet advanced. |
It is well known that an intimate relationship—but too
imperfectly understood—exists between the physical or
psychical condition of the parents and conditions or
characteristics in the offspring. Is it too much for us to
believe that on the line of this relationship may be found
the determining factors of sex ?
It will readily be seen that this theory, viz., that if at
the time of coition the desire for the act be mainly or en-
tirely on the part of the husband, the intercourse, if fruit-
ful, will result in a female child, and a male child if the
desire be mainly or entirely on the part of the wife—in-
volves in its consideration the handling of the most deli-
' cate affairs of conjugal union.
From the very nature of it, it is impossible for any one
man to pronounce this theory correct, from experiments
witnessed, or testimony which he may be able to gather
from the laity. It is not a matter which one man can
devote his life to testing, while the rest of us sit down to
await his verdict.
If it is ever decided, it must be by the concurrent re-
ports of almost the whole profession, and since our pro-
fession is happily not condemned to bachelorhood, what
more trustworthy source of evidence could be had than
the domestic experiences of physicians themselves? Such
experiences could be reported at suitable intervals to
convenient centres, and in ten years a mass of evidence
would be available to fully determine the question.
A candid man would not confine himself to a prejudice,
or any one theory, but would make careful note of the
circumstances attending each act of intercourse (which
acts, of course, must be limited in number), and the full
data—not his conclusions—sent in to the central bureau.
I do not consider myself sanguine at all when I say I
believe that if some such plan were carried out it would
enable our profession to clear up at least one mystery,
and that, too, in but a short time.
James B. ‘l'HompPSon, M.D.
RATHBUREE, SIAM.
SYRUPUS ACIDI HYDRIODICI.
To THe Epitor or THe Mgpicat Recorp,’
Sir: As the time for revising our National Pharmacopceia
is approaching, it may not be amiss to call attention tu
preparations which, like the above, are useless in the doses
usually prescribed. During the course of a recent severe
illness the writer had occasion to test the efficacy of
syrup of hydriodic acid, and found it wholly inert when
taken in doses of twenty to forty minims, as authorized
by the dispensatories.
When made after the formula of the United States
Pharmacopceia, 1880, each fluidounce of the syrup will
weigh 615.3 grains, and will contain 6.15 grains of iodine,
equivalent to 8.04 grains of potassium iodide. Therefore,
one fluidrachm of syrup of hydriodic acid is equivalent
to one grain of potassium iodide. The futility of pre-
scribing twenty- or even forty-minim doses of this prepara-
tion must be at once apparent, yet such is the dose as
given in the dispensatories.
The Pharmacopceia of 1860 contained a Tona for
making what was termed “ Diluted Hydriodic Acid.”
This preparation has been omitted in subsequent revisions,
because of its unstable character. It is rational to sup-
pose that the “Committee” intended to furnish for the
sixth revision a formula for making a preparation of hy-
dniodic acid that would fairly represent the older prepara-
tion, minim for minim; as a matter of fact, the old
contained ten times more iodine than the new.
While awaiting the appearance of the Pharmacopoeia
of 1890, let us cherish the hope that the seventh revision
will contain a formula for the preparation of a syrup of hy-
driodic acid of such strength as to be available for thera-
peutic purposes.
J. F. GoLDING, M.D.
Brook yn, N. Y., September 8, 12889.
SAFRANINE A NEW REAGENT FOR THE DETECTION OF
SuGAR.—A new reagent for detecting sugar in urine has
been found in safranine, which is said to possess the ad-
vantage of not being decolorized by uric acid, creatinine,
chloral, chloroform, peroxide of hydrogen, or the salts of
hydroxylamine, all of which reduce Fehling’s solution.
Albumen, however, does decolorize it. The process rec-
ommended is to boil 1 c.c. of the urine with 5 c.c. of a
solution of safranine of the strength of 1 in 1,000, and
2 c.c. of a solution of caustic potash. If decolorization is
effected the urine is diabetic, normal urine containing too
little sugar to decolorize completely so much of the re-
agent. Chloral and chloroform do attenuate the red
color of the safranine, but never completely destroy it.
Chloride of barium has been found by Dr. A. N. Hare to
act as rapidly as digitalis in slowing the heart, contracting
the blood-vessels, and increasing the blood-pressure. He
states that it does not act as an irritant poison unless the
dose be many times larger than the medicinal one. In
five cases of valvular affection of the heart, and two of
functional disturbance of that organ, it was found to act
beneficially by Dr. Hare.— Zhe Provincial Medical Jour-
nal.
334 THE MEDICAL RECORD.
[September 21, 1889
Army Tews.
Official List of Changes in the Stations and Duties of CM-
cers serving in the Medical Department, United States
Army, from September 8 to September 14, 1889.
WALKER, FREEMAN V., First Lieutenant and Assistant
Surgeon. By direction of the Acting Secretary of War
the leave of absence on surgeon’s certificate of disability
„granted in S. O. 92, April 20, 1889, from this office,
is extended one month on surgeon’s certificate of disabil-
ity. S. O. 211, A. G. O., September 11, 1889. Upon
the expiration of his present leave of absence, to report
in person to the commanding officer at Jackson Barracks,
La., for duty at that station, and by letter to the command-
ing general, Division of the Atlantic. Par. 2, S. O. 212,
A. G. O., September 12, 1889.
aMedical Items.
ConTaGious DIsEASES—WEEKLY STATEMENT. — Re
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending September 14, 1889:
Cases. | Deaths.
Typhus LEVER esi sects occa cteotd a cee en o o
Typhoid LOVED sisideripi eieren raras ki RIRES 69 I5
Scarlet fever........... Ge oosessnsossesenorseseene 23 2
Cerebro-spinal meningitis..............ccceceeces I o
Measl€S E E E O T E E 12 I
DI PtR Orie esis aie seg toy sawed ysnee is ERa INES 64 19
DIMGI-DOX ices ve Vo paweosisecseesesane micas, «sk o o
Mellow LOVER R EEN WLS aSek o o
Cholera saroiou pA ees EErEE DESEE o o
THE New YorK Srare MEDICAL ASSOCIATION will
hold its sixth annual meeting at the Hotel Brunswick,
Fifth Avenue and Twenty-seventh Street, this city, on
September 25th, 26th, and 27th inst. ‘The programme is
as follows: First Day, Morning Sesston.—“ Inversion of
the Uterus, Novel Treatment,” “ The Latero-dorsal Posi-
tion in Gynecic Irrigation,” by Dr. George E. Fell; ‘The
Treatment of Uterine Fibroids by Electricity,” by Dr.
Henry D. Ingraham ; “ Pelvic Cellulitis in Women,” by
Dr. W. H. Robb; “ Report of a Case of Laparotomy
for Ruptured Pyo-salpinx : Error in Diagnosis ; Recovery,”
by Dr. C. S. Wood ; “ The Use and Abuse of the Forceps
in Obstetrics,” by Dr. J. P. Garrish, all of this State.
Afternoon Session.— Discussion on “ Tubal Pregnancy,”
in which the following will take part: Drs. William T.
Lusk, of New York; William Goodell, of Pennsylvania ;
George T. Harrison, of New York; Howard Kelly, of
Pennsylvania ; ‘Theophilus Parvin, of Pennsylvania ; Isaac
E. ‘Taylor, of New York; T. Gaillard Thomas, of New
York ; Ely Van de Warker, of New York; W. H. Parrish,
of Pennsylvania; and W. H. Wathen, of Kentucky.
Night Sesston.— Prognosis in Pulmonary Phthisis. How
much has it been Improved, and by what Means?” by
Dr. Avery Segur ; “ Affections of the Eye, Symptomatic
of Disease of the Central Nervous System,” by Dr. Alvin
A. Hubbell; “A New Portable Accumulator,” by Dr.
Robert Newman; “The Warming and Ventilation of
Public School Buildings,” by Dr. Ira B. Read; “A
Word in Favor of Free Dispensary and Free Hospital
Work,” by Dr. E. J. C. Minard ; “'The Microscope in
Diagnosis ; Personal Observations,” ‘ Forced Respira-
tions; Additional Observations,” by Dr. George E. Fell,
all of this State. Second Day, Morning Session. —“ Ad-
dress on Surgery,” by Dr. Francis Bacon, of Connecticut ;
“ Alcoholic Paralysis,” by Dr. T. D. Crothers, of Connec-
ticut; “A Few Fads,” by Dr. H. D. Didama, of New
York ; “Some of the Uses of the ‘Transfixion Ligature,”
by Dr. T. H. Manley, of New York; “The Shadow Line
of Insanity,” by Dr. John Shrady, of New York. <A/ter-
noon Session.— Discussion of the “ Treatment of Hernia,”
by Drs. Joseph D. Bryant, William T. Bull, Charles W.
Brown, T. H. Squire, William S. ‘Tremaine, William T.
Ball, Roswell Park, Charles McBurney, Charles L. Squire,
D. M. Totman, Frederick S. Dennis, and John A. Wyeth,
all of this State. The points which will come in for a
share of attention are the special mechanical treatment,
the injection, open and non-open methods, the technique
and the best plan of treatment when gangrene of the sac
or its contents becomes a complication. Night Session.
—‘ Lantern Views,” by Dr. Edward K. Dunham, of
New York; after which a collation will be served.
Third Day, Morning Session —Address on Medicine :
“On the Bacteriological Test of Drinking-water,” by Dr.
Edward K. Dunham, of New York; “The Cure of
Hemorrhoids by Excision, and Closure with the. Buried
Animal Suture,”. by Dr. Henry O. Marcy, of Massachu-
setts ; “ Report of a Case of Ataxic Paraplegia,” by Dr.
Darwin Colvin, of New York; ‘ Observations on Dislo-
cations of the Hip,” by Dr. U. C. Lynde, of New York.
Afternoon Session.—Discussion of the “ New Hypnotics,”
by Drs. W. H. Flint, Austin Flint, E. G. Janeway, Charles
Rice (Ph.D.), Charles G. Stockton, and John G. Truax,
all of this State ; ‘ Extraction of Cataract without Indec-
tomy,” by Dr. Charles Stedman Bull, of New York ; “Two
Cases of Angular Deformity of the Knee-joint,” by Dr.
Lewis Hall Sayre, of New York. ‘The Committee of Ar-
rangements are as follows : William T. Lusk, President, and
E. D. Ferguson, Secretary, ex-officio Members of the Com-
mittee ; John G. Truax, Chairman ; Charles E. Denison,
Secretary ; E. S. F. Arnold, Glover C. Arnold, William
R. Ballou, Alfred L. Carroll, John W. S. Gouley, John
H. Hinton, Charles A. Leale, J. R. Macgregor, S. B.
Wylie McLeod, Augustus D. Ruggles, John Shrady, and
Isaac E. Taylor. The presence of the members of the
profession is especially desirable.
“ ELECTRICITY IN GYNECOLOGY,” was the title of a paper
read at the recent meeting of the Alabama Medical Asso-
ciation, by Dr. W. E. B. Davis, of Birmingham. He be-
lieved that ultra-enthusiasm had led to frequent failure in
the use of this remedy, but said there should be no ques-
tion as to its importance as a therapeutic agent in gyne-
cological practice, when such men as Apostoli, the Keiths,
Engelmann, and other competent observers, who have had
experience in its application, report most satisfactory re-
sults. He advised the use of the current of the Edison
circuit, direct from the dynamo when it could be had,
thereby avoiding the annoyances and inconveniences of a
battery. Great stress was laid on the importance of the
application of the faradic current in subinvolution of the
uterus. Every woman who had had an abortion or had
been confined at full term was placed on ergot, but
should there be incomplete involution at the expiration of
six weeks, he began at once the use of the faradic current,
with the bipolar, intra-uterine excitor of Apostoli, and
repeated the application every second or third day until
the organ had returned to its normal size, “which can’
always be counted on with mathematical certainty.” Cases
were reported to show the value of the faradic current in
subinvolution of the uterus, and to illustrate its efficacy
in displacements due to the enlarged, hyperzemic condi-
tion of the organ followirg parturition. The current of
tension-—the current from the long, fine wire—had proven
a valuable agent for the relief of pain, and cases showing
permanent relief were quoted. To illustrate the power of
the faradic current on the perineum, vagina, and uterine
ligaments in relieving prolapsus of the uterus, and also the
effects of the current in relieving pain, the following case
was reported: Mrs. P , aged thirty five, had last child
four vears ago ; since which time she had suffered almost
all the time from pelvic pains, insomnia, and very marked
nervous symptoms. ‘The pain was so severe at her men-
strual periods that she had been advised by her physician
September 21, 1889]
to have her ovaries removed, and it was for this purpose
that the speaker was consulted. The uterus was normal
in size, but prolapsed to a marked degree, which was due
to its relaxed supports. The bipolar vaginal excitor, with
strong current, was used every second or third day for
two weeks, and at the next period she did not know when
the flow appeared. In eight weeks her uterus remained
in proper position; she was relicved of insomnia, and her
nervous symptoms improved. ‘Two months after the
treatment was stopped she became pregnant. Both the
currents of quantity and tension were used at each con-
sultation in this case—the former for the relaxed muscle,
the latter for pain. ‘The patient always felt better after
each séance. ‘The currents of quantity and tension have
been used with very satisfactory results as indicated by
Apostoli, but he has begun to use the current of tension
not only for pain, but to stimulate relaxed and enfeebled
muscle fibre. ‘The current of tension is borne better by
the patient, and he has been unable to recognize the supe-
rior results of the current of quantity on muscle over the
current of tension. In displacements of the uterus he
supports the organ with wool tampons, and does not ob-
ject to any form of pessary, properly fitted, in connection
with the treatment by electricity. He believes proper sup-
port of the organ, combined with the proper application
of electricity, to be the most rational treatment for this
condition. When the uterus is enlarged from hyperplasia,
the continuous current is indicated. All cases of chronic
endometritis are amenable to galvanism—the positive cur-
rent when there is much leucorrhcea or profuse menstrua-
tion, and the negative in other cases. From seventy-five
to one hundred and fifty milliampéres are used twice
weekly for five minutes at a time. The sound is usually
introduced through a bivalve speculum, and the handle
ailowed to rest on a large wad of absorbent cotton, which
prevents injury to the endometrium. This is preferred
because it permits of more thorough antisepsis, and allows
the physician to rest his hand during the operation. He
did not claim that electricity would do away entirely with
such surgical procedures as shortening the round ligaments
—Alexander’s operation—or attaching the cornua of the
organ to the abdominal wall, or the narrowing of the
vagina by the many methods at present in vogue ; but he
insists that many cases could be relieved by this method
of treatment which would otherwise be condemned to the
knife. The local application of the faradic currenf is
capable of relieving many cases of amenorrhcea due to
atrophy of the uterus. In menorrhagia due to relaxation
of muscle, to engorgement, when the patient menstruates
from eight to nine days, after a few applications the men-
strual periods would only last from four to five days. The
positive galvanic current is the remedy indicated for
hemorrhage due to a disease of the endometrium, and is
the current usually indicated for hemorrhage. Women
often become pregnant soon after being treated by elec-
tricity, and it is unquestionably a valuable remedy for
sterility due to nervous causes, described by Dr. Campbell.
In neuralgic dysmenorrhoea and dysmenorrhcea in women
of a hysterical temperament—whom the slightest excite-
ment or worry will cause to suffer greatly—those cases
where there is no apparent pathological lesion—he has
succeeded, as with no other remedy, by the application of
the current of tension or by the mild positive galvanic
current. ‘The negative current is indicated when the pain
is due to mechanical causes in the cervical canal—and
when there are inflammatory deposits around the ovaries,
etc. He did not think that galvanism would take the
place of the removal of the ovaries and tubes, but said
each had its special field, and, should electricity fail, no
harm had been done, and the operation could still be re-
sorted to. He said the subject which had concerned the
profession most in cunnection with the use of electricity
was the treatment of fibroid tumors, and that the results
of the treatment in the hands of Apostoli, the Keiths, En-
gelmann, Lapthorn Smith, and others, had demonstrated
that this is the proper treatment for fibroid tumors, which
THE MEDICAL RECORD.
335
“ offer probabilities of healthy retrograde metamorphosis.”
He had followed Apostoli’s instructions in this class of
neoplasms, and believed that the majority of cases could
be symptomatically cured. Certainly Apostoli’s treatment
should be tried before resorting to hysterectomy.
‘THE SENSIBILITY OF TELEGRAPHERS.—The following in-
cidents are from an interesting illustrated paper by Dr. J.
Emmet O’Brien, of this city, in Zhe Century for Septem-
ber, on “ Telegraphing in Battle.” ‘In Butlers advance
on the Petersburg & Richmond Railroad, May 7th, a line
was carried along with the column to within sight of that
road, and worked until Beauregard struck us at Drewry’s
Bluff, on the 16th, when General Butler ordered his chief
operator to ‘bring the line within the intrenchments.’
In these trenches one night Maynard-Huyck was awakened
from sleep, not by the familiar voice of his instrument,
but by the shriek of a Whitworth bolt, a six-pound steel
shell, which passed through the few clothes he had doffed,
then ricochetted, and exploded beyond. Congratulating
himself that he was not in his ‘duds’ at the moment, the
boy turned over and slept through the infernal turmoil of
an awakening cannonade until aroused by the gentle tick
of the telegraph relay. We used no ‘sounders’ in those
days at the front. In illustration of the sensibility of
hearing acquired by the military operators for this one
sound, the writer may be pardoned another personal inci-
dent. At Norfolk, in April, 1863, he happened to be
alone in charge of the telegraph when Longstreet with
a large force laid siege to Suffolk. In the emer-
gency he remained on duty, without sleep, for three
days and nights, repeating orders between Fort Mon-
roe and the front. Toward morning on the third
night he fell asleep, but was aroused by the strenuous
calls of the fort, and asked why he had not given ‘ O. K?
for the messages just sent. He replied that none had
been received. ‘ We called you,’ said the operator at the
fort; ‘you answered, and we sent you two messages, but
you failed to acknowledge them.’ ‘The despatches were
repeated and forwarded, when, on taking up a volume of
Scott’s novels, with which he had previously endeavored
to keep awake, the writer was astonished to find the miss-
ing relepraiis scrawled across the printed page in his own
writing, some sentences omitted and some repeated. It
was a curious instance of somnambulism.”
‘THE Mystery OF Pain.—The philosophy of pessimism,
associated with the names of Schopenhauer, Hartmann,
and Leopardi, owes its influence in no small degree to the
depressing relations which a resolute contemplation of the
vast amount of suffering and sorrow in the world is apt to
excite in some minds. ‘The universality of suffering and
disappointment ; the wide prevalence of disease; the
ubiquity of pain; the frustration of effort; the general
admission that the present is unsatisfying, and that only
the hope of a better future for the individual and the race
keeps energy alive ; the confession that “ man never is,
but always to be blest ”—such reflections suggest a basis
for pessimism, and explain, if they cannot justify, its hold
over many minds of a superior order. But, happily, the
pessimistic logic contains one rather obvious fallacy,
which robs it of much of its cogency. It accentuates evil
and suffering, but omits to take account of the benefits to
humanity of which they are indirectly the source and the
occasion. The more we reflect upon the subject, the
more convinced shall we be that pure, unmixed, unredeem-
able evil hardly exists, and that some compensation can
be found or created in connection with the direst calam-
ity. ‘The hurricane seems the embodiment of destructive
and maleficent activity; but if in its train are found ruin
and death, there also may we discover a purified atmos-
phere, the arrest of disease, and the descent of fertilizing
rain. When cholera sweeps over wide regions with its
pestilential breath the scene is one of destruction, death,
despair ; but how great the benefit to unborn generations
if such a calamity tends to the more careful study and
more systematic application of the laws of hygiene. Pain
A
336
itself, the most universal of evils, has a side the contem-
plation of which lends no countenance to pessimism.
On this side we shall look for a moment or two. In the
first place, pain obviously plays a great part in the preser-
vation of life. If fire did not cause pain in burning, if the
knife could pierce the flesh without suffering, if the
noisome gas caused no inconvenience to sense or brain,
it is difficult to see how, with our present organiza-
tion, life co.ld be long preserved. We should be con-
stantly courting death, and should remain in ignorance of
danger until the mischief effected was irremediable. ‘lhe
child who burns its hands, or cuts its finger, or knocks its
head against a table, or swallows some noxious mess,
suffers, indeed, but, from another point of view, may be
more truly said to be learning invaluable lessons of self-
preservation. Probably this, although a painful way, is
the only one in which such knowledge could be acquired.
In spite of the fact that experience is such a stern in-
structor and punishes so promptly, it is one of the most
common of commonplaces that we are slow to profit by
its admonitions, and only learn wisdom after repeated
warnings. ‘The pain that follows a breach of Nature’s
laws may not always follow so quickly upon error as in .
the cases just cited, but not the less is it salutary. The
malaise that follows excessive intellectual effort or a
drunken debauch is Nature’s admonition that her rule
cannot be set at defiance with impunity. The persistence
In any course of life, any habit, diet, or occupation inim-
ical to health, is always attended by warnings—at first few
and faint, but by degrees more frequent and peremptory
—that Nature is being outraged, and that her vengeance
will not tarry long. Such warnings are painful, but plainly
they tend to the good of the individual and the preserva-
tion of the race. ‘The uses of pain are, however, by no
means wholly, perhaps not even chiefly, physical. Pain
is the great teacher, the great agent in the development of
character. It may be doubted whether any of the nobler
virtues—self-sacrifice, self-knowledge, courage, patience, -
tolerance—ever have been, or ever can be, fully devel-
oped without the agency of pain. It is those who have
suffered who are strong. It is he who has bome
pain in his own person who best knows how to relieve, or
to sympathize with, the suffering of others. Thus the
pain of the individual becomes the fountain of help and
consolation to the species. ‘The sorrow of one becomes
transmuted into the joy of many. ‘There are also ben-
efits arising from pain which are reflex or vicarious in
character. It not only strengthens and purifies the suf-
ferer, but it develops the helpfulness and sympathy of
those upon whom he is dependent. Oliver Wendell
Holmes beautifully remarks that the long, anxious, ardu-
ous tendance upon a sick friend whitens the hair, but also
whitens the soul. ‘There is consolation in the reflection
that, if sickness and suffering increase the cares and re-
sponsibilities of others, there may arise compensation
where it is least looked for. It is one of the most pleas-
ing traits of human nature, that we seem naturally to be
most bound to those for whom we have suffered most.
The mother loves her child not less but more because
she suffered in bringing it into the world, and because her
only anxiety on its behalf partakes often of the nature
of pain. No careful thinker will pretend that the above
considerations fully explain “the mystery of pain.” It
remains a mystery in some respects still ; but such reflec-
tions tend to lighten its darkness, and to suggest that in
ways not yet evident the sorrowing and suffering of the
world may be working out the world’s regeneration.— Zhe
Lancet.
THE TREATMENT OF OZANA WITH GLYCERINE.—At a
recent meeting of the Society of Military Surgeons in Vi-
enna, Dr. Sidlo strongly recommended the treatment of
ozæna with glycerine. His method consists in daily wash-
ing out the nasal cavity with a two per cent. solution of
chloride of potassium, to which ten per cent. of glycerine
has been added. This is followed up with the insertion
THE MEDICAL RECORD.
[September 21, 1889
of rolls of cotton soaked in a mixture of one part of glyc-
erine and three parts of water, the tampons being allowed
to remain in place for an hour atatime. Using this
method, he claims good success in the management of
ozena. The method requires some weeks to effect a cure ;
but no one who has treated ozzena often will think a few
weeks too long to devote to any method which is likely
to be successful. ‘The one proposed by Dr. Sidlo is so
simple, and apparently so rational, that it certainly seems
worthy of further trial, and if other medical men can cure
such cases as he has cured in this way, it will be a very
useful addition to our therapeutic resources.—A/edical ana
Surgical Reporter.
OLD PRIMIPARZ.—Dr. Truzai, of Milan, has studied the
statistics of a lying-in hospital in that city from 1852 till
last year, with a view to ascertain the truth of certain
statements respecting first labors comparatively late in life.
Most of these statements, familiar to readers of obstetric
manuals, were confirmed. The rate of morbidity was
found much higher than in younger primiparz. ‘This fact
was ascertained, so far as Dr. ‘Truzzi’s cases were con-
cerned, to be due in the majority of cases to renal disease.
Puerperal convulsions were found to be more frequent
than in younger subjects. A slight degree of contraction
of the pelvis caused far more trouble than in more youth-
ful cases. ‘The period of dilatation of the os was long;
lacerations of soft parts frequent. Instrumental labor was
very often necessitated, especially the forceps, which had
frequently to be applied to remedy nimple uterine inertia.
— British Medical Journal.
VENTILATION IN IcELAND.— The extreme cold of the
winter in Iceland reduces the system of domestic ventila-
tion in that country to very primitive principles. A trav-
eller there was so choked one night by the close atmos-
phere of the air-tight little chamber in which he slept, with
all the male members of the family, as to be compelled to
wake his host, who sprang out of bed at the call, pulled a
cork from a knot-hole in the wall for a few minutes, and
then, replacing the cork with a shiver, returned to bed.—
College and Clinical Record.
GUM-CHEWERS’ PARALYSIS is the latest form of profes-
sional neurosis recorded in medical literature.
FREEDOM OF AIR FROM GeERMS.—Dr. Le Fort says
that microbes are never conveyed in the air, but only by
contact with the fingers, instruments, etc.
SaLT IN MILK.—Jacobi recommends the addition of
common salt to milk for infants, as it prevents the coag-
ulation in large masses.
CoaL-o1L IN InrussuscepTion.—Dr. Whitney, of Dav-
enport, Washington, reports two cases of intussusception
relieved by enemata of coal-oil.
LocoMOTIVE ENGINEERS are inclined, it is said, to
obesity.
FRECKLES are said to be readily removed by a lotion
composed of equal parts of lactic acid and glycerine.
SULPHONAL is recommended as an almost unfailing rem-
edy against night-sweats.
Dean Docs FoR MEDICAL STUDENTS.—Some medical
students having asked the Mayor of New York to allow
them a certain number of condemned dogs from the
pound, for experimental purposes, that functionary, as the
newspapers report, has duly considered the request, also
the protest of a certain humane person who dreads the
cruelty to which the dogs might be subjected by the stu-
dents, and has come to the conclusion that he will allow
the students a supply of dead dogs, but no live ones.
This generosity is about equal to Artemus Ward’s, as ex-
emplified in his answer to a person who had asked the
privilege of seeing his show without paying: “ No, you
can’t go in without paying, but you can pay without going
in.”"— The New York Medical Journal.
‘The Medical Record
AW 7 Journal of Medicine and Surgery
Vol. 36, No. 13
ee ee eee a a
Origina Articles,
CHRONIC ENDOCARDITIS.’
By FRANCIS DELAFIELD, M.D.,
NEW YORK.
Ir is proper that I should offer to you some reason for
selecting so ordinary a disease as is chronic endocarditis
as the subject for this paper. But the ordinary diseases
are, after all, the important ones, and often as we see them
we never really know them well enough. Any fresh record
of facts, any new way of grouping or of looking at these
facts, must be of some little service. It is the object of
this paper, therefore, not to give a systematic account of
endocarditis, but to draw attention to some features of the
disease ; not to give a history of the views of other ob-
servers, ‘but to state simply what I have put together from
my case-books and post-mortem records.
Of the ordinary diseases few are more common than is
chronic endocarditis. In few of them is there so great a
variety in the severity of the symptoms. From the con-
dition of a trifling inconvenience to that of a distressing
and fatal disease there seems to be no limit to its various
phases. We constantly meet with patients whose heart-
valves are seriously damaged, and who yet enjoy good
health ; can follow laborious occupations, and are often
ignorant that they have any disease. On the other hand,
we, with equal frequency, see patients in whom the same
valvular lesions are attended with the most serious symp-
toms and with death. It is, therefore, a matter of prac-
tical importance to determine, as accurately as we can, why
it is that some of these patients do so well and others so
badly. For it is in this way that we are most likely also
to determine a rational treatment for the disease.
It seems evident that nearly all the most important
symptoms of chronic endocarditis are due to the disturb-
ances produced in the distribution of the blood throughout
the body. It is by these disturbances of the circulation
that the cerebral and pulmonary symptoms, the loss of
nutrition, and the dropsy are produced. ‘The problem be-
fore us, therefore, is to determine why in some cases of
chronic endocarditis there are disturbances of the circula-
tion, and why in other cases there are not. It might seem
at first that the solution of this problem is an easy one,
that the disturbances in the circulation are simply in pro-
portion to the stenosis or insufficiency of the valves. A
very moderate experience, however, is sufficient to show
that this is not the case. The problem is a complicated
one, and the disturbances of the circulation are due to a
number of causes which act singly or together. We may
enumerate these causes as follows: The endocarditis ;
the dilatation and hypertrophy of the ventricles ; the in-
flammation or degeneration of the walls of the heart ; the
inflammation of the coronary arteries ; the abnormal heart-
action ; the associated pulmonary emphysema, chronic
endarteritis, and chronic Bnght’s disease.
To follow out the mode of action of all these causes is
not possible in a paper of this character. I confine my-
self to the consideration of three of them—the endo-
carditis, the abnormal heart-action, and the secondary and
complicating changes in the kidneys. Not that the others
are unimportant, but that these three are perhaps the most
important of all.
1 Read before the meeting ofthe American Medical Association,
June 26, 1889.
New YORK, ‘SEPTEMBER 28, , 1889
See ee an ia, See
Whole No. | 986
1. Zhe Endocarattis.—In thinking of persons with .
valvular lesions we must remember that some of these
persons, while under our observation, are suffering from
chronic endocarditis, and that some are only suffering
from the changes produced in the valves by an endocarditis
which no longer exists. In the one case they suffer from
a chronic inflammation ; in the other, from a deformity.
It may be indeed that such a deformity leads to progres-
sive changes in the cavities and walls of the heart. But
this is much less likely to happen than if the changes in
the valves are also progressive.
Chronic endocarditis may directly follow acute endo-
carditis; it may be developed after a long interval in
valves damaged by an old attack of endocarditis ; it may
from the first be a chronic lesion. We find, especially in
children, an uninterrupted history of cardiac symptoms
beginning with an acute attack and continuing as a
chronic disease for years. We find in older persons, with
marked cardiac symptoms developed late in life, a history
of an acute endocarditis in childhood from which they
had apparently recovered. We find in adults the gradual
development of one cardiac symptom after another, so
slow and so gradual that we can hardly date the begin-
ning of the disease.
Chronic endocarditis, when it has once commenced,
seems to have a natural tendency to persist and to involve
other portions of the endocardium. The cases vary as to
the activity of the endocarditis and the intermissions in
the course of the inflammation. It is apparently possible
for the endocarditis to stop at any time, and the valves
will then undergo no further change.
Chronic endocarditis is a productive inflammation, with
the. formation of new tissue, but without exudation. In
its most active form there is a very considerable growth
of cells, and also a death of cells, so that the inflamed
endocardium is thickened in some places, ulcerated in
others, and on the roughened surfaces thus made thrombi
are formed. This is the most active and dangerous form
of the disease. In its more chronic form the growth of `
cells is not as great, the cells do not die, the basemert
substance is thickened. Although the surface of the en-
docardium is somewhat roughened, and small vegetations
are often formed, there are no thrombi. In either form
of inflammation there may be added degeneration or cal-
cification of the inflamed endocardium and of the thrombi.
It may very well happen that the patient, after suffering
from the chronic form of endocarditis for years, may then
develop the more active form in the same valve, or in one
of the other valves. In the more active form of the dis-
ease a large number of the cases run their course within
six months from the time of the commencement of their
symptoms. A considerable number do not live longer
than six or seven weeks. ‘The symptoms are pronounced :
Disturbed heart-action ; delirium, convulsions, paraplegia ;
cough, hzmoptvsis, dyspnoea; nausea and vomiting ;
dropsy ; loss of flesh and strength, and anzemia, and a
rise of temperature. ‘These patients are apt to get rap-
idly worse, but there may be intermissions, and the in-
flammation may stop altogether. It seems evident that
in the treatment of these patients we must remember that
they are suffering from an inflammation of some activity,
and that rest in bed, the use of cold or of counter-irrita-
tion over the heart, are measures likely to be of use. On
the other hand, in the slow form of endocarditis the disease
lasts for many years. ‘There are usually intermissions in
its course, and it may stop altogether at any time. Many
338
THE MEDICAL RECORD.
[September 28, 1889
of the patients have no symptoms. In those who do,
some one symptom is first developed, and then, as the dis-
ease progresses, others are added. ‘These patients are
regularly better for an out-of-door life, with as much ex-
ercise as they are able to take.
2. The Abnormal Heart-action.—It is possible for
a chronic endocarditis to run its entire course with a per-
fectly regular action of the heart. ‘This, however, is the
exception. The rule is that the heart’s action is dis-
turbed, and this disturbance is often the most important
feature of the disease, and furnishes the principal indica-
tion for treatment. Such a disturbance of the heart’s ac-
tion may be due to:
a. The endocarditis existing as an inflammation of
some activity and producing changes in the heart’s action
in the same way as does an acute endocarditis.
6. Such a degree of stenosis or insufficiency of the
valves as will mechanically interfere with the heart’s ac-
tion. This often does not become a factor of much im-
portance until the stenosis or insufficiency is well marked,
and for this reason it is easy to be deceived as to the
character of the lesion.
c. Dilatation and hypertrophy of the ventricles are
often present, and certainly have their effect in changing
the character of the heart’s action.
d. Chronic myocarditis and disease of the coronary
arteries produce the most extreme and intractable disturb-
ances of the heart’s action. Fortunately they are not very
common. |
e. Contraction of the smaller arteries throughout the
body, with increase of arterial tension and venous con
gestion.
This condition, although a frequent complication of
endocarditis, nephritis, endarteritis, and emphysema, and
occurring as an independent condition in some cases of
angina pectoris, is yet something concerning which our
knowledge is imperfect. Whether contaminated blood
irritates the arteries, whether the nervous centres are
irritated by contaminated blood, or in what way the con-
traction of the arteries is produced, we do not know.
But such a contraction is produced, and lasts for hours,
days, or months. The same patient may never have but
one such attack, or he may have many. In patients who
have had many attacks the muscular coat of the small
arteries is thickened. Such a contraction of the arteries
at once changes the character of the heart’s action. It
becomes rapid, forcible, feeble, or tumultuous. The de-
gree of the cardiac disturbance is apparently in propor-
‘tion to the degree and suddenness of the contraction of
the arteries, but is not related to the severity or extent of
the endocarditis. In the early stages of endocarditis we
very often see patients who complain of nothing but dysp-
noea on exertion and on lying down, and of precordial
pain. Otherwise they feel perfectly well and have normal
urine. We find the heart enlarged, its action rapid and
forcible, and a murmur indicating disease of one of the
valves. ‘he radial pulse is distinctly tense. If by treat-
ment the arteries are dilated the dyspnoea disappears, the
heart’s action becomes natural, and the patients feel well.
Or in further advanced and progressing endocarditis we
may follow patients for years, who in spite of their endo-
carditis feel well except when they have attacks of con-
traction of the arteries. When they have such an attack,
dyspnoea and other symptoms are developed and con-
tinue for weeks or months. ‘Then, asthe attack subsides,
the symptoms disappear, and the patients feel well. ‘The
first attacks yield readily to treatment. But as time goes
on the attacks are more frequent and more obstinate.
The pulse is tense, but small. The heart’s action is no
longer forcible, but feeble or tumultuous. Occasionally
we see patients who go on with a chronic endocarditis for
many years, but with few or no symptoms. ‘Then, with a
slight pleurisy, or pericarditis, or without discoverable
cause, 4 sudden, extreme, and intractable contraction of
the arteries is established, causing the most urgent dysp-
noea, and continuing up to the time of the patients
death. ‘These attacks of contraction of the arteries are
at first readily relieved by the drugs which dilate the
arteries—nitrate of amyl, chloral hydrate, nitro-glycerine,
opium, and potassium iodide. ‘The patients do well with
an out-of-door life and regulated exercise. But as the
endocarditis advances and the valves are more damaged,
especially by stenosis, these attacks are less readily re-
lieved, and it becomes necessary to keep the patients more
and more quiet. |
f- Unknown causes, which apparently act through the
nerves which regulate the arteries of the heart. These
form a large, important, and obscure group of cases. In
some of these cases the abnormal heart-action is associ-
ated with advanced disease of the valves, and it is only by
the results of treatment that we can discriminate how
much of the disturbance of the heart’s action 1s due to
the valvular lesion, and how much to nervous influences.
The pulse is of low tension, feeble, and rapid. ‘The heart’s
action is feeble or exaggerated. The condition of the
patients is often very bad, and yet in some of them very
marked improvement is obtained by treatment. These pa-
tients at first require complete rest, then massage, and later
regulated exercise. ‘The most efficient drugs are digitalis,
strophanthus, caffein, convallaria, and barium chloride.
The heart seems to be always really a weak heart, even
though its action is exaggerated. It is often natural to
believe that there is degeneration or inflammation of the
walls of the ventricles, but yet after death no such changes
are found. In other cases the endocarditis is not ad-
vanced, the valves are but slightly narrowed or insufficient,
there is little or no change in the size of the heart. The
heart's action is rapid, either feeble or exaggerated. The
pulse is soft and rapid. ‘The patients often have pain or
abnormal sensations referred to the heart; the general
health may be very much impaired. Although these pa-
tients have endocarditis, yct it is really the abnormal heart-
action which makes them ill and calls for treatment.
Some of these patients are very easily managed, the heart's
action soon becomes normal, the pain disappears, and the
patients feel well, although the lesion of the valve still ex-
ists. Some of them, on the contrary, do not improve.
The disturbance of the heart’s action and the other symp-
toms continue, but yet the patients do not die, nor get
worse beyond a certain point. ‘There are, however, occa-
sional cases in which the heart’s action becomes very bad.
and the patients become very feeble and die. After death
we find but moderate changes in the valves, and no changes
in the walls of the heart. ‘The management of these cases
1s apt to be difficult. Attention to the diet, the general
health, the habits, the climate, the exercise, is of especial
importance. Of drugs one or other of the cardiac stimu-
lants is often indicated.
3. The Secondary and Complicating Changes in the Kid.
neys.—Of the persons who suffer from chronic endocar-
ditis a large number never have any complicating disease
of the kidneys. In the persons who die from endocarditis
it is rare to find normal kidneys. In judging of the
frequency of the kidney lesions the most certain criterion
is the autopsy. During life it is not sufficient to examine
for albumen and casts, which are often absent, but the
quantity of the urine, its specific gravity, and the propor-
tion of urea to the ounce of urine must also be determined.
Advanced changes in the kidneys often exist in patients
whose urine is said, after a superficial examination, to be
normal.
In persons who die from chronic endocarditis we find :
Chronic congestion of the kidney; chronic degeneration
of the kidney; chronic nephritis.
1. Chronic Congestion of the Kidney.—The kidneys are
of medium size, or large. ‘Their weight is increased, they
are hard, uniformly congested, their surfaces are smooth.
The epithelium of the cortex tubes is opaque, flattened, or
swollen. The glomeruli show a dilatation of the capillaries,
with more or less thickening of their walls, and swelling
of the cells which cover their walls. In the stroma there
is nothing but some exaggeration of the subcapsular areas
September 28, 1889]
of connective tissue, which are found in normal kidneys.
The arteries are normal, the pyramid veins are congested,
and sometimes dilated. The urine is diminished in quan-
tity at the times when the heart’s action is bad, and re-
turns to the normal when it is better. It 1s apparently
never increased, except from accidental causes. The
specific gravity is usually between 1.020 and 1.025, but
may for a time be down to 1.010, or up to 1.035. ‘The
quantity of urea is rarely less than ten grains to the ounce,
it may be as high as twenty-one grains. ‘The specific
gravity and the quantity of urea must be judged by ex-
amining the urine of twenty-four hours, for several days,
with the proper allowance for diet and exercise. Albu-
men and casts are absent, or present in very small quan-
tities. The effect of the congestion of the kidneys on
their functions is simply to diminish the quantity of urine.
The quality of the urine is good, and the exudation from
the vessels amounts practically to nothing. Apparently
the only way in which this lesion of the kidney can add
to the symptoms of the endocarditis is by diminution in
the quantity of the urine.
2. Chronic Degeneration of the Kidney.—The kidneys
are considerably increased in size and weight, weighing
together from sixteen to twenty ounces. Their surfaces
are smooth ; the cortical portion is thickened, of pink or
white color ; the pyramids are red. ‘The gross appearance
is that of the so-called large white kidney. The epithelium
of the cortex tubes 1s swollen and opaque. In the glomer-
uli there is dilatation of the capillaries and swelling of the
tuft-cells. There are no changes in the stroma, or in
the arteries; the pyramid veins may be congested. The
quantity of the urine varies with the changes in the action
of the heart, sometimes abundant, sometimes scanty, some.
times suppressed. ‘The specific gravity 1s not diminished,
nor is the proportion of urea to the ounce decreased.
Albumen and casts in small quantities are more frequently
present than with chronic congestion. While it is difficult
to separate the kidney symptoms from the ‘eart symp-
toms, yet one has the impression that this kidney lesion is
more serious than chronic congestion, and has its effect in
increasing the symptoms of the endocarditis, especially the
loss of nutrition and the anzmia.
3. Chronic Nephritis.—A chronic inflammation of the
kidneys may follow chronic congestion or chronic degen-
eration ; it is then evidently a direct result of the endocar-
ditis ; or it may be developed as an independent inflam-
mation, and is to be regarded as an associated, and not a
secondary, lesion.
a. Chronic nephritis following chronic congestion of
the kidneys. ‘The kidneys remain increased in size, or be-
come somewhat smaller. ‘The capsules are adherent, the
surface of the kidney is finely nodular, the consistence of
the organ remains hard, and the general venous congestion
continues. The epithelium of the cortex tubes is opaque,
swollen, or flattened. The tubes may contain coagulated
matter. ‘The straight tubes of the cortex and pyramids
may contain cast matter. The capillaries of the glomer-
uli are swollen, their walls are thickened, there is an in-
crease in the size and number of the cells which cover the
capillaries. ‘There is a considerable growth of connective
tissue in the stroma, distributed according to the arrange-
ment of the normal subcapsular wedges. Within these
masses of new connective tissue the tubes and glomeruli
are atrophied. ‘The walls of the arteries may be thickened,
the capillary veins in the cortex may be dilated and their
walls thickened. ‘The quantity of the urine varies very
much at different times in the same patient; sometimes it
is above, sometimes below the normal. The specific grav-
ity falls to 1.020 or 1.016. The proportion of urea to
the ounce is somewhat diminished. Albumen and casts
in moderate quantities are regularly present at some time
in the course of the disease, but during much of the time
they are entirely absent. The patients seem to be espe-
cially liable to spasmodic dyspnoea and to loss of flesh and
strength.
6. Chronic nephritis following chronic degeneration of
THE MEDICAL RECORD.
339
the kidney. The kidneys are large, their surface smooth,
the cortex thick and white, the pyramids red. ‘The epi-
thelium of cortex tubes is opaque, flattened, or swol-
len. The convoluted tubes contain coagulated matter,
the straight tubes cast matter. ‘The capillanes of the
glomeruli are dilated, and the cells covering the capil-
laries are swollen. ‘here are no changes in the arteries.
The quantity of urine varies at different times; often it is
very scanty. ‘The specific gravity keeps close to the nor-
mal, or may even be above it. The proportion of urea
to the ounce of urine is not diminished. Albumen is regu-
larly present in considerable quantities ; casts are some-
what less constant. The patients who have this form of
nephritis are apt to exhibit the anzmia and dropsy in a
very marked degree, and to get worse rapidly.
c. Chronic nephritis associated with chronic endocar-
ditis, but apparently not caused by it. Such an association
of chronic nephritis with chronic endocarditis is of very fre-
quent occurrence. Either one of the lesions may be devel-
oped the first, either one may be of the most importance.
In all of these cases, while there is much variety in the
gross appearance of the kidneys the changes in structure
are much the same. The epithelium of the cortex tubes
is degenerated ; some of the glomeruli are converted into
fibrous tissue, in others there is only a growth of the tuft-
cells ; there is a considerable growth of eonnective tissue
in the stroma; the walls of the arteries are thickened.
There are, however, two points in which these kidneys
differ from each other: the quantity of exudation from `
the blood-vessels and the rapidity of the changes in the
kidney. To these two points of difference correspond
the differences in the clinical histories. We may, there-
fore, for clinical purposes, distinguish three forms of
chronic nephritis.
1. Chronic nephritis, with a large and continued exuda-
tion of serum from the blood-vessels of the kidney into
the tubes. The urine is sometimes diminished, sometimes
very much increased in quantity. The specific gravity is.
lowered, often about 1.016. The proportion of urea to
the ounce of urine is diminished. The urine constantly
contains considerable quantities of albumen and numbers
of casts. ‘The patients do badly. Dropsy, anzemia, loss
of flesh and strength, and chronic uremia are the regular
symptoms.
2. Chronic nephritis, with moderate and intermittent
exudation from the blood-vessels. The urine is moře or
less increased in quantity, except when the patient has an
attack of contraction of the arteries; then it is diminished.
The specific gravity is lowered. The proportion of urea
to‘the ounce of urine is diminished. During much of the
time no albumen or casts are present, but from time to
time, when the patient is doing badly in other ways, they
appear in moderate quantities. ‘These patients usually
live for a number of years, slowly getting worse. ‘They
are especially liable to attacks of contraction of the ar-
teries, with dyspnoea, headache, sleeplessness, and con-
vulsions.
3. Chronic nephritis, with little or no exudation from
the blood-vessels, the nephritis advancing very slowly.
These kidneys are considered by some authors to be ex-
amples of fibroid degeneration rather than of chronic in-
flammation. ‘The urine shows no change, except that the
specific gravity and the proportion of urea, from year to
year, are gradually lowered. Some of the patients never
have any renal symptoms; some of them have attacks of
contraction of the arteries; some of them simply lose
some flesh, and a great deal of strength, and die quietly. ©
SALICYLIC ACID IN ‘TONSILLITIS.—Dr. Haberkorn, wnt-
ing in the Ceatralblatt fur Chirurgie for August 10, 1889,
recommends the local use of salicylic acid in tonsillitis,
whether simple or diphtheritic. He uses the dry crystals,
applying them by means of a throat-brush. ‘This causes
no irritation, he says, but the salicylic acid, dissolving
gradually, exerts a continuous antiseptic action.
By A. P. BUCHMAN, M.D.,@
FORT WAYNE, IND.
Ir, in a considerable number of cases of typhoid fever,
who all suffer from the same fundamental lesions, present
nearly, if not quite, a typical temperature-curve, and alto-
gether run about the same course, and, including environ-
ments, receive the same treatment, one observes an amel-
ioration of symptoms that can be safely credited to the
particular course of treatment instituted and kept up all
through the time of high-temperature manifestations, and,
in a modified degree, during the period of convalescence,
it will, I hope, serve the purpose for which this paper was
written, viz., to call attention to the mode of treatment, to
present the history of one of the cases.
On July roth I was asked to prescribe for Mr. W——,
aged about fifty, by his wife, she describing a case of sim-
ple intermittent malarial fever. I sent him a prescription
composed chiefly of quinine, and heard nothing more of
the patient until the evening of July 22d, a little more
than three days having elapsed, when word was sent for
me to call and see the patient. I saw him at 8.30 P.M.,
and found a temperature of 105° F., tongue red at tip
and edges, centre dry and shining, some gurgling in the
iliac fossz, slight tympanites, and some half-dozen thin
and rather offensive bowel-discharges during the day just
passed ; a general tired feeling, some headache, and such
other symptoms as go to make up the typical typhoid con-
dition. In addition to this there was acute mental worry,
owing to unpleasant business complications. After pre-
scribing and leaving general directions for the night, I
left the house in no very pleasant frame of mind. Very
acute, almost stinging, mental worry, and a typhoid fever
under headway for five days, with the subject working at
his desk and on his feet all of this time, was, to say the
least, a very disagreezble foreshadowing. I called again
next morning, at nine o'clock, when the temperature was
103.5° F., tympanites much increased, some delirium,
and very offensive bowel-discharges. ‘This day was passed
with extreme restlessness, and at my evening visit the tem-
perature had gone up to 105.8° F., small, thready pulse,
very rapid, bowels greatly distended with gas, and so much
delirium that it was necessary for someone to remain at
his bedside constantly. Just what to do next was a prob-
lem that presented itself for immediate solution.
I concluded to wash out the colon with a large enough
quantity of water to thoroughly cleanse it, and to this end
procured a fountain-syringe of two-quart capacity ; filling
the reservoir with water directly from the hydrant, to
which I added two ounces of listerine, I proceeded to fill
the colon.
After waiting a few minutes, the patient was assisted on
the commode ; the entire ccntents of the colon were easily
passed, thus relieving the ileo-colic valve, and permitting
the accumulated gas in the small intestines to pass away
as well. ‘The odor accompanying this discharge was
~ simply vile. The patient was now returned to the bed,
and I passed my hand over the abdomen to note the cun-
dition. I found it flat and soft, all of the distention gone.
Within the succeeding forty minutes his temperature had
dropped to 101.4° F., the skin became moist, and before
I left the house he had fallen into a quiet, peaceful sleep
which lasted, with one or two slight interruptions, the
whole night. At this point I dropped all drug medication,
save a one-grain dose of quinine, three times a day, and
substituted colon-flushing. Every time the temperature
approached 103° F. the colon was thoroughly flushed,
which was from one to three times every twenty-four hours.
From July 26th to August 8th there was seemingly gradual
but steady approach to the health-level. I say seemingly,
for on the morning of August gth, at four o’clock, I was
hastily summoned to the patient. ‘The messenger stated
that for an hour previous there seemed to be a great
1 Read betore the Fort Wayne Academy of Medicine.
THE MEDICAL RECORD. [September 28, 1889
ae,
change for the worse. On arriving at the bedside I found
the bowels rather distended, the breathing labored and .
slow—abdominal. My patient was in a state of shock’
nearly profound, resulting from, as I believed, intestinal
hemorrhage. Until 3 A.M. everything had been quiet and
favorable. Twice during the night he had taken nourish-
ment with evident relish, but suddenly at this hour the
whole scene changed, and they thought the patient dying.
I immediately washed out the colon with hot water, first,
for its stimulating effect, and, second, to relieve the
bowels, as no blood had been discharged. Very soon the
water, very bloody, came away, and soon I had the satis-
faction of seeing the patient rally, and in less than two
hours he seemed as well as he had been at any time the
preceding day. From now on he convalesced rapidly.
The colon-flushing was continued unremittingly, from one
to three times every twenty-four hours, until the period of
convalescence had ended, which was, to me, a surprisingly
short one. I saw the patient last on the morning of
August 20th, when he was moving about the room, and
was gathering strength rapidly.
On July 20th I began to use the same method of treat-
ment on a series of five other cases of typhoid fever, giv-
ing no drug save one- or two-grain doses of salicylate of
quinine three times a day. They have all progressed very
favorably, and at this time (August 27th) I have so treated
a total of thirteen cases. I wish to add here that at no
time did I neglect to have a cold sponge-bath given at
least once every twenty-four hours. ‘The diet was chiefly
In summing up, I find the situation about as follows :
1. ‘hat from one to three quarts of cold water can be
easily and safely passed into the colon, which will rapidly
lower a high temperature. |
2. That I believe, in some of the cases, the water
passed the ileo-colic valve, entering the small gut.
3. ‘That tympanitic distention will always disappear with
passing away of the water so injected.
4. That putrefactive fermentation of the bowe!-contents
is prevented by such use of water.
5. ‘That toxic substances are more rapidly absorbed by
the czecum than by any other portion of the intestinal
canal, and that, by a judicious and careful washing with
antiseptic water, we can prevent the absorption of such
toxic substances, and prevent and modify general sys-
temic poisoning.
August 27, 1889.
MISAPPLIED INGENUITY.—An Indian contemporary nar-
rates some curious instances of misapplied ingenuity on the
part of certain habitual criminals in that country. ‘The dis
covery on a prisoner of a heavy leaden bullet, about three-
fourths of an inch in diameter, led to an inquiry into the
object to which it was applied. It was ascertained that it
served to bring about the formation of a pouch-like recess
at the base of the epiglottis. ‘he ball is allowed to slide
down to the desired position, and it is retained there for
about half an hour at atime. ‘This operation is repeated
many times daily until a pouch of the desired size results,
in which criminals contrive to secrete jewels, money, etc.,
in such a way as to defy the most careful search, and with-
out interfering in any way with speech or respiration.
Upward of twenty prisoners at Calcutta were found to be
provided with this pouch formation. The resources of
the professional malingerer are exceedingly varied, and
testify to no small amount of cunning. ‘The taking of
internal irritants is very common, but would-be in-patients
very frequently overshoot the mark and render recovery
impossible. Castor-oil seeds, croton beans, and sundry
other agents are employed with this object in view, apd
the medical officers of Indian prisons have to be continu-
ally on the lookout for artificially induced diseases which
baffle diagnosis and resist treatment. Army surgeons are
not altogether unfamiliar with these tricks, but the British
soldier is a mere child in such matters compared with the
artful Hindoos.—Medical Press and Circular.
September 28, 1889 |
RHEUMATISM OF THE OCULAR MUSCLES.’
By JOHN W. WRIGHT, M.D.,
COLUMBUS, O.
ALTHOUGH some particular parts of the body are more
disnosed to acute rheumatism than others, yet it cannot be
denied that all fibro-muscular structure, wherever found,
is more or less liable to this affection; and the same
cause that will produce it in the muscular tissue in one
part of the body 1s hable to affect this tissue similarly,
wherever found.
That persons of rheumatic diathesis do frequently suffer
from rheumatism of the fibro-muscular structures of the
eye and its appendages, there cannot be a doubt.
That the optico-orbital muscles, as well as the ciliary
muscle and the iris, are subject to both the acute and
chronic types of the disease, is evident, especially when the
patient is possessed of the rheumatic habit.
I believe that iritis, when not traumatic or specific, is
generally rheumatic. The same may be said of cyclitis,
and perhaps choroiditis. One thing we know full well,
that these affections are liable to follow acute attacks of
rheumatism, and are liable to attack persons of rheumatic
diathesis.
It is not my desire to enter into a discussion of the
pathogenesis of rheumatism here; although the general
pathology which considers it a blood disease may be re-
garded as correct, we have never been able to explain by
it the symptoms of an acute attack, where, in addition to
the constitutional disorder, we have local pain, occasional
heat, redness, and swelling, with febrile symptoms ; for it
is not shown that exudation occurs, or that it is followed
by the usual results of that condition.
If there is effusion in acute rheumatism, which is doubt-
less true, I do not pretend to offer a solution as to its dis-
posal, but one thing is quite sure, that in iritis following
rheumatism, or what we are pleased to call rheumatic in-
tis, there #s effusion of plastic or serous matter, which
frequently plays an important part in the futurity of the
eye.
Owing to the structure of the eye, the iris being promi-
nently exposed to view, this exudation is readily seen, and
the inflammatory process can be carefully watched ; while
in other parts of the body the muscular structures are
covered and hidden from view by the integument, the
connective, and often other muscular tissue.
As this paper has to do with rheumatism of the ocular
muscles, we shall proceed to the symptoms preceding and
accompanying this affection.
There is generally, at the inception of the affection,
constipation, a dry, heavily coated tongue, and a foul
breath, accompanied by headache and insomnia; then
chills followed by fever, the increase in temperature
being usually from one to four degrees.
Like acute rheumatism affecting other parts, rheumatism
of the ocular muscles often seems to follow a certain reg-
ular and migratory propensity in its attacks, first visiting
the muscles of one eye, then those of the other. Often
the muscles of one eye alone may become affected, but
most frequently those of both. ‘The ocular muscles only
may be affected, but generally other parts of the body
are at the same time similarly acted upon. I have fre-
quently noticed patients complain of pain in one knee,
which, in a short time, would be transferred to the other,
then to some other joint, as the ankle, then again to the
Other ; then again, as before mentioned, to the ocular
muscles. |
Another interesting fact is that while there is pain in
the joints there is usually none in the region of the eyes,
and vice versa. As in acute rheumatism the joints are
sometimes swollen and red, and the connective tissue in
their region infiltrated, so also the conjunctiva and the
connective tissue in the region of the ocular muscles be-
come cedematous, and in some cases there is severe con.
4 Read before the Central Ohio Medical Society, September 5, 1889.
THE MEDICAL RECORD.
341
ae — -—
junctivitis and chemosis. As in ordinary rheumatism
there may be severe pain with very little tenderness or
swelling of the joints, so in the rheumatism of the ocular
muscles there may be no conjunctival irritation nor in-
filtration of the connective tissue in the region of the af-
fected muscles, nevertheless the pain is quite severe.
Sometimes all of the ocular muscles are affected, fre-
quently but one or two. This can be readily determined
by making pressure upon the closed lids, and the affected
muscles thus located, the patient complaining frequently
upon the slightest pressure over the affected muscle.
The migratory and systematic order in which acute
rheumatism often affects the joints, is again evidenced in
rheumatism of the ocular muscles. When the internal
rectus of one eye is thus affected and there is a metas-
tasis to the other eye, the internal rectus is the one gen-
erally to suffer. When all of the muscles of one eye are
affected, the transfer affects those of the other alike.
When but one or two of the ocular muscles become
rheumatic, there is usually but little or no conjunctival
irritation ; but when all of the muscles are involved,
there is always conjunctivitis with more or less infiltration
of the connective tissue, and frequently much chemosis.
In some cases of the affection there is excessive hyperx-
mia of the ocular and palpebral conjunctiva, the blood-
vessels being engorged with a superabundant lachrymation,
presenting the characteristics of catarrhal conjunctivitis.
Sometimes the eyes alone are affected, other parts of the
lody being entirely free from rheumatic pains. In cases
of this kind I have frequently doubted the existence of
the affection, when properly directed treatment applicable
to rheumatism would mitigate the disease.
The pain and swelling of the ocular muscles are usu-
ally confined to the sheaths of their tendons, to which
the disease has extended, but particularly to the points of
their attachments to the sclerotica, where there is fre-
quently much infiltration, from which the conjunctiva is
uplifted, and by reason of this pressure which it (the in-
filtration) exerts from beneath, the conjunctival vessels
are emptied, giving this point the appearance of a pin-
guecula or an abscess. When there has been very severe
inflammatory action I have seen this condition existing
at the points of attachment of all the recti muscles. For
a considerable time after such severe attack upon the
ocular muscles the eyes cannot be moved in any direc-
tion without pain. The same causes that predispose to
acute rheumatism of the other parts of the body will de-
velop it in the pcular muscles, such as exposure to damp-
ness and cold, and occupying damp rooms,
I am now abundantly satisfied that many of the intrac-
table head pains from which so many suffer are due to
some form of rheumatism of the ocular muscles, and that
a due regard to this fact would contribute very greatly to
palliating much suffering.
BACILLI ON A Barpo Heap.—Dr. Saymonne claims to
have isolated a bacillus, called by him “ bacillus crinivo-
rax,” which is the cause of alopecia. It is, he says,
found only on the scalp of man, other hirsute parts of the
body and also the fur of animals being free from it. ‘The
bacilli invade the hair-follicles and make the hair very
brittle so that they break off to the skin. ‘Then the roots
themselves are attacked. If the microbes can be de-
stroyed early in the disease, the vitality of the hairs may
be preserved, but after the follicles are invaded and all
their structures injured the baldness is incurable. ‘The
following is Dr. Saymonne’s remedy to prevent baldness :
Ten parts crude cod-liver oil, ten parts of the expressed
juice of onions, and five parts of mucilage or the yolk of
an egg, are thoroughly shaken together and the mixture
applied to the scalp, and well rubbed in, once a week.
‘This, he asserts, will certainly bring back the hair if the
roots are not already destroyed, but the application of
the remedy must be very distressing to the patient's friends
and neighbors.
342
THE MEDICAL RECORD.
[September 28, 1889
Clinical Department.
GANGRENE FOLLOWING CONTINUED FEVER.’
By F. W. P. BUTLER, M.D.,
EDGEFIELD, S. C.
On the morning of November 27, 1888, I was called
some miles into the country to see M. M——, twenty-
eight years of age. Family history, as far as I could
ascertain, was good, with probably two exceptions—his
grandmother and an uncle, I learned, had died with a
trouble very much like the one from which he was now
suffering. On entering the cabin I found my patient
lying over in a dark corner ; he was very much emaciated,
weak, and covered over with four or five heavy quilts.
As soon as I entered the hut I recognized the characteristic
gangrenous odor. I w covered the affected limb, and
discovered a cold, darkened leg, irsensible to the touch of
my hands, or to the prick of a pin. The line of demar-
cation had just begun to be formed, and I should have am-
putated then, but was compelled to endeavor to revive
the dying leg. The family told me he had been sick two
or three weeks, and had been attended by a physician in
the neighborhood, who had given up the case.
I was certain I had a case of gangrene, with no lesion
or traumatism to cause it. I really did not know the
true cause then, but told them it was gangrene, and I
would endeavor to save it, but thought it was too late. I
dressed the leg antiseptically and with warm applications,
and put the patient on tonic pills of iron, quinine, and
strychnia, for then he was suffering no bowel or stomach
trouble, but was intensely weak and reduced; also or-
dered small qnantities of milk-punch regularly and often.
I did my utmost to save the limb, but told them, after
the second visit, that on my next visit the leg would have
to come off, for now the line of demarcation had fully
formed and the odor was terrific, and I saw that, under
the existing circumstances, pyæmia would soon set in.
So, on December 4, 1888, accompanied by Drs. Hill and
Tompkins, I repaired to the place to amputate. Ifor-
got to mention that when I first saw the man I also
found him suffering from an immense, putrid, black,
nasty smelling bed-sore in the lower part of the back, near
the prominent portion of sacrum ; this was protected as
well as circumstances would permit. I amputated about
six inches below the thigh-joint, as I was fearful of a re-
currence of the gangrene. I made part skin and part
muscular flaps. ‘The parts were brought together with
wire, and a wet sublimated dressing (1 to 2,000) applied
over the stump, and on top of the wet dressing carbolized
gauze and borated cotton, with bandages over all. ‘The
patient stood the operation well, notwithstanding his
great weakness and depletion. I remained in the neigh-
borhood that night, and he passed a tolerably good night.
The whiskey and milk were increased, as was the quinine.
The bed-sore mentioned above was dusted over with iodo-
form and wheat-flour, and protected from the bed. The
enormous bed-sore added to the magnitude and apparent
hopelessness of this terrible case. ‘The patient was de-
lirious, wandering, and feverish for four or five days, pulse
weak, quick, and thready. I then put him on tincture of
digitalis combined with the whiskey. Everything went on
as well as I could expect until the fifth day, when, owing
to a mse in the temperature and an unpleasant odor of
the stump, Í dressed it. Much to my regret, I found the
femur had projected, then the flaps and the parts were in
a complete state of suppuration. Evidently the man, in
his delirium and restlessness, rolled over on the stump, and
the bone pushed through the skin. I now determined to
apply a dry dressing of sublimated gauze, and did so.
In the meantime I did all I could to protect the bed-sore,
but found a hard job, for two more bed-sores of a gan-
1 From a paper read before the annual meeting of the South Caro-
ina Medical Association, 1889.
grenous character now appeared on each hip-bone, to
which I also applied iodoform, and protected them with
pillows as best we could. These bed-sores gradually
sloughed off and began to granulate. I gave him as a
nourishment bovinine and milk, with soup and light diet.
Fortunately for me and my patient, his stomach never
failed him once, and he took everything apparently with
relish. He was doing well, the bed-sores healing, and the
projecting bone gradually disappearing by healthy gran-
ulating tissue. After the febrile state had subsided to
some extent, I prescribed sulphate of strychnine, gr. j.,
and solution of malate of iron, 3 j., fifteen drops to be
given three times a day. The quinine, gr. iij., was kept
up continually.
I was just beginning to congratulate myself, as I now
thought my patient was good to recover ; but lo and be-
hold, on the third week after the first amputation the
other foot began to pain and get cold. I at once began
warm applications, and tried every conceivable plan to
save this leg, but all my efforts were futile. So soon as
the line of separation began to form, I determined to
operate, and, in fact, the poor unfortunate negro begged
me to do so. I saw that the dorsal artery was affected,
and that gangrene had begun. On February 7th, with
the assistance of Drs. Beall and Nicholson, I amputated
just below the knee, obtaining a good muscular flap. I
concluded to dress this stump differently from the other,
so I brought the flaps together with horse-hair and ap-
plied a dry dressing of sublimated gauze made of cheese-
cloth. The man stood the operation well, took the same
kind of anesthetic as given before, easily. The bed-sores
were healing, and the patient from this on gained strength
daily. ‘The stump healed by first intention, and there
have been no signs of a return of gangrene in any part of
the body. He is now doing well without his legs. I am
led to conclude, from my experience with this case,
though it is limited, and hardly enough to form opinions
on, first, that as soon as we notice no signs of return of
life to the part affected, sometimes even before the line of
separation or demarcation forms, amputate high up above
the seat of trouble ; second, that judging from my meagre
experience and that of my professional brethren in this
town, a dry dressing antiseptic gives the best results.
POISONING BY TANSY.
Dr. W. A. BELT, of Kenton, O., reports the following
case: “Mrs. K—, not having her menses for some
five weeks, thought herself pregnant, and not wishing to
have any more children followed a neighbor’s advice and
set about taking five drops of the oil of tansy every few
hours. Not succeeding in bringing about her menses she
took about one drachm on sitting down to breakfast. She
felt no unusual symptoms for about a half-hour, when a
“ dizzy sensation ” came over her. She ran out doors and
a moment later was picked up by her husband in convul-
sions resembling epilepsy. There were the spasmodic
contractions of the limbs, frothing at the mouth, and uncon-
sciousness. I found her in this state, with a thready pulse,
very intermittent, respiration scarcely percertible, and cyan-
otic. ‘Thinking there was enough food in the stomach from
her breakfast to hold a good part of the oil yet unabsorbed, I
administered apomorphia muriate, gr. 4y, hypodermically.
In a few moments she vomited very profusely, there being
a great amount of gastric juice. After this she revived
by repeated doses of brandy, but did not regain her con-
sciousness for two or three hours. She remembered noth -
ing about what had happened. Her tongue was lacerated,
as is often seen after a severe epileptic fit, the pulse ran
up to 120, and temperature to 101° F. for the balance of -b
the day. Headache persisted for three days, and fainting
every three or four hours for two days. The menses
made their appearance, but not from the action of the
drug, for she was nursing a child about six months of age,
and they had been irregular. There were no signs of an
abortion.” į
September 28, 1889]
THE MEDICAL RECORD.
343
Progress of Medical Science.
REGULATION OF BREATHING IN SEASICKNESS.— Dr. Ivan
A. Mitropolsky, of Moscow, warmly recommends, on the
ground of his personal experience, the following simple
method for} preventing or aborting all symptoms of sea-
sickness. As soon as giddiness, nausea, etc., appear, the
author shuts his eyes, and begins to make deep and slow
inspirations and expirations. In a few moments (some-
times after three or four respiratory cycles) the symptoms
disappear, to yield to a comfortable subjective sensation.
On their reappearance the same procedure is repeated
again and again. If the recurrence be rather frequent, it
is better to perform the procedure in a recumbent posture
(with closed eyes). Since the time the author has begun
to practise the method he never yet suffered from vomit-
ing when on board. In referring to this case in the Lon-
don Medical Recorder, Dr. Idelson says that Dr. Mitro-
polsky seems to think that the means proposed by him
is novel. Meanwhile, in the British Medical Journal,
March 24, 1888, p. 676, he will find a very interesting
note by Dr. J. J. Leiser, in which the writer says (1) that
seasickness is caused by irregular and imperfect respira-
tion, leading, necessarily, to an inadequate aération of the
patient's blood, which consequently becomes poisonous to
his brain and gives rise to sympathetic sickness ; (2) that
a system of regular, free breathing prevents sickness or
rapidly relieves it ; and (3) that his experiments were suc-
cessfully repeated by Drs. G. C. Stockman and C. W. C.
Prentice, who, having selected ten suffering passengers,
each seated himself with five of them and “timed the
breathing in the following manner: they (the doctors)
raised the hand from the knee, indicating an inspiration,
and down again for an expiration, thus timing the respi-
rations to exactly twenty per minute. At the expiration
of one hour the active symptoms in each case had entirely
subsided.” By this time the doctors had thoroughly edu-
cated their patients in the modus operandi of the cure.
The cases continued to be permanent “ cures” during the
remainder of the voyage from Queenstown to the United
States. The writers conclude by asserting that “ the cure
is infallible in all cases that persist in carrying it out.")3 4
{ MovasLE Heart.—Of five cases of movable heart
studied by Professor Rumpf, three were the results of
dietetic and medicinal attempts to cure obesity, one oc-
curred after violent nervous excitement, and in one no
cause could be assigned (Zhe Lance/). The chief com-
plaint of the patients was great debility and incapacity for
work ; other symptoms were pains in the chest, uneasiness,
anxiety of mind, vertigo, asthma, and accelerated pulse.
One symptom especially is always present in these cases—
all the signs become less in the patient when lying on his
back, and worse when he is on his side, and he feels bet-
ter when he is standing up, though the pain does not dis-
appear ; occasionally, however, there is vertigo and
malaise. The examination of the heart in the erect or
horizontal position, and with the thorax bent forward,
shows nothing whatever abnormal ; when, however, the
patient lies first on the left and then on the right side, the
abnormal mobility of the heart becomes very distinct. In
one case the apex beat shifted thirteen centimetres, in
another from four to five centimetres. When the patient
lies on his left side the area of the cardiac dulness seems
larger, when on his right smaller, while at the same time
the position of the aorta and of the pulmonary artery is
also changed ; in one case they moved one centimetre in
the direction of the displaced heart. Dr. Rumpf con-
siders the movable heart to be not a mere irregularity, but
a pathological symptom, as the average normal movement
of the heart is at most twocentimetres to the left and one
and a half centimetre to the right, as he qbserved
this dislocatton in one case of tuberculosis of the lungs
and in one case of muscular atrophy.
LocaL APPLICATION OF CHLOROFORM IN EPIDIDYMI-
Tis.—Dr. Clemens, of Frankfort, claims that he has ob-
tained great benefit in cases of epididymitis, both specific
and non-specific, by means of chloroform locally applied.
He regards as most unsatisfactory the treatment of the
affection by other methods as compared with his own,
which he has employed now for a great many years (Zhe
Lancet). It consists in laying some cotton wool saturated
with chloroform and spirit at the bottom of a large glass
vessel, into which the genitals are then put and packed
round with dry cotton wool, the buttocks and thighs form-
ing a cover, this application being continued for from
fifteen to twenty-five minutes, and repeated two or three
times a day. Pathologically, he considers venous conges-
tion of the epididymitis and the cord through retention of
semen a predisposing cause of the disease. He also con-
siders epididymitis as very likely to occur when gonorrhoea
has been contracted in excessive venery. He mentions a
case of treatment by chloroform, thirty-six years ago, not
of epididymitis, but of periodical “ heat,” occurring in the
human subject. The man used to suffer periodically from
a form of orchitis, during which the testes felt hot and
swollen, and the plexus pampiniformis was full and tur-
gescent like a varicocele. He was ordered the local ap-
plication of chloroform three times a day, from fifteen to
twenty-five minutes each time, but the first time he bore
the chloroform for nearly thirty-five minutes, after which
the pain of the severe attack completely ceased and the
swelling considerably decreased. ‘This treatment lasted
three days, during which time he was able to walk about,
the cotton wool which had been used for the chloroform
being put into the suspensory bandage and the testes
covered with it. After that both the swelling and sensi-
bility disappeared. Another case is mentioned where
epididymitis had been caused by the continuous pressure
of a rudder handle on the hypogastrium, in which similar
treatment proved entirely successful. Again, a class of
cases that is usually very difficult to treat—viz., that of
gonorrhceal orchitis—seems to have proved fairly tract-
able when managed with the help of chloroform. Here
one of the first signs of improvement was frequently tho
re-establishment of an old discharge, which was soon cured
simultaneously with the epididymitis.
THE TYPHOID BACILLUS IN THE Fcaetus.—Dr. Eberth
has reason to believe that the bacilli of typhoid pass from
the mother to the foetus. From a woman who died in
the fifth month of gestation he removed the foetus, and
examined fluid from the heart, spleen, and lungs (Ze
Medical Press). He found bacilli that possessed all the
morphological and vital characteristics of the bacillus of
typhoid. Dr. Gaffky, the well-known authority on the
bacillus in question, agreed with the writer that the bacil-
lus thus met and that of typhoid were identical. It is rather
important to know whether the bacillus of typhoid can pass.
from the blood of the mother to the foetus, z.e., whether a
child can have typhoid before its birth, and it appears on
present evidence that it can.
DYSMENORRH@AL MEMBRANE.—Is membranous dys-
menorrnæa a little more than menstruation and le;s than
pregnancy ? Can dysmenorrhceal membrane always be
distinguished from the decidua in early pregnancy ?
These questions are of high import and deserve the atten-
tion of practitioners and histologists. ‘Ihe subject was
raised at the July meeting of the Obstetrical Society of
London, where some decidua-like fragments were exhib-
ited. ‘They had been discharged from the uterus some
time after removal of the appendages. The theory that
membranous dysmenorrhcea represents periodical abortion
within one month after impregnation is very plausible.
It is supported by Dr. Cory’s case, published in the
“ Transactions of the Obstetrical Society,” vol. xx., 1878,
where no membranes were passed at period whenever the
patient lived apart from her husband. ‘lhe phenomenon
might, on the other hand, be explained by the sexual rest
which temporarily cured a true “ dysmenorrhcea,” as dis-
344
THE MEDICAL RECORD.
[September 28, 1889
tinguished from. an incipient pregnancy. All. cases of
membranes passed from the uterus at regular intervals de-
serve the most careful clinical record, and, at the same
time, the membranes ought to be preserved in spint and
sent to a competent histologist. ‘The habits of the patient
should be investigated ; the effects of separation from her
husband very closely watched. On the other hand, the
histologist, as a man of science, should feel sure that he
can correctly interpret the microscopical appearances of
the membranes. Above all, he must not give an opinion
unless he knows, from practical research, the appearance
of the endometrium at and between the catamenia, and
also in early pregnancy.— Zhe British Medical Fournal.
UNSUSPECTED LEAD-POISONING.—Dr. Lermuseau has
brought before the Liège Medical Society some instances
showing that a good many cases of colic, the ongin of
which is unsuspected, are in reality nothing but cases of
lead-poisoning. A large number of them are due to the
practice of pumping up beer in public-houses through
leaden pipes, or at least through pipes which contain a
considerable proportion of lead. Publicans and others
frequently drink this beer early in the morning on an
emptv stomach, and this habit is a most fruitful source of
lead colic. Of course, in many cases there is a blue line
to be found on the gums, but sometimes this is absent,
and then the diagnosis is very difficult. Occasionally,
the so-called method of Cicconardi may be useful in
clearing up the diagnosis. It has been employed in Pro-
fessor Rommelaere’s wards, and consists in painting the
surface of the skin covering the thorax with a six per
cent. solution of sulphite of soda. If lead is present in
the tissues a dark discoloration caused by the formation
of the sulphide soon makes its appearance. Dr. Lermu-
seau complains of the apathy and incredulity of publicans
even after their attention has been called to the danger of
using leaden pipes for their beer—a danger from which
the publican is usually the very first to suffer. It is urged
that a stringent law ought to be passed entirely forbidding
the use of leaden pipes for beer-pumps. Dr. Lermuseau
suggests the substitution of glass or hard rubber pipes, but
these substances are less convenient, because they cannot
be bent in all directions in the way that lead can. It
would appear that, according to a law made in 1790, the
communal administrations have all along had ample
power to deal with cases of this kind, if they would only
exercise it. Something more stringent is evidently neces-
sary, and Dr. Lermuseau urges upon his confrères to
bring all the pressure possible to bear upon members of
the two Houses of Parliament, in order to get some more
satisfactory legislation on the subject.— The Lancet.
PHYSICAL AND MENTAL CHANGES AFTER REMOVAL OF
OVARIES OR UTERUS.—Dr. Glevecke, of Kiel, has lately
published a paper in the Archiv fur Gynakologie on this
subject. According to this author the changes usually
met with were those observed at the menopause (Berlin
Cor. Medical Press). Menstruation permanently ceased,
immediately or shortly after the operation of removal, in
eighty-eight per cent. of the cases. In the remainder it
was less frequent and more scanty. Practically, no vica-
rious menstruation was observed. Menstrual molimina
were observed in thirty per cent. In the time between
the periods the familiar characteristic disturbances were
observed—hot flushes, perspiration, and faintness. He
looks upon them as disturbances of the vaso-motor sys-
tem, in consequence of the cessation of the ovarian func-
tion ; an observation, by the bye, that does not throw much
light on the subject. He does not remark the very long
continuance of this most uncomfortable condition in
many of the cases—four and five years. In four cases
out of a total of forty-three, palpitation and headache
came on, in one nausea coming on several times a day,
in another vomiting, in one diarrhoea, in one acne of the
face lasting over a year, and in two increasing weakness
of intellect. Atrophy of the internal genitals was a con-
sequence of the operation. In twenty-three cases in
which the operation was performed for myoma uteri, dis-
tinct shrinking took place in the tumors in ninety per
cent. In forty-two per cent. of the cases a distinct in-
crease in weight, due to deposit of fat, was observed.
Sexual desire was unchanged after removal of ovaries in
only a few women. Both desire and pleasure were much
diminished, but not in the same proportions in all cases.
As regarded the psychical condition, almost always a de-
pressed, low-spirited condition was remarked. Many
women became melancholic, others showed a changeable
and petulant disposition. Actual psychoses developed in
three cases; two recovered in the course of a year, the
third was incurable.
The changes were different when the uterus was extir-
pated. Menstruation ceased and no vicarious menstrua-
tion followed. Out of thirteen cases of total extirpation
of the uterus, strong molimina were observed in nine. If
the ovaries were not removed atrophy of the external
genitals did not take place. But little increase of weight
took place after extirpation of the uterus. Sexual mat-
ters were almost unchanged, a slight diminution of sexual
pleasure was acknowledged in a few cases. Psychically,
no change was observed in one-half of the cases ; in more
than a third a melancholy so great as to constitute a
psychosis was observed. On the whole, the bodily and
mental changes after castration were much greater than
after extirpation of the uterus.
ACUTE TRAUMATIC PNEUMOoNIA.—Dr. Sokolowski has
published a paper on acute croupous pneumonia of trau-
matic origin. ‘Two cases came under his observation
lately. ‘They refer to lads of fourteen and nineteen, who
received violent traumatic injury to the chest anteriorly,
and in whom, several days later, there developed croup-
ous pneumonia localized in the region injured. In both,
the attack was rather severe and characterized by an in-
tense local pain, the course of the disease being typical,
and terminating by a well-pronounced crisis. Such cases
are well known to clinicians. ‘They are not so very rare,
to judge from the fact that among Frerich’s 300 cases
there were as many as 14 which had a distinct etiological
connection with traumatic causes. From the point of
view of modern etiological theories their causation may
be explained, seemingly, pretty simply: a traumatically
injured pulmonary tissue appears to lose its power or re-
sistance to the pathogenic microbe of pneumonia ; hence
the inflammation arises. Practically, cases of the sort are
especially important in forensic respects. The expert
may be asked whether this or that traumatic injury to the
chest (for instance, inflicted during a fight) can be re-
garded as a real cause of an attack of pneumonia devel-
oping more or less immediately after the injury. Such
cases as Dr. Sokolowski’s seem to justify a positive answer
to the question.— St. Louis Medical and Surgical Journal.
THE INFECTIVE PERIOD IN CONTAGIOUS DISEASES.—
In the Glasgow Medical Journal, Dr. James Finlayson
contributes an article in which he has collected and tab-
ulated the views of recent authorities on the infective and
incubation period in contagious diseases. ‘The author
has drawn up three tables, one showing the various views
of well-known authors as to the infective period, another
showing the period of incubation, and a third showing
the period of quarantine necessary to enforce in cases
where the patient has been exposed to infection, before
they should be allowed to be considered safe to mix with
others. Some such rules are also required as to the time
when it is safe to allow healthy children to return to
school, if they have brothers or sisters suffering at home
from infectious diseases, especially if they themselves
have once had the disease. The infective penod for
scarlet fever is from seven to eight weeks ; measles, three
to four weeks ; Rétheln rather less; mumps varies from
two to four weeks, and whooping-cough is usually put
down to eight weeks or more. ‘The paper is a very in-
structive one, and every general practitioner would do
well to keep a copy of it always ready for reference.
September 28, 1889]
THE MEDICAL RECORD:
A Weekly Fournal of Medicine and Surgery.
———
GEORGE F. SHRADY, A.M., M.D., EDITOR.
aa
PROPRIETORS AND PUBLISHERS
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
New York, September 28, 1889.
AN OLD SURGICAL SUPERSTITION EX-
PLODED.
Dr. H. A. Hare has been making an experimental study
of the effects of the entrance of air into the circulation,
and he has obtained results quite opposed to current sur-
gical teaching regarding this matter.
Dr. Hare experimented upon seventy dogs, of all sizes,
ages, and conditions. He injected air into the jugular
veins and carotids in doses of from a slight bubble up to
forty cubic centimetres. He found that air injected in
the above amounts into the veins caused no serious effects
whatever, except, perhaps, a brief quickening of respiration
and fall of blood-pressure.
When air was injected into the carotid, however, the
effect was different. In from one-half to one second res-
piration ceases at once, unconsciousness asserts itself, and
the animal is apparently dead, save for the action of the
heart, which keeps on as if nothing had occurred. Ina
moment respirations are renewed, the breathing becomes
at first more powerful, then less and less so till death
really ensues—a result which can be indefinitely postponed
provided artificial respiration is kept up. Sometimes the
animal begins to breathe voluntarily, and lives indepen-
dently of any such aid ; in others he dies at once when
the artificial respiration ceases.
Dr. Hare reviews all the various experimental and surgi-
cal evidence on which is based the prevalent opinion that
air getting into the veins causes death. He thinks this evi-
dence quite valueless and adds : “‘ While we have a large
number of cases reported of sudden death under operations
where veins were opened, in the majority of them the
cause of death has been guessed at and not proved. ‘The
only case which approaches in any way toward authen-
_ ticity is that of Mott, who saw a serious but not fatal re-
sult induced by the entrance of air into the facial vein,
and even this is not a proved case. The case of Barlow
is equally doubtful as to the real cause of death.
“ There are a number of cases on record where death has
resulted, according to the physician in charge, from’ the
entrance of air into the uterine sinuses.” These are not
discussed by the writer, as they are somewhat different in
their character, in that the character of the accidents and
the peculiar anatomical arrangement of these veins render
the entrance of large amounts of air more easy of ac-
complishment.
The conclusions reached, then, are : 1. Death never oc-
curs from the entrance of air into the ordinary veins of
THE MEDICAL RECORD.
345
the body unless the quantity be enormous—from one to
several pints, a quantity which cannot enter unless delib-
erately sent in by the surgeon.
2. The cases on record have been due to other causes
than air and have not been proved.
3. The tendency of the vessel to collapse and the leak-
age of blood prevent any entrance of air, and it would
seem probable that a clot has generally caused death, not
the air itself.
It must still be remembered that Dr. Hare’s positive
evidence of the innocuousness of air in the veins is based
entirely on experiments upon lower animals.
THE NEW BUILDING FOR THE ACADEMY OF MEDI-
CINE.
THE corner-stone of the new building for the New York
Academy of Medicine will be laid, with appropriate cere-
monies, at Nos. 17, 19, and 21 West Forty-third Street, on
Wednesday, October 2d, at 4 P.M. Thus the time comes for
a realization of hopes, long deferred, for a fitter dwelling-
place of the medical profession of this great metropolis.
It will be the new home around which will eventually
centre all those social and scientific influences, which will
make the medical fraternity a power for good, not only in
this city but throughout the land. It will, we trust, be an
event ever to be remembered in the medical history of
New York as marking an era when the foundations for
professional unity and brotherly love shall be securely
laid, and when each and all shall be stimulated by the
laudable ambition to work for the common good. It well
becomes one and all to enter heartily into the spirit of the
occasion. Every member of the Academy should lend
the influence of his presence, and prove to the laity that
their generous donations have not been vainly or un-
worthily bestowed.
Heretofore the profession has not been as responsive
to public interest as it should have been. The laymen
are hardly prepared for such indifference, and are con-
sequently ready with excuses when donations are required.
It goes without the saying that the profession must first
show itself in earnest in enterprises of the kind to which
we refer, in order to have a becomingly responsive action
from the men of money and influence who can aid us.
Therefore a large gathering 1s to be expected—members
of the Academy surely, and as many of their friends, male
and female, as can come. The exercises will be interest-
ing, and the addresses, particularly the one on behalf of
the Academy, will be well worth hearing. The following
will be the programme :
Invocation, by the Right Rev. Henry C. Potter, D.D. ;
Address by Ex-President A. Jacobi, M.D. ; Remarks by
the Hon. Grover Cleveland ; Laying of the Corner-stone
by the President, Alfred L. Loomis, M.D. Benediction.
SUCCESS IN PRACTICE,
SIR ANDREW CLARK, one the most successful and dis-
tinguished of English physicians, has recently had a por-
trait of himself presented by the staff of the London
Hospital. In his speech replying to the presentation ad-
dress Sir Andrew gave some account of his life and of
the causes of his professional success. His story deserves
perusal. Sir Andrew was born in Scotland, and went to
346
THE MEDICAL RECORD.
[September 28, 1889
London thirty-six years ago, a young man in delicate
health and without a single friend or influential connec-
.tion. He had, however, a “small patrimony ” and was
‘enabled to pursue the study of pathology and to keep
‘himself quite free from any intrigues or quarrels. He
devoted himself to work, and before many years, despite
ill-health and opposition, he was made physician to Lon-
don Hospital. His subsequent success was slow but con-
tinuous, and was achieved without any definite expecta-
tion at first that it would eventually be so brilliant. Sir
Andrew gave the following as some of the conditions
necessary for success in medicine : |
“ Firstly,” he said, “I believe that every man’s success
is within himself, and must come out of himself. No
true, abiding, and just success can come to any man in
any other way. Secondly, a man must be seriously in
earnest. He must act with singleness of heart and pur-
pose ; he must do with all his might and with all his con-
centration of thought the one thing at the one time which
he is called upon to do. And if some of my young
friends should say here, ‘ I cannot do that—I cannot love
work,’ then I answer that there is a certain remedy, and
it is work. Work in spite of yourself, and make the habit
‘of work, and when the habit of work is formed it will be
transfigured into the love of work; and at last you will
not only abhor idleness but you will have no happiness
out of the work which then you are constrained from
love to do. ‘Thirdly, the man must be charitable, not
censorious—self-effacing, not self-seeking; and he must
try at once to think and to do the best for his rivals and
antagonists that can be done. Fourthly, the man must
believe that labor is life, that successful labor is life and
gladness, and that successful labor, with high aims and
just objects, will bring to him the fullest, truest, and hap-
piest life that can be lived upon the earth.”
THE BRITISH MEDICAL ASSOCIATION DIVIDED.
Tue British Medical Association has been of late years
so continuously prosperous, and so active in every kind of
work pertaining to the interests of the medical profession,
that the announcement of a fatal splitin its ranks awakens
astonishment as well as regret. Yet, if we may believe
the Medical Press and Circular, “ L'affaire Mackenzie
has assumed proportions which threaten the life of the
Association.” Our contemporary goes on to say that
« The party of dissatisfaction has publicly intimated that
unless the Council listens to the representations which it
has made as to the management of the Journal, it will se-
«cede from the organization. ‘The Council has not had
the discretion to recognize that this party includes the
majority of the very best men in the Association, and has
been so undiplomatic as to return a gratuitously curt and
offensive answer to their letter ; there is every reason to
apprehend that the threat of the dissentients will be car-
‘ried into effect without delay, and that the defection will
take with it out of the ranks of the Association most of
those members whose presence has lent éc/a¢ to the meet-
ings.
‘The influence of the party in hostility to the Coun-
cil cannot fail to be vitally injurious to the Association,
and already has had the effect of preventing the annual
meeting from taking place next year in London, as was
intended.”
We incline to think that our esteemed contemporary
takes rather too dark a view of the matter. The extra-
ordinary growth and popularity of the British Medical
Journal has never been a source of unmixed satisfaction
to its rival weeklies, and a split in the Association might
mean, perhaps, a little more even distribution of circula-
tion. If, however, the medical profession of England
allows its strongest and most useful organization to be
wrecked simply because of personal dissatisfaction with
one of its members, it will be a lasting disgrace to our pro-
fession. And it will afford the strongest proof yet offered
that doctors cannot agree, even in trying to promote their
own interests. Indirectly it would also affect our own
Association, which can yet but ill afford discouragements.
NAVUS TREATED BY INJECTION OF ALCOHOL.
THE treatment of nzvus is various, and, if the old rule
holds good, this fact proves that no method of treatment
yet invented is satisfactory in all cases. Dr. Holgate,
(Archives of Pediatrics, June, 1889), describes still another
method, as far as he knows a new one, which has given
satisfaction in the two cases in which it wastned. He
first reviews briefly the best methods heretofore employed.
The compound tincture of iodine is efficacious when ap-
plied to small nzvi, but fails to cure large ones. ‘Tartar
emetic, one part by weight to four of galbanum plaster,
collodion, collodion with corrosive sublimate, and creo-
sote, have all proved satisfactory in some cases. Vacci-
nation on the nevus cures at times, as does also the ap-
plication of caustic potash or of nitric acid, but all of
these leave a scar which may be more unsightly than the
nevus itself. Injection of perchloride of iron has been
successful ; but in a case cited ten minims produced in-
stant death in a child. Setons have wrought cures some-
times, and cure has also followed ligation, after the pass-
ing of pins under the tumor. Excision is too bloody, and
leaves a scar. ‘The passing of a silver wire into the skin
around the nzevus, and out again at the point of entrance,
the wire being then gradually tightened, has cured with-
out leaving a scar. Many other methods have been em-
ployed, one of the best being destruction of the growth by
electrolysis. ‘Ihe objection to this method is that it re-
quires the use of an electric battery and needs consider-
able practice. One of the latest suggestions is to apply
the ethylate of sodium or potassium to the nevus. If the
application is repeated from time to time it will event-
ually effect a cure.
In 1885 Dr. Holgate was requested to remove a pen-
dulous vascular nzevus, situated outside the right ala nasi
of a boy four years of age. It was half the size of a fil-
bert, soft and compressible, but swelling out quickly when
pressure was relaxed. At birth it was a port-wine mark,
level with the skin. It had several times bled profusely
and persistently. Fearing hemorrhage and a resulting
scar, if scarification were used, he determined to try the
injection of ninety-five per cent. alcohol. Applying a
common eyelid-clamp around the base of the growth, to
arrest the circulation, he passed a hypodermic needle
through its centre, longitudinally, near its base, and injected
September 28, 1889]
347
THE MEDICAL RECORD.
from five to seven minims of rectified spirit of wine,
gradually withdrawing the needle as he injected. The
tumor became quite solid. Finding it, a fortnight later,
softer and much shrunken, he now passed the needle into
the growth at a point from which its vessel-supply started.
Six weeks later it was one-eighth its original size. It was
injected again at this time, and a fourth time two months
later.. As the nzvus had become so small, it was quite
difficult on these last two occasions to pass the needle
into the skin. ‘Three years later, when this article was
read, the nzvus had become so reduced and the skin
over it had returned so far toward its normal condition
that an observer would see no difference in the ale
unless his attention were directed to the existence of the
nevi. No treatment was now employed except painting
the spot from time to time with glycerine. ‘There was no
scar, except at the point where it had previously ruptured
spontaneously and bled.
The second patient, a baby, two months old, presented
a nevus on the chest, which was at birth only a port-wine
mark, but had rapidly grown into a vascular nevus nearly
as large as that before described. The growth was en-
circled by a metal ring, and circulation to and from the
part arrested. Alcohol was injected, as in the former
case. But one injection was made, and this not only ar-
rested growth, but caused its disappearance as a tumor.
A month later .it was level with the skin, and three-fifths
of its surface had regained the normal color of the
skin. ‘There was no scar. The part which remained of
a port-wine color spread a little during the next three
months, but another injection or slight scarification would
probably remove all the remnants of the nzevus.
Encircling the growth by a ring is always to be recom-
mended, as it confines the alcohol to the diseased part,
and also makes it act more strongly. By contracting the
vessels beyond the nzevus, it prevents the entrance of clots
into the circulation.
‘The syringe must, of course, be free from air when the
Injection is made. This method has the advantage of
simplicity, and the necessary apparatus is already at hand.
Dr. Holgate thinks that with ordinary care it is safe.
He suggests its use in goitre.
SYPHILIS IN OLD AGE.
‘THERE are few subjects in medicine that can compare
with syphilis in the richness and variety of its literature,
yet singularly enough, the peculiarities of the dissase in
the aged seem to have passed comparatively unnoticed by
syphilographers. ‘Ihe first monograph on the subject
dates back only to 1878, when Sigmund, of Vienna, pub-
lished the results of his study in this field ; and since that
time not more than three or four memoirs, as far as we
know, have appeared. ‘This must be due rather to the
paucity of clinical material than to inattention on the part
of students of syphilis, for the disease, when contracted in
old age, while not remarkably different in its course from
that of the same affection in younger subjects, yet pre-
sents certain modifications which are sufficiently striking
to deserve study.
The latest contribution to the subject of senile syphilis
is presented by Dr. Alexandre Renault, in the Annales de
Dermatologie et de Syphilographie for March, April, and
May, 1889. In this article the author presents a fairly ex-
haustive review of the subject, and points out quite clearly
the modifications imposed upon the course and symptoms
of the disease by the senile changes in the organism. As
might be expected, since the system is already weakened
by the advance of age, and 1s, therefore, less able to com-
bat disease, syphilis is a much more serious matter in the
declining years of life than it is in early manhood.
The differences are apparent even in the course and
duration of the primary sore. The chancre has at first
much the same appearance as that in persons of any age,
but it has a remarkable tendency to ulceration. ‘This is a
point of some importance, since it is liable to lead to an
error in diagnosis, especially if the chancre be extra-geni-
tal, for it may in such case readily be confounded with
epithelioma, which is so common in old age. Cicatriza-
tion is also slow, many months sometimes elapsing before
this process is complete. Another point worthy of notice is
the tardiness in the appearance of adenitis. In the adult this
makes its appearance usually within a fortnight, while in the
aged its development is often a matter of six or seven weeks.
But it is during the secondary period that the peculiar-
ities of senile syphilis are the most striking. ‘The syphi-
litic fever is apt to be quite marked ; indeed, the condition
of the patient at this time is sometimes so grave as to give
occasion to the diagnosis of typhoid fever, or of profound
malarial infection. ‘The syphilides of the secondary
period are distinguished by their tendency to become
confluent, by their obstinacy and resistance to ordinary
therapeutic measures, by the frequency of relapses, and
finally, by a remarkable proneness to assume the charac-
teristics of tertiary eruptions. Cutaneous gummata are
not uncommonly observed at this stage, and in general they
appear much earlier in the aged than in adults. On the
part of the nervous system the disturbances are often
most marked. Disorders of sensation and motion, of the
special senses of sight and hearing, and of the mental
functions are commonly met with at this period. And,
finally, a profound anzemia and a most pronounced ca-
chexia are often seen, and indeed may be regarded as
characteristic of the secondary stage of senile syphilis.
It is often difficult to separate the tertiary from the
secondary lesions of syphilis in the aged, since there may
be no interval of apparent cure between them, the tertiary
accidents supervening directly upon those of the second
stage. The cutaneous lesions of this period are charac-
terized by their more general diffusion over the body, by
a marked propensity to ulcerate, by persistence despite
active treatment, and by a pronounced tendency to relapse
after apparent cure. The nervous symptoms are similar
in character to those seen in adult subjects, but they are
more grave as a rule, and appear much earlier.
We have passed over many points of great interest,
which are dwelt upon by Dr. Renault, owing to the neces-
sity of being brief in our review. But we have drawn
from him sufficiently to show that syphilis in the aged is
an affair of much greater moment than it is ordinarily in
adult life. It seems, indeed, as though nature knew that
the subject of her displeasure had but a short time in
which to pay the penalty of a violation of her laws, and
that she was therefore impatient to crowd all the stages
close together, so that her chastisement, though more
brief, should be proportionately more severe.
THE MEDIC
EXx-SURGEON-GENERAL JOSEPH BEALE, with relative
rank of Commodore, United States Navy, died on Sep-
tember 23d, at his residence in Philadelphia, Pa. Dr.
Beale was born in that city, December 30, 1314, and re-
ceived his classical and medical education in the Univer-
sity of Pennsylvania, from which institution he graduated
in 1836. He practised his profession for one year, at the
end of which period he entered the United States Navy
as Assistant Surgeon, and afterward rose to the position
of Surgeon-General of the Navy, to which he was ap-
pointed in December, 1873. He was placed on the re-
tired list in 1876.
Dr. Curopak, of Vienna, has succeeded the late Pro-
fessor Breisky in the Chair of Obstetrics and Gynecology
at the University of Vienna.
THE COLD-BATH TREATMENT OF ‘TYPHOID FEVER IN
AUSTRALIA.—Dr. Hare, of the Brisbane Hospital, at Syd-
ney, states (Medical Press) that the cold-bath treatment
of typhoid fever has been rigidly applied since July, 1887.
The result has been a reduction of the mortality-rate
from 14.8 to 7 per cent.
Doctors’ Bitts Unpaip.—A controversy has arisen
between Health Commissioner Griffin, of Brooklyn, and
the local Civil Service Commission over the action of the
former in appointing twerty physicians to serve as sani-
tary inspectors during the summer months. They were
selected by the Health Commissioner, and were to get
$2.50 a day each. They put in their bills for eighteen
days’ work during July, and Commissioner Griffin approved
them. ‘They were forwarded to Auditor Rutan, who was
about to audit them, when he received a letter from the
Civil Service Commission ordering him to throw the bills
out, as they were illegal. ‘They were at once returned to
Commissioner Griffin. ‘The trouble lies in the fact that
the appointments of the physicians should have been
made legally from the eligible list of the Civil Service
Commission. The Health Commissioner appointed whom
he chose, and if the young doctors do not get their pay
they may. thank the commissioner.
‘TRYING TO CLOSE A SO-CALLED MEDICAL COLLEGE.—
Dr. L. D. Broughton, President of the New Jersey College
of Medicine and Surgery, whose diplomas the Hudson
County Board of Health refused to recognize a month
ago, has made a complaint to the State Attorney-General,
and asked for a mandamus compelling the Board of
Health to issue certificates to the students who hold di-
plomas. ‘The college is said to have received its charter
in 1870 by a special act of the Legislature. It did not
open a school until 1887, and the first students graduated
from it this year. The counsel to the Board of Health
says that the board must recognize the diplomas issued
by the college, and it was against his advice that the board
acted. Dr. Leonard J. Gordon, president of the board,
says the fact that the college leans to eclecticism had
nothing to do with the board’s action. He says the board
will fight any proceedings the college may bring to com-
pel it to recognize the diplomas.
AL RECORD.
[September 28, 188
THE Jonns Hopkins HOSPITAL : A STATEMENT FROM
PRESIDENT GILMAN.—In view of the reports which have
recently been published respecting the Johns Hopkins
University, President Gilman authorizes the statement
that the university will begin its next year on October 1st
with unimpaired efficiency. Neither the salary of the
president nor those of the professors have been cut down,
and several new appointments have been made. The in-
dications during the summer have pointed to the usual
number of students, and the courses of instruction will be
given as announced in the programme. As to the finances
of the university, it is no secret that the income derived
from the Baltimore & Ohio Railroad was cut off some
time ago, but the accumulated income of former years,
the income from investments outside of the railroad, the
income from tuition (which amounted last year to nearly
$40,000) are available. Besides all this, a number of ger.-
erous persons have subscribed the sum of $108,000 to be
expended as an emergency fund during the next three
years. In addition, a new building, given by Mr. Eugene
Levering, of Baltimore, is now going up. A lectureship
in literature has been endowed by a gift of $20,000. By the
death of John W. McCoy the university inherits at once his
choice library of eight thousand volumes, and is the resic-
uary legatee of his estate. ‘The exact amount to be receivec!
from this source cannot yet be ascertained, but the most
prudent estimates place it above $100,000, exclusive of the
library. This gift is free from conditions. It is safe to
say that within six months the Johns Hopkins University
has received from these various sources nearly $300,000,
and other gifts are expected. The national character of
the institution is a strong reason why its work should re-
ceive important aid from a distance. It will thus be seen
that no consideration need be given to alarming rumors, as
the present efficiency of the university is assured for the
next three years.
Dr. J. Emmet O'BRIEN, OF SCRANTON, Pa.—The
item in a recent issue of THe MEDICAL Recor referring
to an article on “Sensibility of ‘Telegraphers ” should have
given the residence of the author, Dr. O’Brien, as Scran-
ton, Pa., where he has long been one of its leading practi-
tioners.
THE MEDICAL DEPARTMENT OF THE PARIS EXPOSITION.
—In view of the prospect of a World’s Fair being held
in this country in 1892, the medical work of the Paris
Exposition is of interest. Its report for the months of
June and July, has been published. ‘There is, it appears,
a well-organized ambulance system. ‘he stretchers are
always ready to pick up patients, who are then attended
to and conveyed to their own homes or to a hospital.
The following statistics may be found interesting. The
medical service had consumed during the two months of
June and July 2 litres of ether, 20 litres of camphorated
spirits, 60 litres of eau de mélisse (a kind of aromatic
spirits), and 100 litres of carbolic water. Fifty mustard
plasters were applied, and 300 hypodermic injections of
morphia and of cocaine were practised on patients at the
Exhibition. ‘The number of dressings amounted to 1,780,
of which 935 were for visitors. One workman died from
accident ; among the visitors there were six cases of
sudden death. In this period of two months 18 workmen
and 490 visitors were sent to the hospital.
September 28, 1889]
Society Reports,
ASSOCIATION OF AMERICAN PHYSICIANS.
Fourth Annual Meeting, held in the Army Medical Mu-
seum and Library, Washington, D. C., September 18,
19, and 20, 1889.
First Day, WEDNESDAY, SEPTEMBER 18TH— MORNING
SESSION.
"THE Association was called to order at ro A.M., by the
President, Dr. Francis MINOT, of Boston.
The first business was the reading of the President’s
address.
THE PROGRESS OF MEDICINE DURING THE LAST FIFTY
YEARS.
The immediate causes of the great alvancement of
medicine were the growth of physiology and pathology,
including bacteriology, and the improvements in clinical
and laboratory teaching of the present day, which have led
to a better acquaintance with the nature and causes of
disease, to a more rational and successful therapeutics,
and to the prevention by means of hygiene of a large num-
ber of diseases, including some of the most fatal. These
means have been greatly aided by the progress of science
in general, and by the conveniences of modern civilization,
which enable observers from different countries to as-
semble together for interchange of knowledge and experi-
ence. A large share of medical progress is also due to
the dissemination of knowledge by means of well-con-
ducted journals, which enable thousands of practitioners
who cannot leave their homes, to be constantly supplied
with the most recent discoveries relating to pathology and
the diagnosis and treatment of disease. ‘The organization
of this Association is particularly adapted for the progress
of medical science, representing no one section of our
country, but including practitioners from all parts of the
United States and Canada, whose experience, knowledge,
observationy and ability are brought together for com-
parison and for mutual instruction.
The President reported the deaths of the following
members: Drs. H. D. Schmidt, New Orleans ; John C.
Dalton, New York (honorary member) ; Robert Palmer
Howard, Montreal ; and Edward T. Bruen, Philadelphia.
Dr. C. F. FoLsom, of Boston, read a paper entitled
THE EARLY STAGE OF GENERAL PARALYSIS.
The author first reported a number of cases illustrating
the early stage of the disease, in which the motor disturb-
ances were very slight, and might readily be overlooked
and escape detection. ‘The striking loss of muscular con-
trol or power, generally considered a part of the disease,
was not found unul a late period of the disease. ‘The
mental symptoms consist in impairment of a peculiar
_ quality, often so slight as to be made out with difficulty.
The disease arises most commonly under prolonged
strain, particularly when associated with unaccustomed ex-
cesses. At least two-thirds of the general paralytics have
had syphilis. ‘The relation of the disease with syphilis is
too frequent to be accidental. The disease is, however,
not a stage of syphilis, and is not benefited by specific
treatment. ‘The prognosis is probably not so hopeless as
it is generally considered to be. |
The common early treatment is harmful. Foreign
travel is injurious. The only hope of at least partial cure
or marked amelioration is in entire mental and physical
rest.
DISCUSSION.
Dr. RoBertT F. Epes, of Washington, reported the case
of a man suffering now from pronounced general paralysis,
in whom the first symptoms of the disease made their ap-
pearance some twenty years ago. If the anatomical view
of general paralysis is accepted, he did not consider it
THE MEDICAL RECORD.
349
strange that mental symptoms might precede the motor,
depending upon the seat of the lesions.
Dr. S. WEIR MITCHELL, of Philadelphia, was sure that
certain cases of general paralysis began most markedly
with motor trouble, while others began most decisively
with mental conditions. In regard to syphilis, he agreed
with the author, except that he had seen cases due to
syphilitic disease in which cure followed specific treat-
ment. He had also seen cure follow, in a small number
of cases, where the treatment was begun in the early stages,
but whefe the motor disturbance and the mental incapacity
were sufficiently marked to render the diagnosis reason-
ably certain. In all of these cases there had been a total
abandonment of all previous pursuits, with absolute men-
tal and physical rest. He agreed with the author that
foreign travel was often injurious.
Dr. JAMES J. PUTNAM, of Boston, remarked that the
fact that syphilis acts in this disease not by producing a
direct lesion, but in an indirect manner, justifies us in
looking for other causes of degeneration which might act
in a similar manner. He asked if the reader had seen
any cases in which chronic lead-poisoning was the appar-
ent cause of the general paralysis, and related a case in
which the imperfect and slow speech, the imperfect hand-
writing, and the expression of apathy and indifference,
suggested a diagnosis of general paralysis. In this case
there was, however, a history of drinking of water con-
taminated with lead, and there were certain local symp-
toms indicating lead-poisoning.
Dr. WILLIAM PEPPER, of Philadelphia, believed that he
saw these cases from a different stand-point than that of
Dr. Folsom. ‘They come to him as cases of dyspeptic
lithzemic disturbance and the like, and are under his care
for some time before symptoms leading to recognition are
developed, sometimes for years before the paretic symp-
toms appear. He could not regard syphilis as in any way
essential in the causation of general paralysis. In regard
to the early stages of the disease, there was not one symp-
tom mentioned by Dr. Folsom, or described by others as
indicating the early stage, which he did not often find in
cases of nervous lithemia. There may be a grouping of
these symptoms, or a delicacy on the part of the diagnos-
tician, which will enable a finer and finer shade of these
differences to be recognized, which does constitute a basis
of diagnosis. He thought that general paralysis could be
initiated by many disturbing, depressing, or irritating
causes, and that in its early stages and slight degrees it
was capable, not rarely, of being entirely cured. If these
cases are permitted to go on with neglect of hygiene and
with excesses, sexual, alcoholic, or business, a notable pro-
portion will end with symptoms of general paralysis.
Dr. C. F. FoLsom, of Boston, said in regard to lead,
that while he had seen cases in which this agent had pro-
duced symptoms similar to the initial symptoms of gen-
eral paralysis, he had not seen a case in which the
terminal symptoms of general paralysis had been produced.
As illustrating apparent cure after specific treatment, he
referred to a case in which the use of large doses of
iodide of potassium apparently produced complete recov-
ery, and the patient returned to his previous business.
The symptoms after several months reappeared, and have
continued to steadily progress. Whether this is the result
in all such cases, he was unable to say.
Dr. JAMES STEWART, of Montreal, read a paper en-
titled |
TETANY.
The details of the following case were referred to :
The patient, a male, aged forty, has been troubled
during the past eight years with regularly recurring at-
tacks of tetany. He served as a soldier during the
American civil war. Suffered at that time and subse-
quently from chronic dysentery and malarial attacks.
For upward of ten years he has been troubled with diar-
rhœa. Patient is tall, emaciated, and anemic. ‘The first
subjective symptom of his tetany is usually double vision,
350
THE MEDICAL RECORD.
[September 28, 1889
which is quickly followed by characteristic contractions
of the flexor muscles of the hands. Occasionally, the
flexors of the forearms and the adductors of the arms be-
come spastic, muscles of the face almost constantly suf-
fer, muscles of the lower extremities rarely. The affected
muscles are the seat during the attacks of fibrillary twitch-
ing. ‘The attacks often last several days (seven to twelve),
unless terminated by the very free use of morphia.
The galvanic irritability of the nerves is found to be
greatly increased, also the mechanical irritability of both
nerve and muscle. Knee jerks exaggerated during at-
tack, absent in intervals. (Edema of the hands and
arms, with herpetic eruptions, frequently to be seen after
particularly severe attacks. The quantity of urine ex-
creted during attacks is usually normal in amount, and
contains urea and indican in great excess. Patient has
been under observation for more than three years, and it
has been noticed, during the past two years, that he has
been getting gradually dull and apathetic. It takes him a
long time to answer questions, he complains of general
numbness,“ his face and lips are swollen; symptoms
closely resembling those seen in myxcedema.
Tetany may be divided into four varieties :
1. Epidemic or “rheumatic” tetany, common in
Europe, but extremely rare in America. The course is
acute and favorable.
2. Tetany from exhausting causes, as lactation, diar-
rhoea, etc. Course is chronic and favorable.
3- Tetany from removal of the thyroid glands. Course
generally is usually either quickly fatal or chronic and in-
curable. -
4. A form of tetany occurring in cases of dilatation of
the stomach. Very fatal.
Infantile tetany is excluded from above division, as
what is so frequently called tetany in infants is not that
disease. No doubt, true tetany may occur in childhood.
Experimental Tetany.—When the thyroid gland is re-
moved from cats, dogs, or monkeys, a condition very
similar to the typical tetany of the human subject is ob-
served, viz., fibrillary tremors and intermittent spasmodic
contractions. Death usually follows in a week, and no
change can be found to adequately account for it.
The fact that there is a great increase in the electric
irritability of the nerves after the removal of the thyroid
gland is strong evidence of the similarity of the tetany of
man and animals. Of the many forms of muscular con-
tractions seen in man, in none, with perhaps the exception
of cholera, do we find any marked increase of the electric
irritability of the nerves and muscles.
Morbid Anatomy.—No changes that in any way can be
considered characteristic have been described.
Nature of.—All recent observers tend to. confirm the
conclusion of Schiff, that the tetany following removal of
the thyroid gland is directly due to the loss of the gland,
and that the thyroid gland in some way has a direct influ-
ence over the nutrition of the nervous system. It is dif-
ficult to explain how causes so diverse in their operation,
as “rheumatic” influences, diarrhoea, pregnancy, lacta-
tion, and removal of the thyroid, can induce similar symp-
toms. It appears probable that impoverishment of the
nerve-centres is one of the main factors in its production.
Dr. JoHN T. CARPENTER, of Pottsville, Pa., read a pa-
per entitled
TETANY, AND A NEW THEORY OF ITS PATHOLOGY.
The author defined tetany as a nervous disorder accom-
panied by tetanic spasm of an intermittent character,
which may extend from the extremities to the jaw, and
be reproduced during its periods of intermission at will, by
pressure on the track of the affected nerve-trunk, or over
the blood-vessels obstructing the circulation.
A historical review of the disease was given. ‘Tetany
was regarded, not as a special disease, but as a sequel of
precedent phenomena only. ‘The affection was regarded
as the result of septic absorption. The diminution of
cases of tetany, coincident with the successful treatment
and the prevention of septic poisoning, was regarded as an
argument in favor of the connection between septicemia
and tetany. Cases illustrating this view were cited. ‘The
views previously held in regard to the pathology of tetany
were discussed, and considered untenable.
DISCUSSION.
Dr. Francis P. Kinnicutt, of New York: I have
seen but two cases of intermittent tetany, both occurring
in patients with dilatation of the stomach. In one the
dilatation was due to pyloric stricture, resulting from
cancer; in the other there was non-malignant stricture.
In both of these cases the conditions were favorable to ab-
sorption of poisonous matter.
“Dr. F. T Mires, of Baltimore, reported the case of a
young woman, twenty-two years of age. She had suffered
for six or eight years from dilatation of the stomach;
had vomited acid matter, but never offensive ; had several
times had numbness of fingers and toes. She suffered her
first attack of tetany twenty-four hours before her death.
In this case the stomach had never been washed out.
Dr. A. Jacost, of New York, had been struck with the
stress laid by the readers upon sepsis as the cause of tet-
any. In one of the cases reported by Dr. Stuart, which
he thought was due to absorption of putrid material, the
stomach was twisted, and Dr. Jacobi suggested that-the
Intermittent contracture was due to nervous influence, re-
sulting from the twisting, rather than to absorption. He
did not doubt that there were cases in which septic ab-
sorption produced such symptoms, but when we recall the
fact that the contracture is temporary, we must conclude
that the influences giving rise to that attack were also
temporary. Many of these cases are, I think, the result
of nervous irritation. In some of the cases reported, I
shouid attribute the condition to anzmia.
Dr. JAMES J. PUTNAM, of Boston, remarked that the
reported cases of tetany showed such a varicty of infec-
tious sources, that it seemed hardly prubable that they
should act in such a similar manner, unless there was
something else behind. Two or three things are to be
considered: First, the influence of habit—the disease
set up by a variety of causes may continue a$ a result of
habit ; second, the suggestion that in such cases of dis-
ordered action we have to deal with an over-sensitiveness
of physiological arrangement is important. In these con-
ditions we have the disordered manifestation of what is
really a function, but one which is not ordinarily recognized,
as it has no independent existence. It would seem that in
the absence of further knowledge with regard to infec-
tion, and the manner in which this infection, arising from
various sources, may act, we should insist upon the possi-
bilities of explanation which are presented to us by what
we know of the physiology, and disordered physiology, of
the nervous system, in attempting to explain conditiors
met with in this and similar diseases.
Dr. JAMES STEWART, of Montreal, said in connection
with the influence of peripheral irritation, that in the
cases of dilatation of the stomach where tetany had
caused death, the symptoms came on a few hours after
the stomach had been washed out. This would point to
Irritation rather than decomposition as the active cause
in this class of cases. There are many other cases where
infection could not enter.
Dr. Jonn T. CARPENTER, of Pottsville, Pa., said, in re-
gard to anzmia as the cause of tetany, that we should
have to go back of the anzmia to the cause that pro-
duced it. He knew of no cause that would produce
anzemia so surely as septic absorption.
Adjourned.
AFTERNOON SESSION.
Dr. A. B. BALL, of New York, read a paper entitled
THROMBOSIS OF CEREBRAL SINUSES AND VEINS. |
The author first referred to the influence of the following
factors in the production of thrombosis: 1st, blood stasis ;
September 28, 1889] THE
2d, vessel lesions; and 3d, blood changes. ‘The anatom-
ical conditions in the sinuses that favor thrombosis were de-
scribed at length ; and a number of cases cited of marantic
thrombosis of cerebral veins and sinuses in chlorotic girls.
The symptoms were next considered. Much importance
has been attached to distention of external veins collateral
to the internal veins supposed to be affected, giving rise
to hemorrhages and cedema. ‘These signs are frequently
absent, and may be due to other conditions. The mobility
of the symptoms has bcen considered of value. In these
cases the cerebral symptoms undergo strange alternations,
not seen usually in other affections. Active delirium is
exceptional. The depression continues, but alternates
with a certain amount of improvement. Fever is absent
at first, and, if present, is to be attributed to complicating
conditions. Paralytic symptoms, of varying extent, are
usually present. With the exception of the variation in
degree, the paralysis does not differ from paralysis from
other causes.
DISCUSSION.
Dr. WILLIAM OSLER, of Baltimore, exhibited two speci-
mens illustrating the conditions described by Dr. Ball.
The first specimen was one of extensive thrombosis of the
lateral sinus, occurring in a man who died from phleg-
monous erysipelas of the cheek.
symptoms in that case.
The second specimen was from a woman dying of con-
sumption. It was thought that gradually incrcasing coma,
and the onset of cerebral symptoms, were supposed to be
due to basilar meningitis.
Dr. A. Jacosi, of New York, enumerated certain ad-
ditional aiding causes. ‘The first was a disproportion be-
tween the white and red blood-corpuscles. The second
cause was the relative absence of muscular tissue in a
number of the veins. A third cause was absence of water in
the blood, often due to the withholding of sufficient fluid
in the diet of patients. The last cause referred to was
weakness of the heart. When in exhaustive diseases the
heart is allowed to become feeble, thrombosis, with all its
bad results, must be expected. It is certainly a good
therapeutic measure to stimulate and strengthen the heart
in every disease that will last long, or tends to terminate
in exhaustion.
Dr. WiLL1aAM H. WELCH, of Baltimore, said there is
one point of great force in explaining the production of
thrombosis, that is, the possibility that there is some form
of intoxication analogous to that produced experimentally
by various substances, such as the fibrin ferment. Under
such circumstances there is almost instantaneously exten-
sive thrombosis, wherever the ferment reaches. Patholo-
gists are aware of the frequency with which thrombi,
usually of a mixed character, are found in the cerebral
sinuses, particularly the superior longitudinal sinus, in
cases that have presented no symptoms during life.
Dr. SAMUEL C. Busey, of Washington, D. C., read a
paper entitled
THE EFFUSION OF CHYLE AND OF CHYLE-LIKE, MILKY,
FATTY FLUIDS INTO SEROUS CAVITIES.
The object of the paper was to present the subject
of effusion of chyle, chyle-like, and fatty fluids into
serous cavities. It was limited to the effusion of such
fluids into the cavities of the pleura, peritoneum, and
tunica vaginalis. The subject of traumatic injuries of
the absorbent vessels seems to have been peculiarly attrac-
tive to many of the older writers. Ruysch, as early as
1665, drew attention to wounds of the lymphatic vessels.
The reported cases of effusion of chyle and milk-like fluids
into the pleural and peritoneal cavities, including the
doubtful cases, do not exceed forty-three, and these cases
cover a period of one hundred and ninety years. Never-
theless, twenty-three cases of effusion of chyle and chyle-
like fluids into the abdominal cavity have been observed
during the present century—fifteen since 1850, and thir-
teen during the last and present decades. The increasing
frequency of the occurrence is thus clearly shown.
MEDICAL RECORD.
There were no special .
351
Effusion into the Pleural Cavities, Chylo-t thorax.—Of
this, including the doubtful cases, there have been ten
cases reported. In five of these the chyle poured di-
rectly from the thoracic duct. The diagnosis in these
cases can only be made by evacuation and examination of
the fluid. The prominent symptoms are dyspnoea and
accumulation of fluid in one or both cavities. The prog-
nosis is unfavorable and the treatment expectant.
~ Effusion into the Tunica Vaginalis Testis —The case of
galactocele reported by Vidal (de Cassis) seems to have
been the first observation of this class of effusions. In two
of the reported cases the patulous orifices of the vessels
from which the lymph exuded were found. Since 1885
there have been reported in this country thirteen cases in
which filaria were found, and two of these were cases of
lymphocele. It has not been shown, however, that filaria
are present in every case of lymphocele. It is conceivable
that adenitis, gonorrhoeal lymphangitis, or other conditions
which obliterate the permeability of neighboring and con-
necting glands, might cause stasis of lymph and dilatation
and rupture of lymph capillaries and plexuses, with which
the serous membranes are so richly supplied. The opin-
ion of those who have had the best opportunity to study
the relation of filaria to disease in general seems to be
that of Sir Joseph Fayres, that “it has been shown that
disorders of the lymphatic system are most frequently as-
sociated with, if not caused by, the filaria. ‘The recent in-
vasion of portions of the subtropical belt of this country by
the filaria, and the reports of cases of disease with which
the parasite has been so uniformly associated, together
with the fact that the mosquito has been proven to be its
intermediate host, present considerations of the highest 1m-
portance to the profession and general public. Some of
the cases have been cured by injection of iodine, others
have been cured by dissecting back the vessels and tying
the bundle e# masse with a silk ligature.
Chylous and Oily Ascites—A tabulated statement ar-
ranged chronologically, presenting a condensed summary
of the reports of cases of chylous and oily ascites, was
given. ‘The number of cases reported was thirty-three ;
primary rupture occurred in but five cases. Chylous as-
cites may be the secondary result of a variety of morbid
conditions which directly or remotely obstruct the flow of
the chyle through the lacteals, receptaculum, or thoracic
duct, impede its exit into the left subclavian vein, or re-
tard the current of blood in the left subclavian vein,
right side of the heart, or lesser circulation. ‘The relation
of puerperal conditions to the effusion of chyle are not
susceptible of explanation. In five cases the fluid found
in the peritoneal cavity was associated with tuberculosis,
and in four it is stated that the peritoneum was more or
less studded with tubercle. No perforation or rupture of
chyle-conveying vessels was found in any of these cases.
Tne symptomatology of effusion of chyle into the peri-
toneal cavity is not sufficiently distinctive to differentiate
such cases from ordinary ascites, and a diagnosis is only
possible after examination of the evacuated fluid. Of
the thirty-three cases, nineteen died, nine recovered, and
in five the result is not stated. Of the twenty-two cases
of chylous ascites proper, twelve died, five recovered, and
in five the result is not stated. Meagre and unsatisfac-
tory as are the clinical details of these cases, they point
to two conclusions: first, that a free and unobstructed
channel of communication between the venous system
and the chyle-conveying vessels is essential to the
proper nutrition of the body and preservation of life ; and
second, that death following the partial or complete oblit-
eration of this communication is the result of inanition.
In seventeen of the thirty-three tabulated cases, tapping
was practised, and, in most of the cases, repeated several
times. Six of these recovered. In two laparotomy was
resorted to, with recovery of both patients. One was a
case of intact retention cyst, and the other was probably
a ruptured cyst. Asa medical resource, paracentesis is of
questionable value. ‘The treatment is mainly directed to
the prolongation of life. The causative condition may in
most cases some surgical procedure might offer a prospect
of cure. In filarial cases the treatment applicable to such
would be admissible. Sonsina thinks that astringents,
such as gallic acid and tincture of the chloride of iron,
with rest, tonics, and proper alimentation, are useful.
Lancereaux thinks that the parasitic forms of -lymphatic
diseases are curable. He has found mercurial inunction
in the region of the affected gland, in connection with
hydropathy, of service. He suggests the injection of par-
asiticides into the affected glands for the purpose of de-
stroying the female adult worm.
DISCUSSION.
Dr. WILLIAM OSLER, of Baltimore, said that in ordinary
post-mortem work it was not infrequent to meet with va-
rices of the chyle vessels of the mesentery covering the
walls of the intestine. Sometimes there are extravasations
which may form large chylous cysts.
With reference to chyluria, he was positive that there
was a non-parasitic form. He had made thorough exam-
Inations in one such case, and failed to find filaria. On
post-mortem examination nothing was discovered. Also,
in a case of lymph scrotum, he had examined the fluid
and the blood, and had found no embryos. He laid a
great deal of stress upon these cases, as it is generally
stated that these conditions are always parasitic.
Dr. WiıLLiıaM H. WELCH, of Baltimore, exhibited a
specimen of chyle removed from the abdominal cavity of
a boy twelve years of age. He described the chemical
and microscopical characters of the fluid, and dwelt upon
the importance of distinguishing between chylous and fatty
hydrops.
Dr. J. F. A. Apams, of Pittsfield, Mass., read a paper
entitled
SUBSTITUTES FOR OPIUM IN CHRONIC DISEASES.
The disadvantages attending the use of opium are: 1, In
an overdose it is a poison; 2, in ordinary doses its bene-
fits are largely offset by various functional derangements ;
3, its use involves the danger of the opium habit.
Remedies that may be Substituted for Opium for the
Relief of Pain.—The antipyretics—antipyrine, acetanilide,
phenacetine, and exalgine—have well-grounded claims to
be regarded as rivals of opium. ‘They are, however, less
certain and less prompt, particularly when pain is very
violent. Antipyrine, in five- to ten-grain doses, had been
found valuable as an analgesic, particularly in headache,
neuralgia, and rheumatism.
Acetanilide he had found less active than antipyrine ;
he used it in doses of seven or eight grains. He had
found it particularly serviceable in lumbago and dysmen-
orrheea. In the latter condition one or two doses had
afforded prompt relief.
Salicylic acid and its sodium salt should be included on
account of their marked effect ın the relief of pain in
rheumatism, particularly its acute form.
Substitutes for Opium to Induce Sleep.—Paraldehyde is
an excellent hypnotic, although rather uncertain. Hydrate
of amy] is generally preferable to paraldehyde, Leing more
reliable as well as more agreeable. Sulphonal is more
extensively employed than either of the above, and is ap-
plicable to all forms of insomnia.
Chronic Diarrhea.—lIt is probable that no remedy has
been used in this affection so largely as opium. ‘The
effects of this mode of treatment have been far from
satisfactory. Recently the author had treated these cases
antiseptically, with far better results. The remedy chiefly
used has been salicylate in five- to ten-grain doses, three or
four times a day. He had also used salol with success.
We now have remedies which may be used in place of
opium in all chronic affections, where formerly this remedy
was our chief reliance. For producing sleep, and for the
treatment of chronic diarrhoea, we have certain hypnotics
and antiseptics which are not only as efficient, but so
much more satisfactory, that we may practically iay aside
THE MEDICAL RECORD.
[September 28, 1889
gesic opium still stands at the head of the list for prompt-
ness and certainty, but the antipyretics mentioned are
probably capable of replacing it in the majority of chronic
cases, and the relief afforded by these remedies is attended
with less disturbance of the system than that induced by
opium.
DISCUSSION.
Dr. G. M. GARLAND, of Boston, referred to the value
of the fluid extract of gelseminum as a substitute for
opium. In frontal headaches it has an admirable effect.
It is used also with advantage in difficult and painful
menstruation, and certain forms of neuralgia. Asa simple
hypnotic gelseminum answers well in cases of temporary
congestion with insomnia and headache. In hysterical
conditions, this agent will often induce sleep in a short
time. ‘The drug is given in doses of five to ten drops
every half-hour, until the desired effect is obtained, or its
physiological effect is produced in diplopia and plasis.
These appear sufficiently early to serve as a warning.
Dr. IsraEL T. Dana, of Portland, reported two cases
of opium habit occurring in a man and wife. The hus-
band was a young man who had for some time given hypo-
dermic injections of morphia to a patient dying of cancer.
He subsequently broke his leg, and remembering the effect
of the injections in the case of cancer, he tried them on
himself. ‘The result was so exhilarating, and as he “ could
not see why his wife should not have a little of the fun,”
he began giving her the injections, although she was per-
fectly healthy. In this way the habit was induced, and
when admitted to the hospital each one was taking six
grains of morphia daily.
Dr. M. G. Dapiman, who had practised in Asia
Minor and Constantinople, stated that he had never seen
a case of opium habit in his practice in these places.
Dr. D. W. PRENTISS reported a
REMARKABLE CASE OF SLOW PULSE,
ranging from thirteen to forty per minute, continuing for
two years, without organic heart disease, in a man of fiftv-
seven years, in otherwise good health. ‘The cause was
supposed to be tobacco poisoning, the man being an in-
veterate smoker, or malarial poisoning, or perhaps both.
The report was supplemented by a review of such similar
cases as the literature of the subject affords. The prin-
cipal interest in the case turns on the pathology—whether
the slow pulse is due to over-stimulation of the inhibitory
nerve, or to paralysis of the sympathetic, or to lesion in
the nerve-centres. The treatment in the case has been
addressed chiefly to stimulation of the sympathetic. The
patient was presented to the inspection of the Association.
Adjourned.
SECOND Day, ‘THURSDAY, SEPTEMBER 19TH— MORNING
SESSION.
Dr. FREDERICK P. Henry, of Philadelphia, read a
paper on the
RELATION BETWEEN CHLOROSIS, SIMPLE ANAEMIA, AND PER-
NICIOUS ANEMIA.
The discussion of the relation between chlorosis, simple
anzmia, pernicious anæmia, etc., may be divided into
three heads :
1. Are they separate diseases ?
2. Are they of kindred nature ?
3. Are they different stages of one affection ?
Pernicious anzmia is first considered, because the de-
termination of its status is of fundamental importance.
It is admitted by all that the clinical features of this dis-
ease are common to a number of affections, especially
cancer and atrophy of gastric glands ; but those who argue
most forcibly in favor of its independent nature exclude
from the category of pernicious anzemia all cases in which
an anatomical lesion of any organ is found. ‘This appeared
to the author unscientific, for an independent disease is one
September 28, 1889]
which rests upon a constant anatomical basis or is invaria-
bly produced by the same specific agent. Hunter has en-
deavored to establish pernicious anzemia as an independ-
ent disease by the demonstration of an excess of iron in
the liver in cases of that affection. He regards this as
the essential anatomical feature of pernicious anzmia.
The work of Hunter is of great value, and certainly
demonstrates the existence of an excessive hemolysis in
that disease. In the author's opinion, however, this ex-
cessive hemolysis is a consequence of defective hamogen-
esis, for certain facts show the red corpuscles of pernicious
anzemia to be abnormally weak and perishable. Chlorosis
is universally admitted to be due to defective hæmogen-
esis, and therefore he regarded it and pernicious anzmia as
closely related affections. ‘Transitions from the one af-
fection to the other had also been observed by himself
and others.
Conclusions: (1) That pericious anzemia iS a process,
not a disease; (2) that it is closely related to chlorosis ;
(3) that it may be the terminal stage of other diseases,
and especially of cancer of the stomach and atrophy of
the gastric glands.
Leucocythzmia and Hodgkin’s disease, in that they are
always associated ‘with lesions of the blood-making organs
—spleen, lymph-glands, bone-marrow, etc.—are inde-
pendent diseases, or, rather, different stages of the same
disease, for several cases are recorded in which an un-
doubted transition from one to the other has been ob-
served.
Dr. F. FORCHEIMER, co-referee, of Cincinnati, read a
paper entitled
THE RELATIONS OF ANAEMIA TO CHLOROSIS.
The speaker first referred to the confusion which existed
in regard to the definition of the two diseases. Immer-
mann states that we are justified in saying that anemia
is that condition in which there is a diminution of red
corpuscles as well as of the albumins of the plasma in the
blood (hypalbuminosis). Striimpell considered that “ the
essential element in anzemia is therefore a diminution in
the number of red corpuscles or so-called oligocythzemia,”
and states further that “ oligocythzmia is not invariably
accompanied by a diminution in the amount of serum-al-
bumin (by which he means plasma—hypalbuminosis).”
Going on, it is found that anzmia or oligzemia vera really
means a diminution of the quantity of the blood, and that
this condition can be divided into hydreemia, oligocy-
thzemia, oligszemia sicca, and oligeemia hypalbuminosa.
We have three representative definitions ; the one broad
and general, including a diminution of any one or all of
the constituents of the blood ; a second, in which hypal-
buminosis and oligocythemia are the principal, if not the
only, factors ; and a third, which makes oligocythzemia
alone the characteristic feature, From a purely practical
stand-point the latter seems the best.
The same confusion in regard to definition is met with
in a consideration of chlorosis. Duncan (1867) was,
however, probably the first to make the distinctive fea-
ture, oligochromzemia, characteristic for chlorosis—that is,
in chlorosis we find the individual red corpuscle deficient
in hemoglobin. Unfortunately for this definition, the
term chlorosis is to be looked upon as an essentially clin-
ical one ; it is not going too far to state that by far the
great majority of reported cases of chlorosis are not
chlorosis at all. Another difficulty is that both oligocy-
themia and oligochromemia may occur in the same in-
dividual, so that the term chloranzmia is justified by
observation of existing conditions. It is more than prob-
able that anzemia is a forerunner of chlorosis in a great
many instances, and possibly a number of cases occur in
which there is a combination of both conditions.
Almost every cause put down for anzemia will hold good
for chlorosis. Sex, age, a peculiar composition of the
blood, and certain vascular anomalies are held to be es-
pecially characteristic for chlorosis. ‘The two latter are
the only ones to be found in chlorosis. The process of
THE MEDICAL RECORD.
a a ED SE Se E SS SSS = SS SSS A A ES
353
sexual development is looked to as the time of most com-
mon occurrence of chlorosis. This age also produces a
great number of cases of anæmia ; but children and old
people are subject to anzmia and practically excluded
from chlorosis. The greatest number of cases occur be-
tween the ages of fifteen and twenty-five years, decidedly
after the time of first menstruation. Furthermore, an
anzemic constitution is a strong predisposing cause for
chlorosis.
The clinical characteristic of chlorosis lies in the pe-
culiar changes in the blood. In anzmia the red corpus-
cles, as well as the albumins of the plasma, are reduced in
quantity, and frequently there is production of a greater
number of smaller corpuscles (microcytes). As a result of
the reduction of the number of red corpuscles the plasma
is correspondingly reduced in quantity. In pure chlorosis
the number of red corpuscles is not diminished, and a ten-
dency to the production of larger red corpuscles (megalo-
cytes) is especially well-marked. These changes are, how-
ever, not sufficiently characteristic to establish a diagnosis.
It is also found that the amount of plasma in each cor-
puscle is diminished. It has been said that in anæmia
there is always hypalbuminosis, while in chlorosis this is
absent, but this has not yet been positively proven. `
One respect in which chlorosis is said to differ materi-
ally, if not absolutely, from anæmia consists in the patho-
logical changes, first described by Virchow. These are nar-
rowing of the lumen of the aorta and larger arteries as well
as thinning of their walls. The heart is sometimes small,
sometimes hypertrophied. ‘This view would permit us to
state that chlorosis is always congenital, in some cases
latent for years, while anzemia, in most cases, is acquired.
Many objections have been urged against this view.
The relation of the symptoms of anzmia to chlorosis
depends upon the condition of the blood and the anatom-
ical substrata. Given a case of anemia in which there is
only a reduction of plasma as a result of oligocythamia,
and a case of chlorosis in which there is a reduction of
plasma as a result of oligochromemia, and metabolism in
both these cases will be approximately the same ; but if in
anzmia we have oligocythemia as well as hypalbumino-
sis, which is said to coexist in the majority of cases, the
metabolism must bé different from that of a pure case of
oligocythemia. Asa result of reduction of plasma there is
simply reduction in the process of oxidation ; at the same
time the waste products are carried off and sufficient al-
buminous food is carried to the tissues by the plasma of
the blood, which is unchanged. Hypalbuminosis guts
oligocythzemia produce an entirely different result ;
have the same factor, suboxidation, but we have in 2ddi.
tion deficiency of supply. In mild cases of anæmia, there
is procuced a loss of weight ; in severe cases, the condi-
tion called marasmus. In chlorosis very little, if any, loss
of weight occurs ; very frequently the opposite condition
is brought about by too great supply and by the presence
of too much CO,, preventing decomposition of fats.
When anzmia is associated with chlorosis, we have a very
unfortunate combination, especially if there is a great
amount of hypalbuminosis.
Unless we believe that the anatomical lesions of Vir-
chow belong to chlorosis, there exists no difference be-
tween the symptoms of chlorosis and anzmia.
The therapeutic relations of the two diseases must be
considered. While the indiscriminate use of ironin ane-
mia must be deprecated, yet upon the whole iron is just
as much looked upon as a specific in anzemia as in chloro-
sis. Where in anemia we try to remove the cause and
institute causal treatment, we are satisfied in chlorosis
with removing that symptom which is the essential of the
disease. It has been repeatedly demonstrated that the
removal of this essential symptom is followed temporarily
by complete recovery. Whereas, in anzmia, treatment is
followed by complete recovery or complete failure, iron
in chlorosis will always result in amelioration, even if the
tendency to relapse cannot be removed. ‘There are few
cases of chlorosis, even those with the lesions of Virchow,
354
that are not benefited by the administration of iron in
sufficient quantity. In a great many cases of anzmia, the
use of iron would be followed by negative, or by bad, re-
sults.
DISCUSSION.
Dr. WILLIAM OSLER, of Baltimore, took issue with Dr.
Henry in regard to chlorosis. He held that chlorosis is
absolutely distinct from pernicious anzmia, and for the
following reasons: 1. The sex; he had never seen chlo-
rosis in the male. 2. The pathological conditions; he
regarded thus the hyperplasia of the heart and great ves-
sels as a specific anatomical distinction of a certain num-
ber of cases. 3. The characters of the blood; he con-
sidered the diminution of the percentage of hæmoglobin
a distinctive feature of chlorosis. 4. Curability ; al-
though in chlorosis there is a tendency to relapse, each
given attack can be cured if sufficiently large doses of
iron are employed.
Dr. Francis P. Kinnicutt, of New York, agreed with
Dr. Osler as to the lack of relation between chlorosis and
p2micious anemia. He had never seen true chlorosis in
the male. All his cases of pernicious anzmia, on the other
hand, with one or two exceptions, had occurred in males.
"He agreed with Dr. Henry in regard to the relationship be-
tween Hodgkin’s disease and true leukemia. He reported
a case which came under his observation, with typical symp-
toms of Hodgkin’s disease. At this time the proportion
of white corpuscles to red was normal. The spleen and
liver gradually enlarged, and two years later, at the time
of the patient’s death, there was one white corpuscle to
five or six red.
Dr. W. W. JOHNSTON, of Washington, thought that a
study of certain anzmias which are met with in women
will throw light upon the association of anzmia with dis-
eases of the intestinal glands and gastric tubules. ‘The
explanation of the chronic anzmias of parturition is
probably the continued pressure upon the intestinal tube,
causing a long starvation lasting nearly a year. ‘This
seems to produce an actual organic change in the intesti-
nal glands. Several illustrative cases were cited.
Dr. WILLIAM PEPPER, of Philadelphia, agreed with
Dr. Osler in regard to the relation between true anemia
and chlorosis, and progressive pernicious anzemia so called.
He was not prepared to admit the analogy between true
chlorosis and progressive pernicious anemia. ‘The con-
ditions of the blood are widely antagonistic in these two
affections. The clinical differences are also very marked.
In the present state of knowledge it is probably wiser to
consider essential anzemia as an independent affection.
Dr. FREDERICK P. HENRY, of Philadelphia, thought
that the definition of chlorosis given by Dr. Osler could
not be maintained ; that is, that there is always a diminu-
tion of hæmoglobin with a nearly normal number of red
corpuscles. ‘The arguments that he had advanced were
based entirely upon personal observations. While chlo-
rosis is readily relieved by treatment in the early stages,
yet, if it is neglected, the chlorosis may become more
intense and may present the appearances of pernicious
. anzmia.
Dr. S. WEIR MITCHELL, of Philadelphia, read a paper
entitled
SUBJECTIVE FALSE SENSATION OF COLD, CONSIDERED AS
A SYMPTOM.
The speaker had met with many cases where a feeling of
cold is complained of in members which do not present
any objective changes in temperature. ‘These may be
placed in three classes: 1, those due toa central cause ;
2, those due to neuritis; 3, those whose origin is at
present inexplicable, or due to hysteria. A number of
cases exhibiting this symptom to an extreme degree were
reported. In the first case a marked sensation of cold
involving the left side of the body followed an injury to
the head. ‘Three or four cases were referred to coming
in the second class. ‘The sensation of cold involved the
posterior part of the legs, the back, or buttocks. In all
THE MEDICAL RECORD.
[September 28, 1889
these cases there was either neuritis at the time, or it de-
veloped subsequently. When this symptom is noted,
neuritis may be expected. Two cases belonging to the
third group were described. One was an elderly individ-
ual with no sign of hysteria, the other was a case of a
young woman with marked hysterical symptoms.
DISCUSSION.
Dr. JAMES J. Putnam, of Boston, had frequently seen
the coldness spoken of in chronic spinal disease and in
neuritis, and described such a case in a man with chronic
sensory neuritis.
Dr. F. T. Mites, of Baltimore, regarded this sensation
of coldness as a very important symptom of neuritis, and
reported a case associated with acute neuritis of the ulnar
nerves.
Dr. G. M. GARLAND, of Boston, read a paper on
GASTRIC NEURASTHENIA.
_The author first reviewed Leube’s observations on dys-
pepsia nervosa, and presented a category of the gastric
neuroses. A case of anorexia nervosa occurring in a
woman sixty-three years of age was reported. The wo-
man was of feeble constitution. She digested her food
without consciousness of the process, and her bodily func-
tions were practically normal in every way, except that
she suffered from anorexia. ‘Three cases of vomitus ner-
vosus were then reported.
Case I.—Miss S began, at the age of two years, to
have certain attacks of vomiting. These recurred at cer-
tain intervals until the time of her death. The attacks
lasted twenty-four hours, and it required a week for the
child to recover her strength. At the age of twenty she
began to have excessive muscular twitchings with the at-
tacks. Two years later she began to have severe headaches.
‘These gradually merged into one steady ache. January 1,
1884, the author saw the patient suffering from intense
headache and slight twitching of arms and legs. Vom-
iting appeared the next day, causing intense burning of the
throat from the intensely acid character of the matters
vomited. After four days she gradually improved, and
entirely recovered.
November 12, 1884.—The patient was again seized with
headache. November 15th.—Vomiting and twitching be-
gan. She gradually improved until . December 2d, when
all the symptoms returned and continued until her death,
December 13th. Urine was normal until a few days be-
fore death, when it contained a trace of albumen, but no
casts. At the autopsy no marked organic change was
found in any part of the body.
Case II.—Miss S—, aged twenty-two, first seen Sep-
tember 19, 1888. She was in bed with headache, poor
appetite, constipation, and weakness. Pulse, temperature,
and urine normal ; some nausea. Vomiting appeared in
a few days. She was fed exclusively by the rectum for
three weeks, but the vomiting persisted, and there was se-
vere burning along the entire œsophagus. At times the
urine was scanty, but never contained albumen. She
gradually improved, but is not as strong as before her ill-
ness.
Case III.—Miss D , aged forty-three, had been
subject to bilious headaches. During the summer of 1388
she had a severe attack of vomiting, and she was very ill
for several weeks. During the following September, as a
result of anxiety, her appetite left her and the nausea re-
turned. She, however, did not vomit.
The conclusions drawn from the above cases were : 1.
All the women have been of dark complexion. 2. They
have not been of the so-called hysterical temperament. 3.
Feeding by the mouth was abandoned in every case, and
rectal enemata were necessary. 4. None of the drugs usu-
ally potent in soothing a nauseated stomach were of any
avail. Morphia subcutaneously was the only remedy that
was of benefit. 5. ‘The vomitus caused great discomfort
along the throat, and in one case caused severe glossitis.
In connection with the hyper-acidity, he referred to certain
September 28, 1889]
cases of acid vomiting described by Rossbach, and desig-
nated nervose gastroxynsis. The acidity of these cases
depends upon excessive secretion of hydrochloric acid,
and is independent of the presence of food in the stom-
ach.
Adjourned.
AFTERNOON SESSION.
The discussion of Dr. Garland’s paper was taken up.
Dr. S. WEIR MITCHELL, of Philadelphia, said that in
all cases of neurasthenia, where there are great complaints
of gastric and intestinal difficulty, the presence of hypo-
chondnacal conditions must constantly be considered. It
is rare for grave cases of neurasthenia to present them-
selves without some abdominal symptoms. In regard to
anorexia nervosa, he thought that in the majority of cases
a background of hysteria would be found. It is suspic-
ious that this condition is never seen in men.
Dr. WILLIAM PEPPER, of Philadelphia, asked in what
respects, other than the invariable and extreme acidity of,
the matters vomited, these cases differ from those that
have been descnbed under the head of cyclic and recur-
rent vomiting. He had seen many such cases and some
like the fatal case reported. In some of the cases the
vomited matters were extremely acid. He had had these
matters examined chemically with the hope of finding
some leucomaine, but so far with negative results. In re-
gard to treatment the only remedy that had been of bene-
fit had been antipyrine. In one or two cases this has ap-
parently stopped the attacks.
Dr. W. F. WHITNEY, of Boston, presented specimens
from two cases of cretinism.
Dr. Jonn H. Musser, of Philadelphia, read a paper
entitled
PRIMARY CANCER OF THE GALL-BLADDER AND DUCTS.
The speaker, after describing two cases of this affection
that had come under his observation, reviewed the cases
that had been reported and presented the following con-
clusions :
Primary cancer of the gall-bladder is not so rare as is
generally believed. It occurs in the female nearly three
times as often as in the male. A large number, fifty-seven
per cent., of the cases occur under the age of sixty. Gall-
stones are an exciting cause, especially in persons predis-
posed to the affection. ‘The organ is generally not much
enlarged, save as the result of secondary processes. Me-
tastasis is not wide-spread. By continuity of structure
neighboring organs are involved. Adhesions to adjacent
organs, with ulceration and perforation, are not uncom-
mon. Pain, jaundice, and the presence of a tumor are
the most common phenomena. With them are asso-
ciated cachexia, vomiting, constipation, diarrhoea, and
ascites. Pain was present in sixty-two per cent. of the
cases, at first ill-defined, then becoming localized to the
right hypochondrium, and lancinating in character.
Jaundice was present in sixty nine per cent., gradually
increasing in degree. In some cases, however, it was
intermittent. Tumor was noted in sixty-three per cent.
The tumor was hard, firm, painful, and generally movable
with respiration. ‘The progress of the disease is always
continuous. Some extraordinary cases are reported in
which there was temporary cessation in the progress of
the disease. Death results from exhaustion, frequently
from peritonitis, in some cases from metastasis to other
organs, in some from biliary obstruction. In eight cases
death was due to cholemia. ‘The duration of the disease
is short, the average being six and two-third months. The
progress is rapid after complete occlusion of the biliary
passages, or evidence of inflammation of the biliary passages
has developed.
Dr. Henry Forman, of Philadelphia, read a paper on
THE ANATOMICAL AND PHYSIOLOGICAL RELATIONS OF
LESIONS OF THE HEART AND KIDNEYS.
“The paper was based upon the post-mortem study of three
hundred cases, observed in public and private practice.
THE MEDICAL RECORD.
355
Dr. P. G. RosBinson, of St. Louis, read a paper entitled
THE CONTAGIUM OF DIPHTHERIA.
The subject 1s one which merits our most earnest and
continued study, because of the prominent place it occu-
pies among the prevailing causes of annual mortality, and
because of the diversity of opinion which is entertained
in regard to its etiology, pathology, and treatment. The
disease has become familiar to the practitioner only within
the last generation, although traced historically to a very
remote period. It prevails very generally throughout this
continent, and constitutes one of the chief and most con-
stant causes of mortality, which amounts to nearly one
hundred and twenty five per thousand of the population
of the United States, and of cases reported the percent-
age of deaths is from thirty to thirty-five.
Diphtheria is an acute infectious disease, doubtless due
to a living organism (microbe) the exact identity of which
cannot yet be regarded as settled. Primarily a local af-
fection, the system becomes secondarily and generally in-
fected through absorption of a poison generated at the
primary and localized seat of moculation. ‘The modes of
infection are numerous, the contagium being directly
transferred by contact, in a dry state, through the air for
limited distances, in foul clothing, in polluted food and
drink, milk probably being a prolific source of infec-
tion.
‘The most difficult problem to solve is that which re-
lates to the conditions most favorable to the growth and
development of the germs and the propagation of the
disease.
While, strictly speaking, diphtheria can hardly be called
a filth-disease, since it prevails often to a very limited ex-
tent in those localities whose hygienic surroundings are
apparently the worst, yet certain kinds of filthy accumula-
tions, as the ordure of animals, notably the refuse from
cow-sheds and dairies, seem to furnish the most favorable
conditions for the culture of this particular germ. Until
this problem can be solved and the life-history and habi-
tat of the diphtheritic germ is understood, no definite
plan can be formulated for the arrest of the contagion
nor for the hopeful treatment of the disease.
Adjourned
THIRD Day, FRIDAY, SEPTEMBER 20TH—MORNING SES-
SION.
‘The following officers were elected :
President—S. C. Busey, of Washington; First Vice-
President—William Pepper, of Philadelphia; Second Vice-
President—Henry U. Lyman, of Chicago; Recorder —i.
Minis Hays, of Philadelphia; Secrefary— Henry Hun, of
Albany; Zreasurer—W. W. Johnston, of Washington ;
Member of Council—G. Baumgarten, of St. Louis; Rep-
resentative on Executive Committee of Congress of Ameri-
can Physiciaus and Surgeons—William Pepper, of Phila-
delphia.
MEMBERS ELECTED.
William G. ‘Thompson, William H. Thomson, J. West
Roosevelt, of New York; Charles Carey, Charles G.
Stockton, of Buffalo; Victor C. Vaughn, Heneage Gibbes,
of Ann Arbor; Charles W. Purdy, of Chicago ; Starling
Loving, of Columbus, O.; W. H. Geddings, of Aiken, S.
C.; William C. Dabney, of Charlottesville, Va.; B. F.
Westbrook, of Brooklyn; Henry P. Walcott, of Cam-
bridge, Mass.
The date of the next meeting to be between May 20,
and June 15, 1890.
Dr. JAMES J. Putnam, of Boston, read a paper entitled
A SUPPLEMENTARY INQUIRY INTO THE FREQUENCY WITH
WHICH LEAD IS FOUND IN THE URINE.
The paper embodied further researches as to the fre-
quency with which traces of lead are found in the urine
of persons in good health, or not presenting the classical
symptoms of lead-poisoning ; and discussed the propriety
356
THE MEDICAL RECORD.
[September 28, 1889
of enlarging our clinical conception of that disease. A
table was shown, in which the results of the present in-
vestigation were combined with those reported upon two
years ago, which may be summarized as follows: The
urines of sixty-eight persons, either presenting no symp-
toms (healthy medical students) or only symptoms of
specific or local disease (phthisis, pleurisy, local injuries,
etc.), were found by Dr. A. M. Comey and Dr. C. P.
Worcester to contain lead in the proportion .of about
seventeen per cent.; while those of another group of one
hundred and twenty-five persons, presenting various symp-
toms of disease, such as it was thought might possibly be
due in part to lead-poisoning, contained lead in the pro-
portion of fifty per cent. ‘The largest sub-group of this
latter class embraced thirty-six cases, not strictly homo-
geneous, but made up of chronic or subchronic affections
of the spinal cord and peripheral nerves. One (typical)
fatal case of this sub-group was analyzed at some length,
and the results of the microscopic examination of the
spinal cord and nerves were reported upon. ‘The case
was that of a carriage-painter, who suffered for some
years with progressive anzmia and general emaciation,
and for the two years preceding his death with weakuess,
paresthesia, and impairment of sensibility, with exag-
gerated tendon reflexes and extensor spasm, increasing
finally to complete paraplegia. Lead had been found in
the urine three times, but the patient had never presented
“a blue line,” characteristic of paralysis, encephalopathic
symptoms, or colic, though the bowels had been obstinately
constipated for years. ‘The morbid changes found after
death, besides the signs of general anzemia, were those of
combined antero-posterior and lateral sclerosis of the cord,
on which at the last, a subacute process of diffuse de-
structive softening had engrafted itself.
This latter process, which was characterized by the
presence of a dense infiltration of granule-cells, and by a
breaking down of the nerve-tubes, so as to form round or
oval cavities, such as have often been described, extended
throughout the length of the cord, occupying the position
of the sclerosed system tracts and the adjoining tissue.
The nerve-roots were affected, though to a less degrce
than the cord ; the posterior much more than the anterior.
The acuter process was at its height in the dorsal region.
The gray matter was also affected, apparently in propor-
tion to the severity of the secondary acute change, #.c.,
most severely in the dorsal region. The smaller arteries
were here and there thickened. ‘The peripheral nerves
were degenerated, but only to a moderate degree.
_ It was not assumed that these changes in the cord were
due to lead as a specific poison, though at the same time
the evidence is that such myelitic changes as lead does
set up are diffuse in character and not co-ordinated with
the typical peripheral nerve-degeneration. It was, how-
ever, thought more probable, in view of the circumstance
under which such pathological processes had been seen in
other cases, that the lead acted, if at all, by inducing a
general and—through the thickening of the vessels—a
local anzemia, thus intensifying the effects of other influ-
ences, of which one might be an hereditary tendency.
Another case was cited to show that lead in drinking-water
may cause outbreaks of acute indigestion in children, while
other children exposed to the same influences may be
wholly unaffected.
A number of observations made on Boston drinking-
water, by Dr. E. M. Greene, were reported, showing the
frequency with which lead is present and the length of
time required to wholly rid a pipe of its presence.
Harorp C. ERNST, of Jamaica Plain, Mass., read a
paper entitled
HOW FAR MAY A COW BE TUBERCULOUS BEFORE THE
MILK BECOMES DANGEROUS AS A FOOD SUPPLY.
The observations which he reported were made at the
instance of the Massachusetts Society for the promotion
of Agriculture. The surroundings of the animals and food
were prepared in the most careful manner. One hundred
and fourteen samples of milk were examined for the
bacillus. These were obtained from thirty-six cows,
suffering with tuberculosis of some organ other than the
udder. Seventeen samples were found to contain tuber-
cle bacilli. These seventeen specimens came from ten
cows. ‘The cream was found to contain bacilli as often
as the milk. The bacilli were present with a fair degree
of constancy.
Well animals were then inoculated, with the result of
inducing the disease in fifty per cent. of the cases treated.
Feeding experiments were also made with the result of in-
ducing the disease in a number of calves and young pigs.
The following conclusions were presented: 1, and em-
phatically, that milk from cows affected with tuberculosis
in any part of the body may contain the virus of the dis-
ease. 2. That the virus is present whether there is dis-
ease of the udder or not. 3. That there is no ground
for the assertion that there must be a lesion of the udder
before the milk can contain the infection of tuberculosis.
4. That, on the contrary, the bacilli of tuberculosis are
present, and centre in a very large proportion of cases in
the milk of cows affected with tuberculosis, but with no
discoverable lesion of the udder.
Dr. E. N. WHITTIN, of Boston, read by title a paper
on
PRIMARY CANCER OF THE DUODENUM.
Dr. WILLIAM OSLER, of Baltimore, exhibited a patient
showing anzesthesia the result of lesions of the cauda
equina.
Dr. E. L. TRUDEAU, of Saranac Lake, read a paper
entitled
HOT-AIR INHALATIONS IN PULMONARY TUBERCULOSIS.
The paper presented a brief clinical history of four cases
treated during periods varying from one -to four months
by Weigert’s method. This was considered as secondary,
and only as a basis for the bacteriological study, which is
left to answer the claim of specificity made for the method.
‘The question to be answered is whether breathing of hot
air can prevent the growth of the tubercle bacillus in the
lungs of living individuals. ‘The clinical evidence ob-
tained brings out no positive proof in favor of the treat-
ment. From the bacteriological research the following
notes are made: In all the cases the bacillus which was
present before the treatment remained in the sputum, and
no effect was produced upon that important element of
the disease. The claim of diminished virulence was tested
by inoculations made on rabbits before, during, and after
the treatment. ‘The sputum of one of the patients, who
improved, was found fifteen weeks after the uninterrupted
daily breathing of hot air to produce tuberculosis in the
animals injected, as promptly and to a similar extent as
that injected before the treatment had been instituted.
Conclustons.—1. The therapeutic value of hot-air inhala-
tions in phthisis is doubtful. 2. The evidence obtained
by bacteriological study of the cases recorded does not
confirm the assumption that inhalations of heated air can
either prevent the growth of the tubercle bacillus in the
lungs of living individuals or diminish the virulence of this
microbe when it has gained access to them.
Adjourned.
Se
A CENTENARIAN SURGEON.— The Patria of Buenos
Ayres affirms that there is now in Bolivia a surgeon, Luca
Silva by name, whose age is not less than one hundred
and twenty-nine years. He was born in Cochabamba, in
1760, and devoted himself, after graduating in medicine,
to the practice of surgery. He rendered important ser-
vice tv his country, when, after the famous manifesto of
June 16, 1809, she entered on her struggle for inde-
pendence. His treatment of the wounded, particularly
his operations on the field of battle, won him high distinc-
tion. He also earned signal honor in the combatant
ranks.
September 28, 1889]
THE MEDICAL RECORD.
357
BRITISH MEDICAL ASSOCIATION.
fifty-seventh Annual Meeting, held at Leeds, England,
August 13, 14, 15, and 16, 1889.
(Special Report for Tue Mepicat Recor.)
(Continued from page 33>.)
SECTION OF MEDICINE,
FRIDAY, AUGUST 16TH—THIRD Day.
THE proceedings of the Medical Section on Friday com-
menced by a paper by Dr. RurFrer (Panis Institute of M.
Pasteur),
ON THE PREVENTION OF HYDROPHOBIA BY PASTEUR'S
METHOD.
Dr. Eppison, of Leeds, presided, and before calling
on Dr. Ruffer to read his paper observed that he had for
some time believed that it was useless to send hydrophobia
patients to Pasteur. He had, however, gradually been
compelled to change his mind on this point, as evidence
became clear in the direction of this operation.
Dr. RuFFER said that the disease hydrophobia had ex-
cited immense interest ever since the days of Aristotle.
lt was not a common disease, and many men of great
medical experience had never seen a single case of it.
The fact that a person bitten by a rabid dog was in dan-
ger of his life for a whole year was what made the disease
such a terrible one, for hitherto there had been no chance
of curing the patient when once attacked with symptoms
of the malady. In 1885, in the month of November, M.
Pasteur first stated that he could prevent hydrophobia in
dogs, after they had been bitten, and this announcement
was speedily followed by the treatment of human beings
by this process which had proved successful in the case
of dogs, and at the present time more than twenty estab-
lishments existed in Europe, and throughout the world, to
carry out Pasteur’s process. Hydrophobia was a specific
infectious disease, which never, as far as was known, orig-
inated de novo! Unfortunately in this case, up to this
date, no micro-organism had been seen which caused the
i Experimentally, it had been found that inocu-
lations in all parts of the body with the virus of rabies
had power to produce the disease ; but it was only when
the virus was deposited beneath the dura mater, that the
disease inevitably followed such insertion of it. It was
found in the treatment by Pasteur’s inoculation processes
that abscesses never followed the inoculations, With re-
gard to the incubation period of rabies, it was found that
twenty per cent. of patients who succumbed to the disease
died within a month after the bite, ninety per cent. died
before the end of four months, and only a very small
minority had an incubation of anything like a year. ‘The
- longest incubation period he had been able to hear of was
one where the patient succumbed fifteen months after the
bite. ‘The shortest incubation on record was thirteen days
after the bite. l
The second stage in the attack was the convulsive stage.
Hydrophobia was a bad name for the disease, since the
symptom of aversion to drink might be absent throughout
the whole course of the disease. In dogs this symptom
was usually absent. In rabbits there was no agitation,
but simply paralysis seen. Some human beings died of
the paralytic form of the disease, and Dr. Gamaleia had
narrated twenty cases of death occurring in Odessa from
this paralytic form of rabies, which was now known to be
a far more frequent form of the disease than was former-
ly supposed. Hydrophobia or rabies was always fatal in
man, but not quite so uniformly fatal in dogs. Thus M.
Pasteur found one dog out of three which he inoculated
with rabies which nad only a mild attack of rabies, and
then recovered completely, and was then quite safe
against all inoculations after that event. Ifa rabbit be
inoculated by a rabid dog’s virus, that rabbit would die in
eighteen days, but if a piece of the spinal cord of that
rabbit were inoculated under the dura mater of a second
rabbit, it would die in fourteen days; a third rabbit
treated from the second rabbit would take the disease on
the ninth day, and at length rabbits inoculated under the
dura mater would take the disease invariably on the sixth
or seventh day, and die on the tenth day. This was the
so-called “fixed” virus of M. Pasteur, and was uniform
in its strength for years if inoculations were carried on
uninterruptedly on fresh rabbits. If the spinal cord of
such animals, after death, were hung up in a dry sterilized -
bottle, the virus gradually, and in eleven days, lost its
virulence. If a piece of such an exhausted spinal cord
were injected into an animal, the poison of the special
microbe was injected into that animal. In the case of
the yeast-plant, it died when it had produced a certain
quantity of alcohol and carbonic acid in any medium ;
and all germs produced certain poisons in which they
could not exist if there were much of them. If the
germ of malignant cedema were cultivated in beet-tea,
and if the sterilized fluid were injected into a guinea pig,
and then into a dog, the dog would die ; but if the poison
of the germ were injected beforehand, the dog would be
safe. ‘The animals were then said to be “ vaccinated”
against that virus. ‘This was the explanation of the way
in which the Pasteurian treatment of hydrophobia suc-
ceeded in preventing the outbreak of the fatal symptoms
of the disease.
Pasteur had two treatments which he made use of at
present in treating rabies in patients. ‘The first was the
simple method, the second was the intensive method. If
the cord of thirteen or fourteen days were injected sub-
cutaneously nothing but vaccinatory matter was injected,
and after this if a few of the germs were injected along
with this substance it was possible gradually to arrive at
injections with the virus of the second or third day, when
the patient was rendered unsusceptible to the effects of
the virus of the dog-bite. The simple treatment lasted
fifteen days, and on the first day the patient was inocu-
lated with the cord of the fourteenth and thirteenth day,
and so on, two injections being made daily for fifteen
days. ‘The intensive treatment was had recourse to for
bites about the face, for in such cases an incubation of
only thirteen days occasionally occurred. Here a large
quantity of vaccinatory substance had to be injected
quickly and repeatedly, and four injections were made
daily for twenty days, two days’ rest being given, after in-
jecting a certain number of times, followed by resumption
of inoculation until, in all, twenty days’ inoculation were
given. |
Pasteur never injected the virus of the first or second
day. As to the details of the operation, the occurrence
of erysipelas was avoided by sterilizing the subcutaneous
injecting needles by dipping them into boiling oil before
using them. All of the injections were made in the ab-
domen, and no evil effects ever followed these injections.
Supposing that a patient were bitten by a rabid dog,
would he have a better chance after Pasteur’s inocula-
tions, than if he had not been treated at all? This re-
quired the consultation of statistics before and after this
treatment had come into vogue. ‘Lhe statistics before the
Pasteur process was invented were as follows: In Wur-
temberg, nineteen per cent. of all patients bitten by rabid
dogs or cats had died, and twenty-one per cent of those
similarly bitten in Paris. ‘The best statistics were those
of Leblanc, who found that 15.9 of all persons bitten by
rabid animals had died of the disease. All other statistics
cited showed too high a percentage ; but fifteen per cent.
might be looked upon as pretty near the truth. As to
bites of rabid wolves, the statistics published gave a
mortality of from sixty to sixty-four per cent. after these ;
but, in many cases, the percentage was still higher. Thus
Menchikoff, of Odessa, mentioned that a rabid wolf bit
thirty-five men and twenty-three women, and that twenty
four of the men died and fifteen of the women. Seventy-
seven per cent. of the cases had died. But of people
bitten in the face by such wolves, eighty-eight per cent.
were said to have died. Leblanc’s tables give a mortality
in wolf-bites of this character of eighty per cent.
358
As to the statistics of Pasteur’s laboratory, the cases
were divided into three groups. In the first group were
those patients who had been bitten by dogs found to be
mad by the examination of their brain,in the second the
eases where the dog was certified to be mad by veterinary
officers, and in the third were the cases where the dogs were
reputed to be rabid. The result of the statistics up to the
- present date was that there was a percentage of 1.4 deaths
among persons bitten in the first group, and of .58 in the
cases when the dog was not supposed to be mad. When
the simple treatment was still used the mortality in cases
of bites on the hand and face by rabid dogs was 4.83;
but since the intensive treatment had been applied, fifty
cases bitten on the face and head had been treated with-
out a single death. The percentage of deaths after bites
on the hand had been 1.22 percent. In other countries
the statistics were also very favorable. In St. Peters-
burg, from 1886 to 1888, the mortality had been 2 per
cent. of all treated by Pasteur’s process. In Odessa,
where this simple treatment was applied the death-rate
was 3 per cent. When the intensive treatment was ap-
plied, in 1887, it was only .58 per cent. and in 1888 .6 per
cent. Lately, of twenty-six cases treated there one child
aged seven died, although all the patients had been ter-
nbly bitten by wolves, and one of them had thirty deep
wounds. In Moscow, in 1888, the mortality was only 1
per cent. In Varsovie a medical man, a pupil of Dr.
Koch, and at one time opposed to the preventive treat-
ment, had treated three hundred and seventy persons by
it and they had all escaped. In Italy, at Turin, the per-
centage had fallen to .56 and in Naples Dr. Cantani re-
ported a mortality of from o to 1 per cent. Pasteur'’s sta-
tistics up to 1887 showed a total mortality of 1.37 per
cent. Of 1,501 patients bitten by dogs proved to be
rabid there was a mortality at first of 1.52 which, after-
ward fell to .95 per cent. andin 1888 to .55 percent. It
had been asserted that, instead of preventing hydrophobia,
Pasteur’s inoculations had caused a certain number of
deaths from the disease. This was a complete error. No
such case had been seen, whereas numbers of the assist-
ants in the Pasteur Institute and of the pupils of Pasteur
in foreign countries had such confidence in the process
that they had inoculated themselves preventively, because,
being constantly inthe midst of the redoubtable poison,
they considered it important to “ vaccinate” themselvesin
case of accidental inoculation of the parts. And when
it was alleged that the cases which had died after Pasteur’s
inoculations had been of the paralytic type this was not
of any importance, as that type was every now and then
seen in the course of the natural history of the disease.
Dr. Eppison, of Leeds, in opening the discussion, said
that in Leeds there had been two great epidemics of hy-
drophobia, or rather of rabies, the latter of which names
was far the most scientific. He had seen many cases of
the disease in the Leeds Hospital, i.e., at least twenty.
Some persons would have it that there was no such dis-
ease, and a great teacher in Leeds taught this erroneous
doctrine for many years, and confused many of his pupils
by so doing. He asked Dr. Ruffer whether in the case
when one dog recovered after inoculation of rabies, it was
reinoculated with the same virus or not. Were wolf-bites
worse because the animal was in the height of its disease
and thus bold enough to enter villages. In criticising the
results of Pasteur’s treatment, this should be done as was
done in criticising the results of treatment by any surgical
operation or poison. In such cases it was not said that
the patient died of the treatment, but the aim was to find
how many persons were saved by it.
A MEMBER said he lived in Hertfordshire, and had re-
cently sent a boy to Pasteur’s Institute who had been bit-
ten by a mad dog in his neighborhood. He had also vis-
ited the Institute and seen one hundred and fifty persons
under treatment.
BRIGADE-SURGEON Dwyer (Malta) said that it was
not necessary to go to any great expense in setting up a
Pasteur Institute in any locality. Thus, in Malta last
THE MEDICAL RECORD.
[September 28, 1889
year, aman was bitten by a rabid dog and the Maltese
government at once established a small locale for the in-
oculation of rabbits after Pasteur’s process. This cost
annually only between £200 or £300 or at most £400.
The rabbits were regularly inoculated, but as yet he did
not know that any other cases had arisen in Malta. He
was in the Mauritius for some years and there there was
a great deal of the disease rabies. In the Island of
Bourbon, on the other hand, which belongs to France, no
cases of rabies had as yet been seen, as strict quarantine
on dogs was obligatory on that island. He was not quite
content with the statistics sent from Russia, because in
that country there was but little public opinion, and it
must be remembered that the laboratories there were car-
ried on by private medical men whose interest it was to
make the most of the statistics.
Dr. C. R. DRYSDALE, of London, said he had first visited
the Pasteur Institute in 1886, and had since then visited
it every year. He had read also all the literature of
the subject, and studied it assiduously, and hence he con-
sidered himself able to come to a conclusion. That con-
clusion was that M. Pasteur had completely proved his
assertions, and that he had made the greatest advance in
therapeutics which had been made since the days of Dr.
Edward Jenner. ‘The statistical proof, although most
valuable, was not the proof that had convinced him. Jen-
ner’s proof of the importance of vaccination was shown
by the fact that he used to vaccinate persons, and then
inoculated them in a month or two afterward with small-
pox pus, and these cases did not take variola. In the
same way M. Pasteur had inoculated forty dogs prevent-
ively, and then injected strong virus into their crania, and
yet the disease was not produced. It was this experiment
that convinced M. Graucher and other Parisian physicians,
and made them apply to Pasteur to treat a case of rabies
in a boy in 1885. The statistics so admirably given by
Dr. Ruffer were a splendid confirmation of the induction
made by the greatest of all modern experimenters on
virulent diseases, and it required either an amount of in-
dolence of mind or a great amount of obstinacy for any-
one of intelligence, who had studied the facts, to reject
the conclusions come to in Dr. Ruffers paper. He an-
swered the question, Ought a person bitten by a rabid
dog to put himself under the process discovered by Pas-
teur? in the following way. Yes! without an hour’s de-
lay : because all delay was dangerous, since the incuba-
tion of rabies was sometimes under a fortnight. The
process was perfectly innocuous even to persons who had
no disease, which was found by the great number of gentle-
men connected with the Parisian and other similar estab-
lishments, who had been preventively inoculated without
a minute’s ill health or any suffering being caused, except the
prick of the injection-needle, which in no case ever caused .
suppuration, erysipelas, or any mischief whatever. It was
absurd to exclaim against treatment which was so pleasant,
so rapid, and so perfectly safe. All who had visited the
Pasteur Institute would, he was sure, join with him in the
admiration he felt for the staff, both medical and lay, of
the establishment. The care, incessant watchfulness, pa-
tience, and attention shown by M. Pasteur and his fnends
to the patients was worthy of the warmest eulogiums from
all lovers of therapeutics, ‘and he only regretted that the
discovery made by Pasteur had been made by a gentleman
who was not a member of the profession of medicine. It
was time that the audacious falsehood of that envious
party in this country, which was composed of anti-vac-
cinators, social purists, and anti-vivisectionists, should be
silenced by the unstinted gratitude of the whole of the
medical fraternity of English-speaking nations, and that
the name of Pasteur should become enshrined in the hearts
of all lovers of human health and happiness.
Dr. Saunpsy, of Birmingham, said that he was not
ready to adopt the enthusiastic tone in which Dr. Drys-
dale spoke of Pasteur’s discoveries. He thought that en-
thusiasm was dangerous, and that it was well to keep the
mind cool and in a critical condition. Twenty years ago
September 28, 1889]
THE MEDICAL RECORD.
359
there was a great epidemic of rabies in Birmingham,
and no one contracted hydrophobia. This was a remark-
able fact, and one which should be accounted for. Pas-
teur might have done some other thing to treat patients
for hydrophobia, and might have been successful. ‘The
analogy given by Dr. Drysdale from Jenner’s experiments
to Pasteur’s was not complete ; for Jenner had vaccinated
before the injection of small-pox pus, whereas Pasteur in-
jected preventively after the virus was already in the sys-
tem. Ande this was doubtless also the case when forty
dogs were treated by the same treatment. He suspected
that there had been far too little open criticism of Pas-
teur’s process. In France, it had become a patriotic
thing to sustain Pasteur’s name and no effort had been
made to judge of it on its real merits. Professor Peter,
however, had mentioned the case of a man who had suc-
cumbed to paralytic rabies in his hospital and who had
been treated in Pasteur’s laboratory. ‘That man he, Dr.
Peter, considered probably to have taken the disease
from the preventive inoculations. Other similar cases
had been published where the patients seemed to have
died from the effects of rabbit rabies, and not from dog
rabies.
Sır WILLiAM Moore said that, some years ago, a
teacher of pathology had published a book to show how
poisonous the human saliva was, when injected into ani-
mals. As to the cure of rabies by Pasteur’s process, it
must be remembered that cases had been published when
the incubation of the disease had been as long as seven,
fourteen, and twenty-one years. He had heard of a case
of an incubation of syphilis of twenty-seven months. He
knew of a man who had been bitten by a mad dog, and
who died hydrophobic six years subsequently. Hydropho-
bia was not always fatal, for he had published a case
where the patient had recovered, and Dr. Bristowe had
given another. The result of the statistics put forward
by Dr. Ruffer were, therefore, not conclusive, and it was
not yet time to pronounce decisively on the Pasteurian
process for the prevention of hydrophobia.
Dr. VAUGHAN HARLEY said he had studied at the Pas-
teur Institute for some time, and would remark that the
inoculations for rabies were only a part of the work done
at the Institute. Other virulent diseases were studied,
and he might remark that it seemed not impossible that a
vaccine against diphtheria might ere long be discovered
at that institute. He could fully corroborate the facts
put forward by Dr. Ruffer.
Dr. TORRANCE said that he might perhaps be permitted
to mention what was the treatment of hydrophobia in
Syria. In that country, when the disease supervened, a
mad priest was asked to spit upon some food, which was
administered to the patient, in the hope that like might
cure like.
Dr. Georce Har ey, of London, was greatly obliged
to Dr. Ruffer for his admirable paper. It was not to be
expected that agreement could be arrived at on such diffi-
cult subjects, for human brains were so different that what
was proof to one mind was not so to another. It was a
mistake on Dr. Saundby’s part to suppose that Pasteur
had remained without criticism in his own country. The
very opposite was the case, and the attacks on that great
man had been venomous and unscrupulous to the greatest
degree, just as had been the case and still was the case in
Jenners country when vaccination was discussed. The
value of Pasteur’s new ideas concerning virulent diseases
was quite enormous ; but that great man could not be ex-
pected to do everything. He had never personally seen a
case of hydrophobia ; and it seemed that waves of hydro-
phobia passed over countries every forty years or so.
Forty years ago there was such a wave in England ; and
Waterton, the Yorkshire traveller, suggested the cure of
the disease by means of a poison he had brought from
South America with him, viz., ourari. This did not suc-
ceed because, in the case of rabies, the virus was not
chemical but was a germ. At the time of the famous
poisoning by Palmer, he, Dr. Harley, had made many ex-
periments with strychnine on the spinal cord, and had
been surprised to find that when he applied the alkaloid
to the cord directly no effect ensued, and it was only when
he allowed it to get into the blood supplying the cord, that
spasms were caused. Hydrophobic virus, however, caused
the disease when put in contact with the brain. He wished
to say that insanity in the lower animals was not very un-
common, and that it was in no ways connected with rabies,
and also that temperature had nothing to do with the pro-
duction of rabies. In Kant’s Arctic voyages, it was men-
tioned that sixty-five dogs were attacked by rabies and
died of it in these cold regions. It was a curious specu-
lation that it was the poisons which the germs produced
for themselves which constituted the prevention of rabies,
for it was thus the very product of the animals themselves
which was used as an antidote for them.
Dr. Eppison, of Leeds, said that it was not generally
known that the lower animals may become insane, and, of
course, that had nothing in common with rabies. It was
not always easy to say that a dog was rabid when it had
bitten a person, and the only certain test was the inocula-
tion of rabbits with part of the spinal cord of such a dog.
He would like to say that the pain caused by hydrophobia
was not so great as that caused by many other diseases,
such as cancer or other affections. He had seen cases
where the patient had not suffered much before he suc-
cumbed. As to the cost of a Pasteur Institute, that was
nothing ; the real difficulty in this country in establishing
such an establishment was the existence of a hateful so-
ciety which granted to a gamekeeper or a sportsman the
right to torture the lower animals in traps, while it for-
bade any experiment being made on animals for the good
of mankind. Forty years ago, in Squire Waterton’s days,
hydrophobia was common in Yorkshire; but since then
there had been but few cases in the Leeds Infirmary.
One hundred and fifty sheep were bitten and became
rabid, and thus the disease was seen to be a real disease
in Yorkshire. He would like to ask whether in the Pas-
teurlan inoculations any slight symptoms of rabies were
ever produced. He had been acquainted with Squire
Waterton, and felt sure his family would be gratified to
have his name so alluded to by Dr. George Harley.
Dr. RAPFER, in reply, said that, as to Sir W. Moore’s
cases of long incubation of hydrophobia, he could only say
that he had taken the greatest pains to get at the truth on
this point, and had only found one authentic case where
the incubation period of hydrophobia had extended a
year. As to Leblanc’s statistics, that gentleman, a vet-
erinary surgeon at Rouen, had been most careful in visit-
ing all persons who had been bitten by rabid dogs, and in
getting the history of these animals. Dr. Dujardin-Beau-
metz had recently made some inquiries concerning rabid
patients in Paris, and had ascertained that of three hun-
dred and fifty persons bitten by rabid dogs in 1887, in that
city, three hundred and six went to Pasteur’s Institute
and were treated there ; of these three hundred and six, two
died. Forty-four persons would not go to be treated by
Pasteur, and of these seven died. As to the frequency of
rabies in summer and winter, the statistics of the Pasteur
Institute gave the lowest number of cases of bites in the
month of August, and the highest in February. About
one-third of the cases were ascertained to be rabid by the
inoculation test, and two-thirds by the evidence of veten-
nary surgeons. As to Malta, he had heard, quite recently,
four men had been preventively inoculated in that island
by Dr. Kaulana. Russian statistics were quite reliable,
for all the medical men practising preventive inoculations
in that country had been pupils at the Pasteur Institute.
Saliva, when inoculated under the dura mater, often
proved fatal; but when it did so it killedin one or two
days; whereas, when sterilized rabid cords were injected,
the incubation was always the same, #.¢., six or seven days.
In the former case it was septiczemia that killed. It was
quite true that the diagnosis of hydrophobia was some-
times quite obscure. ‘Thus, in a case cited by a French
observer, a man was brought to hospital supposed to be
360
THE MEDICAL RECORD.
[September 28, 1889
suffering from acute mania; but when the cord was in-
jected under the dura mater of a rabbit, it took rabies.
In another case, a man was supposed to have delirium
tremens ; but he was really hydrophobic, as proved in a
similar way after his death. Dr. Peter’s case made a
great noise, but, when the man died his spinal cord was
procured by M. Pasteur and injected beneath the dura
mater of a rabbit. The rabbit died after nineteen days,
which showed that the man did not die of rabbit rabies,
but from the bite of a dog. As to the political question,
the way in which M. Pasteur had been treated by many of
his own contemporaries in Paris was disgraceful, and
humiliating to contemplate. Dr. Peters, in 1887, had
published the details of a case of chronic hydrophobia.
The patient was said to be in Lille, and accordingly one
of M. Pasteur’s pupils visited him. The man walked in
seven miles from the country to see him, and in short the
case was a fabrication, and not one of hydrophobia at all.
Dr. Bateman, of Norwich, read a paper on
THE JURISPRUDENCE OF APHASIA.
He mentioned many cases to show that a patient might
be permitted to make a will, which was admitted to pro-
bate, although unable to explain himself in speech. - Pro-
bate was granted in 1870 to the will of a man who had been a
deaf-mute. ‘There was also a very remarkable case where
a widower, aged sixty-three, about to marry a young lady,
was suddenly seized with aphasia. This gentleman
showed by signs that he desired to leave £30,000 to the
lady he had intended to marry. After death, it was
shown by evidence that, on being asked what he wished
to leave, he put up the five fingers of his hand, and on
being asked if that meant £5,000 he nodded. He held
up his hand six times, and was asked whether that meant
£30,000. He was then asked if he desired to leave this
sum to Miss R——, and he nodded his head. Asked
whether this was to be left unreservedly to her, he shook his
head. Asked whether the money was to be for her use
during her lifetime, he nodded his head. ‘The will was
made up and witnessed according to these instructions,
and patient affixed his mark. When the case came before
the court, the judge said he would have granted probate
if the mark of the testator had been put in the right
place, but it was made on the body of the deed and not
at the end, and this made the document useless. A
similar case had occurred in an aphasic gentleman, aged
sixty-two, in France, who could not write without copy-
ing his handwriting, and whose will was not disputed by
the courts. In this case the patient’s intellect was excel-
lent, and he could keep up a conversation by means of
the deaf-and-dumb alphabet. These were all cases of
motor aphasia. When there was sentient aphasia, doubt-
less the case was more difficult, as the intelligence was
thus lessened.
Dr. Eppison, of Leeds, said it was often very difficult
to come to a correct opinion as to the amount of intel-
lect remaining in the aphasic patient, and this essay was
most useful. .
Dr. DRYSDALE, of London, cited the case of a cele-
brated civil engineer who had right motor paralysis and
aphasia, but who wrote his own checks, copying them
from a former signature of his own, and who, for many
years, was senior partner of his firm. His partners, how-
ever, did all the work. In this case the gentleman re-
tained enough intelligence to play whist with the cards
spread out before him, and left a will which was not con-
tested. In a debate on this subject at the Worcester
meeting of the British Medical Association, Professor
Gairdner had mentioned the case of a Scottish judge af-
fected with aphasia, who had continued in office for some
years and sat on the bench while suffering from a form
of this malady.
Dr. Rankin, of Kilmarnock, cited the case of a
me ie who had left a will which had not been con-
tested.
CANADIAN MEDICAL ASSOCIATION.
Iwenty-second Annual Meeting, held at Banff Springs
Hotel, Northwest Territory, August 12 and 13, 1889.
(Reported by our Canadian Correspondent.)
MONDAY, AUGUST 12TH—FIRST Day.
Tue selection of Banff Springs as the place of meeting
was demonstrated by the large attendance to be an ex-
cellent one. Every province of the Dominion was rep-
resented, and the arrangements made, both for the
comfortable transportation of the members and their ac-
commodation at Banff, were most complete.
The meeting opened with Dr. GeorcE Ross, President,
in the Chair. He expressed his pleasure at the large and
representative attendance, and briefly introduced the
President-elect, Dr. H. P. Wright, of Ottawa.
RECEPTION OF DELEGATES.
Drs. Conner and Whittaker, of Cincinnati, Drs. Gibney
and Bulkley, of New York, and Dr. Marcy, of Boston,
were then introduced to the Association, and received a
warm and hearty reception.
AN ADDRESS OF WELCOME.
Dr. BRETT, of Banff, on behalf of the Local Com-
mittee of Arrangements, presented an address of welcome
to the Association, in which every assurance was given
that the members present would receive every atten-
tion, and that no pains would be spared to make their
visit as pleasant as possible; so that the most favorable
impression would be carried away regarding the beauty as
well as the health-giving properties of the national parks.
PRESIDENT’S ADDRESS.
Dr. H. P. WricutT then delivered the President’s an-
nual address. His first reference was to the loss sustained
by the Association during the past year by the death of
Dr. R. P. Howard, of Montreal, one of the first presi-
dents of the Association, and a gentleman whose valuable
contributions to past meetings were always so highly ap-
preciated. ‘The importance of establishing a National
Board of Health for the Dominion was then dwelt upon,
and the good results that might be expected to arise from
such an organization were fully commented upon. ‘There
were many reasons for congratulation on the advance
made in the educational interests of the profession, as
might be seen in the raising of the standard of the pre-
liminary examinations required before entering upon the
study of medicine, and in the improvements made in re-
cent years in the methods of instruction now carned
out in Canadian medical institutions. In regard to the
matter of reciprocity of registration between the several
provinces of the Dominion and the British boards, a
question which caused considerable discussion at the last
annual meeting, he said, that through the efforts of the
provincial board in the Province of Quebec, reciprocity of
medical registration had beer secured between that
province and the English boards, and he trusted that
before long the same satisfactory arrangements would be
made by the other provincial boards. ‘The question of
Canadian climatology, Dr. Wnght thought, might be con-
sidered a favorable theme for the consideration of the
Association, meeting as it did this year in what was con-
sidered by many the most healthful portion of the Domin-
ion. ‘The aseptic nature of the atmosphere in the north-
west territories was certainly remarkable, and the virtues
of the hot springs of the National Park, particularly jin
the treatment of rheumatism and syphilis, had already
been successfuly established. ‘The early formation of
medical boards in these western provinces had already
proven of advantage to the public and the profession, and
would no doubt afford protection from quacks and charla-
tans. ‘The address, which was an able review of the pres-
ent condition and scientific needs of medicine in the
Dominion, closed with an extended and able reference
to the influence of bacilli in the propagation of disease,
and drew attention to the liability of certain diseases, such
September 28, 1889]
THE MEDICAL RECORD.
361
as tuberculosis, being communicated from animals to man.
Before taking his seat the President expressed the opinion
that the present meeting would be highly successful, and
that holding the sessions in this western portion of the
Dominion would create fresh interest in the welfare and
prosperity of the Association.
The meeting then went into executive work, after which
it was resolved to adjourn.
TUESDAY, AUGUST 13TH—SECOND Day.
The President, Dr. WRIGHT, of Ottawa, took the chair
and called for the reading of papers, and expressed the
wish that the visiting delegates would feel at perfect liberty
to engage in the discussions.
Dr. ADAM WRIGHT, of ‘Toronto, presented a paper en-
titled
HMATOMA OF THE VULVA AND VAGINA,
a pathological condition arising from pressure on blood-
vessels during pregnancy. He related the history of sev-
eral cases in which treatment had been successful by free
incision.
Dr. Ross, of Toronto, and Dr. Howarp, of Truro,
N. S., spoke of the frequency with which such cases are
apt to occur, and the importance of their early recognition.
Dr. Marcy, of Boston, related the history of a case of
thrombus of the vulva, in which he had advised premature
delivery. The patient, who was pregnant with twins,
would not consent, and went onto full term. Death fol-
lowed the third day after delivery. The autopsy showed
that degeneration of the kidney existed.
Dr. Roppeck, of Montreal, favored leaving these
tumors alone, unless the growth became large and proved
an obstruction, and in such a case he agreed with Dr.
Wright in laying them open with the knife.
Dr. ‘TRENHOLM, of Montreal, had experience in one
case in which he had used the shoemaker stitch, and thus
cut off all blood-supply to the tumor. The results had
been very gratifying.
Dr. Sloan, of Blyth, and others continued the discus-
sion.
Dr. KEennepy, of Fort McLeod, read a paper on
THE CLIMATE OF SOUTH ALBERTA,
with special reference to its advantages for patients with
pulmonary complaints. He gave an interesting descrip-
tion of the soil and the different atmospheric changes com-
mon to that territory. In eleven years’ practice he had
known only four cases of pneumonia, and phthisis was in-
deed a rare disease. Many who came to Alberta with
incipient phthisis recovered. The atmosphere was cer-
tainly peculiarly aseptic, and the rapid healing of wounds
was a wonder to many. ‘They were not altogether free
from disease in the territory, for they were often troubled -
with a mild form of fever pronounced by some to be ty-
phoid, and by others to be entirely of malarial origin. ‘The
climatic influences of Alberta were certainly most favor-
able to health, and he ventured to predict that when the
salubrious climate of the territory became well known,
and its marked suitability as a health-resort were under-
stood by the Canadian people, many would avail them-
selves of its advantages.
Dr. OLDWRIGHT, of ‘Toronto, expressed the hope that
the Dominion Government would establish meteorological
stations, from which valuable observations might be made
in Alberta. ‘This, he thought, would furnish information
much to be desired regarding the climate of the territory.
Dr. McInnis, of Edmonton, spoke of the abnormally
high temperatures often met with in Alberta. He had
frequently noticed a temperature of 108° F. followed by
recovery. What would be considered an alarmingly high
temperature in the east was commonly met with in this
western territory. There was also marked absence of the
typical features as seen in intermittent fever in the east.
He corroborated the evidence of Dr. Kennedy regarding
the great immunity enjoyed by Alberta from pulmonary
diseases.
Dr. HENDERSON, of St. Paul, Minn., had had consid-
erable experience as a railway surgeon in the early history
of Alberta, and had noted the frequency. with which high
temperatures were recorded.
Dr. BENTLEY, of New Westminster, B. C., had found
no cases of intermittent fever which had arisen in British
Columbia. There was considerable difference of opinion
among medical men, at the Pacific coast, as to the real
nature of the mild form of fever they often had to deal
with. While some pronounced it typhoid, others ascribed
to it a malarial origin and called it typho-malarial fever.
Dr. WHITTAKER, of Cincinnati, deprecated the use of
the term typho-malarial, and hoped to be able to return
and inform his confréres in the east that he had at-
tended its funeral on the top of the Rocky Mountains.
Pathological research had, he thought, established the fact
that examination of the blood would disclose whether a
typhoid condition was present or not. Regarding the im-
munity from phthisis in Alberta, he considered this would
strengthen the contention that upon purity of the air more
than upon anything else depended the successful treat-
ment of that disease. To the high altitude of the terri-
tory might be ascribed the more rapid circulation and de-
creased respiration, and these circumstances, with the
aseptic atmosphere, might account for the freedom fo
happily enjoyed from pulmonary diseases. He combated
the idea of the supposed he: editary nature of phthisis, and
was convinced that small apartments and neglect of hy-
gienic measures to secure pure air were great factors in
the cause of that disease.
Dr. Henderson, of Kingston ; Dr. McLennan, of Tren-
ton, and Dr. Praiger, of Nanaimo, B. C., continued the dis-
cussion, and expressed pleasure that the claims of Alberta
as a territory enjoying such freedom from pulmonary dis-
eases had been so well presented.
Dr. Gisney, of New York, opened an interesting dis-
cussion on
THE TREATMENT OF HIP-JOINT DISEASE.
The term hip-joint disease was, he thought, somewhat
misleading. He looked upon it asa disease almost en-
tirely of tubercular origin, and taking this view, we are
greatly assisted in our management of these cases. Ab-
solute and complete immobility of the affected joint was,
he considered, the foundation for all treatment. An abun-
dant supply of pure air, with good, wholesome nourishment,
were most important factors in the treatment. He kad
not had much satisfaction in the use of any of the splints
devised for the treatment of this disease, but thought the
perineal crutch useful in soine cases. A _plaster-of-Paris
dressing extending from the free ribs downward, applied
sufficiently strong to secure immobility, was necessary.
There was no fear of trouble from anchylosis of the joint
in these cases. In conclusion he related the different
steps to be taken, should operation be found necessary.
Dr. Conner, of Cincinnati, thought, with the previous
speaker, that tubercle bacilli were the main cause of hip-
joint disease. ‘The joint was found to be a favorite resting-
place for bacilli, where it became encapsulated, and either
remained dormant or gradually developed, and thus caused
extension of the disease. In reference to treatment, if the
joint were kept absolutely quiet, nature might take care of
the tubercle, and successful or partially successful results
would follow. If, however, operative interference became
necessary, recourse might be had to (1) freely opening and
scraping out the tubercular deposits ; (2) exsection of the
hip-joint ; or (3) amputation of the limb. He had been
obliged to favor the latter in severe cases, but considered
early diagnosis and prompt treatment, by securing com-
plete immobility of the joint, would often render unneces-
sary the operations for the cure of this disease. He em-
phasized the importance of having the patient kept in as
completely an aseptic atmosphere as it was possible to se-
cure,
362
THE MEDICAL RECORD.
[September 23, 1889
Dr. STRANGE, of ‘Toronto, related an interesting case
of hip-joint disease of traumatic ongin. If operation be-
came necessary in cases of a tuberculous nature, he favored
opening the joint freely, and removing with the strictest
antiseptic measures all tubercular deposits. He believed
all such cases should be kept in the open air as much as
possible.
Dr. Roppick, of Montreal, favored extension as a val-
uable addition in treatment of these cases. Careful dis-
tinction must be made between the tubercular ard non-
tubercular forms of the disease. The successful treatment
was very often dependent on the early recognition of the
disease.
The discussion was continued by Drs. Oldwright and
Cameron, of Toronto; Shepherd, of Montreal, and Praiger,
of Nanaimo, B. C.
Dr. BULLER, of Montreal, read a paper on
PREVENTIVE DEAFNESS.
He first produced statistics showing the prevalence of
deafness, and dwelt on the importance of early recognizing
and promptly treating any symptom of deafness in child-
hood. The cause at first might be trivial, and its early
discovery and removal was of the utmost importance.
The oft-repeated fallacies that it was dangerous to check
a discharge from the ear, and that a deaf child often re-
covered without any treatment, were often heard from the
laity, but medical men should discourage and promptly
refute such opinions. Earache, instead of being looked
upon as a trivial matter, should call for a careful exam-
ination and diagnosis. Negligence, in not attending to
what might seem but a slight defect in the hearing of a
child, often led to serious trouble.
Dr. REEVE, of ‘Toronto, said early attention to the walls
of the pharynx, looking particularly for a hypertrophied
condition, would in many cases remove what might ulti-
mately lead to deafness in children.
Dr. GrassiTT, of ‘Toronto, presented a paper on
COLLES’ FRACTURE.
After briefly describing the triple displacement of the lower
fragment of the radius and the consequent difficulty in
getting the displaced portions exactly reduced to their
proper relations, he proceeded to discuss the different
methods of treatment. In treatment of this fracture there
must be no timidity on the part of the surgeon, who must
carefully manipulate until reduction issecured. After that
it mattered but little what form of splint was used, as long
as the displaced fragments were kept exactly in place.
Dr. Roppick, of Montreal, thought care should be
taken to break up the impactions and carefully readjust
the parts. He favored using an anesthetic in all such
cases. In regard to splints, he favored an anterior splint
with a ball in the palm of the hand.
Dr. CAMERON, Of Toronto, spoke highly in favor of
‘Moore’s dressing in Colles’ fracture.
Drs. Sloan, of Blyth ; McLennan, of ‘[renton ; Geikie,
of Toronto ; Bust, of Paris ; Smith, of Seaforth ; Reddell,
of Crystal City, and Stockwell, of Port Huron, Mich.,
continued the discussion.
Dr. JAMES Ross, of Toronto, read the history of an in-
teresting case of
EMPYEMA,
treated by free incisions.
Dr. JAMES STEWART, Of Montreal, presented a paper on
SULPHONAL,
giving the histories of fifty-two cases in which that drug
had been administered as a hypnotic. When severe pain
was present he found the drug useless ; but in those cases
where there was sleeplessness without pain it was highly
useful. In those neurotic cases where the morphia or chlo-
ral habit had been developed, it was the means of securing
beneficial sleep when given in twenty-grain doses. ‘There
was, he believed, no fear of the habit being established, as
in the commonly used narcotics. Sulphonal produces no
disagreeable secondary symptoms, nor any unfavorable
effects on the heart and circulation. Its action was by
giving rest to the cells of the cerebral cortex and thereby
causing sleep. ‘The dose was from fifteen to fifty grains,
the ordinary dose being twenty grains. It was somewhar
slow in its action, so that it was necessary to administer
the drug early in the evening to secure a night’s sleep.
In some cases he had noticed six hours would elapse
before sleep was produced. Large doses had been
known to produce ataxic symptoms, but these were
generally mild in character and soon passed away.
Dr. WHITTAKER, of Cincinnati, said that his experience
in the use of sulphonal confirmed all that Dr. Stewart had
related in its favor. As an agent to procure sleep he
considered it was a most valuable remedy. He had used it
in the largest doses, and had never seen any danger, nor
the least symptoms of danger from its use. ‘There were
persons who could not sleep while travelling on a train or
steamer. Such persons might have a good night’s rest
free from any objectionable after-effects by taking early
in the evening twenty grains of sulphonal. He believed
that it was of no value as an anodyne, but given in those
cases requiring simply a hypnotic it was reliable in its ac-
tion, and as such it was a new and valuable remedy.
Dr. REEVE, of Toronto, read a paper on
PAINFUL AFFECTIONS OF THE EYE AND EAR.
Dr. WHITTAKER, of Cincinnati, presented a paper on
VARICELLA,
reviewing some of the peculiarities sometimes associated
with this disease. f
Dr. George Ross, of Montreal ; Dr. Bulkley, of New
York, and others continued the discussion of the subject.
Dr. F. J. SHEPHERD, of Montreal, read a paper on
NEPHRO-LITHOTOMY,
giving a report of an interesting case in which the right
kidney had been incised for calculus, with success.
Dr. CONNER, of Cincinnati, discussed the subject at
length, giving interesting reports of cases, and affirming
that there should be no hesitation in cutting down upon a
kidney where the existence of calculus was suspected.
Dr. Dupuis, of Kingston, and others continued the dis-
cussion.
Dr. L. Duncan BULKLEy, of New York, presented a
paper on
THE EARLY RECOGNITION AND TREATMENT OF REPI-
THELIOMA.
He first made reference to the importance of the early
recognition of epithelioma, a condition which might often
escape notice for considerable time. ‘There were three
methods by which we might seek to eradicate the disease :
I, excision ; 2, erasure by curette ; and, 3, destruction by
caustic agents. After reviewing all the methods of treat-
ment, Dr. Bulkley gave evidence from his own experience,
of the success obtained from the application of Marsden’s
paste, consisting of arsenic, two parts, to one part of gum
acacia. ‘This, applied for a period of twelve hours, in the
early history of a case, had often served in his hands to
destroy the epithelial cells. He deprecated the use of
nitrate of silver, and other similar agents likely to irntate,
and thereby encourage the growth, but thought that in the
use of the arsenical paste we had a valuable means of
treating epithelioma.
Drs. Stewart, of ‘lruro, N. S.; Chamberlain, of Morris-
burg, and others continued the discussion.
The following papers were read and fully discussed :
“The Radical Treatment of Hernia,” by Dr. Cameron,
of Toronto; “ A Résumé of a Few Surgical Cases,” by
Dr. Praiger, of Nanaimo, B..C.; “Some Improvements
in Medical and Surgical Instruments,” by Dr. Dupuis, of
Kingston.
September 28, 1 889]
ELECTION OF OFFICERS.
The report of the Nominating Committee was pre-
sented, and the following officers were unanimously
elected :
President—Dr. James Ross, Toronto; Vice-Presidents
—For Ontario, Dr. Bruce Smith, Seaforth ; for Quebec,
Dr. La Chapelle, Montreal; for Nova Scotia, Dr. Johns-
ton, Sydney Mines ; for New Brunswick, Dr. Holden, St.
Johns ; for Prince Edward Island, Dr. McLeod, Charlotte-
town; for Manitoba, Dr. Spencer, Brandon; for North-
west Territories, Dr. Brett, Banff ; for British Columbia,
Dr. Evarts, Nanaimo; General Secretary—Dr. James
ell, Montreal; Zreasurer—Dr. W. H. B. Aikins, ‘To-
ronto.
Several resolutions were passed relative to the import-
ance of establishing meteorological stations in the North-
west Territories, and of the desirability of every effort
being made to furnish the fullest information regarding
the climate and other advantages of the territory of Al-
berta as a health-resort.
It was also resolved to continue every effort to induce
all loca] medical societies throughout the Dominion to
incorporate with the Dominion Association, and maintain
friendly relations between the parent body and the differ-
ent provincial and county societies.
The usual motions of thanks were then passed, and the
twenty-second annual meeting of the Canadian Medical
Association was brought to a close.
Correspondence.
SOME OF THE DANGERS THAT THREATEN
INVALIDS WHO TRAVEL IN RAIL CARS.
To THe Epitror or Ins Mapicat RECORD.
Sır: For several years I have made long journeys by rail
in search of climatic conditions favorable to a renewal of
health. ‘Through the South to Florida, west as far as
California and the Pacific Islands; in fact, to all the well-
known resorts of the country. I have travelled principally
by rail. I might call your attention to many things in the
running of the trains by day and night, car construction,
wayside dining conveniences, and in which at slight ex-
pense a great improvement for the benefit of the travelling
public, and especially of invalids, might be made. But
none more important, or that calls for more immediate
action by the companies furnishing parlor or sleeping-cars,
is there than that of improvement in the closet conveni-
ences. I have found in raany, and at all seasons of the
year, that the closet opens directly to the open air beneath,
and the motion of the car compels a strong current up-
ward and inward. In any season of the year this must
be, and is, extremely unpleasant to every traveller, and
especially so, if not dangerous, to invalids on a journey,
whether of one or six days ; but in cold or wintry weather
the exposure to the frosty current is extremely dangerous
to those affected by some, if not all, diseases. On a few
cars I have found ample provision assuring immunity
from these dangerous air-currents, but in the majority of
cases, and especially on the older Eastern roads (using old
cars, etc.), the arrangements are of the most primitive
character. The few new cars occasionally met with on
these roads, though frequently advertised, do not seem to
have been constructed with much reference to the com-
fort of long-distance travellers. The medical profession
should take this matter in hand, and disregarding adver-
tisements (and the few new cars for special exhibition),
ascertain from actual inspection by a reliable person, what
roads reaching winter or summer health-resorts provide
cars convenient and safe for invalids, and not hesitate to
advise their patients in this very important regard. In
fact, the result of such an inquiry ought to be made as
public as possible. MISSOURI.
SARATOGA, September 10, 1889.
THE MEDICAL RECORD.
363
THE PROPER TEACHING OF ANATOMY.
Yo THE EDITOR oF THe Mepicat Racorp.
Sir: I have just read your editorial on “The History and
Cost of the Didactic Lecture,” in ‘THE MEDICAL RECORD
of July 27th, and heartily agree with much that is said con-
cerning the waste of time in hearing tiresome, badly deliv-
ered lectures, containing nothing that cannot be readily
and more agreeably found in current text-books. I heart-
ily approve of the principle that students should be allowed
to attend the lectures of any man who gives interesting
instruction, and not be forced to listen to one teacher be-
cause he happens to be the holder of a certain collegiate
chair. Nothing would so much as this stimulate our col-
lege professors to increased activity in their own sphere.
A man, sure of his fees and certain of a compelled attend-
ance, has little stimulus to scientific enthusiasm and im-
proved methods of instruction.
I cannot, however, avoid criticising your remarks re-
garding anatomy, which are contained in the following
paragraph :
“No wonder, then, that many didactic lectures are
poorly attended. The student knows that he can find all
the information in text-books, and sees no reason why he
should listen to another’s reading of the same. Particu-
larly is this true of a subject like anatomy. It is nota
-fault of any one man or anyone institution. It is a uni-
versal one.”
I have italicized the words because I am so sure that
they are deductions from wrong premises. ‘The reason
that anatomy is considered a dry and wearisome study is
because its so-called teachers do not teach it in an inter-
esting way. In other words, the fault les with the man
and the institution. ‘The chair is often, perhaps usually,
given to a man who does not practise medicine or sur-
gery. As well might materia medica and therapeutics be
given to a man who never wrote a prescription or felt a
pulse. Let anatomy be taught by those whose daily work
brings them in contact with injuries, deformities, and ana-
tomical landmarks, let it be portrayed on the living mod-
els as in our schools of painting and sculpture, let the
student see that the men who teach anatomy make their
professional living by knowing surgical anatomy, let the
electrical current be employed to illustrate the function
of individual muscles and to elucidate the complicated
movements of the joints, and then no student will think
he can find all the anatomy he wants in text-books.
If, however, the teaching of anatomy, the foundation-
stone of all: medicine, is intrusted to life-insurance exam-
iners, to retired practitioners, or to peripatetic scholars who
never. enter a sick-room, it is no wonder that it becomes
a mere catalogue of human tissues, and far less interest-
ing to the hard-worked student than the columns of Dun-
glison’s Dictionary. Anatomy can be taught so as to in-
terest every earnest medical student. In my student days
it was so taught in this city of Philadelphia by at least one
man, and, as he still lives, it can be so taught at this day
by him ; possibly also by those who enjoyed his anatom-
ical lectures in the Philadelphia School of Anatomy.
Don’t blame the science, I beg of you; blame its poor ex-
ponents. Respectfully,
Joun B. Roserrs, M.D.
PHILADKLPHIA, Pa.
NITRATE OF SILVER IN HypDROCELE.—A number of
French surgeons have recently returned to the old method
of treating hydrocele, called by some Defer’s method, and
express a decided preference for it over the treament by
injections of iodine. After drawing off the fluid, a probe,
on the point of which some nitrate of silver has been
fused, is passed through the cannula, and the remedy is
thoroughly applied to the inner surface of the tunica
vaginalis. ‘The reaction following is similar to that after
the use of iodine, and the subsequent course is also the
same. ‘The advantages of the method are that it is more
simple and easy of execution and is also cleaner.
364
Army und Havy Hews.
Official List of Changes in the Stations and Duties of CM-
cers serving in the Medical Department, United States
Army, from September 15 to September 21, 1889.
SMITH, ANDREW K., Colonel and Surgeon. By direc-
tion of the acting Secretary of War, leave of absence for
fourteen days, on surgeon’s certificate of disability, is
granted. Par. 1, S. O. 214, A. G. O., September 14,
1889.
STERNBERG, GEORGE M., Major and Surgeon. By
direction of the acting Secretary of War, having com-
pleted the duties assigned him in War Department order
dated February 4, 1889, S. O. 30, February sth, A. G.
O., is reassigned to duty as attending surgeon and ex-
aminer of recruits at Baltimore, Md. Par. 12, S. O. 218,
A. G. O., September 19, 1889.
Oficial List of Changes in the Medical Corps of the United
States Navy for the week ending September 21, 1889.
BEARDSLEY, G. S., Medical Inspector.
months’ leave with permission to go abroad.
Rutu, M. L., Surgeon. Order granting furlough re-
voked and placed on waiting orders.
Medical Director Hupson, Medical Inspector Woops,
and Surgeon DICKINSON, will continue as president and
members of an Examining Board for examination of ap-
plicants for the position of Assistant Surgeons in the Navy,
at San Francisco, Cal , until June 30, 18go.
Granted six
Medical Items.
ConTaGious DISEASES—WEEKLY STATEMENT. — Re-
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending September 21, 1889:
Cases. | Deaths.
Typhus fever sireci nans wate toesetaceeag nase o o
Typhoid fever a3 ios sess dn dose tes eas edie keo EKSF 41 18
Scarlet [OV OR ss escerai renna Derea cheba 24 3
Cerebro-spinal meningitis...............0ceccceee . o o
Measles occu Saas pe ease che ae Sie EEE ESIE 7 o
Diphthéna esse 5. ces6 cus acbwes Gk os so eeni eae 55 10
Smallpox 6 dade eniccieowceusesen as sevewsasew. en o o
Yellow fever......... eseese.. E E SET o e)
„0
‘THE BREEDING OF SiNNERS.— The French Government
hopes, apparently, by promoting marriages between male
and female convicts, to bring back these stray sheep into
the fold of morality and good conduct. Arrangements
have accordingly been made to facilitate these unions, but
physiologists and pathologists must feel sundry qualms as
to the expediency of such a course. ‘The physical and
moral degradation of many of these social waifs is dis-
tinctly hereditary, and a careful moral training (which is
not provided for) would, at the most, only modify the
tendencies which have brought them within the clutches
of the criminal law. ‘The son of a poet is not of necessity
a poet, but the offspring of a bawd or an assassin is ex-
tremely likely to develop the same proclivities. If even
one of the parties to the transaction were worthy of re-
spect some regeneration might be hoped for, but the asso-
ciation of two hopelessly abandoned bodies and souls is
not calculated to improve matters in any respect what-
ever.—7Z he Hospital Gazette.
Too Many Docrors EvERYWHERE.—As we have had
occasion to note several times, it is not in America alone
that complaint is made of an overcrowded state of the
medical profession. The same condition prevails in Eng-
THE MEDICAL RECORD.
[September 28, 1889
land and France and Germany, and, indeed, all over the
continent of Europe, except in the country districts of
Russia. In the latter there is great need of physicians,
but no money to pay them with. In an article in Ze Con-
cours Médical -Dr. Grellety draws a dismal picture of the
struggle for bare sustenance among the physicians of
Paris. There are plenty of doctors, he says, with hospital
experience, who do not make enough to pay their rent,
and others who live on such short commons that a cutlet
for dinner marks the highest feast-days, and even beans
are regarded as a luxury that is attainable only now and
then. He says that it was once proposed to institute at
the “Ecole des Beaux-Arts” a course for the discourage-
ment of artists; the object of sucha course being to dem-
onstrate the cruelty of inflicting upon the community an
exhibition of such daubs as most so-called artists now
turn out. And he thinks that a similar course as a pre-
liminary to medical studies would serve a most excellent
purpose. The intending student could learn of the hard-
ships of the average physician’s life, the difficulty which
he would have in making both ends meet, and his poor
chance of ever making a success in life as regards either
reputation or money.
A SIMPLE REMEDY FOR HiccouGH.—Dr. Loebl re-
ports, in the Allgemeine Wiener Medizinische Zeitung, No.
32, 1889, the case of a man, aged fifty-four, who suffered
` for five days and nights from a most obstinate hiccough.
After trying all the ordinary measures without avail, he
fell back upon a household remedy as a last resort, and
ordered a teaspoonful of pulverized sugar wet with an
equal volume of wine vinegar, to be taken at one dose.
The hiccough stopped immediately, and did not return
for six hours, and then ceased again upon a second dose
of the remedy.
DANGERS OF CARBOLIC AcipD.— Professor Billroth has
called attention to the danger residing in the popular use
of carbolic acid as an application to wounds and injuries
of all sorts. He says he has seen four cases in as many
months of insignificant injuries of the fingers to which
carbolic acid was freely applied with the result of gan-
grene of the parts. He urges physicians to warn their pa-
tients against this drug, and recommends lead-water as the
safest and most effectual application to slight wounds.
FEMALE PHYSICIANS IN LONDON.—England is said to
have but seventy-three female physicians, of whom the
leading one is Dr. Scharlieb. She was the first woman to
receive a medical diploma from the University of Lon-
don. After residing in India for a time she returned to
London where she soon acquired a very large practice.
Dr. Garett-Anderson, a Paris diplomée, is another of the
leading female practitioners of London. She was instru-
mental in establishing the woman’s hospital in London, and
is dean of the school attached to the hospital, and also
holds the chair of medicine. This hospital is managed
entirely by women, the apothecary and attending phy-
sicians being women, the consultants only being of the
opposite sex.—London correspondent of the Semaine
Médicale.
ELEPHANTIASIS.—Dr. T. J. Bennett reports, in the
Texas Medical Journal, for August, 1889, the case of a
negress, fifty years of age, with elephantiasis of nearly
three-fourths of the entire body. He gives the following
measurements of the patient: Height, 5 feet 3 inches;
weight, 440 pounds; ankle, 264 inches in circumference ;
knee, 314 inches; thigh, 46 inches; abdomen, 6 feet;
largest part, 6 feet 64 inches.
Miss Karte Corey, M.D., a graduate of the University
of Michigan, has recently been admitted to honorary
membership in the Indiana Medical Society, the first time,
it is stated, this recognition has been extended there to a
woman. Dr. Corey has been for four years the principal
surgeon in charge of a hospital at Foochow, China, and
has, it was stated in the convention, performed almost
every surgical operation known.—Medical ana Surgicas
Reporter.
‘The Medical Record
A Weekly Fournal of Medicine and Surgery
Vol. 36, No. 14
@riginal Articles,
THE INFLUENCE AND WORK OF THE
ACADEMY.
BEING AN ADDRESS DELIVERED AT THE LAYING OF THE
CORNER-STONE OF THE NEw YORK ACADEMY
OF MEDICINE, OCTOBER 2, 1889.
By A. JACOBI, M.D.,
EX-PRESIDENT OF THE ACADEMY.
THE New York Academy of Medicine has called upon
the profession and the public alike to assist it in this cere-
mony of laying a corner-stone. Where we are now stand-
ing there will be the home of the Academy, we believe,
for generations to come. If we be mistaken, if this large
building will be too small before long, it will be the pleas-
ant duty of our successors to provide for their wants.
‘That this may become necessary is possible, for the Acad-
emy has experienced a development rapid beyond expec-
tation. Forty-three years ago it was founded, dozens of
years it held its meetings in hired quarters, ten years ago
it occupied its own building, No. 12 West Thirty-first
Street, to-day we are preparing accommodations such as
the profession of New York, or any other city of the coun-
try, has never possessed. Meanwhile, however, the spirit -
and the aims of the Academy have remained intact. Among
these aims are the cultivation of the science of medicine
and the promotion of public health.
In the words of a circular published nearly two years
ago in behalf of our building fund, “these purposes are
accomplished by lectures and discussions in the stated
meetings of the Academy and its numerous sections; by
maintaining reading-rooms which furnish nearly all the
medical journals of the world, and by collecting a library
containing about sixty thousand books and pamphlets,
which are free both to the medical profession and the
public.” The number of its fellows is nearly six hundred.
They have been selected from among those who have
practised medicine in New York City or its vicinity three
or more years. Some time ago fellowship has been ex-
tended to those residing in the State.
In its composition the Academy participates in many
of the peculiar features of our political organization, which
means to benefit all through the co-operation, if not of all,
still of the best. In Europe an Academy of Medicine
means a small body comprising a few select men only,
appointed by the body itself when there is a vacancy, or
by the political rulers. Thus the Academies form an
aristocracy of the mind parallel to the aristocracy of birth,
with all its exclusiveness and real or assumed superiority.
They are representative bodies only in this that the best
minds and most scientific workers are expected or be-
lieved to fill the seats.
The New York Academy of Medicine, however, is a
democratic institution. It is not limited in numbers—
on the contrary, it is desirable that the many respectable
physicians should gather round its flag. Like our politi-
cal commonwealth, it must look for its development and
success in the co-operation of the competent and cultured
masses. Like the Union, it is a voluntary confederation
of peers who make their own laws and obey them be-
cause they are of their own making.
The members have common interests, both scientific
New YORK, OCTOBER 5, 1889
Whole No. 987
and professional. Since ıts foundation, with the changes
for good and bad appertaining to everything organic, the
Academy has prospered constantly, in spite of, or as I
am more inclined to say. in consequence of its very con-
stitution as an independent and democratic body. In the
words of the same circular alluded to before, ‘the Acad-
emy is not connected with any school or college. It is
self-cupporting and is carried on in the interest of the
whole profession. There are no fees nor emoluments of
a private or individual nature. It is not supported nor
subsidized by the State or municipality.” Whatever has
been accomplished by it—its scientific labors, most of
which are laid down it its “ Bulletins” and “Transactions,”
and in the medical journals of the country; the hall in
West Thirty-first Street ; the library and reading-rooms in
the upper stories; the wealth of books and journals at
the disposal of those eager to learn, and so numerous that
they alone compelled us to look for more appropnate
quarters—all of that has been created, with few excep-
tions, by the exertions and pecuniary sacrifices of the
medical men themselves.
All classes of these are represented in the Academy.
It shows you the choice of those who are interested and
active in the promotion of medical science and art; those
who have earned an international reputation ; those who
have deserved well of the community by a life filled with
services rendered to the public ; and those who look for-
ward for the fulfilling of their dreams and the reaching of
their aims through coming years of honest labor spent on
theoretical study and practical work. In this co-operation
of the old and young, the illustrious and those yet un-
known, but promising or anxious to earn renown, the
mature and the maturing, you have one of the features of
a unity of the profession.
Another feature of unity which, moreover, ties the pro-
fession indissolubly to the community at large, is the labor
performed in the service of one and all. It is in these
labors and their results that the community at large ought
to take a deep interest. Modern medicine is probably
the greatest benefactor of mankind. ‘The more medicine
has been founded on the study of the exact sciences,
chemistry, physics, and physiology with mathematics, the
more has its field of usefulness enlarged. ‘The more theo-
retical it appeared to become, the more did it develop
practical usefulness and dignity. Indeed, the dignity of
a science or study rises with its ability of being utilized in
the service of mankind. Now, the promotion of medical
science and art does not mean only the improvement in
diagnosis and in the administration of drugs and remedies,
but the discovery of the best means of placing the human
being in the best possible condition. The labor of the
physician is not exhausted by carrying you through a
severe case of illness, he renders you the greater service,
less remunerative to him though, of preventing you from
falling sick. ns E ,
The peculiar relations of the individual physician to his
patient or the family intrusted to his care, are widened in
the relations of the profession to the public. Great epi-
demics take the place of a single case, the protection of
a community that of the guarding a person, the hygiene of
schools that of a dwelling, the sanitation of a large city
that of inspecting a suspicious trap or sewer in a private
domicile. ‘The more in your health department the med-
ical element will predominate over the military and polit-
ical, the more actual benefit will the people derive from
it. ‘The hygiene of the whole population, the superinten-
366
dence of public buildings in which “many people old or
young are gathered, public hospitals, quarantine stations,
the questions of physical and mental elevation, of legal
responsibility, of the State care of the insane, they all
belong to the domain of the profession. ‘This is not
theory only. No grave question of the kind has come up
without the gratuitous and spontaneous aid of medical
men. ‘The Health Board of the city has long appreciated
that. ‘The Academy has furnished a consulting board to
all the health department’s hospitals. A committee of the
Academy was intrusted with the inquiry into, and the re-
port on, the condition of Quarantine. It is to its report
that the first appropriation for the rebuilding of the Quar-
antine Station was due, and to its recommendations that
improvements are being carried out at the present time.
In this way the medical profession excludes epidemics,
and guards both the physical health and the economic in-
terests of the city. Imagine the pecuniary loss to the city
if the cholera and the yellow fever scare of a year or
two years ago had not been prevented by the profession,
as indeed it was. A week’s panic would have been a pe-
cuniary calamity amounting to the loss of a good many
millions. | .
These are but a few examples of the value of medical
services, both paid and unpaid ones, to the public. The
health of the city is the foundation of its prosperity. Let
epidemics prevail, and not only will your children die, your
families be decimated, and the graveyards be filled with
places where flowers and tears mingle, but your commerce
will be drawn to other ports. It is due to increased
knowledge and activity on the part of the profession, both
official and unofficial, that in spite of the unchanged sever-
ity of the epidemics and the rapidly increasing population
of the city, the number of cases of diphtheria shows an
absolute diminution. |
Such among many are the services of the profession,
not to speak of the gratuitous daily work of hundreds of
medical men in the hospitals and dispensaries. Nobody
can count or calculate, but everybody can appreciate how
many lives are preserved, how many millions are saved
for the poor and rich alike. From that point of view, a
whole-souled, generous woman presented to the Academy
$25,000, in recognition of the services to the public on
the part of the profession, and in accordance with the
esteem her husband held the profession in while he was
alive. To this consideration we owe the bequest of
$70,000, coming to us under the will of Mrs. Alexander
Hosack, who had spent a large part of her valuable life
with illustrious examples of professional worth. It is the
same thought that induced men and women with means,
intelligence, and public spirit to make donations of five,
two, or one thousand dollars. All we require now is
$50,000 to complete this building. ‘here must be many
who have that sum or a part of it to spare in the interest
of the profession ; perhaps to commemorate the name of
a dear one who has passed away, or to imprint his or her
name—and a legitimate ambition it is—on one of the
halls of the new building, or to perpetuate the’ memory
of one who has been saved from a premature grave by the
endeavors of one of those who are now striving to erect a
home for the most practical and beneficent of all sciences
and arts. ‘
It is a home we want, more than merely a house. To
make the house of the medical profession a home, it re-
quires a library. This is to the profession what a tool is
to the mechanic, an engine to the engineer, a telescope
t> the astronomer. A complete library represents the
thoughts, experience, genius, and discoveries both of all
previous centuries and the present time. All of these
treasures must be accessible to the profession whose
knowledge and skill is to be the safeguard of the public's
best interests. To accomplish that end the whole med-
ical literature of all countries must contribute. New York
has never been satisfied with anything that is second class ;
it cannot afford to trust itself to a profession without the
first order of learning and erudition.
THE MEDICAL RECORD.
[October 5, 1889
Why do we insist upon physicians being erudite? Do I
ask why do you apply to a particular watchmaker, an en-
gineer, an architect, a milliner? You select him because
you believe or know him to be well informed or skilful.
And the physician? His practice is the application of
knowledge acquired by hard brain work spent on all
the learning and practice which have been evolved out
of the labor and efforts of thirty centuries. A learned
doctor may happen to be an unsuccessful practitioner for
more reasons than one ; but among those reasons erudition
is not. An uninformed man is never a good practitioner ;
under equal circumstances, the more learned man is the
better man in practice. Practice and learning do not
exclude each other ; on the contrary, the former depends
on the latter. It ought not to suffice for your selection
of a doctor that you met him at a bar, or a ball, or ata
church meeting, or at whist, in a concert, or on a hotel
piazza, or that he be well dressed, pleasant, and tells you
he is your “friend ;” all these are fine opportunities and
agreeable social and personal qualities which may also be
considered when you are credibly informed that he burns
midnight oil over medical literature and that his profes-
sional brethren speak well of his abilities and achieve-
ments. And as far as medical friendships are concerned
your best friend is he who knows best how to protect you
and your children and your parents from disease, and to
cure them when they are sick.
‘The erudition we claim for the profession demands a
large library of constant growth. A fund of $100,000
will enable us to keep abreast with any similar institution.
The library of the Surgeon-General’s office in Washington,
which contains at present seventy thousand volumes and
one hundred and thirty thousand pamphlets, is the result
of industrious and systematic collections. It is not much
over twenty years old, but it ìs the richest and most com-
plete medical library in the world. Still its annual ap-
propriations for the purchase of books have seldom ex-
ceeded five thousand dollars. Thus a fund of $100,000
will enable us to procure nearly everything medical that
appears in any land. Of that sum we have only $10,000.
One-half of that sum was set aside by the Academy, the
other half is a donation separately administered in perpet-
ual honor of a departed one. Such special funds, or ad-
ditions to our general library fund, are urgently requested.
The citizens of New York have developed a metropolis of
large size and commercial power ; they can well afford to
tax themselves in the interest of medical science, than
which there is none more cosmopolitan and humanitarian.
But it is not the medical profession only which will be
directly benefited by the endowment of a large and com-
plete library. ‘The intimate relations of the medical and
legal professions are such that much of what we require
is found in law books, and the lawyer has to look for much
of his information in medical literature. Indeed, forensic
medicine, which originated in law, has its main represen-
tatives in medicine. In both the names of Thenck and
Tloucquet, Farr and Duncan, and our own Beck, and
many others of more modern times, are household words.
Moreover our library is a public one, free to the pro-
fession and the public. Now, there is a class of litera-
ture which in a free and public library hke ours ought to
be well represented. LLaymen intending to avail them-
selves of it expect to find mental food adapted to their
comprehension and taste. ‘That sort of literature 1s by no
means scarce. Much of it is of fair quality, some of it
surpassingly good. Books on anatomical and physiological
topics, those on subjects connected with natural history,
hygiene, and statistics, will always be found interesting
and instructive. ‘They ought to be well represented in
our library, for they cannot be found in large numbers in
the public and circulating libraries. Indeed the frequent-
ers of the latter differ much from the class of readers
consulting ours.
The additional knowledge acquired in this manner will
not only improve a man’s ability to protect himself and
his family, he will also facilitate the work of his doctor.
October 5, 1889]
A person who has filled his mind with comprehensible
ideas and sound facts will no longer study quack adver-
tisements. He who has learned something about the func-
tions of his bodv and been taught to consider the correlation
of causes and effects, can appreciate a disease to be the
result of either a preventable or an unavoidable cause, and
recognize that whatever disease was not the result of faith
cannot be cured by faith, not even by faith in panaceas.
‘The business of the quack may thus cease, the nostrum-
mixers may suffer, but individual and public health will
be the gainers. ‘There is less sickness in a man who has
some knowledge of his body and its requirements; and
when he falls sick he expects relief from natural and in-
telligible sources only. ‘That man isa better patient, more
accessible to reasoning, more obedient to the rules im-
posed in the interest of recovery. If he knows enough to
recognize the superiority or inferiority of his physician, so
much the better. ‘To-day most people have not a sufficient
knowledge to guide them in their selection; there are
many who are so little informed that they do not so much
as care. It in a matter ever so trifling a medical man is
called as a witness before a court of justice, the first ques-
tion he is asked refers to his membership in a medical
society The uninformed public, however, often select
their doctor for reasons known to nobody, least, perhaps,
to themselves. All this would be changed if a small part
of what is the basis of a physician’s thinking and knowing
were made accessible and intelligible to every man and
woman. A library like that which we intend to establish,
is destined not only to supply the professional man, but
furnish healthy mental food to all those who are thirsty
for knowledge. ° ‘Those who have means to spare in the
interest of public education, hygiene, and health, cannot
possibly apply them better than by providing for a library
fund sufficient for the gradual accumulation, from year to
year, under the supervision of experts, of all the good
popular literature on the subjects of anatomy, physiology,
hygiene, dietetics, and statistics.
May all this become true! We are preparing this edi-
fice to be the head-centre of medical study in the city, an
example to the profession of the-country, and a resort for
the brethren who come to us from near or distant parts.
This building when completed will Le an ornament to the
metropolis. What is still more important is that we mean
it to become, and feel assured that it will be, an additional
element of intellectual and ethical power, and in its results
a blessing to the commonwealth.
ON THE BACTERIOLOGICAL TEST OF DRINK-
ING-WATER.’
By EDWARD K, DUNHAM, M.D.,
NEW YORK.
Our interest in the bacteriological examination of water
rests upon the belief that by its aid we may detect the
resence, in a sample of water, of bacteria injurious to
health ; but still more upon the well-founded hope that,
through its assistance, we can, or soon shall be able to,
estimate the chances that a given water-supply will, in the
future, be contaminated with such bacteria.
It is this power of foreseeing danger which gives the
test its greatest value, and it is to that power that I wish
particularly to direct attention on this occasion.
In doing so, it may, I fear, be necessary to consider
some of the details of the test more minutely than strictly
accords with the general character of an address. But it
appears as though the principles involved in the test could
not be clearly manifest without some reference to the de-
tails of which they are in a great measure generalizations.
In the application of this test the greatest difficulty lies
in the proper interpretation of the results obtained by the
employment of some of the simplest of bacteriological
1 Being the Address delivered before the New York State Medical
Association, September 27, 1889.
THE MEDICAL RECORD.
367
procedures—namely, the isolation and counting of the
living bacteria in a given bulk of the sample submitted to
study. And, in practice, we find some diversity in the
manner of interpreting results on the part of different ob-
servers. Some have contented themselves with a state-
ment of the number of living bacteria found in a standard
quantity of water, usually one cubic centimetre, and have
condemned those samples which contained more than a
number previously fixed upon through the examination of
waters free from suspicion of injurious contamination.
Other observers have depended for their judgment
upon the detection of species of bacteria of recognized
pathogenetic character, considering, with justice, the pres-
ence of even relatively large numbers of non-pathogenetic
bacteria as in itself a practically harmless circumstance.
The criticism to which the first of these two methods
is open, is that it is too sweeping in its condemnation of
those waters which contain more than a very few bacteria.
For the numerical standard of good water must be set at
a low figure in order to exclude some waters which are
open to question ; whereas, undoubtedly, many waters
containing large numbers of bacteria are above suspicion.
The second method is open to the serious objection
that, in order to give a decisive opinion, it depends upon
the finding of species of bacteria which may be present in
but small numbers, and which are then very difficult of
identification in the presence of a number of other species.
Therefore, although its verdict is conclusive when posi-
tive, its results can be of no value when negative ; and,
moreover, a negative result can throw no light upon the
chances of a future contamination of the water supply
with injurious bacteria.
There is a third method of interpretation which has a
much higher aim than either of the two already mentioned,
and which is capable of becoming more exact in propor-
tion to the advances made in our knowledge of the part
bacteria play in nature. This method endeavors to trace
the past history of a water by means of a study of the
bacteria it contains, in order to estimate the dangers of
injurious contamination to which it has been exposed,
and the extent to which natural processes of purification
have been active in reducing those dangers.
In its application it involves the determination of the
species of bacteria in the water, together with an, at least
approximate, estimation of the number of individuals be-
longing to each one of those species present in a given
bulk of the water. `
Before proceeding to a more detailed consideration of
this method, it appears desirable to give an outline of the
technical steps taken in counting, isolating, and identify-
ing the bacteria in water.
After the collection of the sample in sterile vessels, in
such a way as to avoid its contamination with foreign
bacteria, the first step in its examination is the prepara-
tion of “ plate” or “ roll-tube ” cultures, which have for
their object the separation, from each other, of the in-
dividual bacteria in the sample. This object is gained
through the use of culture media which may, at will, be
rendered either liquid or solid, without thereby endanger-
ing the vitality of bacteria scattered through them. The
medium commonly used for this purpose is a jelly of con-
siderable firmness, which has been rendered highly nutri-
tious by the addition of meat extracts and peptone, and
then rendered sterile by killing any contained germs with
heat.
Definite. quantities of the water are thoroughly mixed
with several times their bulk of this jelly in a melted state,
and the mixture then poured upon a cold, sterile, horizon .
tal glass plate, where it quickly solidifies in a uniform
layer, forming a “ plate” culture ; or the mixture is solid-
ified in a thin, uniform layer upon the inner surface of a
test-tube, by rotating the latter around its axis, held ina
horizontal position, until the jelly has cooled. ‘This, the
“ roli-tube,” is a modification of, and serves the same
purpose as, the “ plate” culture.
By this mixing of the sample of water with jelly the
368
bacteria contained in the former are separated and dis-
seminated through the mixture, so that, when the latter
becomes solid, each individual bacterium occupies a fixed,
isolated position in the layer of solid jelly. If now these
slates (or tubes) be set aside, under favorable conditions
and protected from the intrusion of foreign bacteria, the
bacteria contained in the jelly will multiply so rapidly
that, in the course of a few hours, many thousand bac-
teria will have sprung from each bacterium originally im-
pnsoned in the jelly.’ But inasmuch as the descendants
of each individual are confined, by the solid jelly, to the
spot originally occupied by their progenitor,” it follows that
in the course of time an accumulation of bacteria large
enough to forma mass visible through the microscope,
and later to the unaided eye, takes place at that spot.
Such an accumulation is a “colony” of bacteria, and
since it must necessarily be made up of individuals be-
longing to a single species,’ it is a “pure culture,” and
serves as the starting-point of other pure cultures of the
species in jelly or other media.
Fortunately, colonies of different species differ more or
less in appearance, and in some cases species may be
identified with considerable certainty by the gross or
microscopic appearances of their colonies on the plate ;
but in most cases this is impossible, and the bacteria mak-
ing up a colony must be submitted to further observation
before it is possible to completely identify the species to
which they belong.
After noting the facts which can be gleaned from an
examination of the colony, small portions are removed by
means of a sterile needle and planted in other culture
media, where the growth of the species, as affected by
differences in nourishment, temperature, and other condi-
tions, may be observed. The colony on the plate also
yields material for the preparation of stained or un-
stained specimens for the direct observation of the in-
dividual bacteria through the microscope, thus furnishing
data as to their shape, size, mode of aggregation, and
motility.
By procuring a sufficient variety of conditions under
which the growth of a given species of bacterium is
studied, it is possible to obtain enough data as to its
charactenstics to distinguish that species from all others.
When this has been accomplished the given species has
been identified.
The media in general use for these purposes are jelly,
bouillon, agar-agar, a gelatinoid substance obtained from
an oriental alga, potato, bread, and coagulated blood
serum. All these media, except jelly, can be used for the
cultivation of bacteria at the temperature of the body,
without altering their physical condition, so that the modi-
fications in the growth of the bacteria due to differences
in temperature can be observed.
A question of a good deal of interest here confronts
us : the question as to the proper conception of a species
among the bacteria. Cultures of the same species may
show considerable variations in their characters when sub-
jected to different environments—variations so wide that
they exceed what are in other cases regarded as specific
differences. This question is too involved and technical
for discussion on this occasion. For the purposes of the
bacteriological test of water, the practical course is to re-
gard any marked characteristic as specific. The object
of the test being to enable us to judge of the past history
of a water by means of the evidence furnished by the
bacteria it contains, the particular conditions under which
those bacteria have developed are a part of the knowledge
we are seeking; and if variations in those conditions are
recorded in corresponding modifications in the characters
of the bacteria, those modifications may be as important
1 There are species of bacteria incapable of growing in gelatine at
ordinary temperatures. ‘The presence of these species is ignored
where gelatine plates are used for water analysis.
2? There are exceptional species which swarm over the plate, so that
distinctly isolated colonies are not formed.
3 The certainty of this purity is proportional to the thoroughness
with which the water was mixed with the melted jelly.
THE MEDICAL RECORD.
[October 5, 1889
to us asa real difference of species, and we may;there-
fore, provisionally, regard them as specific.
We have now rehearsed minutely enough, for our pres-
ent purpose, the technical procedures involved in a bac-
teriological examination of water, and may now turn our
attention to the nature and significance of the results ob-
tained by their application.
If we trace the history of a given sample of water, we
shall arrive at a point in that history when the water must
have fallen as rain. Since water, when it evaporates,
leaves behind it all suspended matter, it follows that any
bacteria found in rain-water must have been washed from
the air, or from the surfaces with which the rain came in
contact. They were either in the atmospheric dust, made
up of fine dry particles wafted into the air by currents, or
they were upon the water-shed.
It so happens that bacteria are not all equally capable
of preserving their vitality when subjected to the desicca-
tion which must precede their presence in floating dust,
and it follows therefrom that rain-water, except under
extraordinary circumstances, will contain only species in-
cluded in a group provisionally designated as “air bac-
teria,” without implying that they are found only in the
air. And, conversely, if all the bacteria in a sample of
water are of species included in this group, the deduction
that it has been exposed to none but aérial contamination
appears reasonable, no matter how numerous the individ-
ual bacteria may be.
If we next imagine that the rain-water has fallen upon
the ground and thence washed into streams, ponds, or open
wells, it is evident that it will carry with it those bacteria
which can be readily detached from the vegetation or the
soil over which it has passed. In brook- or pond-water we
may, therefore, look for not only air bacteria, but bacteria
belonging to a second group of species representative of
surface drainage.
While a portion of the rain-water runs from the surface,
another portion sinks into the ground and eventually be-
comes blended with what is called the “ ground-water.”
During its passage through the soil, most, and probably in
many cases all, of the bacteria contained in it are caught
in the interstices of the ground, or are subjected to un-
favorable conditions and die. Observation has shown that
ound-water is usually free from bacteria, or contains them
in but small numbers; but when the soil is very pervious
the ground-water may yield bacteriological results approxi-
mating those indicative of surface drainage.
The ground water underlies a layer of soil rich in bac-
teria, and is exposed to many chances of receiving them
On its passage toward the surface, where alone it can be of
domestic use. And it is during this passage to the sur-
face that it is exposed to the greatest risks of contamination
with sewage or excrementitious matter, which are especially
liable to contain noxious bacteria.
In such a water the bacteriological test is capable of
detecting the contamination and of determining its nature
with considerable precision.
From a bacteriological point of view, admixture of sew-
age with a water can be injurious only when that sewage
contains noxious bacteria. If, through any process, the
sewage be freed from such bactena, it will be deprived of
all bacteric infectious qualities. ‘The most common nat-
ural process by which sewage is freed of bacteria is filtra-
tion through the soil. If all the bacteria are removed the
sewage can contain no pathogenetic species, but if they
are not all removed and the sewage passes into a water-
supply, the latter will be in danger of infectious contami-
nation so saon as the sewage contains pathogenetic
bacteria.
The detection of the contamination of a water-supply
with sewage is of particular interest because of its relations
to the possibility of infection with typhoid fever following
the drinking of such a contaminated water.
We know of no general natural habitat of the typhoid
bacillus. It may be that, in the future, some natural home
or mode of development of that bacterium will be dis-
October 5, 1889]
covered. When that knowledge has been acquired the
bacteriological test of water can be applied so as to make
practical use of it, but for the present we must consider
the discharges from individuals suffering from typhoid
fever as the source from which typhoid bacilli might gain
access to drinking-water.
If the water were free from bacteria before the entrance
of the typhoid bacilli, and the latter were not mixed with
other species of bacteria, their detection would be simple
and certain, and with the finding of them a bacteriological
examination of the water would come to an immediate
conclusion. But in actual cases the typhoid bacilli are
associated with large numbers of fecal bacteria, and this
mixture disseminated through a large bulk of sewage ; the
chances of identifying the typhoid bacillus are inestimably
diminished by these circumstances, and we are, therefore,
constrained to condemn water containing fecal bacteria,
or those forms of putrefactive bacteria which are frequent-
ly found in sewage, even though they themselves may have
no pathogenetic qualities, and even though the source of
the water was apparently pure.
E. Simple and clear as are the principles underlying the
bacteriological test of water, it does not seem superfluous
to consider a few typical illustrations of their application
to cases met with in actual practice.
I. A sample of water was found to contain an average of
496 bacteria in one cubic centimetre, a very large major-
ity of which belonged to a single species—micrococcus
caudicans—a very common air bacterium. There were but
few other species present, most of which were recognized
as common air species. `
The inference from such a result is direct: The water,
a pure water, had been exposed to the air and then re-
mained subject to conditions favorable for the develop-
ment of the bacteria which had fallen into it until they
had increased to the number found. ‘This conclusion
was confirmed by the fact that the sample, as was after-
ward learned, had come from a tank which was filled with
water previously subjected to a very intelligent process of
filtration. Some of this same water, after being bottled
for a short time, contained 3,970 bacteria per cubic centi-
metre, among which five species were recognized, the
majority of the individuals belonging to the single species
caudicans,
No reasonable sanitary objection could be raised against
this water, either before or after it had been bottled, al-
though the number of bacteria found in both samples ex-
ceeded the usually accepted limit for good water.
Many of the air bacteria seem, after a time, to die out
when introduced into water, as is exemplified by a sample
of rain-water, which immediately after collection, during
a gusty thunder-storm, contained 5,940 bacteria; while,
after standing protected from dust for a few weeks, the
number had fallen to two. On the first examination
there was a large number of species present ; on the sec-
ond examination only a single species, common in both air
and water.
II. Water from a sylvan brook, swollen after a heavy
rainfall, contained over two thousand bacteria to the
cubic centimetre, a large number of which proved to be
bacillus subtilis, a species abundantly found on vegetation
and in earth. There was also present a species frequent-
ly found in soil. No other species other than air species
were found, and it was, therefore, concluded that the
large number of bacteria was due to surface drainage in-
nocent of injurious qualities.
III. A brook was examined at its source, where the
water ran from a loosely covered cleft between two rocks ;
again about half a mile from its source, after it had wound
through a grove and open fields; and again at a third
puint, about three-quarters of a mile beyond the second
place of collection, and several hundred feet below a
point where it received the drainage from some half-dozen
dwellings.
? Bacillus luteus, yellow sarcina, micrococcus cereus flavus, and
some not named,
THE MEDICAL RECORD.
369
At its source it contained 250 bacteria, among which
there were several air species, a few of the more common
water bacteria, also occasionally met with in air, and a
few earth species.
Samples from the second point of collection contained
532 bacteria, similar in character to those at the source,
but the water and soil species were relatively more abun-
dant.
At the third point of collection the number of bacteria
had risen to 4,773, and, besides the species found above,
there were both fecal and putrefactive species present.
The correspondence between the results of the bacterio-
logical examination of this brook and the history of the
water is so close that, if we knew only those results and
the order in which the samples came, we should be
obliged to construct a history of the water essentially
identical with that of this brook.
IV. The water-supply of a certain town is drawn from
a series of driven wells, which are, with the single excep-
tion of one used for making observations on the level of
the ground-water, connected in such a way that the water
is pumped from them all collectively.
A sample of water taken from the main at the pumping-
station contained two bacteria per cubic centimetre, while
a sample taken from the observation-well contained five
thousand. But the bacteria in the latter sample were all
of one species—namely, the same species which has
already been mentioned as persisting in a long-preserved
sample of rain-water. According to our principles of in-
terpretation, these samples must be regarded as equally
free from suspicious contamination. ‘The five thousand bac-
teria were due to an adventitious inoculation of the test-
well with a harmless species capable of thriving under the
conditions there prevailing. After stating that the bac
teria present were of a single species, it is superfluous to
add that the well was kept covered.
V. A deep artesian well, situated in the immediate
neighborhood of a field irmgated with the sewage from a
large public institution, was used as the water-supply for
the inmates. ‘The water had been repeatedly declared
unsafe because of the high yield in total solids, chlorine,
and ammonias obtained on chemical analysis. It was ex-
amined bacteriologically and found to contain very few
bacteria, none of which represented species indicative of
sewage contamination. There were no clinical indications
that the water was unwholesome. In this case it appears
that the natural filtration of the water through the soil
sufficed to free it from bactena.
VI. A stream which was drawn upon to furnish water
to a town, was suspected of being contaminated with sew-
age because of an outbreak of typhoid fever in that town.
Chemical analysis failed to furnish evidence of any such
contamination, but the water was found to contain large
numbers of bacteria belonging to a putrefactive species
common in sewage. ‘This result, while not demonstrating
the presence of typhoid germs in the water, arouses a
strong suspicion of a sewage contamination, which alone
would be sufficient to declare the water untrustworthy.
In conclusion, it is evident that the bacteriological ex-
amination of a water cannot, save under exceptional cir-
cumstances, pronounce a direct verdict as to the sanitary
value of that water. Its legitimate province is the dis-
covery of the relations existing between the water and the
natural or fortuitous distribution of the various species of
bacteria. The significance of those relations must be de-
termined by our knowledge of the causation of disease.
PROGRESS OF CREMATION.—There are now thirty-nine
crematories in various parts of the world. Italy has
twenty-three, America has ten, while England, Germany,
France, Switzerland, Denmark, and Sweden have one
apiece. In Italy there were two cremations in 1876 ; the
number rose to fifteen in 1877, and in 1888 the number
was 226. Since 1876, 1,177 cremations have taken place
in Italy, while the combined numbers from all other coun-
tries bring the total only to 1,269.
370
A FEW CLINICAL CASES SHOWING THE
VALUE OF OXYGEN COMBINED WITH NI-
TROGEN MONOXIDE IN THE TREATMENT
OF PULMONARY AND OTHER TROUBLES.
By E. C. TITUS, M.D.,
NEW YORK,
In THE MEDICAL Recor of July 6th there appeared a
very able article by Professor W. Gilman Thompson,
showing a series of experiments with oxygen upon ani-
mals, and the conclusions arrived at as a result of those
experiments. The conclusions were in the main such as
I have demonstrated repeatedly by clinical experience.
In the treatment of pulmonary complaints the tendency at
the present time is toward local medication. This arises
principally from the general acceptation of the germ
theory, which teaches in the main that diseases originate
from micro-organisms, and the belief that from this it
must follow, as a necessity, that these micro-organisms
must be destroyed or rendered harmless to organized tis-
sues, either as a means of cure, or asa prophylaxis to
such a disease. For these reasons aftention has been di-
rected more particularly to the study of means whereby
antiseptics or germicides may be made to reach disease-
germs in the lungs more directly and safely than has
hitherto been known. ,
If tuberculosis depend upon the presence of infectious
organisms in the tissues, then certainly the most rational
mode of treatment in phthisis must include the adminis-
tration of antiseptic agents. ‘The most powerful anti-
septic known to science is oxygen, for in an atmosphere
of oxygen it is impossible for disease-germs to exist.
It has been found by clinical experience that oxygen
is less irritating and more readily absorbed when com-
bined with a certain equivalent of nitrogen monoxide.
The proportions that I have found most valuable are
two parts pure oxygen and one part nitrogen. In order
to obtain good results, it is of the utmost importance that
these gases should be absolutely pure. Pure oxygen I
believe to be too powerful an oxidizing agent when used
alone ; especially when there exists inflammation in the
air-passages. In cases of poisoning from hydrogen gas,
however, it is better to use it undiluted. Nitrogen mon-
oxide is valuable as a modifier of pure oxygen, and has a
soothing effect upon the nervous system. It renders the
oxygen with which it mingles more assimilable, and hence
more promptly available in the general system. ‘The dis-
cussion at the New York Academy of Medicine, following
the reading of Professor ‘Thompson’s paper, was interest-
ing in showing how generally this agent is now being used
by the most advanced men in the profession. Its useful-
ness as a therapeutical agent may be shown by quoting
the remarks of those gentlemen who engaged in the dis-
cussion. Dr. J. West Roosevelt said that in the simple
anzmia of girls he found patients do better under the use
of oxygen in connection with administration of iron than
under iron alone. That opinion was shared by Dr.
Francis Delafield, expressed some months ago at the
Academy. Like Dr. Thompson, he had seen marked ben-
eficial results where the amount of breathing service was
diminished. Dr. George L. Peabody was of the opinion
that oxygen inhalations were most useful in certain mala-
dies attended by extreme dyspnoea, such as catarrhal
bronchitis, asthma, pleuritic effusions, etc. Dr. Beverley
Robinson thought he had seen absolute proof of the di-
rect, immediate therapeutic action of the inhalation of
oxygen in anzmia, in‘conjunction with iron. In a very
large number of cases digestion and assimilation were
improved, and in so far as it did that, it seemed to have a
wide field of utility. In phthisis he believed it had no di-
rect curative effect, but he thought it proper to use it,
because, first, it forced patients to expand their lungs ;
second, because there was reason to believe it might act in
some degree as an antiseptic ; third, that it was useful in
improving the nutrition. In cases of phthisis with partial
consolidation, with fever, night-sweats, and cough, the ad-
THE MEDICAL RECORD.
[October 5, 1889
ministration of oxygen will be followed by a decline of
the daily temperature, subsidence of the night-sweats, im-
provement of appetite, and more perfect digestion and
assimilation ; patients are taught to breathe more perfect-
ly, which is invariably followed by increased lung expan-
sion. ‘The method of administration is important. The
patient should be instructed to expel as completely as
possible the air from the lungs, and then inhale deeply,
and after fully inflating the lungs it should be held as
long as possible before being expired through the nose ;
there should be an interval of two minutes between each
inhalation ; this method is applicable to the treatment of
phthisis and anzmia. In pneumonia it should be ad-
ministered continuously from three to five minutes, and as
frequently as the urgency of the case demands.
I quote a few cases taken at random from my note-
book, which will suffice to show the general action of this
ent. :
se CASE I.—A gentleman, aged thirty, an actor by profes-
sion, slight in stature, family history negative, was obliged
to remain most of the time in the Northwest, because of
pulmonary trouble. Whenever he returned to his home
in the East his trouble was invariably aggravated. A
physical examination revealed the following condition:
Consolidation of the left apex anteriorly as far down as the
nipple line; also evidence of small cavity in the upper
part, and moist råles throughout the lung ; incessant cough,
profuse expectoration of muco-purulent character. daily
abnormal temperature, followed by profuse night-sweats,
and rapid emaciation. Began inhglations of oxygen for
from fifteen to twenty minutes twice daily. At the end of
one week the night-sweats had matenally diminished,
cough less severe, and general condition much improved.
At the end of six weeks’ treatment he had improved con-
siderably in general condition and weight. An examination
of the lungs showed that the induration had very much
decreased, no evidence of cavity, and almost an entire ab-
sence of rales. Physical examination at the end of ten
weeks showed that the consolidation had entirely disap-
peared, no vestige of the former trouble remaining, and
he was apparently a well man. No return of his former -
symptoms have developed up to date, which is now more
than a year; the only treatment he received, other than
the inhalations, was the iodide of iron.
Case II.—A gentleman, aged thirty-two, by occupation
a civil engineer, of phthisical family ; five years ago had an
attack of pleurisy with effusion, which left a carnified con-
dition of the upper part of the right lung. Three years
later began to lose flesh; a cough from which he had
never entirely recovered became worse, accompanied by
profuse expectoration, rapid loss of flesh ; daily tempera-
ture reaching as high in the afternoon as 103° F., followed
at night by profuse sweating. Patient was advised to go
to Colorado ; after remaining there some months, without
improving, he returned to New York thoroughly disheart-
ened, having given up all hope of ever getting well. Placed
him upon inhalations of oxygen and nitrogen monoxide,
as in the former case. Its use was marked by an increase
of the expectoration for the first week, after which time
it gradually decreased; the appetite, which was entirely
gone, improved rapidly ; the afternoon fever and night-
sweats disappeared at the end of the fifth week, with
gradual improvement in the general health, and slight gain
in weight. The breathing at the commencement of treat-
ment, which under forced inspiration was very limited,
painful, and accompanied by a disposition to cough, gave
place to easier and painless respiration. Patient has been
under constant treatment since November, 1888. ‘The
last two months he has been able to attend to his business
daily, and has exposed himself repeatedly to inclement
weather without any return of his former symptoms. A
slight cough remains, which, I believe, is due to the pres-
ence of pleuritic adhesions. One thing further I would
mention, the chest expansion under forced inspiration was
increased from one and a half to three and a half inches.
Case III.—-Young lady, aged twenty-three, suffering
October 5, 1889]
THE MEDICAL RECORD.
37!
from an extreme form of simple anzmia, which had re-
sisted a thorough employment of the usual remedies, com-
bined with good food and plenty of fresh air; was con-
sulted because of amenorrhoea, loss of appetite, feeble
digestion, and irregular action of the bowels; could not
take proper exercise without marked dyspnoea. A thorough
examination excluded all organic causes. Having tried
iron, arsenic, and strychnine with but slight and only
temporary improvement, I concluded to try inhalations of
oxygen in conjunction with the above-mentioned remedies.
To my satisfaction, and to the patient’s great delight, im-
provement began almost immediately in the appetite, di-
gestion, and assimilation; the pallor of the face gradually
gave place to a healthful rosy complexion, with disap-
pearance of the dyspnoea, and at the end of three months’
treatment the menses were perfectly re-established.
_In the treatment of pneumonia I have used the com-
bination of oxygen and nitrogen monoxide with marked
benefit. It quiets the action of the heart, greatly relieves
the dyspnoea, enabling the patient to breathe more freely
and deeply, and promotes free expectoration. ‘The fol-
lowing case, taken from a number so treated, and cited
because of its extreme form, will suffice to demonstrate
the beneficial effects of this mode of treatment.
A gentleman aged sixty-three, of robust habit, was
taken ill with double pneumonia. Recognizing the case
to be of extreme gravity, because of the rapid respiration
and the early development of delirium, with a rapid, feeble,
and irregular pulse, I immediately began the use of oxy-
gen and nitrous monoxide, with stimulants, and other
remedies. At first the inhalations were given very fre-
quently, as often as every fifteen or twenty minutes, and
for a period of from three to five minutes at a time. After
using a few times, the patient became more quiet, the
breathing easier and less rapid, with clearing up of the
cyanosis, and abatement of the delirium, and free expec-
toration. The remedies were continued through the night.
The following forenoon patient expressed himself better,
and very much relieved by the inhalations. The remedies
were continued through the course of the disease, at either
longer or shorter intervals, as the exigencies of the case
demanded, and was always followed by an amelioration of
the urgent symptoms. During the period of convalescence
the patient seemed to gain strength more rapidly by a
continuance of the inhalations, and made a perfect recov-
ery. This case was seen with me in consultation by Drs.
Thomas E. Satterthwaite and W. A. Shufelt, who heartily
endorsed the line of treatment.
Sufficient has been said to show the efficacy of this
agent in the class of cases above mentioned. Dr. ‘Thomp-
son cited in his paper the great benefit that was derived from
the use of oxygen in the treatment of cholera, during the
epidemic at Marseilles and Toulon in 1886. If such was
the case, why should it not be a most excellent agent to
be used in the treatment of cholera infantum, especially
during the period of collapse? I am convinced that oxy-
gen as a therapeutic agent has not received the attention
that it merits, and I agree with Professor Thompson, that
no consideration of expense should weigh against it.
153 Wast TENTH STREET.
MassaGE IN Rickets.—Dr. Silfverskidld speaks very
favorably of massage in the treatment of rachitis. He
begins with the lower extremities, using considerable press-
ure in a direction from below upward, and making ener-
getic passive movements of the ankle-, knee-, and hip-
joints. He then passes to the abdomen, thorax, neck,
and upper extremities, exciting increased respiratory
movements by making pressure on the chest. Each
séance lasts for from ten to fifteen minutes, and the treat-
ment is continued through a period of from four to six
weeks. At the beginning, the patient usually complains
of pain during the manipulations, but this soon passes
away. The author claims to have obtained excellent re-
sults in a number of cases.
——
INTUSSUSCEPTION AND THE USE OF INJEC.
TIONS.
By W. E. FOREST, M.D.,
NEW YORK.
In THE MepicaL Recor for August 3d is reported a case
or intussusception in a child relieved by the use of sulphu-
retted hydrogen gas from a Bergeon apparatus. It is
stated that this is the first case, as far as known, where
the Bergeon apparatus has been used for this purpose in
this State.
However admirable this method may be in the treat-
ment of the condition in question, if another method can
be shown to be as effective and more safe, more simple,
and more scientific, the former should give way to the
latter. |
Without further introduction, I will suggest to Dr. Ro-
denhurst and the profession in general, a method that will
meet the requirements mentioned.
In using injections of either gas or liquid to overcome
intestinal obstruction, one ought, if possible, to know two
things, namely: rst. How much force (approximately) the
intestine will stand without danger of rupture. 2d. How
much force one is using at any moment in giving the in-
jection.
As to the first point, a series of experiments made by
me and detailed in a paper read before the New York
Academy of Medicine, and published in the Fournal of
Obstetrics in 1886, would seem to show that it is not safe
to use an injection with a pressure exceeding fifteen pounds
to the square inch in a case of intussusception, and this
only in adults. In infants the pressure should not ex-
ceed six or eight pounds to the square inch (see Fournal
of Obstetrics).
Now, with the Bergeon apparatus a greater pressure than
the above might be used, I suppose. With the Davison
syringe I have shown that a pressure of from thirty to sev-
enty pounds to the square inch may be exerted on the in-
testine, and hence a very dangerous pressure.
The objection to the Bergeon apparatus, aside from the
fact that one cannot measure and regulate the pressure
accurately, is its cost and cumbersomeness as compared
with the apparatus I have suggested in the article referred
to.
In order to measure the pressure used in an injection, it
is only necessary to remember that one atmosphere, or
fitteen pounds to the square inch, supports a column of
water thirty-three feet high ; hence a column of water
thirty-three feet high will make a pressure of fifteen pounds
upon every square inch of surface at the base of the col-
umn.
Now, if this column of water be held in a rubber tube
of ordinary size, after allowing for friction of the water in
the tube, it will be accurate enough to say that every two
feet of the column represents a pressure of one pound to
the square inch ; hence a rubber tube six feet long, filled
with water and held vertical, will cause a pressure of three
pounds to the square inch at its base ; and a tube twelve
feet long will exert a pressure of six pounds to the square
inch at its base ; and so on.
Now, apply this principle to a case of intussusception
in a child, for instance. The surgeon, instead of sending
to the nearest city for a consultant and a Bergeon appa-
ratus, goes to the drug store or hardware store and gets a
rubber tube twelve to twenty feet in length. Into one
end is inserted a funnel; into the other a nozzle ofa
Davison syringe. In order that the injected fluid may
be retained, a shoulder may be made on the nozzle about
one inch from the end, by winding a roller-bandage around.
‘This shoulder will retain every drop of the injéction when
pressed against the sphincter. Now a pitcher of warm
salt-water completes the apparatus, and the father of the
child is the assistant surgeon. ‘The patient is taken into
the hallway of the house, so that the requisite elevation
may be gained, the child is etherized, the surgeon inserts
the nozzle of the syringe and holds it in the rectum with
372
THE MEDICAL RECORD.
[October 5, 1889
one hand, while with the other he manipulates the walls of
the child’s abdomen. The assistant pours the water into
the funnel and slowly raises it, mounting the stairs at the
time if necessary. When the funnel has been raised
twelve feet above the level of the child’s body, great care
should be exercised, as the pressure is now about six pounds
on every square inch of colon below the obstruction. It
is seldom that a greater pressure than this will be needed
to reduce a recent invagination. The pressure should be
increased very slowly, as time is an important element in
reducing an invagination.
If in any case the pressure mentioned above does not
bring about the end aimed at, the pressure may be increased
up to ten pounds to the square inch.
For further details as to the method and when to em-
ploy it, as well as for a simple and cheap method for gen-
erating gas and its use in reducing an intussusception, I
must refer to the article in the American Journal of Ob-
stetrics for 1886.
In that article ace the histories of two cases of intussus-
ception successfully reduced by gaseous and fluid ene-
mata introduced from a syphon of Vichy water.
Since publishing the method ‘or the use of a column of
water, Dr. A. S. Hunter, of this city, has used the method
successfully in a case of invagination in a child.
105 WAVERLEY PLACE.
BSrogress of Medical Science.
. PARASITES OF THE BLoop.—A Russian scientific ob-
server some years since discovered in the blood of birds
animate bodies, of the nature of parasites, to which he
has given the name of Polimitus, presenting a striking re-
semblance with the organisms described by M. Laveran
as existing in the blood of persons attacked by malarial
fever. Subsequent researches have shown that the pres-
ence of microbial parasites of animal origin in the blood
is much more common than had been suspected, more
especially in cold-blooded animals. Of warm-blooded
animals, carnivora are more liable to be invaded by these
intruders than others, but it is comforting to learn that,
for the most part, their presence does not appear to entail
any particular inconvenience. Only four or five out of
three hundred birds examined, died in consequence of
lesions caused by the parasites, and the pathological ap-
pearances were then identical with those observed in the
subjects of malarial fever.— The Medical Press.
THIOL, A RivaL oF IcHTHYOL.—Ichthyol has found a
rival in thiol, a new product of chemical synthesis, ob-
tained by artificially sulphuretting unsaturated hydro-car-
bons, and charging these with ten per cent. of sulphur
(Zhe Provincial Medical Journal). Chemical and thera-
peutical researches prove its exact identity with ichthyol.
. Thiol consists of a brown fluid of the consistency of syrup ;
it is completely soluble in water, is totally inodorous, and
has therefore a decided advantage over ichthyol. There
exists also a dry thiol, which has two and a half times the
strength of fluid thiol, otherwise having the same proper-
ties as the latter. ‘Thiol is used like ichthyol in the fol-
lowing diseases: Acne, acute and chronic rheumatic ar-
thritis, other rheumatic affections, contusions, decubitus,
eczema, erysipelas, neuralgia, ischia, leprosy, frost-bites,
prurigo, pruritus, ulcus, cruris, burns, and scalds. On
the initiative of Schweninger, thiol was tried at the Charité
Clinic of Berlin, and Dr. Reeps reports on these trials in
a very favorable light, as does also Dr. Buzzi, whose opin-
ion is based on an even more extended clinical experi-
ence. Dr. Reeps states that it may safely be concluded
that thiol, externally applied in skin diseases, has positively
the same effect as ichthyol. As their effect in these in-
stances is identical, it may also be assumed that thiol will
prove equally efficacious in other diseases where ichthyol
has been employed. Reeps has taken internal doses up
to two and a half grammes without discomfort or disturb-
ance of the stomach ; and he believes, therefore, that it is
comparatively harmless. It has been asserted lately that
this is not the case with ichthyol, but he ascribes the ad-
verse physiological effects of ichthyol to its obnoxious
taste and odor, and these are entirely eliminated in thiol.
He does not consider there is any further doubt that thiol
and ichthyol are two exactly identical substances, and that
thiol will serve to replace ichthyol when the natural
sources of the latter remedy become exhausted ; even now
the discovery may be recognized as a great boon, which
makes us independent of nature’s supply of this valuable
remedy. ‘The following are the usually prescribed for-
mulz :
Vaselit os 32. desde eoneeen + ces kee ee 3)
Eanoln 35.56 4. cat ee e a ea kate cows Zj
M. F. ungt. S.: For external use.
B. Thiol sicc... eesse s seoses esoessssseseeeo gr. ij.
Pulv. glycyrrhizæ.....e...esesssosse o». gr. ij.
Glycerin. tragacanth.......secsee. eors q. &
F. pilula. S.: One pill to be taken three times a day.
B. Thiol sicC......esosesssoorsseocosecoess 3).
“ZINC oxid. ....esesesasoseeecssoee coreo 31}
Amylum.....sesoe es CEEE EE 3).
Tarata eaaa aoa was aes Zij.
F. pulv. S.: The affected parts to be dusted with this powder.
- MALE FERN AND CALOMEL FOR TAPE-WORM.—In the
treatment of tænia Dr. Duchesne strongly recommends
male fem combined with calomel, according to the fol-
lowing formula :
Eth. extract male fern.........ccscee0e 2 drachms,
Calome@liacccct. <502ssacewta oes eeeees 12 grains.
M. Make 16 capsules, which are given two at a time, every
ten minutes until all are taken.
The great advantage of this preparation is that the pa-
tient has nothing to drink, and that the purgative is taken
along with the worm-medicine. For some people, espe-
cially women, capsules are difficult to take, in which case
the medicine is perhaps best taken with molasses. Some-
times the capsules provoke colicky pains, but these can be
avoided by taking twenty grains of antipyrin fifteen min-
utes before the capsules. With these capsules Duchesne
has yet to experience his first failure, and he has already
used them in hundreds of cases. Male fern is the only
remedy that will successfully expel the bothnocephalus.
The treatment of tznia in children is a difficult matter,
but he has been regularly successful with the following
plan: After fasting twelve hours, administer the follow-
ing preparation to a child of five years :
Eth. extract of male fern............-- I drachm.
Calomels oc oevscue ed EEREN 6 grains.
SUGGS oes code oss dace we ke eeeareoeeeees 2 drachms.
Gelatin, q. s. to make a jelly of ordinary consistence.
The patient should be told to take an injection of salt
water when the worm appears at the anus, and then sit
over a vessel of warm water to float the worm and pre-
vent it breaking from its own weight. ‘The one point al-
ways to be remembered, on which success depends, what-
ever the vermifuge used, is the necessity of administering
the purgative soon after the substance which stupefies the
worm.— The Weekly Medical Review.
MENSTRUAL Optic NeuritTIs.—Dr. E. Beck (Zhe Cin-
cinnati Lancet Clinic) has reported several cases in which
optic neuritis has resulted from menstrual anomalies. He
arranges them into several groups. 1. Cases which occur
in young girls, when the menses fail to appear. 2. Cases
which occur in young women, with tardy, scanty, and ir-
regular menstruation. 3. Cases which occur in amenor-
rhceic women. 4. Cases which appear immediately after
the sudden suppression of the menses from cold, fnght, or
any cause. 5. Cases caused by dysmenorrhea. 6.
Cases caused by metrorrhagia. ‘There is finally a small
group of cases in which chronic metritis has led to early
atrophic changes in the uterus, scanty, irregular menstrua-
tion, and sterility.
October 5, 1889]
THE MEDICAL RECORD.
373
ATHREPSIA: A WASTING DISEASE OF CHILDHOOD.—
In the Revue mensuelle des Maladies de l Enfance Dr.
Legournet has published an article on athrepsia, a résume
of which appears in the Archives of Pediatrics. Athrepsia
is a morbid condition of infants which is characterized by
disorders of digestion and nutrition, and results in defec-
tive or improper alimentation. The most striking symp-
tom im the physiognomy of an athrepsic patient is emacia-
tion. The child loses weight rapidly, and may lose as
much as twenty or thirty grammes daily. Parrot divided
the disease into several periods and recognized several
degrees in the gravity of the disease. It frequently be-
gins at the end of the first week of life, the process of
denutrition or innutrition being consecutive to that which
existed at birth. If it is remembered that for the first
few days after birth an infant normally loses thirty or
forty grammes daily even with a good nurse, this loss
being rapidly made up in the succeeding period, it is easy
to understand how great the loss in vitality must be to
infants who lose much more than that and then fail to
gain correspondingly in the succeeding days. Such chil-
dren may live from three to six weeks, being apparently at
death’s door all the time, and becoming more and more
feeble and emaciated. In the pen es of athrepsia
one may distinguish three periods—one which is marked
by the phenomena of indigestion and by green diarrhoea ;
a second which is marked by vomiting, muguet, erythema
of the scrotum, the thighs, and the anal region, emacia-
tion, and chilliness. If suitable food be given it is possi-
hle to restore the child even from such unfavorable con-
ditions. The third period is that of cachexia, and is fol-
lowed by death from exhaustion or from complications
which intervene. The rapid form of athrepsia is the
most common one, the child succumbing in three to six
weeks. In the slow form the child may even gain weight
in spite of bad hygiene, and may reach the age of several
months, dying without complications. The author dis-
tinguishes an acute athrepsia from the rapid variety by
the fact that in the latter the infant has never been able.
to profit by the food which was given him, while the
other made irregular progress, the regimen being tolerated
for a while, and then giving rise to gastro-intestinal dis-
order. ‘The latter will die unless suitable dietetic changes
are made ; the former may be able to exist without much
change of diet if he survives the gastro-intestinal attack.
But a child who survives this bad usage is very likely to
show the effects of it in his physiognomy, his bearing, his
functions, and his nutrition. Such children become rachitic,
have pulmonary or other serious troubles, their teeth appear
late and are badly developed, and the individuals them-
selves usually die young. The disease is easily diagnosti-
cated. A child who does not digest at all, or digests
badly, and instead of jmproving emaciates and loses
weight, or gains very slowly, hasathrepsia. Vomiting and
diarrhoea are not the only symptoms, for such symptoms
are present in simple enteritis or in gastro-intestinal dis-
ease, or in infantile cholera, for these are accidental con-
ditions resulting from errors of diet, from heat, and indi-
gestion. The digestive troubles in athrepsia are the
expression of a morbid state which is brought about by a
defective regimen. In order to thrive, an infant should
gain twenty to thirty grammes in weight daily for the first
four months of life. If he gains less than that, his con-
dition may become a serious one at any time. ‘The le.
sions in athrepsia are those of violent gastro-enteritis,
ulcerations, ecchymoses, softening and granular infiltration
of the mucous membrane of the digestive tract. Finally,
there are thromboses, interstitial hemorrhages, and steato-
sis of the kidneys, lungs, liver, and brain, all of which in-
dicate an acute or chronic inflammation of the digestive
tube, and the trophic disorder which accompanies the
final cachexia. The mortality from this disease is very
great. Inthe authors district, which includes a popula-
tion of four thousand, about one-third of the deaths un-
der ane year of age, and one-seventeenth of the total
number of deaths, were from this cause during a given
period. All the infants were bottle-fed. The statistics:
of the entire city of Paris were even more astonishing, for
there nearly two-thirds of the infants are bottle-fed.
THE ELIMINATION OF MORPHIA BY THE STOMACH.—
Dr. Alt, of Halle, gives his researches on the elimination by
the stomach of morphia injected subcutaneously. Hitzig
had noticed that a dog which had licked up the vomit
of another which had been narcotized by morphia injec-
tion also vomited a short time thereafter. This led Hitzig
to believe that, notwithstanding the very short time between
the injection and the vomiting, a considerable portion of
the injected morphia had been eliminated. Men do not
all react in the same way to morphia—some vomit, others
do not; and authors explain this by saying that a part.
of the ‘morphia is converted, in the circulating blood,
into apomorphia, or that the preparation used is impure.
None of them seem to think that the vomiting may be a.
reflex act setting out from the gastric nerves. Dr. Alt
made many experiments, and found that in dogs morphia
injection caused, in a few minutes, vomiting, and that a
considerable portion was eliminated as morphia by the
stomach. Before the injection the stomach was carefully
washed out, and at short periods after it samples were
taken and tested. The conclusions at which he has ar-
rived are the following: 1. After subcutaneous application
of murphia, it is eliminated by the stomach. 2. This
elimination begins in two and a half minutes, lasts for half
an hour, and ceases in one hour. 3. The inclination to
vomit begins when the morphia appears in the stomach,
and may be prevented by washing it out. 4. The quan-
tity thus eliminated amounts to about half what is in-
jected. 5. Poisonous results are much lessened by wash-
ing out the stomach, and deadly doses were thus borne
without harm. These propositions are true of dogs, and
to a great degree also in man. The practical importance
of these researches lies in the fact that washing the stomach
will be found of the greatest use in opium-poisoning, and
that the medical jurist should in future search for the poi-
son in the stomach instead of the blood, even when it has
been given subcutaneously.— Zhe Edinburgh Medical Jour-
nal, August, 1889.
THE Foop TREATMENT FOR INsomNIA.—Dr. Eggles-
ton says that most students and women who are troubled
with insomnia are dyspeptic, and he has found it easy to
successfully treat such cases without medicine. They are
instructed to eat before going to bed, having put aside
work entirely, at least an hour before. If they are not
hungry, they should simply be instructed to eat; and if
they are hungry, they should eat whatever they want. A
glass of milk and a biscuit is sometimes all that can be
taken at first, or a mashed potato buttered. In a short
time the night appetite will grow, and the appetite will
then need no particular directions. If possible, the night
meal should be taken in another room than the sleeping
apartment, and for men in the city it will be found advan-
tageous to go out to a restaurant. The idea of going out
for something to eat and having to wait a short time for
it will excite the appetite. Before eating, however, a bath
should be taken ; I much prefer cold or cool baths, which
should be given with a sponge or stiff brush, and the body
thoroughly rubbed off with a coarse towel afterward. The
bath need not be more than five minutes in duration.
After the bathing and rubbing, or after eating, a
moderate amount of exercise should be taken. For thisa
few minutes with Indian clubs or dumb-bells is sufficient.
Further than this, the patient should go to bed at the
same hour every night, and arise at the same hour every
morning. . . There is a popular superstition that
grown people should not eat immediately before going to
sleep ; that it will give them indigestion or nightmare, or
both. Dr. Eggleston cannot see why adults should be so
very different in this respect from babies. We know that
young children awake at night, and must have something
to eat before they will sleep quietly ; and some children
actually fall asleep with a nursing-bottle leaking into the
374
THE MEDICAL RECORD:
[October 5, 1889
mouth. It may be true that digestion is carned on slowly
during sleep, and that the digestive function is less active,
but here one need not be in a hurry for the completion of
the operation. The average person should be in bed
seven or eight hours, which is time enough for the diges-
tion of almost anything edible. In our American life, he
thinks, the digestion carried on through sleep probably has
the better chance for thoroughness.— Journal of the Amer-
ican Medical Association.
THE EFFECTS OF ACIDS ON THE FUNCTIONS OF THE
SToMACcH.—1. Acids throw down a considerable precipi-
tate of mucus. 2. They increase the cellular elements
of the gastric contents. 3. Their introduction is fol-
lowed by butyric-acid reaction, most marked after hydro-
chloric acid. 4. Larger quantities of the acids result in
a considerable effusion of bile into the stomach. 5. They
stimulate the secretion of pepsin, but have no influence
upon the secretion of hydrochloric acid. 6. Their long-
continued administration is followed by marked diminu-
tion of the secretion of hydrochloric acid. 7. Even in
large quantities hydrochloric acid produces no gastric
disturbances. On the contrary, a continued administration
of the acid is attended with a feeling of well-being. 8.
‘The difference in the effect between acids and the alkaline
salts on the gastric functions consists in the fact that the
alkaline salts dissolve the mucus and decrease the secre-
tion of pepsin, while the acids precipitate the mucus and
increase the secretion of pepsin. ‘The disappearance of
the alkaline salts from the stomach is followed by a de-
cided increase of the hydrochloric-acid secretion. This
does not occur, or only to a slight degree, in the case of
acids. Both the acids and salts, in large quantities in
continued use, have the same effect in lowering the ac-
tivity, and finally in destroying the function, of the glands
secreting hydrochloric acid.— Jaworski, in Centralblatt für
Klinische Medicin.
THE EXCRETION oF URIC ACID AND ITS RELATION
TO MENTAL Depression.—In the London Practitioner
Dr. Haig has published a paper on the relation between
the excretion of uric acid and mental depression. The
author has published his researches on the relation of
certain forms of headache to the excretion of uric acid
(“ Medico-Chirurgical Transactions,” vol. lxx.), and he now
shows that the mental condition of many patients depends
on the amount of uric acid in the blood. When the acid
is in excess it produces marked depression or irritability
of temper ; when this excess passes off, there is a feeling
of exaltation and sense of well-being. Many suffer from
a certain amount of mental depression and heaviness at
that time of the day at which the excretion of uric acid
is normally at its greatest, that is, in the morning between
breakfast and lunch, during the time the acidity of the
urine is lowest. This corresponds in every way to the
condition artificially produced by giving alkalies, which
wash uric acid in excess into the blood, so inducing de-
pression ; by giving acids sufficient to counteract the alka-
linity of the blood, the heaviness and depression will give
place to feelings of well-being, mental clearness, and pleas-
ure in living. When the blood is strongly alkaline, and
m a condition to hold much uric acid in solution, all the
symptoms of mental depression are present, and are more
or less marked according to the amount of acid present,
the excretion of uric acid in the urine being at the same
time proportionally in excess of the average. When a
dose of mineral acid has been taken the mental conditions
clear up exactly in proportion as the uric acid is cleared
_ out of the blood, and its excretion in the urine diminishes.
When a dose of acid has been taken to cure a headache or a
fit of mental depression, it is extremely common for some
amount of shooting pain in the joints to be present while
the acid is driving the uric acid out of the blood. By re-
ducing suddenly the alkalinity of the blood in this manner,
it 1s very common for the uric acid in the tissues of the
joints to be deposited in the joints instead of passing off
in the blood. In the treatment of cases of mental de-
pression, where it 1s evident that the excretion of uric acid
plays the chief part, it 1s not always certain that a dose of
acid taken now and then will produce a cure; the pre-
vention of the excessive formation must be aimed at by
regulating the diet. A large amount of butchers meat
should not be allowed, but should be replaced by fish,
fowl, and milk, and stirnulants are to be avoided. In
many severe cases the author has met with great success
by insisting on a diet of bread, butter, milk, potatoes, and
a large quantity of fruit, continued for weeks or months.
At the beginning of this treatment the washing out of the
uric-acid stores may be hastened by giving about fifteen
grains of salicylate of sodium three or four times a day,
or in some cases a dose of twenty grains every night is
sufficient.
PUERPERAL ANAMIA AND ITS TREATMENT WITH AR-
SENIC.—Dr. Osler (Boston Medical and Surgical Journal
and American Journal of the Medical Sciences) says that
of the twenty-one cases of pernicious anzemia of which he
has notes, nine were in women, and in five of these the
condition developed post partum. One of them he re-
ports, by way of illustration. The patient began and con-
tinued to grow anzmic after confinement, could not sit up
in bed without fainting, had constant vomiting and uncon-
trollable diarrhoea. Under the continued administration
of Fowler’s solution she steadily improved and became
robust and of a good color, though iron had previously’
been given without any benefit whatever. The author then
reviews the history of the employment of arsenic in per-
nicious anemia, and calls attention to the fact that we do
not fully understand the reason why the drug should be
so useful in some cases and so useless in others. It cer-
tainly has often an effect in profound anemia much re-
sembling that of a specific; like that of quinine in ague,
and iron in chlorosis. The initial dose should be five
drops, increasing gradually to twenty or thirty drops three
times a day. Puffiness of the eyelids, cedema above the
eyebrows, vomiting or diarrhoea, indicate that the drug
should be suspended for a time. Sometimes arsenious
acid is well borne, when Fowler's solution disagrees with
the stomach. The point of greatest importance is that
the medicine must be given for long periods and in in-
creasing doses. In post-partum cases recovery is always
slow, and it is well to intermit arsenic for a few weeks;
but it should be given at intervals for many months,
even when the health is apparently re-established, as there
is a well-recognized tendency to relapse in these cases.
FORMATION OF MELON-SEED BODIES IN JOINTS AND
TENDON SHEATHS.—Considerable light has recently been
thrown by Schuchardt on the mode of production of these
. bodies. After criticising the generally accepted views of
their formation by fibrinous deposition, he gives at some
length the results of his own microscopical examination
of specimens that have come under his notice. His re-
searches seem to show that the mode of their origin is es-
sentially different from that which has been just alluded
to. ‘They either consist really of altered portions of the
lining membrane of the walls of the cavity itself in which
they are contained, or they are developed in connection
with the.tendon sheaths; while a careful examination of
them shows that coagulated fibrin does not really enter
into their composition. In more than one instance the
lining membrane of the joint was found to be covered
with a viscid substance more or less laminated in charac-
ter, and here and there already causing adhesions to take
place between the opposing surfaces of the joints. ‘These
glutinous masses appear to be composed of partially
“necrosei” portions of the joint-wall, which, instead of
passing away, remain connected with the wall and like-
wise become attached to one another. The movements
of the surfaces of the joints upon each other then cause
these bodies to drop into the joints, where they lie loose
as melon-seed bodies, and if the joint is in a fairly healthy
condition they may be evacuated, and leave behind a good
and useful jolnt.— Zhe Practitioner, June, 1889.
October 5, 1889]
THE MEDICAL RECORD:
A Weekly Fournal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., EDITOR.
a a
PROPRIETORS AND PUBLISHERS
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
New York, October 5, 1889.
CONCERNING SUITS FOR MALPRACTICE.
Jupcinc from what we hear from different parts of the
country, suits for malpractice are becoming alarmingly
frequent. ‘There appears, in fact, to be an epidemic of
them throughout the West.
The question, What is to be done under the circum-
stances ? is one fraught with painful interest. To every
thinking man one thing is always evident, that in order to
protect the profession the persecuted members of it should
not be allowed to suffer. The profession in any neighbor-
hood cannot afford to allow a verdict to be taken against
a defendant. We say this much with becoming earnestness
and deliberation. ‘The attorneys generally believe that
the members of the medical profession always stand by each
other in such trials. This is as it should be, because we
ean always give the benefit of the doubt to the right side.
It is a rule, to which there is scarcely an exception, that
the surgeon (for it is he who is most frequently prosecuted)
always does the best he can for the patient, be the latter rich
or poor. Noman would be foolhardy enough to do other-
wise. Fortunately the court allows this in almost every suit
that is brought, although alleged negligence on the part of
the plaintiff is generally one of the important counts in
the indictment. We.are pleased to note that, in spite of
the most strenuous efforts on the part of the prosecution,
this charge is seldom substantiated. Most of the tenable
charges are also based on unskilful treatment and gross
ignorance of the requirements of the case. We say it for
the comfort of those who may now be under the ban, that
it is in the vast majority of instances exceedingly difficult
to prove this. A distinguished author once truly said
that the most directly opposite views upon any scientific
question could be proven by competent authority. ‘The
lawyers know this, and the surgeon must profit by it. The
burden of proof must always be upon the side of prose-
cution. The defence, being forced into the position of
expecting no quarter in the fight, has a right to retaliate
by giving none.
It is easy to see that, except for some outside help
in the way of medical testimony, the prosecution will
have no show. And here let us pause in commisera-
tion of the man who can use his scientific knowledge and
experience against his brother in time of trouble. To our
mind there is never any exculpation for this, even if the
persecuted man be a successful rival or the successful pro-
fessor of another school. No motive, however personal or
exasperating, can excuse such Judas business. The man
THE MEDICAL RECORD.
375
who is persecuted always has our pity, but the wretch who
lends his ammunition to the enemy richly deserves the
contempt of every fair-minded medical man. By his at
titude in fouling the nest in which he is hatched, he may
so load his own wings as to cripple his flying forever—and
he generally does. If this Judas element could be elim-
inated, very few, if any, indictments would be possible.
In some charity for such personages, we are willing to
admit that they are sometimes compelled to take opposite
sides by their open criticism of another’s work. Nothing
is easier for an envious brother, afflicted with caput tume-
factum, to magnify his office at the expense of the mis-
fortune of a rival. Of course, when caught up by the
shystering lawyer, it is too late to escape from wrong-
doing, and he is expected to swear to the point with di-
rectness and force. It is then the last and only re-
source of the traitor and sneak. ‘There is one such in
almost every malpractice suit. So much, then, for the so-
called professional expert on the other side.
It isa comfort, however, to the defendants to know that
very few verdicts are rendered against them. We are
speaking now of properly qualified men, who should not
be blamed for bad results. The law expects of no qual-
ified man more than he can do, with the use of his best
judgment and skill, in the treatment of any case. If the
case goes wrong he has the opportunity of explaining the
fact by contributory negligence on the part of the patient,
bad constitution, unfavorable surroundings, forced opera-
tion, and many other qualifying circumstances which might
tend to a bad result despite the most scientific treatment.
Indeed, if the practitioner even uses ordinary intelligence
in the management of his case, he is entitled to the bene-
fit of a doubt, especially if he wisely refrained from guaran-
teeing good results.
There are no cases more fraught with trouble for
the practitioner in regard to suits than those of fractures
and dislocations, particularly in the neighborhood of
joints. Nine-tenths of all the malpractice cases would
come under one or other or both of these heads. Gen-
erally speaking, the severe and complicated cases are
very difficult of diagnosis and very hard to treat, and al-
though the result may be, on the whole, satisfactory to the
surgeon, it is far from being so with the patient’s friends
and with professional rivals. How easy it is for the man
who was not there to say what the man who was there
should have done. And yet, when the cases are examined
from all points of view, and all the mitigating circum-
stances taken into account, it is found in ninety-nine cases
out of a hundred.that the results are exceedingly good if
not brilliant. Most of the mistakes, when they are made,
are in the direction ‘of diagnosticating fracture for dislo-
cation and treating the case accordingly, or at least of ig-
noring the possibility of a dislocation combined with fract-
ure. This is, of course, very bad, but even in the worst
cases such errors, in view of the great difficulties in diag-
nosis, are scarcely to be avoided. All these are consider-
ations which naturally come up in the general discussion
of such a subject, and may the better help us to appreciate
the true force and inwardness of the following sugges-
tions :
Always be certain of the diagnosis, and share the re-
sponsibility with counsel, if possible. Never guarantee
good results, but always give a guarded prognosis. It is
376
THE MEDICAL RECORD.
[October 5, 1889
always safer, in view of possible results, to treat the case
as a serious and important one rather than otherwise.
Never appear to be lacking in prompt attention to every
possible requirement of treatment, and always be ready
to warn the patient of the ordinary mishaps, short-
ening and deformity in fractures, the dangers attending
operations, and the like, that there may be a proper divi-
sion of risks and responsibilities. Be always on your guard
against contnbutory negligence on the part of the patient.
Promise him but little, and he will not be led to expect
miracles, And, lastly, remembering that you, too, are
mortal and liable at any time to err yourself, never criticise
the work of your brother practitioner, and never under
any circumstances consent to appear in court against him.
This latter is a rule to which there can scarcely be any
exception.
THE NEW BUILDING FOR THE ACADEMY OF MEDICINE.
Tue laying of the corner-stone for the new building of the
Academy of Medicine during the present week will mark
an era in the medical history of New York. It must be
considered a starting-point in a direction for lasting good
to the medical fraternity of this metropolis. The. pro-
fession will now have a home worthy of itself, and can
command that respect and influence which will necessarily
grow out of a unity of purpose and dignity of work—emi-
nently fitting to its high calling and noble aims. From a
few good men and true, who first joined interests in 1847,
and who met until lately in hired halls, it has increased
its membership to that of a large and influential body,
and will soon own an edifice which, in appointments and
fitness for scientific work, will have no equal of its kind
in this or any other country.
The Academy has earned its own right to its present
position. Since its organization it has done an amount
of faithful scientific work of which any similar society
should be justly proud. Its proceedings have been marked
with dignity, learning, and interest, and the papers and
discussions before it have gained a reputation for Amer-
ican medicine throughout the world. It has been, in es-
sence and in fact, a scientific society, which has not cared
to meddle with medical politics, or in quarrels based on
real or fancied ethical rights. Pursuing the even tenor of
its way, it has sought with an effectual and honest purpose
to gather under its influences the best elements for good
which dignified science can bring to bear on good fellow-
ship, and friendly emulation can suggest. Ever since its
beginning it has maintained this course. Its past expen-
ence cannot fail to foreshadow its future.
There is great reason for congratulation in all this. But,
at best, the profession of this city must not allow itself to
say more than that it has made a good beginning. A
great deal of work lies before it to keep up the reputation
of the Academy for good work and good deeds. It must
be admitted that the profession is willing to do its part.
But there is still something more to be done by the laity.
Liberal donations have already been made by lay friends
of the Academy, but the funds are not yet all subscnbed
for. We only wish, in this connection, to state the fact that
fifty thousand dollars is yet required to enable the medical
profession to feel really at home in their prospective build-
Academy. ‘The Academy has shown itself in earnest as
to its desire for a suitable home, and the time has come
for the rich men in and out of the profession to prove
their substantial sympathy in the laudable and necessary
movement. Who will be the benefactors? Science and
humanity stand ready with their benediction.
OUR ILLUSTRATION OF GERMAN MEASLES.
WE present in this issue another of the fine plates from
Morrow's “Atlas” illustrating one of the common eruptions
met with in general practice. It is only within later years
that Rötheln was considered a distinct form of measles,
and the interest in its study has developed accordingly.
The prominent feature of the disease being the eruption,
occasion is taken for the delineation of the latter in the
admirable coloring as shown in the plate. ‘The pale rose
hue is well portrayed, as are also the size, shape, and
general arrangement of the papules. On the whole, it is
an instructive object-lesson of a lesion the associated
symptoms of which are worthy of study. As a work of
art, it ranks with the beautiful and life-like representations
of scarlet fever and measles previously published in THE
MEDICAL RECORD, and likewise taken from Morrow's ad-
mirable “ Atlas.” :
THE LATE SESSION OF THE NEW YORK STATE
MEDICAL ASSOCIATION.
‘THE recent session of this Association was characterized
by an exceptionally large attendance, and much manifest
interest in the proceedings. ‘The topics discussed made
a home-like appeal to the general practitioner, whose zeal
is in the direction of “ the first care ;” they were practi-
cal, well-selected, exhaustive, and scholarly. Many new
men, destined to make their mark, surprised both them-
selves and others with the applause gained by their am-
bitious endeavors and the results of their work. There
were some disappointments, owing to the failure of a
rather crowded programme and the absence of certain
advertised participants, but, on the whole, these drawbacks
were more than compensated for by the eagerness of vol-
unteers to fill the gaps, so that there was no real dearth
of substantial material.
The set discussions on the collective-investigation
plan, which seem to have come to grief across the ocean,
were both satisfactory and successful. The themes se-
lected, such as “ Tubal Pregnancy,” the “ Treatment of
Hernia,” and the “New Hypnotics,” were timely and
well treated. We may say, in fact, that they were ex-
ceedingly well handled, and, so far as the detailed ques-
tions were concerned, assigned to those who were able to
speak by authority. ‘There were very little crudities of
thought or looseness of statement, but, on the contrary,
much honesty of investigation, some sceptical interroga-
tion, and a deal of logical candor.
Much as we have deplored the Code schism, we are
fain to acknowledge that, when families become too large,
the component individuals may gain in energy and bene-
faction by separating for the purpose of house-keeping on
their own account ; at all events, in the present instance,
sympathy appears to drift somewhat toward the young
couple, especially when zeal and honest endeavor go
ing. There is no argument needed for a full realization | hand-in-hand. Certainly, if the Association aim for influ-
of the beauty of charity on the part of the friends of the | ence and additions to our stock of knowledge, not only
October 5, 1889]
THE MEDICAL RECORD.
377
the profession but the public at large cannot fail to be
benefited—the field is large, the harvest ripe, and the
laborers none too many.
SUGAR OF MILK AS A DIURETIC.
AT a recent meeting of the Academy of Medicine of
Paris, Dr. Germain Sée referred to the diuretic action of
milk, and proposed to study this property more closely, in
order to see upon what constituents of this substance the
action in question depended. ‘That the increased diuresis
was not the result simply of the ingestion of a larger
amount of fluid, was shown by the fact that the excretion
was much in excess of the quantity of milk taken.
Arguing by exclusion, M. Sée came to the conclusion
that it was to the sugar which it contained that the milk
owed its diuretic properties, and he then put his theory
to the test by giving sugar of milk to a number of pa-
tients suffering from dropsy. In some cases the diuresis
was prompt and very pronounced, in other cases the
amount of urine was very slightly, if at all, in excess of
what it had been before the beginning ofethe experiment.
This discrepancy in the results was found to be due to
different causation of the dropsy. When the trouble was
purely cardiac, with but little, if any, disease of the kid-
neys, the remedy was certain in its effects ; but when there
was extensive renal disease, but little diuretic action was
noted. In cardiac dropsy, the author believed sugar of
railk was the best and most certain diuretic that we pos-
sessed, the excretion of urine caused by it being greater
than that due to any other drug. He found that it acted
similarly to, though more powerfully than, caffeine, while
possessing none of the disadvantages of the latter remedy.
Lactose acts, however, solely upon the kidneys, and is
only of service in relieving the dropsy of heart disease,
being without effect upon the dyspncea. For the latter,
M. Sée resorts to iodide of potassium, which may be given
at the same time with the sugar of milk. The ordinary
dose of lactose, in order to obtain the most certain diu-
retic action, is about three ounces in the twenty-four
hours.
UNIFORMITY IN REPRINTS.
Dr. CHARLES EVERETT WARREN has been writing, in the
Boston Medical and Surgical Fournal, regarding the in-
conveniences that accrue to those who write in medical
journals, and to the collectors of pamphlets, from their
very varying size. The Pittsburg Medical Review has
taken the matter up and attempted a solution of the
trouble. It finds that the columns of forty American
medical journals measure from 2} by 74 inches to 44 by
7% inches, It is suggested that by the adoption of two
regular sizes an absolute uniformity of publication can be
secured. A page 54 by 81, which may be called size No.
1, would sufficiently serve all journals whose column
width is from 2} to 3% inches, inclusive. This would
leave a margin of 1} inch for the smallest column 'and
4 of an inch for the largest, ample space for binding and
for the good appearance of the page. Of the forty jour-
nals noted, sixteen would come within this form. For
the remainder, a page 74 by 10 inches would prove satis-
factory. ‘This size, which may be called No. 2, would
allow of a double column in all journals whose column
width is 2} inches or less, and a single column for all
of those 4 inches or more in width. |
We would say that contributors to THE MEDICAL
RECORD would have to order a size slightly larger than
No. 2, since its page measures 33 by ro} inches. Re-
prints can, however, always be made of such style as the
author of the article desires.
News of the GHeek.
Dr. BEARDS WORK ON NEURASTHENIA, which was
translated into German by Dr. Neissier, has just reached
a third editon.
THE NEXT CONGRESS OF AMERICAN PHYSICIANS AND
SURGEONS.—At a meeting of the Executive Committee of
the Congress of American Physicians and Surgeons, held
in Philadelphia, September 21st, Dr: S. Weir Mitchell
was elected president of the next Congress, which will
be held in Washington in September, 1891, Dr. W. H.
Carmalt, of New Haven, Secretary; Dr. J. S. Billings,
of Washington, Treasurer ; Dr. William Pepper, of Phil-
adelphia, Chairman of the Executive Committee; and
Dr. S. C. Busey, of Washington, Chairman of the Local
Committee of Arrangements.
Dr. I. Minis Hays has retired from the editorship
of the Medical News, and Dr. Hobart A. Hare succeeds
him. Dr. Hays, we are glad to learn, will continue to
edit the American Fournal of the Medical Sciences.
EXECUTION BY ELECTRICITY.—At a recent meeting of
the Paris Academy of Sciences a communication from
Mr. Edison was read respecting the use of eleetricity as
a means of inflicting capital punishment. He is of
opinion that an alternative current will cause death with-
out pain, but he adduces no experimental evidence in
support of that contention. The matter was referred to
the Medical Section of the Academy, which is to have
the assistance of M. Marcel Desprez, the electrician, in
drawing up a report on the subject.—British Medical
Journal.
THE CELEBRATED PAINTING of Rembrandt, called the
“ Anatomical Lesson,” has been bought, it is said, by Mr.
Ellesworth for the Institute of Art, of Chicago, It for-
merly belonged to the Princess de Sagan.
TRANSPLANTING A CHICKEN’S CORNEA.—The Progrès
Médical, July 13, 1889, announces that Dr. Gravenigo, of
the University of Padua, has been successful in an opera-
tion which has been tried hitherto in vain in France and
elsewhere. This operation consists in grafting the cornea
of a chicken upon a human eye. The graft was made re-
cently, and the cornea is said to be very transparent, shin-
ing, and convex.
MEDICAL EXAMINERS FOR TENNESSEE.—The Governor
of Tennessee has appointed the six members of the State
Board of Medical Examiners, and they have organized
with Dr. James B. Murfree, of Murfreesborough, as presi-
dent, and Dr. T. J. Happel as secretary. According to the
law not more than four members may be appointed from
the same school of practice. In addition to the above
there have been appointed Dr. E. E. Hunter, of Elizabeth-
town, and Dr. Heber Jones, of Memphis ; with Dr. W. B.
Halbert (eclectic) and Dr. T. H. Hicks (homceopath).
378
THE STATE EXAMINATION OF MEDICAL STUDENTS.—
The law, passed last winter, requiring students having no
baccalaureate degree to be examined before entering upon
medical study, says the New York Medical Fournal, is
being put in train for enforcement by the Regents of the
University. A circular, dated August 2oth, has been sent
to the colleges and to individuals giving information re-
specting the methods of these examinations. The secre-
tary, Professor Melvil Dewey, may be addressed at Albany
for copies of the circular. Students who had entered
upon a three-years’ course prior to June 13, 1889, are not
affected by the new law. The earliest date for which an
examination has been set down is September 3oth, at Buf-
falo. Hence, we judge, a certain proportion of this year’s
entries at the colleges will be in the plight of a legal
oversight, unless there happens to be some provision that
1s not explicitly stated in the circular of the Regents.
However, as it is not the object of the act to lay a hard.
ship upon the students of the current term, there will prob-
ably be no difficulty in obtaining an amendment from
the next Legislature by which their cases may be passed
upon equitably. It is not generally known that the Re-
gents’ certificate is required to be filed with the dean or
secretary of the medical school “ prior to entering upon
the prescribed three-years’ course of study of medicine,”
and without this preliminary filing it is forbidden to the
schools to grant the degree of doctor of medicine. ‘The
act does not apply to persons who “ have already entered
upon ” the said course of study. The word “already”
must be construed to refer to the date of the approval of
the act by the Governor, on June 13, 1889.
PROFESSOR BRIEGER has received the sum of fifteen
hundred marks to enable him to prosecute his studies of
the ptomaines.
A VERY BOLD EXPERIMENTAL OPERATION for the re-
lief of the myxcedema which has followed complete re-
moval of the gland is now under tnal. It consists in
inserting a fresh, healthy piece of the gland in the abdom-
inal cavity, with the hope that it may form attachments
and perform its mysterious function. In one case, prob-
ably by pressure upon the large intestines, the inserted
mass, after the complete healing of the wound, caused
such violent colicky attacks that it had to be removed,
but in most instances no evil effects have followed the
insertion. What becomes of the transplanted gland is
not yet known. A case was recently shown that had
been operated upon about three months previously, in
which the presence of the gland in the abdomen could
apparently be still demonstrated by palpation, etc., and
in which, the patient asserted, his general condition was
much better than before the abdominal section.— Thera-
peutic Gazette.
FIGHTING A SUPPOSED “ MEDICAL TrRust.”—The fol-
lowing item is copied from the Evansville (Ind.) Courter
as an example at once of clear English expression and
intelligent economical science. “ It has become custom-
ary with all corporations, societies, companies, and many
private individuals, when they have a job of building, re-
pairing, painting, glazing, papering, printing, or any work
to do, to ask for bids for the same. ‘This has become so
common that a large number of citizens have lately joined
together for what they claim is self-protection, and will
THE MEDICAL RECORD.
[October 5, 1889
soon hold a mass meeting to act upon measures already
proposed for mutual protection. Among these the one
most necessary is some means .to protect themselves
against what they claim to be the exorbitant charges of
the medical trust. To do this blanks will be given to the
heads of families for the purpose of getting bids for at-
tending their families by the year or by the job, as they
may deem best. This seems to be a good move, if carried
out properly, and should include, besides the physicians,
preachers, lawyers, and all other professions and artisans
that have formed trusts, and thus a revolution will occur
that all would gladly see succeed.”—Boston Medical and
Surgical Journal.
DEPOPULATION OF FRANCE.—The movement of popu-
lation in France indicated by the summaries published
for 1888 in the Journal Officiel cannot be read without
regret. ‘They are summed up pithily by M. Georges
Michet in a few words: Diminution of marriages, aug-
mentation of divorces, decrease of legitimate births, in-
crease of illegitimate births, excess of deaths over births
in forty-four departments. But for illegitimate births,
the population of France would decrease.
Dr. DUTZE, formerly assistant in Dr. Unna’s clinic at
Hamburg, has been invited to proceed to Honolulu by
the Hawaiian Government, and to remain there some
time to study leprosy and to investigate the effect of new
methods of treatment.
SEVERAL OF THE MEDICAL JOURNALS OF Paris have
united to form a protective association. Over thirty
journals have already become members, many of which
are well known on this side of the Atlantic.
A MISTAKE THAT PREVAILS IN Boston.—The Boston
Medical and Surgical Journal says, aphoristically but
heterodoxically: “Woman has some organs outside the
pelvis.”
TRIED THE ELIXIR WITH STARTLING REsuLTS.—Dr.
Slominski experimented with the famous Brown-Séquard
elixir of life in his rooms, 507 South Thirteenth Street.
Both subjects were middle-aged men who had suffered
strokes of paralysis. ‘The first man was J. E. Bruner, and
the second was Tim Kelley. The modus operandi consists
of piercing a hole in the arm and then expelling the air,
after which the elixir is injected. Mr. Bruner stood the
operations wonderfully well, but Mr. Kelley did not.
Kelley turned almost deadly sick, and gonorrhoea immedi-
ately set in, but was checked by the physician.—Omaha
Dispatch.
A Rare ANOMALY: ABSENCE OF PECTORALS.—AS is
known, there exists a curious “law” according to which
very rare or exceptional cases of biological anomalies (dis
eases or anatomical defects) tend to occur in groups. The
“Jaw” is once more well illustrated by the congenital ab-
sence of the pectoral muscles. As your correspondent
stated in his preceding letter (vide the Reporter, July 13,
1889, p. 44), the literature of that extremely rare anomaly
had been recently supplemented by Drs. Schulthess, of
Zurich, Kobler, of Vienna, and Bradel, of Sophia (Bul-
garia), who had published each a case almost simultane-
ously and quite independently of each other. A few days
after my letter had been mailed to Philadelphia I received
a current number of the “ Proceedings of the Omsk (Si-
berian) Medical Society,” No. 3, 1889, which contained
MEDICAL RECORD
October 5 1889.
ROTHELN-GERMAN MEASLES.
From Dr. P A.Morrows Atlas of Venereal and Skin Diseases.
WILLIAM WOOD & COMPANY. Pithlishers.NEW YORK.
UNONER, EDDY 4 CLAUSS, LITH. N. Y. J Pru
October 5, 1889]
another instance of the defect, described by Dr. Nikolai
A. Tiiberovsky, house-surgeon to the Kiildjinsky Lazaretto.
The case is that of a young, strong, healthy, and otherwise
perfectly well-developed Siberian Cossack, twenty years
of age, in whom an accidental examination revealed a
congenital absence of the sterno-costa] portion of the right
major pectoral muscle, as well as of the whole pectoralis
minor, accompanied by an anomalous inability of the cor-
responding acromio-clavicular joint, the right clavicle and
acromion being longer and thicker than the left ones. No
functional disturbances were detected. Dr. ‘Tiiberovsky
adds that Professor W. A. Gruber, the illustrious Russian
anatomist, had seen only ome similar case (absence of the
clavicular portion of the major pectoral) during his forty
years’ practice, and Professor Lesshaff, of St. Petersburg,
only two (absence of the sterno-costa] portion).— Berne
Correspondence of The Medical and Surgical Reporter.
LAYING OF THE CORNER-STONE OF THE NEW
BUILDING FOR THE NEW YORK ACADEMY
OF MEDICINE.
THE New York Academy of Medicine laid the comer-
stone of its new building at 17, 19, and 21 West Forty-
turd Street, on Wednesday afternoon, October 2d, with
the assistance of Bishop Potter, the Rev. John Hall, Grover
Cleveland, Drs. A. Jacobi and A. L. Loomis, and an audi-
ence of several hundred persons. ‘The medical profession
turned out in force and filled every space within hear-
ing distance of the speakers. The platform was occupied
by officers and ex-officers of the Academy, with the dis-
tinguished laymen who were invited to participate in the
ceremonies. Among the medical gentlemen on the plat-
form were Drs. Fordyce Barker and S. S. Purple, ex-Pres-
idents of the Academy, Gouverneur M. Smith, George A.
Peters, S. D. Hubbard, W. H. Draper, F. N. Otis, A. M.
Jacobus, F. A. Castle, Alexander T. Hunter, C. A. Leale,
and George F. Shrady.
Bishop Potter opened the exercises with a prayer, and
the address was delivered by Dr. A. Jacobi, an ex-Presi-
dent of the Academy and the Chairman of the Committee
on Funds for the new building (see page 365).
ADDRESS OF EX-PRESIDENT GROVER CLEVELAND.
Mr. Cleveland’s remarks followed Dr. Jacobi’s address.
He congratulated the members of the Academy upon the
occasion that brought them together, and declared that it
signalized an important step in advance for medical sci-
ence, wrought by their activity and enterprise. He re-
ferred to the fact that he had lately seen a statement
printed by the Academy only three years ago, in which it
was set out that the aim of the organization since its for-
mation had been the acquisition of a building for its use
and the accommodation of its library, and that a com-
modious building had at last been obtained, and afforded
all the room the organization was likely to need for some
time. It was a remarkable evidence, he thought, of the
success of the Academy that that building, so commodious
only three years ago, had now been outgrown, and one
m or four times as large was about to be substituted
or it.
“'The nobility and sacred character of this mission have
been often dwelt upon,” he said. “It is an old story, but
it will never lose its interest while humanity is touched
with human woe, while self-sacrifice receives the homage
of Christian hearts, while the sufferings and sorrows of
our fellow-men start the tear of pity, nor while their allevi-
ation brings comfort and satisfaction to the soul of sym-
pathy. All your fellow-citizens may well claim a share,
not only because they are interested in the promotion of
the science and art of medicine, by reason of their liabil-
THE MEDICAL RECORD.
379
ity to accident and disease, but because such advance in
any profession as is here demonstrated adds to the glory
and renown of our common country. I am here to claim
for the laymen among your fellow-citizens a part of the
pride which grows out of the progress and achievement
of our medical profession. I base this claim upon the
fact that in this favored land of ours all interests are so
interwoven and all activities lead, or should lead, so di-
rectly to the accomplishment of our common national
destiny, that none of us can be indifferent to an important
advance among us in any science or industry.
“ I am sure that you are not inclined to ignore the aid
you have received in the project you have undertaken
from the laymen among your fellows. Nor can you for-
get that, underlying all that you have done and all that you
have received, are our free American institutions which
encourage and give scope to every worthy effort, and
which offer fitting rewards for intelligent and well-di-
rected labor in every condition of life.
“« You will not, therefore, I trust, deem it impertinent if
I remind you that none of us are absolved from the duty
of aiding in the maintenance in complete integrity of these
free institutions, and that this requires the thoughtful care
and attention of every citizen. You do much for your
country when you raise the standard and enlarge the use-
fulness of your profession, but you do not accomplish all
you can, nor do you discharge your full duty of citizenship,
unless you also attempt to better the condition of public
affairs, and give to political topics and movements the
benefit of your trained thought and well-informed judg-
ment. In this way you assist in making safe and sure the
foundations upon which must rest the success and value
of all your professional efforts and accomplishments.
“ I hope, when we shall celebrate here the discovery of
our country [applause], that we may point out on this
spot, in your completed building, a splendid monument of
the progress of our medical education; a monument
which shall not only prove to the stranger that our physi-
cians are proud of their profession, but one which shall
also be a reminder that those who govern within its walls
do not forget, in their devotion to the science and art of
medicine, their other duties of citizenship,”
The President, Alfred L. Loomis, then conducted the
imposing ceremony of laying the corner-stone, expressing
the hope shared by the multitude present that the act was
the harbinger of a brilliant future for the Academy and for
the science to which it was devoted. Dr. John Hall pro-
nounced the benediction.
THE NEW BUILDING OF THE ACADEMY.
The New York Academy of Medicine long since out-
grew its house at No. 12 West Thirty-first Street, and the
need for a larger building has been frequently talked of.
The money with which its present house was bought was
almost wholly derived from members of the medical pro-
fession, and it was only by the exercise of a scrupulous
economy that the society was able to pay off the mortgage
three years ago, and maintain its free library and reading-
rooms. With the recollection of forty years of effort to
acquire a suitable meeting-place for the profession, it was
not a matter of slight importance when Mrs. Charles Woer-
ishhofer gave to the Academy, through Dr. Jacobi (then
the President), $25,000 as a memorial of her husband, to
be applied to the procuring of a larger and better build-
ing. From this moment the agitation of the project, which
will result in the new building here described, became
active, and it was not long before information was received
that Mrs. Celine B. Hosack had bequeathed to the Acad-
emy $70,000, also to be applied to the erection or purchase
of a new building, with the sole condition that a certain
part of the building so acquired should be distinctively
recognizable as a memorial of her late husband, Dr. Alex-
ander Hosack.
With these two handsome gifts, and the value of its
present building, there seemed no reason why the Academy
should delay action, and a large subscription committee
A
9
80
was appointed, embracing several well-known citizens of
other professions, and more money was asked for.
A smaller committee was appointed to look for a
site, and for more than a year efforts were made to obtain
a location which would be acceptable. Owing to differ-
ences of opinion, and the scarcity of eligible sites, and,
perhaps, quite as much to the want of assured means,
there was some delay in arriving at a choice; but finally
the one selected seemed to all immediately interested to
be the most desirable. A purchasing committee was ap-
pointed, consisting of the President, Dr. Loomis, and Drs.
Herrick, G. A. Peters, and Castle, which committee was
subsequently made a building committee, Dr. Jacobi be-
ing added.
Several eminent architects were at once asked to submit
preliminary plans; and the excellence of all of them
necessitated several meet-
ings of the committee for a
choice. Finally the plans of
Mr. R. H. Robertson were
accepted, and, with slight
modifications, are the ones
now being followed.
It had been proposed to
use fire-proof construction
for the library and assembly-
hall only, but it was ultimate-
ly decided to make the entire
structure fire-proof, notwith-
standing the increase in cost.
The new building here
represented is on the north-
ern side of Forty-third Street,
about two hundrec and for-
ty-five feet west of Fifth
Avenue. Between it and the
Avenue the Century Club is
now erecting a house cover-
ing a plot one hundred feet
square, and between the two
buildings is that of the St.
Louis College. ‘To the
westward of the Academy site
the adjoining lot has since
been bought by a gentleman
with a contract to erect a
first-class private residence,
and the next fifty feet, run-
ning through two hundred feet
to the southern side of For-
ty-foarth Street, is being ne-
gotiated for by a syndicate
of art societies, with the in-
tention of erecting a building
which will accc mmodate the m
with rooms and furnish extensive galleries for exhibitions.
The proximity of the railroad depot; the stations of
the Elevated Railroad ; the horse-cars on Forty-second
Street, Madison and Sixth Avenues; and the stages on
Fifth Avenue, make the site as nearly central as it is pos-
sible to obtain, and there is little doubt that it will re-
main so for many years to come.
The new building covers a plot 75 x 100 feet, and has
a basement, four full stories, and two half-stories. Its
front is entirely of red sandstone, of fine texture, up to
the spring of the arches of the second story windows.
From thence brick-work will be introduced in increasing
proportion until the apex of the gable is reached, where
the finale is of carved stone-work.
There will be an assembly-hall 42 x 57 feet ; a conver-
sation- and smoking-room 26x 36; five rooms for meet-
ings of sections of the Academy and medical societies,
besides the large hall; four toilet-rooms, a reception-
room, coat-room, eight committee-rooms, ante-rooms,
apparatus- or specimen-rooms, and private study-rooms ;
a reference library 37 x 43; a stock-room with a floor
ST let IZA,
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THE MEDICAL RECORD.
[October 5, 1889
area of 1,882 square feet, two small rooms for the use of
the librarian, a strong room for the storage of valuable
books and papers; three reading-rooms 25 x 28; a labora-
tory or microscope-room 28x28; a dining-room or
banqueting-hall 28x31; and a kitchen beneath it of
about the same size, with serving-rooms attached; making
altogether thirty-three rooms exclusive of halls and pas-
sageways, and the rooms in the basement used for air-
chamber, coal, boilers, engines, unpacking books, etc., as
well as the apartments for the resident librarian in the
upper part of the building.
‘The entrance, on the side toward Fifth Avenue, is but
a step or two above the sidewalk. A central stone col-
umn supports a flat arch which admits to an outer vesti-
bule about 8x 20 feet. An inner vestibule, about 6x10
feet, leads to a staircase-hall 15 x 33 feet, having on the
i eastward a reception-room
11 x 13 feet, and in its rear a
coat-room 8 x 13 feet. A
well for the rear staircase
and elevator 14 x 20 feet
brings us to the rear end of
the hall. To the westward,
on entering, opens a doorway
to a committee- or reading-
room (which can be used as
an extra coat-room) 15 x 27
feet; beyond that is a pas-
sage to the smoking- ard
conversation-room of 26 x 36
feet, intended for the use of
fellows who do not desire to
enter the assembly hall or
library. ‘The next opening
to the westward is that to the
assembly-hall, and adjoining
it, at the northern end of the
staircase-hall, is the door to
the banqueting-hall. The
assembly-hall and banquet-
ing-room adjoining, and the
wainscoted partition of the
latter on the side toward the
assembly-hall, is made to be
raised into the wall above so
as to throw the two halls into
one. So, too, the 14 feet
doorway between the assem-
bly-hall and the smoking-
room can be opened on the
occasion of an audience of
unusual size, and about a
hundred additional sittings
within view of the speaker be
secured. The ingenious man-
ner by which a large space can be seated on occasions,
and yet the lonesomeness of a large hall with a small au-
dience may be avoided on others, is quite admirable.
With the approval of the executor of the will of Mrs.
Hosack, this assembly-hall and the adjoining banqueting-
hall are to be the memorial of Dr. Alexander Hosack, and
will be known as the
i
oe ae r apor
emes =
at a ~ -
ar È Ti
4 - =
p= TS “
——
HOSACK HALL.
The half-story above the first enables a height of 26 feet
to be gained for the Hosack Hall in the rear, while in
front a meeting-room of 30 x 43, and a reading-room or
committee-room of 25x28 feet are secured. On the
level of and in the rear of the larger room, is a logia or
gallery 43 feet long, overlooking the assembly-hall, which
considerably increases the space for an audience, and pro-
vides a place for manipulating a magic lantern when
needed to illustrate a lecture.
Arriving at the second floor, a door opposite to the
staircase gives admission to the public room of the
library, 37 by 43, and 23 feet high. It is this room to
October 5, 1889] THE MEDICAL RECORD. 381
which the public will be admitted, and it will possess all
the essential characteristics of a library. Cases arranged
in alcoves will extend to about half the height of the room.
In this room the librarian and his assistants will have their
desks. It is the intention to place in the cases of this
room books of reference or such as are in current de-
mand, or of decorative character, and, perhaps, certain
special bequests to serve as memorial alcoves. The great
mass of books will be stored in a stock-room in the rear
and over the Hosack Hall, this room having a capacity
for two hundred and fifty thousand volumes. A private
room for the librarian, and a strong room for valuable
papers are connected with the stock-room, and adjoining
Society Reports,
MEDICAL SOCIETY OF VIRGINIA.
Twentieth Annual Session, held in Roanoke, Va., Septem-
ber 3, 4, and 5, 1889.
(Special Report for THe Mapica, Recorp.)
TUESDAY, SEPTEMBER 3D— FIRST Day.
THE session was called to order by the President, Dr. E.
the reference library is a reading-room 25 by 28, connect-
ing with corresponding rooms above and below it by a
special staircase. These three rooms are for the accom-
modation of current medical periodicals. On this floor
is a detached study-room, 16 by 17 feet, and a commodious
The toilet-room for the accommodation of
the first floor, it should have been stated, being in the
basement. ‘The half-story above the second is mainly oc-
toilet-room.
cupied by the upper part of the reference library and
` stock-room, but space is also found for the upper one of
the three journal-rooms, 25 by 28; another study-room,
16 by 17; a toilet-room, and small rooms for the storage
of duplicate books, etc.
The third story, fourteen feet in height, has four meet-
ing-rooms for sections of the Academy, or other small
gatherings. They vary somewhat in size, the smallest
being 27 by 28, and the largest 33 by 37. ‘They are all pro-
vided with ante-rooms and rooms for storage of appar-
atus and pathological specimens, laboratory work, etc., and
one will be provided with a northern skylight arranged
for photographic work, where fellows of the Academy,
whose offices do not permit of such work, can secure a
good light for photographing interesting cases. These
small rooms vary in size from 11 by 12 to 9.6 by 21. A toi-
let-room also communicates with the hallway on this floor.
The fourth story, besides having a room 28 by 28 feet
which can be used as a meeting-room, museum, or labor-
atory, has an area of 37 by 43 feet arranged for the apart-
ments of the resident librarian. These with the staircase-
hall, will cover but about half the area of the building.
The remainder will be a level, open deck, covered with
flat tiles and surrounded by an iron railing, which can
be used as an open-air promenade.
The gable contains, besides the main trunk into which
will open the ventilating flues, space which can be used, if
needed, for storage of furniture, rooms for attendants, etc.
The basement is utilized for a large kitchen under the
banqueting-hall ; an air-space under the assembly-hall.
from which warm or cool air can be forced by a revolving
fan into all parts of the building; a room for unpacking
books ; a room for fuel, and, in the sidewalk vault, the
boilers and necessary pumps and other engines.
This is, in brief, an account of the building which the
Academy expects to occupy about October, 1890. Com-
pared with the room over the office of a coal-yard of forty
years ago, it will be most sumptuous. When completed it
will afford accommodations for a medical library of the
first magnitude, a meeting-place for medical and other sci-
entific bodies second to none in this country, and rooms
suited to the prosecution of scientific study which will rival
the laboratories of any of our wealthy universities. In the
event of an International Exhibition being held in New
York in 1892, it will become the headquarters for all visit-
ing physicians, and by its existence contribute greatly to
the credit which, it is to be hoped, this city will acquire
for the liberal encouragement of the arts and sciences:
Physicians will be proud to be enrolled among the fel-
lows. The existence of its free public library will bring
the profession into more intimate relations with the sym-
pathies of the community in general, and endowment of
the library and of lectureships will offer to liberal patrons
ways for expending money which has heretofore been de-
voted to objects less closely allied to the public welfare.
W. Row, of Orange, Va. After prayer, and the address
of welcome, by Dr. A. Z. Koiner, of Roanoke,
Dr. ‘lHomas J. Moore, of Richmond, delivered the
‘ Annual Address to the Public and Profession,” select-
ing as his subject,
MAN AND HIS DEVELOPMENT.
The first meeting was open to the public, and the
Opera House was well filled with ladies and gentlemen.
The report of the Committee on Nominations (Dr. W.
D, Turner, of Fergusson’s Wharf, chairman), recom-
mended about fifty-five applicants for fellowship, each of
whom was elected a fellow of the Society.
The report of the Recording Secretary, Dr. Landon B.
Edwards, of Richmond, stated that fifteen fellows had
died during the year, and six had tendered their resigna-
tions of fellowship—having either removed from the
State or discontinued practice—leaving a total member-
ship of about seven hundred and thirty-five.
The reports of the Executive Committee (Dr. W. W.
Parker, of Richmond, chairman), and of the Publishing
Committee (Dr. C. W. P. Brock, of Richmond, Va.,
chairman), were also presented.
WEDNESDAY, SEPTEMBER {4TH—-SECOND Day.
Dr. JoHN A. WyETH, of New York City, read, by in-
vitation, a paper on
THE STATUS OF COCAINE IN SURGERY,
referring first to the dangers of the drug, due to the idio-
syncrasies of patients. Its dosage is uncertain in different
individuals, and even in the same persons at different
times. As a rule, begin with the minimum dose, and
gradually increase—always carefully watching the pulse,
face, respirations, and pupils. In small doses it is a car-
diac and respiratory stimulant ; but in large doses it ar-
rests the heart in diastole and paralyzes the respiratory
muscles. Itis not applicable to children under ten or
twelve years of age. In adults, he has several times wit-
nessed pallor of the face and fainting, but has thought
these the results mostly of the patients being overcome by
the sight of blood in operations, etc. Exhilaration is not
uncommon—amounting to boisterousness in some. He
has seen convulsive movements followed by opisthotonos
in one case. In another, a decided convulsion occurred
fourteen hours after the gradual injection of thirty
minims of a four per cent. solution. Systemic absorption
of the drug, when not applied about the eye or its direct
connections, is proven by the dilatation of the pupil. His
usual formula for hypodermic administration is approxi-
matively a four per cent. solution (cocaine muriate, 3 j.,
boracic acid, gr. iij, and distilled water, 3 j.). Always use
water free of lime for cocaine solutions.
When operating on the extremities, with cocaine as the
anzsthetic, the speaker first applies an Esmarch bandage.
For amputation ‘of the fingers, it is best to arrest the
` circulation by simply using a rubber tube or band applied
around the finger, as high up toward the metacarpal junc-
tion as possible. As direct injections (along the line of
proposed incision) retard union and repair of wounds by
first intention, it is best to employ the indirect method
(injections near the nerves at the base of the finger) when
possible, although this latter requires a larger quantity of
mad
382
THE MEDICAL RECORD.
[October 5, 1889
cocaine and a little longer time for anzsthesia. The
ligature at the base of the finger being in position to
tighten, just before tightening it insert the smallest hypo-
dermic needle through the skin, on the lateral aspect of
the dorsum of th2 digit, about an inch from, and on the
distal side of, the ligature. Inject two minims ; push the
needle a quarter of an inch farther, and inject two more
minims, and thus proceed until at length the needle-point
rests just beneath the skin, on the plantar aspect of the
finger, when two minims more are injected. ‘The opera-
tion is immediately repeated on the other half of the fin-
ger—the entire operation not lasting longer than half a
minute. A smarting, burning pain is felt as the fluid
enters the tissues. At once tighten the ligatures around
the base of the finger, thus holding the solution at a
standstill for absorption, which may be hastened by mas-
sage. Insensibility sufficient for amputation of the last
phalanx occurs in about two minutes. The total quantity
of solution that may be used varies from fifteen to thirty
minims. Of course, some of the cocaine is eliminated in
the hemorrhage of the operation itself. The amputation
being finished, loosen the ligature for only a minute,
which restores the circulation, when some more of the
cocaine is washed out by the renewed hemorrhage ; but a
good deal of it is carried back into the system by the ven-
ous return of blood. Tighten the rubber again for two or
three minutes, make the necessary sutures, and apply
the dressing. ‘Then for a minute or so again loosen the
tourniquet, and again tighten, and thus repeat two or
three times, to prevent the heart and nerves from being
overwhelmed by the sudden taking up into the system of
all the cocaine that was put into the finger.
THE ADVANTAGES OF THE DIRECT METHOD
are: Rapidity of anesthesia, the smaller quantity of co-
caine used, escape of much of the solution through the
wound of incision. This method is preferable when the
necessary anzesthesia can be obtained by not more than a
drachm of a four per cent. solution, as, for instance, in
incising felons, removing diseased nails, foreign bodies un-
der the skin, etc.
In operations upon the trunk, the immediate absorption
of the solution renders greater precaution necessary. For
instance, if a fatty tumor is to be removed, insert the nee-
dle in the deeper layers of the skin (not subcutaneous fat)
along the line of proposed incision, and inject a half-min-
im to one minim; advance the needle one-fourth inch
and repeat the injection, and so on, as far as the needle
will reach from the original puncture. The anesthesia is
evidenced by the pallor of the overlying cuticle. Divide
the skin through the anzsthetized line, and dissect later-
ally—usually about an inch—until pain is felt. Then
inject a half-minim or more at all sensitive points to be
cut.
In eye surgery the value of cocaine is well known. In
the buccal cavity its applicability has even a wider range.
It anzsthetizes sufficiently to remove tumors of not more
than one inch. Small epitheliomata and suspicious ulcers
are painlessly removed from the tongue when from five to
twenty minims of solution are injected around and be-
neath their bases. Dr. Wyeth has twice dissected out
ranulz painlessly under cocaine anesthesia. Complete
clefts of the soft palate in the adult can be painlessly
closed by applying the solution with a brush to the mu-
cous surfaces which are to be “freshened up.” Cocaine
is in every-day use for operations about the nose, naso-
pharynx, and larynx.
For internal urethrotomy, regardless of location, he now
rarely employs general anzsthesia. After disinfecting the
urethra with boracic acid solution (gr. x. to 3j.), inject
from 3j. to 31j. of a four per cent. solution of cocaine
with the ordinary P-syringe. In a minute or so, let all of
the cocaine solution run out that will do so. If the ure-
throtomy is to be in the membranous portion, pass Otis’
long curved tube into that part, and inject from twenty to
day after the operation, for the introduction of the sound,
be careful not to overdistend the canal with the prelim-
inary solution of cocaine; about a drachm is enough.
Cocaine anesthesia is also very useful for numerous blad-
der troubles, examinations, etc.
Circumcision in adults no longer requires general nar-
cosis. Constrict the penis near the pubes, pull forward
the prepuce, and enter the hypodermic needle at the free
border in the middle line on top, defween the mucous and
cutaneous layers. ‘Then carry the point of the needle as
far back as the proposed line of section, and inject one
minim of the cocaine solution. Withdraw the needle
half-way, and carry it forward again to the nght and left,
and force out a minim for every quarter-inch of the pro-
posed section. As the frænum is very sensitive, inject
two or three minims here.
In Levis’s operation for hydrocele, cocainize the point
where the trocar is to enter. If the hydrocele is small,
Volkman’s operation may be done under cocaine.
But in the open operation for varicocele, cocaine is not
sufficient ; nor is it sufficient for external urethrotomy,
cystotomy, hernia, etc.
But small hemorrhoids may be injected with the co- —
caine solution, and almost painlessly removed. Cocaine
is also sufficient for incising anal and rectal fissures and
ulcers ; also for slitting up single and superficial anal
and rectal fistule.
Dr. HuNTER McGuire, of Richmond, did not think
Dr. Wyeth’s paper dwelt sufficiently on the dangers of co-
caine. It is a very tricky agent. He had, however, used
it nearly every day for the past five years, because it is
just the anesthetic often wanted when it acts well. While
he has had no fatal case from its use, he has yet come
very near killing one or two patients with it, so uncertain
is its paralyzing effect in some cases—which cases cannot
be foretold. He had read in one of his journals that Dr.
Sims had injected a few minims of a twenty per cent. so-
lution into the male urethra, and in twenty minutes, he
thinks it was, his patient was dead. Dr. McGuire said
he had cocainized a great many children without observ-
ing in any case the very serious effects referred to by Dr.
Wyeth ; in fact, he had come to the conclusion that chil-
dren stand cocaine anesthesia as they do chloroform—
very well. But there are objections to cocaine, which
belong to the experimental therapeutist to remove if he
can. Undoubtedly it interferes with the repair of wounds
by first intention. During the session of this Society in
Richmond, two years ago, a distinguished author, then re-
siding in New York, affirmed that there was no such thing
as a “cocaine habit,” in the sense in which the term
“habit” is applied to the “ whiskey habit,” the “ morphia
habit,” etc. But Dr. McGuire is certain he has seen cases
of “ cocaine habit.” l
Dr. WYETH remarked, in conclusion, that he indorsed
what Dr. McGuire had just said. The dangers of the in-
discriminate use of cocaine are very great. His paper-did
not intend to imply the idea that danger in the use of co-
caine with children was in the drug itself ; but that it was
not suited to them because of the difficulty in properly
administering repeated hypodermic injections to children
under any circumstances, and the peculiar sensation of loss
of feeling in the part, which frightens them.
Dr. E. W. Row then delivered the President’s address,
his subject being
MEDICAL REFORMS,
with special applicability to the profession of Virginia.
: CROUPOUS
was the subject for general discussion.
Dr. B. L. Winston, of Hanover Court House, in open-
ing the discussion, confined his remarks to uncomplicated
cases, Diagnosis, if physical signs are resorted to, 1S
easy, though the disease sometimes is not recognized with
such examination. Pain is probably never present, un-
PNEUMONIA
thirty minims. When the time comes, about the third ' less pleurisy complicates the pneumonia. Rusty-colored
October 5, 1889]
sputa, although pathognomonic, according to his experi-
ence, by no means occur in the majority of cases; and
yet text-book authors would lead us to expect this in
every instance. The causes of the diseases are either
specific, exciting, or predisposing. The theory of the
specific origin of pneumonia does not meet with common
approval. Yet pneumonia is not a simple inflammation
of the lung ; this is but an expression of a general disease.
The lung inflammation itself deserves no higher rank
than the intestinal ulcers of typhoid fever. Croupous
pneumonia is not produced by extension vf inflammation,
although lobular pneumonia is the result of such exten-
sion. It is not produced by inhaling irritating gases, nor
by traumatism, nor by “ cold,” as are other inflammations
of the air-passages. It is a self-limited disease, and often
occurs as an epidemic. The asthmatic tendency cannot
be due to the height of the fever, nor to cardiac weakness,
nor to the amount of lung consolidated, for the amount
invaded is often very small. Besides, the heart-failure in
no way corresponds with the severity of the other symp-
toms. ‘The heart-failure which is the alarming symptom
in uncomplicated cases is apparently due to a morbific
agent acting on the nerve-centres. But the exact cause
of croupous pneumonia is a subject for further investiga-
tion. The germ theory may or may not be true. The pre-
disposing causes are age, under sixty; the male sex; the
negro race; winter and spring seasons; and certain dis-
eases, as typhoid fever. The exciting causes are, in general,
such things as tend to lower the vital powers, as expos-
@ire to inclement weather, insufficient clothing—especially
the neglect of flannel. The disease is more common
South than North—being almost unknown in the frigid
zone. During the cold months, almost all food is old;
thus it is probable that the character of food then taken,
while the vital powers are at their lowest, contributes
most largely to the development of the disease. As to
treatment, almost every drug has been tried, and yet the
mortality is second only to that from consumption. Ma-
raghona abstracts from five to ten ounces of blood on
the fourth or fifth day, when the heart is on the eve of
being overpowered by the pneumonic toxic matter.
While venesection may sometimes be required, Dr. Win-
ston does not think the evidence sustains the general
adoption of Maragliona’s practice. Large blisters are of
doubtful propriety, although they. do oftentimes relieve
pain. Calomel has no place in the treatment of croup-
ous pneumonia. Aconite in the commencement, and
quinine from the start to abort the disease, may at times
prove useful. But Dr. Winston, as a rule, -has gotten
the best results when he has used the least medicine.
Hot poultices, opium to relieve pain, stimulants when
needed, food, hygienic measures, and, above all, skilful
nursing, will be all that can be done in uncomplicated
cases.
Dr. H. C. BECKETT, of Scottsburg, read the next pa-
per, covering much of the ground of the first. He said the
specific cause of croupous pneumonia is unknown; no age
is exempt, though the disease is very rare in children
under five years; occurs mostly in males; .in laborers
more often than in those who live in-doors, etc. Erysipe-
las, measles, diphtheria, small-pox, etc., are predisposing
causes, as are a previous attack of pneumonia, and trau-
matism, especially in the old. It is most frequent in the
Middle and Southern States. It often prevails as an epi-
demic in the mountainous regions of the South, and oc-
curs mostly during the first five months of the year. In
short, everything that tends to depress vital action predis-
poses to croupous pneumonia. As to treatment, use
stimulants or depressants as required. Bleed, if both
lungs are involved so as to leave but little breathing sur-
face. In such cases, the relief is immediate. Large hot
poultices over the lungs reduce blood-pressure, while the
heat acts as a cardiac stimulant. Aconite is preferable
to veratrum when a heart-sedative is needed. Antifibrin
is the best antipyretic, and should be followed by quinine,
which latter he considers the sheet-anchor in pneumonia
THE MEDICAL RECORD.
383
—about five grains every four hours until the fever breaks.
In the second and third stages, combine ammonium car-
bonate and digitalis if indicated. The early use of a
large dose of calomel is beneficial. Use opium to allay
pain and restlessness. Expectorants have no place in the
treatment of pneumonia. Blisters at the beginning of the
third stage hasten resolution. Alcohol is essential as
food and a stimulant. Some believe pneumonia to be
contagious, and that the period of incubation 1s four days ;
but Dr. Beckett does not believe it is contagious.
Dr. Lewis G. Pepico, of Roanoke, read a paper on
SEDATIVE DOSES OF CALOMEL IN ACUTE CROUPOUS
PNEUMONIA.
He reviewed the literature relating to the use of the so-
called heroic or sedative doses of this drug in various
acute diseases, set forth in systematic order the various
effects of such doses on the secretions, the temperature,
and the nervous system, and argued that these effects an-
swer to the indications in pneumonia. ‘The doses referred
to in this paper range from thirty grains upward. The
favorite method of administration is to sprinkle dry on the
tongue.
Dr. BEDFORD Brown, of Alexandria, gave a résumé of
his personal experience in the
TREATMENT OF CROUPOUS PNEUMONIA
during a period of forty-one years. During this time he
has seen four or five different methods of treatment
adopted and practised, and finally discarded. First, the
depletory. At first it was used in every case, then in
only certain cases, and finally it was entirely discarded.
Then came the mercurial, in which calomel in small doses,
with Dover's powder, blistering, and mercurial inunction,
was used until ptyalism occurred. ‘The great majority of
cases recovered under this treatment. Then followed
the sedative treatment—veratrum, aconite, and ultimately
digitalis. The sedative treatment of Norwood gave birth
to all of our subsequent ideas of sedation. ‘This was an
advance on the pure depletory treatment, and resulted in
real good. ‘Then, again, came the stimulant treatment.
This was a still further advance, and has brought more
and better points than any other single treatment. This
also may be modified and combined with elements of the
other treatments with advantage. Dr. Brown has not de-
rived benefit from the pure antipyretic treatment. He
has in former years seen much of the epidemic form—a
typhoid pneumonia—the tendency to collapse in which
was constant and great. In this form he has used large
quantities of whiskey (a quart per diem), carbonate of am-
monia, tincture of nux vomica, and chloroform, internally.
In this form he has also used, in connection with stimu-
lants, liquor ammoniz acetatis, tincture of nux vomica, and
tincture of chloride of iron with benefit. Dr. Brown does
not think, from this long experience, that adherence to any
one single routine treatment exclusively will give as good
results as the mixed—combining some of the good por-
tions of all, but never forgetting stimulants and nourish-
ment. He has seen cases of pneumonia with slight fever,
slow pulse, and moderately excited respiration recover
without medication.
Dr. J. H. Nerr, of Harrisonburg, believed that acute
croupous or lobar pneumonia is a general disease due to
a specific poison. This theory has been ably presented
for some years, and much can be said for and against it.
But each year’s experience has strengthened his opinion
in its favor. The’ future organic chemists and bacteriolo-
gists must prove whether it be a chemical poison or an
organized germ. Believing that it is a general disease,
due to a specific cause, for which there is no specific
medicine capable of aborting its course, the treatment
must be determined by the nature of the disease in each
individual constitution. He has never bled or given a
dose of aconite or veratrum viride, nor used mercury ex-
cept to give occasionally an ordinary dose of calomel in
the beginning. Many cases will recover without medi-
384 THE MEDICAL RECORD.
cine if properly nursed ; this was observed and recorded
more than twenty-five years ago. He has seen cases of
double pneumonia with scarcely a bad symptom. The
area of lung involved does not always determine the grav-
ity of the disease. He gives opium or morphia to allay
pain, lessen shock, produce sleep, etc. He regards qui-
nine as the safest antipyretic ; besides, it has special vir-
tues in lessening the gravity ‘of all local inflammations.
He has never seen it produce collapse, and hence prefers
it to other arterial sedatives. If not needed as an anti-
pyretic, it may be of benefit in small tonic doses, He
gives antipyrin to children; and if he has any routine
treatment, it is to envelop their chests with an oil-silk
jacket, lined with soft, fine flannel. Digitalis, alcohol,
ammonia, and chloral have all, in their places, been of
much service.
Dr. J. G. WILTSHIRE, of Baltimore, Md., said that, study-
ing the subject of croupous pneumonia after Lépine,
Sévestre, and Charcot, one must accept the theory that it
finds its origin ina specific pathogenetic germ ; yet it can-
not be denied that there are certain meteorological condi-
tions that stand in a strong causative relation to its pro-
duction, it occurring more frequently in a low temperature
—one acting as a specific, the other as an exciting cause.
We are constantly exposed to the invasion of the pneumo-
cocci, but, for the want of the necessary conditions to ren-
der the mucous membrane of the lung a suitable soil for
their culture and growth, it is able to resist them for a
time; only to yield when such exciting causes as cold
and traumatism supplement the specific influence of the
germs. Apropos of the theory that the pneumococci have
other habitats than the lungs, he called attention to the
study of Sévestre of an epidemic of broncho-pneumonia
complicating cholera infantum and other enteric troubles,
in which he found the microbes, of pneumonia in the in-
testinal tract, whence they were carried to the lung by the
lymph-channels. ‘The treatment of croupous pneumonia
calls for heart-sedatives, and heat and moisture, in the
form of hot cloths. ‘These, if used in the first stage, may
abort the disease. Should it, however, pass into the stage
of red hepatization, a supporting and stimulating plan
should take the place of the sedative one. Watch the
temperature and heart as closely as the powers of the pa-
tient. Alcohol is important in the second and third stages.
Quinine and antipyrin, when used together, are the best
antipyretics. ‘They not only reduce the temperature, but
preserve the power of the heart. Carbonate of ammonia
does the twofold work of aiding in liquefying and expec-
torating the fibrinous deposit, and keeping the heart’s
force up.
Dr. Henry M. PATERSON, of Staunton, said that if
this is a specific disease, the treatment given has certainly
been at variance with such an idea. He does not believe
that it is a simple hyperzemia of the lungs. The gravity
of the attack depends on the amount of exudation. How
to remove the engorgement is the question. This is the
time to abort the disease, if such a thing is ever possible.
His present success with the lancet is as great as it was
when he began practice in 1851, and compares most
favorably with the results of other plans of practice of
to-day. As a food and stimulant, he gives alcohol during
the second stage in almost every case. He has also had
some remarkably satisfactory experience with ergot.
Dr. Henry V. Gray, of Roanoke, also discussed the
same subject.
ELECTION OF OFFICERS.
The election of officers was then held, with the follow-
ing result: Dr. Oscar Wiley, of Salem, President. Drs. J.
M. Estill, of Tazewell Court Houre ; Alfred C. Palmer, of
Norfolk; and Casper C. Henckel, ‘of New Market, Vice-
Presidents. Dr. Landon B. Edwards, of Richmond,
Recording Secretary. Dr. J. F. Winn, of Richmond,
Corresponding Secretary. Dr. Richard T. Styll, of Hol-
lins, Va., Zreasurer. Dr. John S. Apperson, of Glade
Spring, was elected to deliver the Address to the Public
[October 5, 1889
and Profession during the session of 1890, and Dr. C. T.
Lewis, of Clifton Forge, was selected as the Leader of
the Discussion of the selected subject for 1890.
THE TREATMENT OF THE SUMMER DIARRHCEA OF CHIL-
DREN.
Drs. R. F. Young, of Love’s Mill, and P. B. Green, of
Wytheville, were nominated for commission as Members
of the Medical Examining Board of Virginia, to fill va-
cancies occasioned by two resignations.
Rockbridge Alum Springs was selected as the place
for the Annual Session of 1890, some day between Au-
gust 25th and September sth, as the Executive Com-
mittee may hereafter determine.
Dr. E. T. Brapy, of the Southwestern Lunatic Asylum
at Marion, read a paper entitled
MENTAL ACTION-——MATERIAL ACTION.
The doctor stated that he would treat the title as a
fact, considering it established by the following three prop-
ositions, viz. :
1. That mental impressions involuntarily originate phys-
ical action, and that material impressions give rise to
this involuntary mental action.
2. That loss of cerebral substance is followed by loss
of physical or expressional function, and that disuse of
mental function is followed by a corresponding atrophy
of cerebral substance.
3. That abnormalities of organic function have as
their sequence abnormal ideation.
He devoted his paper to the support of these proposi-"
tions by arguments based upon normal and abnormal
phenomena, and cited records, clinical and post-mortem,
of several interesting cases illustrative of his subject.
Dr. WILLIAM F. Cooper, of Woodville, presented the
REPORT ON MATERIA MEDICA AND THERAPEUTICS.
From the phenol group, comes Phenacetine, a white,
glossy, crystalline, tasteless powder, freely soluble in alco-
hol, less so in glycerine, and still less so in water. Thera-
peutic attention was called to it in 1887. It is a non-
toxi¢, reliable antipyretic and antineuralgic. ‘The usual
dose of seven and one-half grains lowers the temperature
from 1.8° to 3.6° F., for hours. It is best given in pow-
ders or soluble pills. S«/phonal promptly causes natural
sleep, in from a half-hour to two hours, of several hours’ du-
ration, in doses of fifteen to forty-five grains. It does not
act unfavorably upon the heart, respiration, temperature,
or digestion. It creates no desire to increase the dose.
It is given in wafer, or it may be dissolved in soup or
tea. Amylene hydrate, an isomer of amylic alcohol,
is physiologically ranked between chloral and paral-
dehyde. It is a colorless, slightly oily liquid, boils at
102.5°C.; sp.gr.o.81. Its odor resembles that of par-
aldehyde, with a faint suggestion of camphor. It feels
warm in the mouth, and has a hot aromatic taste. It is
freely soluble in alcohol, but requires eight parts of water.
It is given with extract of licorice, or in red wine and
sugar. In doses of from fifty to seventy-five grains, it
causes neither nausea, headache, indigestion, nor other
unpleasant after-effect ; but more frequently than other
hypnotics it induces refreshing sleep. Methylal is a new
hypnotic, with sweet taste, ethereal odor; is soluble in
water, rapidly eliminated, and leaves no ill ‘effects. Dose
three to five grammes. ‘Salufer (neutral sodium silico-
fluoride), a white inodorous compound, requiring % j. water
to dissolve gr. ijss., is a powerful, unirritating surgical ant-
septic. For ordinary uses a grain is dissolved in an ounce
of water, to syringe out cavities, etc. It corrodes steel,
but does not affect sponges. Gwasacol, an ether derived
from beech-wood creosote, is a colorless liquid, of aroma-
tic odor, slightly soluble in water, but readily so in alco-
hol and fixed oils. It is used, by inhalations or in doses
of a half to one minim several times daily, in consump-
tion. ‘The solution should be kept in colored bottles.
(To be continued.)
Sixth Annual Meeting, held at the Hotel Brunswick, New
York, September, 25, 26, and 27, 1889.
WiiuiaMm T. Lusk, M.D., of NEw YORK, PRESIDENT, IN
THE CHAIR.
First Day, WEDNESDAY, SEPTEMBER 25TH—MORNING
SESSION.
Dr. GEORGE E. FELL, of Buffalo, read the first scientific
paper, entitled
PARTIAL INVERSION OF THE UTERUS,
in which he related the history of a case occurring in a
multipara, in whom, eight hours after normal delivery, he
was sent for hastily and found the patient in high fever,
with anxious countenance, great pain in the pelvis, and
partial collapse. The uterus could not be felt above the
pubes. ‘The hand in the vagina revealed the fundus uteri
low down, the left cornua being most inverted. He
placed the patient in the left latero-dorsal position, and
made uterine irrigation with hot water while making man-
ual pressure. ‘The organ was wholly and easily replaced
in about five minutes. It was necessary to give morphine
to quiet the after-pains. ‘There was no recurrence of
the partial inversion. Dr. Fell attributed the accident in
this case to the fact that in her first confinement she had
been delivered by forceps, and the uterus forcibly drawn
entirely out of the pelvis.
Dr. Marcy, of Boston, thought partial inversion after
delivery was more common than had been supposed.
An article had recently appeared in which ten cases were
given. The etiology was obscure. The cause to which
it had been attributed in Dr. Fell’s case was very instruc-
tive.
Dr. FELL also read a brief paper entitled
LATERO-DORSAL POSITION IN VAGINAL IRRIGATION.
His reason for describing the method was its superi-
urity over others, and the fact that, as iar as he was in-
formed, it was new. An ordinary table, sofa, or bed could
be used, the nght side being covered with oil-cloth raised
in folds to carry the water into a bowl at the bedside.
The patient was then placed on the oil-cloth, the buttocks
very slightly over the edge of the bed, lying on the left
Side, the limbs flexed. Irrigation in this position allowed
the water to pass over the gluteal region into the bowl at
the bedside, and could be carried out with ease and suc-
cess. i
Dr. W. H. Ross read a paper entitled
PELVIC CELLULITIS IN WOMEN.
The first part of the paper quoted views, pro and con,
on the existence of pelvic cellulitis. ‘The author thought
there was no reason to suppose inflammation might not
exist in the pelvic tissues of the pelvis as well as elsewhere.
It might be simple or complicated. He thought the in-
flammation should receive the name pelvic cellulitis when
the cellular tissue was principally involved. He was un-
able to account for the fact that in different patients the
three stages of the disease varied much in duration. ‘The
first stage was that of congestion, which might end in reso-
lution. The second was that of effusion, and in some
cases was of long duration, and might terminate in reso-
lution or go on to the formation of pus. In the way of
treatment, during the acute stage, he found veratrum viride
an excellent drug for: controlling the temperature and
pulse. He also used sulphate of morphine hypodermi-
cally. Recognizing infection in the etiology of many cases,
he made vaginal, sometimes uterine, irrigation with a so-
lution of carbolic acid, and introduced iodoform. A
flaxseed poultice was applied over the abdomen. When
pus formed it should be evacuated at once. To reach it,
laparotomy might be necessary.
Dr. Marcy called attention to the fact that while the
author had presented the claims of pelvic cellulitis to be-
THE MEDICAL RECORD.
385
ing classified as an independent affection, yet he had ad-
mitted that its origin was likely to be infection from with-
out; in other words, that it was a bacterial inflammation,
whether the bacteria gained entrance through the uterus
and tubes or other channel. ‘This fact had an important
bearing on treatment. ‘The earlier one was able to re-
move the direct factor in the production of the disease
the more likely would the patient’s life be spared.
Dr. E. M. Moore spoke of the mode in which pelvic
abscesses should be evacuated. He had employed both
incision and drainage, and aspiration, and expressed
preference for the latter, as less likely to be followed by
certain symptoms attending sudden and complete empty-
ing of pus-cavities by the knife. He saw no reason why
pelvic connective tissue might not be the seat of inflam-
mation just as might connective tissue and all tissues else-
where in the body.
Dr. E. D. Fercuson thought unfavorable symptoms
were no more likely to follow incision than aspiration un-
less infectious matter were introduced. ‘The aspiration
should not be employed unless one knew just what tissues
the needle had to pass through to reach the pus.
Dr. Cronyn accepted Dr. Moore's views regarding the
value of the aspirator, and expressed preference for opi-
um to morphine, aided by quinine ; opium removed the
cause of the fever, while veratrum removed the symptom
only. Indeed it had not been efficient in his hands even
for this purpose. |
Dr. Ross related a case in which the aspirator-needle
had been introduced in three different directions. No pus
was found. An abscess afterward formed, however, which
he believed had been excited by the punctures.
The objection to opium was that the stomach rejected
it in many cases. Veratrum, in reducing the pulse, tended
also to cure the inflammation by lessening the amount of
blood pumped through the congested parts by the over-
acting heart. —
Dr. C. S. Woop, of New York, reported a case of
LAPAROTOMY FOR RUPTURED PYO-SALPINX-——-ERROR IN
DIAGNOSIS— RECOVERY.
The case well illustrated the difficulties sometimes en-
countered in diagnosis. The patient was an unmarried
woman, aged twenty-eight, who had been in good health,
except at times pains were present in the lower part of
the abdomen. In May last Dr. Wood was called, and
found her suffering from abdominal pain, slight fever, and
gastric disturbance. A cathartic was administered, which
acted the following day. The pain became greater in the
pelvic region, especially in the region of the czecum, where
was present indistinct hardness. The tumor in this re-
gion increased in size, and Dr. Wood became convinced
the case was one of perityphlitic abscess. She was get-
ting along well until after some days she was awakened in
the night by “ sickness of the stomach,” had a severe chill,
and partial collapse. ‘The induration in the iliac region
was found to be softer and less prominent. Projective
vomiting of watery fluid took place when she was turned
on her side for examination. The temperature was 103.5°
F., pulse 140. Being satisfied of rupture of a perityph-
litic abscess, Dr. Wylie was called in consultation, lapa-
rotomy was performed, and they were surprised to find no
evidence of inflammation or tumor in the immediate re-
gion of the cecum; instead, there was an effusion of
lymph over a large surface, matting together of pelvic
viscera, and rupture of a pyo-salpinx on the right side,
which had been mistaken for a perityphlitic abscess.
The sac and ovary were removed. ‘The ovary on the left
side being cystic, it was also removed. ‘The patient re-
covered within four weeks. He afterward learned that
she had, five years previously, brought on an abortion,
which might account for the attacks of pelvic pain.
Dr. EDIBOHLS mentioned two diagnostic points in dis-
tinguishing between perityphlitic abscess and pyo-salpinx.
In the former the tumor lay midway beneath a line drawn
from the anterior superior spinous process of the iium
386
to the umbilicus. ‘he second point was that during the
first six or seven days, or until the tumor reached a large
size, a perityphlitic abscess could not be felt by the two:
fingers introduced within the vagina, or one introduced
into the vagina and the other into the rectum, whereas a
pyo-salpinx could invariably be felt in that manner.
AFTERNOON SESSION.
THE PRESIDENTS ADDRESS.
Dr. Lusk read his address, which opened the
DISCUSSION ON TUBAL PREGNANCY, *
including relative infrequency of other forms of extra-
uterine pregnancy; the interstitial, intra-ligamentous, and
pedicled forms ; the physiology, pathology, and diagnosis ;
clinical history and objective signs; the possibility of
early diagnosis prior to rupture; and treatment, both
prior to and after rupture, and after viability of the child.
He first gave the histories of two illustrative cases which
occurred in his practice last winter. The first was that
of a woman whom he was called to see in consultation on
November 19, 1888. She was suffering from severe shock
and intense anzemia. On the 11th she had been seized
with cramps, nausea, and at times vomiting. When he
was sent for, on the roth, she had suddenly become ex-
sanguinated, suffered from increased pain in the pelvic
region, was excessively anzemic and vomited constantly ;
the pulse was 140. The pains had ceased on his arrival.
The uterus was found pressed somewhat to the left; on
the other side, and posteriorly, was an irregular soft mass,
which obscured palpation of the uterine appendages.
The diagnosis was rupture of tubal pregnancy, with intra-
peritoneal hemorrhage. Laparotomy was recommended,
and the next day, in spite of the fact that the patient was
feeling comfortable, she was transferred to the hospital
for operation. She arrived in a state of prostration, but
was revived by stimulants during the night, and operated
upon the next morning. When the peritoneum was in-
cised a stream of dark blood, probably not less than two
quarts, gushed out. The pelvic cavity was filled with clots,
which he removed. The hemorrhage seemed to proceed
from a sac in the broad ligament, which had ruptured
into the peritoneal cavity. A silk ligature was made to
include the tube, sac, and ovary, the ligated mass was re-
moved by thermo-cautery, and the pedicle was dropped.
The other tube and ovary were perfectly healthy. ‘The
abdominal cavity was irrigated. The operation lasted
about forty-five minutes. In the afternoon, while vomit-
ing, a large amount of fluid was forced through the drain-
age-tube, but he subsequently concluded that this was not
due to secondary hemorrhage, of which he at first had
fears. The patient made a good recovery. The embryo
corresponded to about the sixth week. Reviewing the
case, he said the first hematoma had formed between the
folds of the broad ligament. The distention caused by
effused blood had converted the posterior layer at the
point of pressure into asac, in which, at the time of opera-
tion, an opening was found about the size of a man’s
thumb. It appeared, then, that hemorrhage into the tube
occurred first, and corresponded to the symptoms of the
11th. The thinning of the tubal walls was such that the
non-occurrence of rupture of the intra-peritoneal wall at
that time seemed almost a miracle. If the rupture of the
tube was coincident with the occurrence of the first
hemorrhage, separation of the folds of the broad ligament
and formation of a pouch probably took place gradually.
Sudden anzemia and prolonged unconsciousness on the 19th
marked rupture of the sac and pouring of blood into the
peritoneal cavity. Subsequent formation of clots in the
pelvis served as a temporary check to hemorrhage.
The other case was similar; there was rupture of the
sac, laparotomy was performed easily, the ovum was pre-
sumably of the fourth week, recovery seemed almost cer-
tain, when she suddenly died on the eighth day, of albumi-
nuria. The two cases illustrated the ordinary history of
THE MEDICAL RECORD.
[October 5, 1889
tubal pregnancy. In the one instance the blood made its
way between the folds of the broad ligament; in the other,
it poured into the peritoneal cavity. Mr. Tait, he said,
held that all cases of extra uterine pregnancy were in the
beginning tubal. ‘They might become abdominal by rupt-
ure ; but he regarded the ovarian form as possible. The
subject was too new, however, for any scheme to be re-
garded as final. It was not likely, however, that the ovum
was capable of forming a nutritive connection with the
peritoneum in the first place. In more advanced stages
many cases of assumed abdominal pregnancy had been
placed in evidence. They could be divided into two
classes : 1, Cases in which the tubes had been reported
intact, but in which there was direct communication be-
tween the tube on the affected side and the abdominal
cavity; 2, cases in which the tubes had been reported
intact, and not in communication with the cavity. ‘The
author criticised some of the reported cases of this nature.
There was little question, he thought, of the occasional
occurrence of ovarian pregnancy. Mr. Tait was undoubt-
edly right in insisting on the importance of chronic forms
of salpingitis in the etiology. ‘Tubal pregnancy was associ-
ated with the formation of a uterine decidua, which dif-
fered in no way from the decidua of uterine pregnancy,
except that the three layers were less marked.
Unquestionably, early rupture of tubal pregnancy was
the rule. Mr. Tait had not been able to satisfy himself
that it was ever delayed beyond the twelfth week. Rupt-
ure at the placental site gave rise to hemorrhage, invariably
fatal to the foetus. The same was true, with rare excep-
tions, when rupture occurred at any point on the pen-
toneal surface. In most cases in which the pregnancy
reached an advanced stage the development of the tube
took place principally between the folds of the broad liga-
ment. ‘The support furnished the tubal walls by the gradual
unfolding of the ligament hindered rupture. Occasionally
pregnancy went on to viability without encroaching on the
intra-ligamentous space. ‘The tube then arose above the
pelvic brim.
The intra-ligamentous form lay close to the uterus. In
others the uterine end of the tube varied greatly in length.
In the so-called pedicled form the uterus was crowded to
one side or retroverted ; the uterine end of the tube was
usually long and thickened. The relations of the sac were
often obscure.
The interstitial variety was that in which the ovum de-
veloped in the uterine portion of the tube. In twenty-six
cases collected by Hégar all ruptured before the sixth
month, Tait said before the fifth month. .
A burning question connected with tubal pregnancy was
that of diagnosis. Mr. Tait assumed a skeptical] attitude
in relation to the claims of some men to ability to make a
certain diagnosis in all cases. The subjective symptoms
and physical signs previous to an operation might prove
deceptive. ‘Ihe use of the uterine sound in diagnosis had
been the cause of many needless abortions. Moreover,
intra-uterine pregnancy not infrequently persisted after the
cavity had presumably been shown to be empty by one or
more passages of the sound.
Main reliance must be placed on local symptoms and
changes collectively. In the intra-ligamentous form the
chances of error in diagnosis were slight. ‘There was dis- -
tinctive evidence of a rapidly growing tumor, early fluctu-
ation ; bimanual palpation made it possible to determine
whether the tumor was independent of the uterus. Dr.
Lusk thought not much reliance could be placed upon
uterine changes during the early months. Grandin at-
tached importance to the presence of rhythmic contractions
in the uterus after the third month of uterine pregnancy,
as distinguishing that form from extra-uterine and certain
other conditions. More clinical observation was needed
on that point. In his own experience lateral flexion of
the uterus simulated ectopic gestation to a surprising de-
gree. There was a considerable number of cases in which
diagnosis could scarcely be doubted.
Regarding the value of electricity, he had had two cases
October 5, 1889]
THE MEDICAL RECORD.
387
in which it was used, the diagnosis having been confirmed
by Dr. Thomas. In both the tumor shrivelled, the other
signs of pregnancy disappeared. The only argument
against the method, when used properly, was its liability to
cause rupture, and the retained ovum to undergo suppu-
ration. But these possibilities were very slight. The
method was only applicable during the first three months.
No one in this country advocated electro-puncture.
Electricity did not stand in the way of subsequent laparot-
omy. It was safer in the hands of the inexperienced
than was laparotomy.
Dr. WILLIAM GOODELL, of Philadelphia, opened the
discussion. With reference to the causation of extra-
uterine pregnancy, he did not think we were at present in
a position to accept wholly the views of Mr. Tait. There
were strong arguments in their favor, and also against
them. He did know that fibroid tumors had been, or
seemed to have been, the cause of extra-uterine pregnancy.
Distortion of the womb or tubes through adhesions was
undoubtedly a cause. This statement was supported by
the fact that in many cases the extra-uterine pregnancy
followed a long period of sterility after a first pregnancy
or pregnancies. He believed the trouble was much more
common than had been recognized. While there was
reason for some doubt, yet he was disposed to accept Mr.
Tait’s view that originally the pregnancy was always tubal,
and secondarily might become intra-ligamentous and ven-
tral. In the course of its development the intra-ligamen-
tous form of extra-uterine pregnancy behaved like an
intra-ligamentous cyst, splitting up the layers of the perito-
neum on the posterior surface of the womb, on the blad-
der, its reflection from the bladder to the abdominal wall,
etc. The same course of development accounted for the
occurrence of fecal fistula in some cases.
With regard to symptomatology, there was usually sup-
pression of the menses, which might last two months be-
fore the physician was consulted, or after two weeks it
might be followed by dribbling of blood. Colicky pains
were usually present, and in connection with suppressed
menstruation led him to suspect extra-uterine pregnancy,
especially if inflammation were absent A symptom on
which he was disposed to lay some stress was the fact
that in early pregnancy there was usually increased fre-
quency of micturition, especially at night. This seemed to
be more marked in extra-uterine pregnancy. ‘lhe chief
objective symptom was displacement of the uterus by the
tumor. Often, however, an operation was justifiable al-
though an absolute diagnosis could not be made.
In treatment he agreed with Dr. Lusk, that the aspi-
rator should not be used. He had been surprised to read
of the number of cases of cure by injection of morphine,
yet he would not feel himself justified in resorting to it.
He would not employ electricity. There were only two
circumstances, he thought, which justified it, (1) where
the patient peremptorily objected to an operation ; (2)
where the physician had not sufficient experience ‘and
skill to do laparotomy. Ifthe child were viable, say at
the seventh month, he would be disposed to wait until the
eighth month. He had met with one case in which there
was twin pregnancy, the one intra-uterine, the other ex-
tra-uterine.
Dr. Goodell related the causes of extra-uterine preg
nancy which had come under his observation ; in at least
two the patients refused an operation, and died ; in some
the diagnosis had not been made by others ; in some it was
more or less conjectural. In his last four cases, in three
of which the diagnosis was made before the operation, re-
covery followed laparotomy.
Dr. Marcy, of Boston, related two cases in which the
autopsy showed extra-uterine pregnancy, and conclusively,
as he thought, of the ventral form from the first. The
foetus was located quite above the brim, quite central, at-
tached to the intestines, etc. He opposed the use of elec-
tricity.
Dr. J. E. JANVRIN emphasized the diagnostic value of
colicky pains, when taken in connection with other signs
of extra-uterine pregnancy. He attributed the pain to
distention of the peritoneal covering of the tumor. He
advocated the knife.
Dr. Lusk thought colicky pains were so frequently as-
sociated with other conditions that they could not be re-
garded as of great value.
EVENING SESSION.
Dr. E. J. C. Minarp read a paper entitled “ A Word in
Favor of Free Dispensary and Free Hospital Work,”
which had been read on a previous occasion.
Dr. GeorGE E. FELL read a brief paper entitled
THE MICROSCOPE IN DIAGNOSIS; PERSONAL OBSERVATIONS.
The microscope revealed the intimate structure of tis-
sues, and illustrated the morphological changes producing
pathological conditions; yet the range of the instrument
in diagnosis was somewhat limited.
The following letter, received from Dr. U. C. Lynde,
was one of several showing its value in diagnosis and
prognosis of pulmonary affections: “In the summer of
1884 I was attending two patients, aged about forty ; both
had night-sweats, hectic fever, emaciation, rapid pulse,
etc., physical signs alike; and so similar were their symp-
toms that my progriosis was the same for both—unfavor-
able, my diagnosis being pulmonary tuberculosis. Sputa
were sent to your office for microscopical examunation,
you having no knowledge whence the sputa came. The
sputum of one was found loaded with bacilli, while that
of the other contained none. The former died inside
four months, while the latter recovered and is now
well.”
In some cases the result of the examination had been
negative, but more frequently it was of a positive nature.
Dr. Fell also read a paper entitled
FORCED RESPIRATION—ADDITIONAL OBSERVATIONS.
His further experience had been in cases of opium nar-
cosis, and the asphyxia of the newly-born. It went to
confirm his former favorable opinion of the method.
He was satisfied the method must in time take the place
of artificial respiration.
Dr. Henry F. Riscu read a paper entitted
THE RATIONAL DRESSING AND TREATMENT OF THE UM-
BILICAL CORD AND UMBILICUS.
After mentioning several other methods and their disad-
vantages, he described that practised some years by him-
self and Dr. Otto Risch, with great satisfaction. The
cord was tied with one or more strands of thick silk
“just exactly on neutral ground,” or “ between what be-
longs to the child-and what does not.” ‘Then, after tying
the usual second ligature on the cord, it was cut between
the two. The jelly of Wharton was then industriously
rubbed out, the stump most carefully dried, and either
wrapped in scorched linen or muslin, or, better, dressed
with powdered charcoal or animal carbon. The navel
band should be kept perfectly dry. If the dressing re-
mained dry, it was not changed until the little stump fell
off, which usually occurred on the second or third day.
The navel thus formed was smaller than after the usual
dressing, nor did it ever protrude. The danger of septic
poisoning and gangrene was avoided by this method.
Dr. T. D. CROTHERS, of Hartford, read a paper en-
titled
ALCOHOLIC PARALYSIS,
which will appear in a future issue of THE RECORD.
Dr. FERGUSON mentioned a case in a woman, in whom
alcoholic paralysis led to an unusually early and fatal
termination. He asked Dr. Crothers if he had seen many
such cases, and received an affirmative answer.
Dr. E. M. Moore had listened to the paper with a great
deal of pleasure, both because it marked a new departure
in medicine, and presented views which had lingered in
his own mind many years. Our knowledge of the subject
388
of alcoholic paralysis had been retarded by the fact that,
as a rule, only the immediate effects were looked to, and
the cure regarded as perfect as soon as the effects of the
debauch had passed away. The paper took the right
view, that the effects did not pass immediately away, but
that a profound influence was produced, which might
never pass away. ‘There would be no difficulty in con-
trolling the class of cases described when the law should
recognize them as cases of insanity. They would then be
confined, and receive appropriate treatment.
Dr. CARROLL wished to hear from Dr. Crothers what
he regarded as the intemperate use of alcohols. When
the quantity which the person was capable of oxydizing
had been exceeded, the alcohol began to produce a para-
lyzing attack, and in the end led to degeneration.
Dr. CROTHERS replied that all research went to show
that alcohol was a complex body, and it would require
centuries of laboratory research to answer the question
what could be regarded as the temperate use of alcohol.
Clinical observation was at present of more value.
Dr. H. D. Dipama next read a paper entitled
A FEW FADS,
in which he treated humorously and sarcastically of “ faded
fads,” “ fading fads,” “ blooming fads,” and “ fads in full
bloom.” Among the first was the “ blue-glass fad ;” and
among the second was the “ new elixir fad.”
Dr. ALFRED L. CARROLL being asked to open the dis-
cussion, said he thought it might more appropriately be
opened by a gynecologist. He ventured to suggest some
future fads. For instance, it had been observed that in
enteric and malarial fevers, the spleen was enlarged. Re-
moval of the Fallopian tubes had been shown to prevent
pyo-salpinx ; might not removal of the spleen prevent
the development of typhoid fever? Again, an enter- |
prising young surgeon might become notorious and have
an income of five thousand a week, based on the fad of
extirpating the vermiform appendix of all newly born, and
thus removing the cause of many cases of abdominal
surgery. :
Dr. T. H. MANLEy read a paper entitled
SOME OF THE USES OF THE TRANSFIXION LIGATURE.
The authors investigation in this direction had been
instigated by a case in which the transfixion ligature
saved the life of his patient. While dissecting out tuber-
cularly enlarged glands of the neck, suddenly a large
stream of blood gushed out, which he was unable to con-
trol by pressure. The common carotid had been opened,
and the patient was in imminent danger of exsanguination.
Observing a needle with a ligature lying on the table, he
hastily passed it under the tissues whence the hemorrhage
proceeded, ligated the tissues, and at once the bleeding
ceased. ‘The patient was discharged cured after ten days.
He then experimented with the transfixion ligature on
the cadaver and on dogs, and found that injury to nerves
or important parts was not likely to take place in the
case of most of the vessels of the extremities, and if
antiseptic precautions were observed infection would be
avoided. ‘The ligature, of course, was only temporary, to
be employed in urgent cases where vessels had been
wounded by accident, or in operations in which it was
preferable to render the parts bloodless by this method
rather than by the Esmarch bandage, etc. He was con-
vinced that the transfixion ligature could be safely and
easily applied to any healthy vessel in the external region
of the body. Its use being only temporary, injurious
results from suppression of function of parts included in
the ligature would not be likely to occur ; most was to be
feared in this respect from its use on the large vessels of
the neck, where important nerves might be included.
Strict asepsis should exist. He had employed this method
while operating for a femoral aneurism, and also in a
case of epithelioma of the lip. In the latter instance it
was of special value, since it completely controlled hemor-
rhage, which could not be done in any other way. ‘Ihe
THE MEDICAL RECORD.
[October 5, 1889
method had also been tested and proven efficient in
secondary dressing of a wound of the wrist in which the
radial and ulnar arteries had been divided. By its use,
many lives might be saved on the battle-field, now lost
from primary hemorrhage.
SECOND Day, THURSDAY, SEPTEMBER 26TH—AFTERNOON
SESSION.
Dr. Jonn SHRapy, of New York, read a paper on
THE SHADOW LINE OF INSANITY,
in which he pointed out the faint dividing lines between
the suspected and acknowledged forms. He said that the
harmless classes of cases, attracting as they did but little
attention in their several communities, might be developed
under favoring circumstances into the more dangerous.
‘They need not necessarily be tabooed or isolated, as they
often contributed not a little to the general good, and
might be even classed among the children of genius, being
somewhat of the nature of excrescences, though of a start-
ling variety. Of such were Coleridge, Lamb, De Quincy,
‘Charlotte Bronté and Edgar A. Poe, all of whom were
brilliant and exceedingly unpractical. As long as there
were no particular explosive forces at work, they were safe
enough, but although not subject to judicial isolation, on
account of the law’s jealousy for individual liberty, they
might well bear watching. There were very few who
might be designated as absolutely sane of mind, nor was
there any great necessity that they should be thus consti-
tuted, since society was the mechanism and man the unit,
and society was willing to pay for special graces at special
rates. Here the individual is nothing, and society being
strong, can well afford to defend itself.
DISCUSSION ON THE TREATMENT OF HERNIA.
Dr. JosepH D. Bryant, of New York, opened the dis-
cussion. Six questions were propounded, and formally
discussed by Dr. Bryant and others. They related to
mechanical treatment, the injection method, the open or
non-open method, medicinal and manipulative methods
in strangulated herniz, the technique of taxis, and treat-
ment when gangrene existed.
Dr. Bryant said there could be no doubt but what
the truss cured some cases, but the number was small.
He thought, however, that its use should never be entirely
dispensed with. The cure by this method was usually in
the young. The patient should have three forms of truss,
a strong one for use in heavy labor, a light one for use
during rest, and a waterproof form for use in the bath.
His conclusions on the question of mechanical treatment
were : 1. No form of truss could be relied upon to cure
any variety of simple irreducible hernia. 2. The manner
of treatment of hernia, and that of its so-called cure by me-
chanical appliances, were such that cure by this means
alone could not be relied upon. 3. Relief from annoy-
ance of hernial protrusion might be had by means of her-
nial appliances to be worn during all unusual physical ef-
fort. 4. Apparent cures resulted from the resiliency or
contraction of the tissues, and not from inflammatory
process set up. 5. A hard, slightly convex pad with elas-
tic steel spring attachment furnished the best hernial ap-
pliances. 6. Suspension, elevation, and contraction of
irreducible hernia] protrusions were the main indications
for mechanical treatment. He had had no experience
with Heaton’s injection method. ‘There were certainly
other better operative methods.
Regarding operative methods, he drew the following
conclusions :
1. The open method of treatment was the most rational
and simplest method for the radical cure of hernia. 2.
That the additional time for treatment required by the open
method was time well employed, since there was less likely
to be a return than from any other method. 3. That the
interweaving of the sac with the pillars of the ring (a new
method of his own), followed by the open or closed method,
October 5, 1889]
afforded in many cases equal, if not greater, security than
any other method.
Morphine injections and hot-water baths with elevation
of the part, were the most available means aside from
operative interference and taxis. ‘Taxis should not be
continued longer than fifteen minutes. That length of
time was sufficient if it were properly employed ; if not so
employed, any length of time was too long. Repeated
attempts at reduction by taxis on the part of different
physicians was pernicious.
The following conclusions were drawn concerning gan-
grene : 1. When gangrene of the intestine had taken place
and the condition of the patient would permit, intestinal
repair should be practised at once and the gut returned to
the cavity. 2. When gangrene occurred, presumably involv-
ing a portion of the upper two-thirds of the intestine, the
intestine should be repaired at once and the gut returned,
even if the immediate result should be somewhat doybtful.
3. When gangrene had occurred and the condition of the
patient would not permit of immediate operation, a tem-
porary artificial anus should be made. 4. It was better
to form an artificial anus when the medical attendant
was not acquainted with the details of the more difficult
procedure.
Dr. MILLIGAN discussed the mechanical treatment. In
the Hospital for the Ruptured at Forty-second Street they
had found the simple apparatus of Dr. Knight answer in
most cases, but in some other methods had to be resorted
to. The instrument demanded differed according to the
variety of hernia (he considered only the inguinal), which
might be divided into three : (1) Simple bubonecele, with-
out viscus in the canal ; (2) where the hernia had
the external ring without obliteration of the canal; (3).
where the canal was obliterated and the external ring
enlarged. The first two varieties were controlled by
almost any kind of truss. Five kinds of trusses were de-
scribed.
Dr. ROSWELL PARK discussed the open and non-open
operative methods, giving the preference to the former.
‘The cicatrix left by the closed method was much broader,
being three-eighths to three-fourths of an inch in width,
and must, he thought, undergo stretching and absorption.
In his cases the patient wore no truss after the operation,
since he believed its pressure encouraged absorption of
the cicatricial tissue. He was opposed to injections. The
risks of the operation were not greater than those of rail-
road travel. He was favorably impressed with Dr. Bry-
ant’s description of his method of interweaving the sac
with the pillars. The last few years he had hardly ever
employed drainage, the wound being aseptic. He had
operated sixty times, and had heard of a return in only
three cases, and suppuration in one or two.
Dr. W. T. Buti, of New York, read a paper on
OPERATIVE METHODS,
in which he cited what he regarded as formidable objec-
tions to the closed method, particularly the liability of
recurrence. No operation could be regarded as absolutely
radical. A return of the hernia had been observed at
the Hospital for Ruptured and Crippled in persons who
had submitted themselves to the different operative pro-
cedures. He reported 72 cases in which he had operated
over a year ago. Of this number 38 were treated by lig-
ature, excision, and suture; 34 by ligature and excision.
There were three deaths, which, however, could not be
attributed to the operation. In 2g cases the hernia was
reducible, in 31 irreducible, in 12 strangulated. Of the
78 cases only about 40 were seen after leaving the hospi-
tal. The percentage of cases relapsing within twelve
months after treatment by ligature and excision, was 62 ;
after treatment by ligature, excision, and suture, 75. The
result caused disappointment so far as radical cure was
concerned, but when relapses occurred the hernia was
less difficult to control by truss. He advised a light truss
after the operation. The open treatment reduced to a
minimum the danger of septiczemia.
THE MEDICAL RECORD.
389
Drs. D. M. Torman and Leroy J. Brooks discussed
the medicinal and manipulative methods in
STRANGULATED HERNIÆ.
Dr. DETMOLD said that, about fifty-two years ago, a
young lady, just married, came to him and asked if a hernia
could be operated upon. She had a small femoral hernia
which her husband took for a bubo derived from improper
courses, and refused to have anything to do with her.
Dr. Stevens and others discountenanced an operation,
and he had at that time no precedent to go by. How-
ever, he made an incision down to the crural canal, avoid-
ing the vessels, filled the canal with lint several weeks,
and thus cured the hernia. The husband was so moved
by the devotion manifested by his wife, that he returned
to her and nursed her through the long illness.
Dr. Marcy said the fault with most methods of operat-
ing was failure to close the inguinal canal in the oblique
line observed by nature. The sac should be removed,
the cord pushed inward, a row of sutures placed in the
bottom of the wound laying open the canal from the
lower angle to the upper, and another row of sutures in
the more superficial parts in the opposite direction. Thus,
the obliquity of the canal and its normal le were pre-
served. Animal sutures should be used, buried. He did
not confine the patient to bed, nor advise a truss. All
who had trouble with the hernia should be operated upon.
He believed over ninety per cent. of his cases remained
cured, and he had operated about one hundred times.
Dr. E. M. Moore said that about 1837, when he was
a medical student, Dr. Pancoast had him bring in four
patients with hernia, on whom he made practically hypo-
dermic injections into the sac of tincture of cantharides,
with the view of setting up adhesive inflammation and ob-
literation of the sac. This was done at a time when they
had great fears of injury to the peritoneum. The result
was what had been desired, the hernia was apparently
cured.in each instance, although the cases could not be
followed up.
When Heaton began his method of treatment, he placed
a young man under Dr. Moore’s care into whose hernia
he injected with a glass syringe (after making an incision
with the knife) several drops of oil of cloves. ‘The man
afterward followed his former occupation of porter in a
hotel, wore no truss, and had no return.
In one case Dr. Moore inserted needles and turned the
sac subcutaneously in such a way as to bring its surface to
gether, then inserted a row of pins along the line of the
canal and across at the commencement, which held the
sac in the new position and caused adhesive inflammation
and cure of the hernia.
The subject was further discussed by Drs. Didama,
Armstrong, Van Danhoff, and Manley.
At the evening session Dr. E. K. Dunham exhibited
lantern views of bacteria, and Dr. Stewart a urethrograph.
THIRD Day—FRripay, SEPTEMBER 27TH—MORNING SES-
SION.
The following papers were read by title: ‘‘ The Use
and Abuse of the Forceps in Obstetrics,” by J. P. Gar-
rish, M.D. ; “ Observations on Dislocations of the Hip,”
by U. C. Lynde, M.D.; “Two Cases of Angular De-
formity of the Knee-joint,” by L. H. Sayre, M.D.
Dr. E. K. DUNHAM, of New York, read the address on
medicine (see p. 367) entitled
THE BACTERIOLOGICAL TEST OF DRINKING-WATER,
Dr. H. O. Marcy, of Boston, read a paper entitled
THE CURE OF H&MORRHOIDS BY EXCISION, AND CLOSURE
WITH THE BURIED ANIMAL SUTURE.
The paper covered in a degree nearly the entire field of
hemorrhoids, but dealt more particularly with the operative
methods in treatment; pointing out the objections to
Allingham’s procedure, that by crushing, and by injection ;
of carbolic acid, etc. The method practised by the au-
399
THE MEDICAL RECORD.
[October 5, 1889
thor was a modification of Whitehead’s, which, he said,
was a distinct advance over procedures previously dis-
cussed. Among the conclusions were: 1. That the liga-
tion of tissues for the purpose of producing necrosis, and
resulting antiseptic decomposition, should to-day be con-
sidered unsurgical, and never to be resorted to in any part
of the body. 2. The destruction of tissue by the actual
cautery was provocative of pain and suffering, and was
unwarranted in that it was unnecessary, with rare excep-
tions, in surgery. 3. The dissection and removal of the
hemorrhoidal plexus of diseased vessels, was as rational
and scientific as the dissection and removal of diseased
tissues elsewhere ; that the danger of hemorrhage from
excision of these structures had been greatly exaggerated.
4. That by the method which he (Dr. Marcy) practised,
the operation could in no sense be considered a bloody
one ; it was smple and easy to do after a little experience ;
there was no material hemorrhage, the important blood-
vessels being secured before division by continuous en-
circling sutures, which served still further the purpose of
holding at rest the divided tissues, Necrosis of the parts
was entirely avoided, and with the care practised in
modern antiseptic surgery the wound was maintained
aseptic. The superficial tissues were accurately coaptated,
so that no stitch acted as a foreign body. “He used ani-
mal sutures altogether, that from the tail of the kangaroo,
the fascia latz of the moose, or possibly that of the
buffalo, although this could scarcely be obtained on ac-
count of extinction of the animal. ‘The advantages of
the buried suture over the excision method of Dr. White-
head were: It secured constriction of the blood-vessels
before division ; more accurate readjustment and closure
of the parts through continuous sutures which were buried
and incorporated in the tissues. The time required in
the use of interrupted sutures was longer.
Dr. Darwin CoLvIN read a paper entitled
REPORT OF A CASE OF ATAXIC PARAPLEGIA.
He first saw the patient, a young farmer, in March last.
‘The preceding January he noticed a weakness of the legs,
which, after a time, developed into unsteadiness of gait.
At no time had there been pain, but occasionally there
was some aching in the sacral region. In March he was
walking with a cane, could extend the leg with force,
while flexion was weak. Increased difficulty in turning
was very apparent. ‘The patella reflex was much exagger-
ated, and there was well-marked ankle clonus ; sensation
was unimpaired except very slight numbness and tickling.
At no time was there constriction around the waist, no
inco-ordination of hands or arms, no loss of sexual power,
sphincters normal, no muscular atrophy ; inability to stand
with the heels together and eyes closed ; appetite good.
The gait was not that of locomotor ataxia, from which
affection the author gave the differential diagnosis.
Dr. CHARLES S. BuLL, of New York, read a paper en-
titled
EXTRACTION OF CATARACT WITHOUT IRIDECTOMY, WITH
REPORT OF ONE HUNDRED CASES.
Useful vision was regained in all but one. In that one
the blind had been rendered blind previous to operations
hy frequent attacks of indochoroiditis. No eye was lost
from suppuration. Fifty-two patients were males, forty-
eight females ; the youngest thirteen, the oldest eighty-
seven years of age.
isted in many ot the cases. Reduction of the prolapsed
iris after the extraction of the lens occurred spontaneous-
ly in 56 cases, and was replaced by the spatula in 44.
In 83 there was neither incarceration nor secondary pro-
lapse of the iris. In 53 there were no posterior synechia
or adhesions of the iris to the lacerated capsule. In 47
these adhesions were present, and in Iro of these they
were due to plastic iritis. The healing process was nor-
mal in 86, though in some the process was slow. Iritis
of the mild plastic type occurred in 10 cases, and retrac-
tion of the iris toward the ciliary processes in 3; loss of
Complications of different kinds ex- |
corneal epithelium in 2, “ striped” keratitis in 1. The
wound became infiltrated in 3, necessitating the use of
the galvano-cautery. Choroiditis and hyalitis occurred in
2 cases, and irido-choroiditis with occlusion of the pupil
in 2 cases. Capsulitis occurred in one.
Accidents during the operation were, 1, loss of vitreous
in 13; 2, hemorrhage into the anterior chamber in 2;
3, complete collapse of the cornea in 2 ; 4, dislocation of
the lens in 3; 5, the lens was removed with the blunt
hook in 5.
The duration of treatment varied from eleven to forty-
seven days. Secondary or after-operations in 53 cases.
Discission or laceration of the capsule in 50, and exci-
sion of a piece of capsule in 3. ‘he resultant degree of
vision was as follows: $$ in z6 cases; $8 in 13; f$ in
24; $$ in 22; $$ in 21; $% in Io; Th in 2; counting
fingers at several feet, in one.
DISCUSSION ON THE NEW HYPNOTICGS.
Dr. W. H. FLT, before reading his paper opening the
discussion, permitted CHARLES Rice, Ph.D., to first make
his remarks. Mr. Rice said the demand for the new hyp-
notics was in about the following order, beginning with
that least consumed : Hypnon, amylene hydrate, urethral,
sulphonal, paraldehyde. Paraldehyde was uszd more
than sulphonal because cheaper. Hypnon was objection-
able because of its disagreeable taste ; amylene hydrate
because of its bad after-effect. Sulphonal was the best
hypnotic of the group, but was almost insoluble in wa-
ter, and it was difficult to get a quick effect from it.
‘The white crystalline sulphate of hyoscyamin wes
cheaper than the alkaloid hyoscine, but the latter was
„much more efficient as a hypnotic and would, when it
should become cheaper, take the place of the former.
Dr. Wm. H. Fuinr reviewed the literature of the new
hypnotics, and then gave conclusions based principally on
his own experience with them. He had used sulphonal
most as being the most efficient or desirable of the new
hypnotics. Its physiological action had not yet been
thoroughly established. As a hypnotic it was valuable in
some forms of insanity, neurasthenia, acute sthenic febrile
diseases, opium habit, gastric irritability, and some cases
of anemia. In gastralgia, gastritis, and some other con-
ditions, it was contra-indicated. Toxic symptoms were not
likely to manifest themselves unless the dose exceeded
thirty grains in the adult. A large dose caused fatigue,
depression, vertigo, tinnitus aurium, and cedema of the
eyelids ; it might cause even collapse. It was best ad-
ministered by the mouth, with hot beverages or liquid
food an hour and a half before the desired action. He
had not yet seen a sulphonal habit. ‘There had been
about eighty per cent. of successes in his cases. He had
administered amylene hydrate in thirty-eight cases of in-
somnia, in various diseases, obtaining hypnotic effects in
over seventy per cent. Its physiological effects were
similar to those of alcohol. Its odor was disagreeable
It should not be given in gastric disease, because slightly
irritating. He had recently used paraldehyde in thirty-
five.adult cases for insomnia, with successful results in
seventy-two per cent. It was not irritating to the stom-
ach. If too large doses were given a long time, a condi-
tion resembling chronic alcoholism might develop. It
was best given in soft capsules. He spoke less favorably
of the other hypnotics.
Dr. Joun G. TRruax continued the discussion with a
paper. Sulphonal had proven, in his experience, more ef-
fectual, and applicable in a larger number of cases, than
any of the other new hypnotics. It had been of most
benefit in the restlessness, cough, and slight pains of phthi-
sis pulmonalis. ‘lhe conditions in which the new hyp-
notics were useful were those in which there was not
much pain nor acute inflammation, absence of violent
mania, where dehrium did not depend upon congestion.
They would not take the place of the older hypnotics 10
the class of cases in which these were applicable.
Dr. SQuiss expressed some hesitation in discussing the
October 5, 1889]
subject. His views were conservative. ‘The new hyp-
notics were large in number, and would yet be larger.
‘The same was true of the opium preparations ten years
ago. This could be largely accounted for by the remark
of one of the speakers, that there were “ millions in it” to
the successful advertiser.
It would be observed that none were susceptible of hy-
podermic use; they were slowly absorbed, owing to the
nature of the fluids in the stomach. In the stomach of
the healthy, who needed no hypnotic, sulphonal was ab-
sorbed more readily. Artificial alkaloids were being con-
stantly made by the chemist from natural sources. ‘The
molecules of a given agent, as that from which hyoscin or
quinine were obtained, had their cleavage in different di-
rections, according to the reagent applied, and thus was
produced the alkaloid or derivation leading up to it, but
which had no existence prior to the labors in the labora-
tory.
A CASE OF AMPUTATION OF THE HIP-JOINT WEARING AN
ARTIFICIAL LEG.
Dr. L. H. Sayre presented a young man who, about
seven years ago, suffered from an attack apparently of
rheumatism of the right knee. He continued an invalid
from knee-joint disease until about six months ago, when
Dr. Reginald Sayre performed amputation at the junction
of the lower with the middle third of the femur. It be-
came evident afterward that disease existed in the hip-
joint, and it was decided to amputate in a manner, if po-
ssible, to permit of future use of an artificial limb, instead
of in the old way and condemning the patient to the use
of crutches all his life. Consequently the circular incision,
through the soft parts was made below the trochanter, and
the femur enucleated through a longitudinal incision reach-
ing above the trochanter. When presented, the patient
was wearing an artificial limb for the second time, the
muscular stump supplying attachment and motion. He
believed that to his brother belonged the credit of doing
this operation for the first time.
Dr. L. A. Sayre said he had suggested a similar am-
putation with the same object in view, fifteen years ago,
but had not had occasion to perform it. He was de-
lighted at the result in this case.
Dr. Jonn G. Orton was elected president for the
ensuing year.
Correspondence.
INTUBATION FOR THE REMOVAL OF FOR-
EIGN BODIES.
To THE EDITOR or Tue MebpicaL RECORD.
Sır : The interesting case reported by Dr. S. J. Meltzer
in THE RECORD of September 21st, in which intubation
was successfully practised for the removal of a foreign
body from the air-passages, suggested the following re-
marks :
The size of the croup tubes was not modelled after the
normal larynx, but they were so constructed as to avoid
dangerous pressure when the lumen of this organ is almost
obliterated by inflammatory infiltration of its mucous
membrane and submucous tissues. To facilitate the ex-
trusion of foreign bodies from the air-passages, therefore,
a tube of much larger calibre can be used. It should be
constructed as follows: not over an inch long, cylindrical
in form, of very thin metal, perfectly straight, with small
flanges laterally, none anteriorly, and having a bore at
least three times as great as that of the tubes now used in
the treatment of croup. The obturator should fit per-
fectly at the distal end, otherwise it would be difficult to
insert.
No retaining swell is necessary, as the size alone is suf-
ficient to hold it in place.
With a strong string attached, such a tube may be al.
THE MEDICAL RECORD.
391
lowed to remain in the larynx twenty-four hours if re-
quired, without injury, but if retained for the same length
of time in a case of croup would undoubtedly produce
sloughing of mucous membrane of the subglottic division,
of the larynx. ‘This is the smallest portion of the upper
air-passage, and at the same time the most unyielding,
because it is completely surrounded by cartilage. There
is no danger of injury to the vocal cords, even if worn for
a much longer time.
Foreign bodies enter the larynx during inspiration, when
the vocal bands are widely separated, but their expulsion
is prevented by the spasm excited by the slightest irritation
applied to the under surface of these bands.
The introduction of such a tube as I have: described
overcomes this difficulty, and at the same time gives rise
to a violent attack of coughing, which should prove suc-
cessful in the great majority of these cases when the for-
eign body is not impacted in the lower air-passages.
Taking advantage of gravity by holding the patient’s
head downward, as was practised by the mother in Dr.
Meltzer’s case, is also worth trying, particularly if the for-
eign body be heavy. J. O'Dwyer, M.D.
967 LEXINGTON AVENUE.
Hew instruments.
A NASAL ECCHONDROTOME.
By MOREAU R. BROWN, M.D.,
PROFESSOR OF RHINOLOGY AND LARYNGOLOGY AT THE CHICAGO POLICLINIC, CH1-
CAGO, ILL.
SoME time since, a foreign-made instrument, said to have
been intended for the purpose of operating on the nose,
was put into my hands. I have not been able to ascertain
the name of either its maker or the inventor ; however,
from the idea given me by it I have had con-
structed by Messrs. Truax & Co., of this city,
an instrument much altered from the former.
This improved instrument, illustrated by the
accompanying figure, and described in the fol-
lowing lines, I would call a nasal ecchondro-
tome.
The ecchondrotome consists of two parts,
the handle and blades. On the back of the
former is a steel slot, which can be pushed up
and fastened in position by a binding screw.
The slot, when raised, half encircles the groove
in, and thus forms a purchase for, the milled
nut on the short blade. This screw, when
turned, preferably with the forefinger and thumb
of the disengaged hand, forces the cutting
edges of the two blades slowly toward one an-
other. If it is desired to finish an operation
rapidly, the slot is lowered and the blade
pushed forward with the thumb. One blade is
made fast in the handle by a screw, and cuts
from within outward ; the other blade slides
along the former
and cuts in the op-
posite direction, 2.¢.,
from without in-
ward. The two
screws which hold
the blades together
prevent the cutting
edges of the latter
being pressed to-
gether and blunted. 5
The blades can be turned so as to operate in either the
left or right nasal cavity.
This instrument will take the place of the saw, the
knife, and the chisel in many intranasal operations, par-
ticularly in removing ecchondroses and cancellous exos-
toses, which comprise, as is well known, the majority
ofall growths from the septum of the nose.
a E =
aii i
392
THE MEDICAL RECORD.
[October 5, 1889.
In suitable cases one can operate more rapidly and
easily with the ecchondrotome than with any other instru-
ment.
e In using the knife to remove cartilaginous growths from
the septum the operation must often be finished with the
saw or chisel: not so with the ecchondrotome, as it will
readily cut its way through these formations.
The principle on which this instrument works is sim-
ilar in some respects to the Mackenzie tonsillotome.
126 STATE STREET, CHICAGO, ILL.
Army and Bauy Mews.
Official List of Changes in the Stations and Duties of CM-
cers serving in the Medical Department, United States
Army, from September 22 to September 28, 1889.
Pore, BENJAMIN F., Major and Surgeon. By direction
of the Secretary of War, the leave of absence granted in
S. O. No. 54, August 17, 1889, Department of Texas, is
extended one month. Par. 6, S. O. 224, A. G. O., Sep-
tember 26, 1889. E
Lorinc, Leonard Y., Major and Surgeon. By direc-
tion of the Secretary of War, his station is changed from
Fort Mojave, Ariz. Terr., to Fort Wingate, N. M., and
he will report for duty at the latter nlace accordingly.
Par. 7, S. O. 219, A. G. O., September 20, 188ọ.
CuHarin, ALonzo R., Captain and Assistant Surgeon.
Granted leave of absence for fourteen days, with the ap-
proval of the Secretary of War. Par. 10, S. O. 223,
A. G. O., September 25, 1880.
BuRTON, Henry G., Captain and Assistant Surgeon.
By direction of the Secretary of War, will report in per-
son on expiration of his present sick leave of absence, to
the commanding officer at David’s Island, N. Y., for tem-
porary duty at that station, and by letter to the superinten-
dent recruiting service. Par. 3, S. O. 223, A. G.O.,
Washington, September 25, 1880.
+
Oficial List of Changes in the Medical Corps of the United
States Navy for the week ending September 28, 1889.
Gorcas, A. C., Medical Director. Detached from
Examining Board and ordered to hospital, Philadelphia,
Pa.
Horp, W. T., Medical Director. Detached from hos-
pital, Philadelphia, Pa., and to wait orders.
Bocert, E. S., Medical Inspector. Detached from
New York Navy Yard and ordered to Examining Board.
McMurtrig, D., Surgeon. Detached from U. S. S.
Vermont, and ordered to Navy Yard, New York.
Basin, H. J., Surgeon. Ordered to the Receiving Ship
Vermont. -
Hatt, C. H. H., Passed Assistant Surgeon. Resigned
from the Naval Service, tu take effect November 1, 1890,
and resignation so accepted.
For THE RELIEF OF Coryza.—Dr. Kohler recom-
mends inhalations of camphor as affording great relief in
the early stages of an acute coryza. He puts one tea-
spoonful of powdered camphor in a rather deep vessel,
half fills the latter with boiling water, and covers it with
a paper cone. The end of this cone is torn off so as
just to admit the nose. ‘The warm camphor-laden vapor
is then inhaled through the nose, not the mouth, for a
period of from ten to fifteen minutes. This procedure is
repeated every four or five hours. After the third inha-
lation, even the most stubborn catarrh, says Dr. Kohler,
will be found to have completely disappeared. Any
laryngeal catarrh, which may be present at the same time,
will be found to be considerably benefited by the action
of the camphor vapor.—Zettschrift für Therapie.
Medical Mems.
` CONTAGIOUS DIsEASES—WEEKLY STATEMENT. — Re
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending September 28, 1889:
Cases. | Deaths,
TYPHUS fever fics was tds ceed a eee sees eae o o
PY DNOIG fever noose ts na arrela TTAN Erkek 58 7
Scarlet lever sigs isc seed iisa e Eia 26 3
Cerebro-spinal meningitis.................es2ce08 o c
Measlés corretas esten ran dsm E E a I0 I
Diphtheria.. e cereos i hia Oe a EE CEE E E e 57 17
Smallpox 5 os voids ccwtineis oscbae wees eee aen e See o o
Yellow fever.........sossessosoosecssonessssessso o o
Cholil ecset ceoeia uante NUA NER o o
FRAULINA SCORBILIS IN DYSENTERY.—Dr. Aphel has
obtained good results in the treatrnent of dysentery by
means of fraulina scorbilis. He employs the powder in
doses of seven grains every two or three hours. It pos-
sesses a stimulant and local astringent action, and is iv-
dicated chiefly in adynamic forms of the disease.—Los
Avisos Sanitarios.
ANTIPYRIN IN D1aBETES.—Drs. Gley and Germain
Sée report a number of .cases of artificial glycosuria in
dogs, in which the good effects of antipyrin in this affec-
tion were well illustrated. To a dog passing thirteen
grammes of sugar a day, one gramme of antipyrin per diem
was given for eight days, at the end of which time the
amount of sugar had fallen to eleven grammes. At another
time the quantity of sugar was reduced by the same
means from about ten to less than six grammes. Dr. Sée
has also employed the -drug in the treatment of glyco-
suria in the human subject with good results. Lépine and
-Porteret have shown that antipyrin has the effect of re-
tarding the transformation of glycogen in the liver and
muscles into glucose. M. Huchard has previously related
several cases of polyuria and glycosuria, in which the ex-
hibition of antipyrin was followed by good results. The
latter author believes that this drug has a special utility
in bulbar neuroses, among which he classes diabetes,
polyuria, and exophthalmic goitre.—Revue Générale de
Clinique et de Thérapeutique.
LEMON-JUICE IN NOSEBLEED.—In a case of rebellious
epistaxis, which had resisted various modes of treatment,
including plugging of the anterior nares, Dr. Fauchon
obtained a cure by means of the local application of
lemon-juice. An injection of the juice was made by a
glass syringe into the nostril from which the blood was
escaping, with the result of immediately arresting the
hemorrhage.—Xevue Générale de Clinique et de Thera-
peutique.
TREATMENT OF THE PoTtaTu DISEASE.—At a recent
meeting of the Academy of Sciences of Paris, M. Pril-
leux sent a communication upon the treatment of potato
disease by means of a copper solution which had been
found useful for a similar affection of tomato plants. He
experimented with some potato plants which were found
to be in the initial stages of the disease although there
were quite a number of black spots on the leaves. He
selected nine hills for the experiment, reserving six others,
without treatment, to serve for comparison. ‘The liquid
was carefully applied with a watering-pot so as to thor-
oughly wet all the leaves. ‘The potatoes were dug up eleven
days later, when from the nine hills treated one hundred
and fifteen healthy potatoes were taken, none of which
were diseased. From the six hills reserved for com-
parison fifty-three tubers were taken, and of these seven-
teen were diseased. The solution, called “ bouillie bor-
delaise,” was composed of six parts each of sulphate of
copper and of chalk in -one hundred parts of water.—
Journal d’ Hygiene.
The Medical Record
A Weekly Fournal of Medicine and Surgery
Vol. 36, No. 15
——— eee ee o ‘ŘS aS
Original Articles,
THE RELATION OF DIET TO URIC-ACID
FORMATION.’
By WILLIAM H. DRAPER, M.D.,
NEW YORK.
Ir is not my purpose in this brief paper to discuss the
question of the origin of uric acid. Whether this sub-
stance is the penultimate of urea, or the result of the im-
perfect metabolism of glycocin in the liver, are questions
which are still involved in much obscurity. Nor do I
intend to consider the relations of the real or apparent
increase of uric acid and its salts in many pathological
conditions that come under the observation of the practi-
cal physician, such, for example, as the febrile state,
cirrhosis and cancer of the liver, splenic leukzemia, and
many other diseases. I desire simply to call attention,
very briefly, to the relation which deposits of uric acid
and its salts bear to the ingestion of particular classes of
foods, and their association with the special forms of in-
digestion which are observed in litheemia and gout.
It is important to premise, however, that, in all proba-
bility, deposits of uric acid are properly to be considered
as the indication and measure of the acidity of the urine,
and consequently of the diminished alkalescence of the
blood, and not perhaps so much the cause of the symp-
toms with which they are associated as themselves one of
the effects of the imperfect blood-elaboration which is
essentially the antecedent of the lithæmic state.
The blood, it must be remembered, in spite of the
amount of acid material which enters it, always presents
an alkaline reaction, and the maintenance of healthy nu-
trition doubtless depends upon the preservation, within
certain limits, of what may be termed normal alkalescence.
This equilibrium is secured partly by the organic and in-
organic salts of the alkaline bases which are ingested with
the food, and partly through the discharge of acids by the
lungs, the stomach, the skin, and the kidneys. Whatever,
therefore, tends to disturb this equilibrium must do so
either through some defect in the conversion of the food-
supply, or in the mechanism by which an excess of acid
is removed from the body.
Assuming that uric acid is only one of the products of
imperfect metabolism, and that it is associated with a
diminished alkalescence of the blood, its relation to diet
would seem to depend largely on the manner in which
certain articles of food affect the reaction of the blood.
Though the salts which are contained in our food are for
the most part alkaline, a considerable amount of acid
salts, such as the bicarbonates and acid phosphate of
sodium, enters the circulation in the ingesta; another
source of free acid is that which is present in wines and
beers, and still another, and perhaps the most important,
is found in the process of fermentation which goes on in
the alimentary canal in the saccharine, amylaceous, and
fatty elements of the food. It is especially in connection
with the acid dyspepsia to which this fermentative process
gives rise that we find deposits of uric acid and its salts.
It is this form of indigestion, moreover, which is associated
with the so-called lithæmic symptoms, and which is often
antecedent to the development of gout.
1 A paper read before the Practitioners’ Society, May 24, 1889.
NEw York, OCTOBER 12, 1889
Whole No. 988
The generally received opinion is that an excess of al-
buminous food is the source of any excess in uric-acid
excretion, and the practical deduction from this view is
that nitrogenous foods should be more or less strictly pro-
hibited in the diet of litheemic subjects. While there can
be no doubt that a nitrogenous diet increases, pro tanlo,
the amount of urea excretion, it is not so clear that it in-
creases in equal proportion the uric-acid excretion; and
inasmuch as a very large apparent increase of uric-acid ex-
cretion often occurs with a non-nitrogenous diet, it seems
probable that deposits of uric acid and its salts in the urine
are not so much the result of an excess of nitrogenous
foods as of some condition of the blood which affects the
solubility of this substance. ‘Ihe clinical evidence, based
upon the effects of certain kinds of foods in producing
showers of uric acid and sediments of urates in the urine,
would seem to indicate that these phenomena are the re-
sult of an imperfect conversion of the carbohydrates,
which gives rise to the introduction into the circulation of
acids which diminish the alkalinity of the blood, and so
impair its solvent power over uric acid.
It is the evidence of this nature, derived from a consider-
able clinical experience, to which I wish to ask your con-
sideration. Many years ago my attention was called to
the fact that gouty and lithzmic subjects exhibited a
striking inability to digest the carbohydrates. I observed
this in the victims of acquired as well as of hereditary
gout, but especially in the latter, and often at a very early
age. ‘This inability to convert the carbohydrates I found
manifested itself primarily in an acid dyspepsia, with in-
creased acidity of the urine, with showers of uric-acid
crystals or deposits of urates; and, secondarily, in the
nervous derangements and the catarrhal lesions of the
skin and mucous membranes which characterize the lithe-
mic state. Closer observation led me to the conclusion
that the essential, and often the only successful, means of
combating these derangements was the withdrawal, more
or less complete, of the sugars and starches from the diet.
I am aware that the necessity for restricting the use of
the carbohydrates in the dietary of gouty and lithemic
persons is now pretty generally recognized ; but I think
that the opinion still largely prevails that animal foods are
not only responsible for the origin of gout and lithemia
but that the rational treatment of these disorders neces-
sarily involves the more or less strict prohibition of these
foods. So general, indeed, is the prejudice against the
use of nitrogenous articles of diet in the treatment of
gout—a prejudice founded mainly upon the teachings of
the English authorities upon this disease—that it 1s only
within a comparatively recent period that there has been
any question about its correctness. Some of the later au-
thorities, however, both German and English, recognize
the baneful effects of the carbohydrates in the diet of
gouty subjects, and strongly urge a diet composed largely
of animal foods. My own experience leads me to believe
that in aggravated cases of the morbid conditions under
consideration a diet as rigidly exclusive of the carbohy-
drates as that required in glycosuria is necessary to control
uric-acid formation and its consequences. ‘The failure to
recognize this fact often interferes very seriously, in my
judginent, with success in the management of severe cases
of this nature, for there is no therapeutic measure which,
so far as I know, can compare with a properly regulatea
diet in controlling and preventing the miseries which are
incident to this special derangement of nutrition.
Even those who are inclined to acknowledge the gen-
594
eral truth of this statement fail sometimes to appreciate
the necessity of attention to details in carrying out the
principle involved in what may be called the anti-lithæ-
mic diet. It is only by careful observation and experi-
ment in any given case that the dietetic cause of lithæmia
can be ascertained. In the group of carbohydrates and
their derivatives which enter into an ordinary dietary, it is
often only necessary to exclude the fermented preparations
of alcohol to correct the tendency to uric-acid formation.
Wines and beers are perhaps more often responsible for
this condition than any article of table use. After these I
am inclined to class fruits as a frequent cause of lithæmia.
It is not an uncommon experience to see attacks of gout
even provoked by strawberries, watermelons, apples, and
oranges, as readily as by Madeira and Burgundy. The
reason why fruits are so prone to produce in gouty sub-
jects primary and secondary derangements of digestion,
is probably because of their saccharine property. They
are to be classed among the sweets, and, as I have re-
marked, are often more apt to excite and perpetuate the
lithæmic condition than other forms of sweet desserts.
The cases are not very rare, in my experience, in which
the exclusion of the carbohydrates may need to be ex-
tended to the farinaceous foods. I have known instances
in which an almost absolute exclusion of them was re-
quired in order to control an acid dyspepsia, with its con-
comitant phenomena of uric-acid showers and deposits of
urates.
I would not be understood as affirming that anything
like the rigid exclusion of carbohydrates from the diet of
litheemic persons, which I believe to be sometimes neces-
sary, is often required. Experiment only can determine
what particular group of this class of foods is the source
of mischief in the digestive process. It may be the fer-
mented liquors, it may be fruits, it may be the sweet des-
serts, it may be the farinaceous foods, and it sometimes
happens that the lithzmic subject will have to be as
strictly debarred from indulgence in all of these things as
the glycosunic.
There is one point in regard to lithzemia and its rela-
tion to diet to which it is important to refer, and that is,
that the inability to convert the carbohydrates which we
believe to be the real source of this condition, is occasion-
ally intermittent, and is apparently excited or aggravated
by nervous exhaustion from any cause, such as overwork,
anxiety, or insomnia. ‘his is especially common in
neurotic persons. It is needless to observe that it is more
common in persons of sedentary habits and intellectual
pursuits, and its frequency is probably largely due to the
failure to adapt the diet to the kind of work which the in-
dividual is called upon to perform. ‘There seems to be
good reason to believe that a diet composed largely of
farinaceous foods is best adapted for the evolution of
muscular work, since such a diet requires for its complete
combustion a larger supply of oxygen; while for mental
labor, and for the occupations which require only a limited
amount of mechanical exertion and necessitate an indoor
life, a diet composed largely of nitrogenous elements is
most readily and perfectly assimilated. This idea, as
far as a non-nitrogenous diet is concerned, is in accord-
ance with what has been found by practical experience to
be the most successful method of regulating the diet of
animals and men from whom a !ong and steady evolution
of muscular work is required. In regard to the superior
adaptation of the nitrogenous foods for the development
of the higher forms of vital energy the evidence is per-
haps not so clear, though the experience of practical
physicians in dealing with the common dyspeptic ailments
of intellectual workers would tend, I think, to justify such
a conclusion.
I have thus indicated in a brief and very imperfect
manner what my own observation at least leads me to
believe is the relation of uric-acid formation to diet. So
far as the chemistry of this relation is concerned, I am
aware that the explanation I have suggested is more or
less speculative, and is, perhaps, entirely false. The points
[October 12, 1889
upon which, in conclusion, I would lay stress are : 1st,
That deposits of urtc acid and its compounds in the urine
do not necessarily indicate so much any considerable in-
crease in the formation of this substance as they do a con-
dition of the blood which affects its solubility and the
facility of its excretion. 2d. ‘That this condition of the
blood is one of diminished alkalescence. 3d, That this
diminished alkalescence is produced by the entrance of
acid substances into the circulation, largely through the
fermentation in the alimentary canal, or the imperfect
conversion by the liver of the saccharine and farinaceous
elements of the food. 4th, and finally, ‘That clinical ex-
perience, which, after all, in the present state of our knowl-
edge of the chemistry of digestion, is our best guide, tends
to show that the withdrawal, more. or less complete, of
the non nitrogenous foods, and the allowance of a larger
admixture of the nitrogenous elements, constitute the most
efficient means of controlling the formation and excretion
of uric acid and the protean functional and tissue derange-
ments which belong to the lithzemic state.
A MALIGNANT TUMOR IN AN UMBILICAL
HERNIAL SAC, WITH REMARKS ON THE
ETIOLOGY OF CANCER.’
By DANIEL LEWIS, M.D.,
SURGEON TO THE NEW YORK SKIN AND CANCER HOSPITAL,
Mrs. B-——, a widow, aged sixty-seven years, had suf-
fered from umbilical hernia fifteen years, but had never
worn a truss, having always reduced the protruding intes-
tine easily and frequently, until about a year before apply-
ing to me for treatment.
She then began to suffer pain about the umbilicus, and
so much soreness, that for the three preceding months she
had not attempted to replace the tumor. The pain in-
creased rapidly, and radiated to the stomach and pelvic
regions, and a marked failure in flesh and strength, fre-
quent vomiting, constipation alternating with diarrhea,
sleeplessness, and fever, compelled her to seek advice.
A monthly metrorrhagia of more or less severity had
excited no especial surprise in the patient’s mind, al-
though continued more than twenty-five years beyond the
usual period.
Upon examining the supposed hernia, I found a hard,
nodulated tumor of a bluish-red color, the surface of
which was slightly ulcerated, in the fold of skin at the up-
per portion. It extended nearly an inch beyond the
border of the hernial ring, seemed quite movable with the
skin, and it was a hope shared by Dr. S. N. Brockway,
who saw the case with me, that the disease had not in-
vaded the peritoneal cavity. An operation was advised,
and after the patient was etherized, so that a thorough
examination of the base of the tumor could be made, it
was found to invade the ring, and all hope of a slight op-
eration was abandoned. An elliptical incision being
made, the tumor was dissected out as far as the ring, and
then carefully examined for any intestinal contents. It
evidently contained no gut, and was removed in order to
facilitate examination of the parts beneath. ‘he sac
contained some omentum which was not diseased. The
subperitoneal tissue was infiltrated as far as the finger
could reach. It was thoroughly removed, and the wound
then closed as after ovariotomy.
‘The patient rallied well after the operation, but died
sixty hours afterward, apparently from shock, no pento-
nitis having developed.
It should be stated that an examination, while the pa-
tient was under ether, revealed a much enlarged cervix,
but no sign of cancer, although the body of the uterus was
so large as to suggest the possibility of its being the seat
of malignant disease.
‘The first section from the apex of the tumor proved to
be a large, round-celled, alveolar sarcoma.
1 Read before the Medical Society of the County of New York.
October 12, 1889]
The second section was from a portion of the base of
the tumor just outside the neck of the sac, and is of es-
pecial interest on account of the gland-tissue which it con-
tains, the origin of which is believed to be embryonic.
Dr. George T. Elliot has very kindly furnished me the
following description of this rare form of tumor :
“The portions of the tumor removed from the umbili-.
cal region, which were received by me for microscopical ex-
amination, were hardened in alcohol, and the sections were
stained with borax-carmin and pyrogallic acid and iron.
“ It was not difficult to determine the nature of the
growth, since portions of the sections were found com-
posed of small spindle-shaped cells, with here and there a
few large round cells, while in others these latter were ar-
ranged in more or less large alveoli formed by the bun-
dles of connective tissue. In many of these alveoli, cap-
illary blood-vessels, which were abundant throughout the
tissue, penetrated in between the cells contained in them.
From these features it was evident ‘that the new-growth
was a sarcoma composed of mixed cells, spindle-shaped
and round.
“ In addition to the sarcomatous tissue, however, there
were found other histological elements which greatly in-
creased the interest taken in the specimen. Distributed
throughout the sections, more or less abundantly, glan-
dular tissue was found, which was in every way identical
with the glands of Lieberkuhn existing in the small in-
testines.
“The glands were composed of a basement membrane
and columnar epithelium, and they were separated from
one another by more or less connective or sarcomatous
tissue. Some were unchanged, others were hyperplastic,
while still others had undergone cystic degeneration.
‘« The tissue between them was more or less infiltrated
with small round infiltration-cells.
“ The presence of the intestinal glandular tissue in this
tumor is not an extraordinary fact, but yet one which is
rarely met with. Growths of this class occur at the um-
bilicus, and are known under the name of enteroteratoma.
To understand the occurrence of these growths, it must be
remembered that in foetal life the ductus omphalo-me-
sentericus 1s prolonged into the umbilical cord, but nor-
mally disappears before birth. Abnormally, however, it
may persist and develop into a tube resembling intestine,
and either form a congenital diverticulum of the small in-
testines, or more rarely, if this development has occurred
in the portion of the duct situated just in front of the
navel, there remains a small tumor after the falling off of
the severed umbilical cord.
“ This seems to be the only way in which the presence
of the intestinal glands in the tumor could be explained,
that is, that the original growth was an enteroteratoma to
which no attention had been paid, but which persisted and.
finally underwent sarcomatous degeneration. It seems,
however, remarkable that it should have persisted so
long before undergoing change.”
The details of this case have been quite fully given for
two reasons. In the first place, it is the only recorded
case, as far as I have been able to learn, where malignant
disease has been developed in an old hernial sac ; and,
secondly, its appearance therein is new evidence in favor
of the fact, now fast becoming accepted by surgeons,
that diseases which are perfectly non-malignant in the
beginning may, and often do, prove to be the exciting
cause of cancer.
Before proceeding further, permit me to state what we
mean by the term “cancer.” Much confusion still exists
on that point, owing to the various diseases to which the
term has been apphed by different authors. Dr. Snow
enumerates the following characteristics belonging to can-
cer :
1. Resistance to all known medicinal agents.
2. Proneness to invade other organs and tissues of the
body, than those in which it has originated.
3. Liability to recur after removal by caustics or the
surgeon’s knife.
THE MEDICAL RECORD.
395
4. The pain to which it commonly gives rise.
5. ‘The tendency to destroy life.
Upon this basis the name of “cancer” becomes sim-
ply a general term to be used for convenience, to indicate
any neoplasm which presents the characters enumerated,
whether it be carcinoma in any form, any variety of sar-
coma, epithelioma, or lymphadenoma.
This use of the term seems to me not only reasonable,
but almost a necessity, for the accurate nomenclature of
these malignant diseases can only be made by the micro-
scopist, and is seldom necessary in determining the course
of treatment which should be adopted.
The discussions concerning the etiology of cancer may
all be classified under three heads, viz.: 1, Hypothesis ; 2,
analogy ; 3, fact.
Under the first head we find the old theory of a dys-
crasia—a peculiar condition of the blood manifested in the
form of cancer. In the same category come those whose
supposition is that heredity is the cause of cancer in a
majority of cases, and Sir James Paget believes in all cases,
if we could know the correct history.
In other words, because your paternal grandmother
died of a cancer of the uterus at the age of fifty, and your
brother’s son, aged twenty-five, has a sarcoma of the neck
or an epithelioma of the neck. we should attribute it to
heredity as acause. There would be just as much reason
in attributing every other disease to heredity, for have we
not all suffered more or Jess from disease with which our
near and remote kinsmen were afflicted? The fact is
that the distribution of a disease as prevalent as cancer
would of necessity affect a relative of yours or mine now
and then.
Among nearly two hundred cases of tumors, mostly
malignant, in my own practice, not ten per cent. give any
family history of cancer.
The attempt to definitely and forever settle the etiology
of cancer, by comparing it with tubercular disease as its
analogue, is now in the height of public and professional
favor.
Nearly all writers on cancer, for the past hundred years,
have discussed the same question, and arrived at varying
conclusions, all agreeing on one point only, that both dis-
eases usually terminate fatally.
Since Koch’s discovery of the bacillus of tubercle, we
have been told that the bacillus of cancer would soon be
discovered. A committee appointed by the British Medi-
cal Association, after a very careful investigation, has re-
ported a negative result.
Scheurlen’s discovery of the bacillus of cancer has not
been confirmed by others, or successfully maintained by
himself. ‘here, however, remains the possibility, and
even hope, that the microscope will yet reveal the actual
cause of cancerous growths; but even then we shall be
obliged to depend upon facts gleaned from clinical ex-
perience for effective methods of treatment. Hence the
history of such a case as we have described becomes im-
portant, as it presents an unusual, if not unique, instance
of the long continued irritation of an unretained hernia,
finally causing a neoplasm of a very malignant type.
Nothing can be plainer to a careful observer than that
a prolonged local irritation, such as a broken tooth upon
the lip or tongue, inflamed hemorrhoids in the rectum, or
chronic inflammation in a lacerated cervix uteri, will very
often cause cancer. ‘This case adds another possible
cause, and there can be little doubt that if, in the pre-
cancerous stage, as Mr. Hutchinson has named it, a
proper truss had been applied, she would have been alive
to-day.
‘The statement has been made, concerning traumatism
in these cases, that a prolonged irritation will cause car-
cinoma, while a sudden injury, like a single blow upon the
breast, will be followed by a sarcoma, in case any tumor
occurs. From a study of my own cases, there seems to
be no foundation for the opinion. It is a matter of no
clinical importance, however, as one variety is liable to
be as malignant as the other.
Statistics are not yet ample enough to he of great value
on this subject, but enough is known to justify the state-
ment that traumatic causes play an important part in the
etiology of cancer.
Tumors of non-malignant type often prove a source of
Irritation to adjacent tissues, and so cause cancer, or the
tumor itself degenerates into a disease of a malignant
character. Of this class the following is a good illustra-
tion : A man, aged fifty-five, with a wen on the vertex, one
inch and a half in its longest diameter, which had existed
for a score of years or more, accidentally struck it against
a sharp piece of wood, which, if I remember rightly, caused
slight bleeding. Inflammation of the tumor followed, then
ulceration and sloughing, which was followed, after a few
weeks, by cancerous disease of the entire border and
even base of the ulcer. There was no family history of
cancer.
‘The instances in which cancer has developed in con-
genital moles, warts, in syphilitic ulcers of the tongue and
lips, in the penis where an old phimosis has irritated the
organ, and in cicatrices of various kinds, more especially
after burns, have been often noted.
Dr. A. D. Pomeroy referred a patient to me a few days
ago, who was injured several years ago by a splinter of
hot iron striking the bridge of the nose, and glancing to
the nght, ploughed its way nearly to the internal can-
thus. It healed pretty promptly, but had always been a
little tender near the eye. For a few months past it has
been more troublesome, and when he presented himself at
the clinic a well-marked epithelioma had developed in
that portion of the cicatrix nearest the angle of the eye.
_ In the meantime, since the injury the man had reached
the age of forty-nine, when cancer is much more liable to
occur than in earlier years.
At least four cases are now on record where epithelioma
has developed on a psoriatic base—two by Dr. White in
1885, one by Cartay in 1878, and one by Hebra.
In White’s and Hebra’s cases .there was a transition of
warty growth of the plaques, a form to which the name
psoriasis verrucosa is given. ‘These cases, while showing
that psoriasis is not simply a parakeratosis, but also of in-
flammatory nature, renders a prognosis of much greater
moment in cases where any appearance of a warty growth
is manifested
All these instances simply teach us that any prolonged
irritation in organs most subject to cancer is liable to set
up the disease, and, from the practitioner’s stand-point, the
successful treatment of such cases depends to a great ex-
tent upon prompt and thorough eradication of all these
predisposing causes of the disease when possible.
Before closing, permit me to enter a strong protest
against the common practice of trying the effect of mild
caustics, such as nitrate of silver, pyrogallic acid, resorcin,
and many others, upon these malignant diseases. Nearly
always such applications stimulate the progress of the dis-
ease, and very seldom do any good whatever. ‘This is
eminently true of the galvanic current as applied to the
surface of tumors.
A scirrhous tumor of the breast, which the physician in
charge permitted me to examine recently, had made such
remarkably rapid progress that some special cause was
sought for, and found, as I believe, in the mild and fre-
- quently repeated galvanization of the tumor by an over-
zealous advocate of that remedy.
62 PARK Avanug.
Is SaACCHARIN INjuRIOUS?—M. Dujardin-Beaumetz
having been quoted as saying that saccharin was injurious,
writes to the Journal de Médecine de Paris that he was
misrepresented. He regards saccharin as a most valuable
acquisition in the dietetic treatment of diabetes. But
what he had protested against was its use in the adultera-
tion of food. Such use, he maintained, was not only fraud-
ulent but was injurious, not because the substance is in any
sense poisonous, but because it is Innutritious, and the con-
sumer gets what he supposes is a food but which is not.
THE MEDICAL RECORD.
[October 12, 188
A CASE OF RHINOLITH AND TWO CASES OF
+ A TOOTH IN THE NOSE.
- By JONATHAN WRIGHT, M.D.,
BROOKLYN, N. Y.
WHILE rhinoliths are by no means very frequently found,
yet they are not so rare as to be unknown in the experi-
ence of any laryngologist who sees annually a large num-
ber of cases of nasal disease. ‘They are more often seen
in dispensary practice than among private patients. ‘This,
no doubt, is due to the neglect of symptoms caused by
the presence of a foreign body in the nose among this
class, and to the fact that the children of well-to-do pa-
rents are more carefully watched, and the introduction of
foreign bodies prevented or detected. A rhinolith always
has as a nucleus a foreign body which, in the great major-
ity of cases, whatever the age of the patient, has been
introduced into the nose during childhood, although it is
the exception to obtain a history of the event. After the
lapse of time it gradually becomes coated with lime-salts,
deposited upon it by the nasal secretions, rendered abnor-
mally abundant by the irritation of its presence. The
longer it remains the larger it grows, and the greater the
local irritation it causes. ‘The nucleus is most frequently
a relatively small object, because a large one soon causes
such symptoms as to be noticed by the parents of the child.
or by the patient himself, and thus becomes the subject of
investigation. The nucleus may be anything, and nearly
everything has been found, from shoe-buttons and pieces
of coal, to maggots and parasites. The rhinolith, as it
grows by the accretion of lime-salts, hollows out for itsclf
a cavity in: the nasal fossa, usually the inferior meatus,
and this cavity may be of considerable size. ‘The bony
walls may be encroached upon, causing necrosis of bone,
but the destructive process is rarely, if ever, extensive.
After a time, a condition of the nose exists which, at first
glance, has every appearance of idiopathic ozæna. ‘There
may even be atrophy of the mucous membrane. ‘This
appearance is always unilateral, while ordinary ozena
rarely, though occasionally, is. A frequent symptom Is ex-
cessive epistaxis, especially when the nasal fossa 1s probed.
The foul smell, which may be that of necrosed bone, often
resembles syphilitic ozæna. Pain of varying intensity may
be present, as well as various reflexes, such as sneezing,
coughing, asthma, neuralgias—in short, any or all the symp-
toms due to intra-nasal pressure, or to irritation from other
causes.
The nasal discharge is usually copious, and may be
thick, forming crusts easily, or muco-purulent, stained
with blood, or simply watery. Occasionally portions of
the lime salts may come away with the discharges, the
patient speaking of them as “gritty.” Such symptoms,
when unilateral, are almost pathognomonic of a foreign
body in the nose, which may or may not have lime-salts
around it.
A rhinoscopic examination reveals, as a rule, no foreign
body to the view, because it is imbedded in its cavity and
surrounded by hypertrophic mucous membrane ; cleansing
the nasal fossze by a spray fails to bring it to sight. The
application of cocaine, by shrinking the tissues and en-
larging the field of vision, may often disclose the source
of the trouble. ‘The probe is the most reliable means of
diagnosis, the grating of the hard body revealing its pres-
ence. ‘The presence of dead bone from syphilitic necro-
sis is practically the only other condition which can de-
ceive the experienced examiner. ‘This can still further
be eliminated by measuring with the bent probe the limits
and the shape of the bared surface, and by its mobility.
If the foreign body is not easily extracted at the first
sitting, it is well to give the patient an alkaline nose-wash
with a syringe, and direct him to keep the nose clean for
a few days by the use of them. Often, at the next visit
the discharges and the swelling, as well as the subjective
symptoms, will have largely abated. A stiff probe is often
useful in prying the body out of its cavity. By bending
a right-angled hook on the end of the probe the body may
October 12, 1889]
be dragged out by this simple means. A snare may be
used to encircle it, washing the nose out from behind with
a post-nasal syringe ; a sudden expiratory effort by the pa-
tient, after the object has been dislodged, may bring it out.
The best forceps for the purpose are those devised for
general nasal work by Dr. C. H. Knight, of New York
City. I believe there have been various instruments speci-
ally devised for extracting a foreign body from the nose.
I doubt if they are necessary. |
Of late years, the journals devoted to laryngology and
rhinology have abounded in descriptions of cases of rhin-
oliths and other foreign bodies in the nose, and a reference
to them will easily disclose the literature of the subject.
The case of rhinolith reported here is one of several that
have come under my observation, distinguished from others
simply by its size and the character of the nucleus.
D. L——, aged thirteen, a schoolboy, applied at the
Demilt Dispensary for treatment on April 27, 1888.
Three years previously his nose had begun to trouble him,
bleeding easily and discharging offensive material, and
always from the left side. No history could be obtained
of the introduction of any foreign body whatever.
There was marked tenderness to touch on the left side
of the nose. An intra-nasal examination showed an object
covered with secretions lying in the left inferior meatus.
A foul odor was emitted from this side of the nose. The
object seemed about the size of a hazel-nut, and gave a
grating sound and sensation on the impingement of a
probe. It was necessary to break it into several fragments
before extraction. It was found to consist of two layers
of hard calcareous material, between which sponge-tissue
could be plainly distinguished. ‘The calcareous material
had infiltrated only the outer portion of the sponge, leav-
ing the central part free from it. The rhinolith had hol-
lowed out for itself a nest between the septum, the inferior
turbinated bone, and the floor of the inferior meatus ; all
nasal symptoms soon subsided after the extraction.
As has been said, many such cases have been reported.
The presence of a tooth in the nose is, however, a very
rare circumstance. ‘here is a record of one case,’ where
a right upper canine tooth was removed from the left or-
bit of a child. ‘This was evidently a dentigerous cyst,
which must have begun development at a very early stage
of embryonic life. Many cases of dentigerous cysts have
been reported, and they are not by any means confined to
the maxillary regions.
Dr. Wyeth,” several years ago, reported to the New
York Pathological Society a case in which a displaced
tooth was found in the antrum of Highmore. Dr. Grif-
fin * found a tooth growing upward in the nose in a case
of cleft palate. This produced no symptoms. Dr. Mar-
shall,* and Dr. Ingalls,® of Chicago, have each reported a
case in which the tooth had apparently ulcerated through
into the nose, from the upper jaw. It is doubtful how
the teeth in the cases reported by Schaeffer,’ Roy,’ and
Hall ° became nasal inhabitants. ‘These six cases are all
that I have been able to find recorded, after a careful
search, though other reports may have been overlooked.
In all the cases reported the teeth were the anterior ones,
canines or incisors; and the reasons are obvious, since
the posterior ones, if inverted, as in Griffin’s case, would
grow into the antrum, and probably produce no symptoms.
I have seen skulls in which a tooth had attained full
growth within the alveolar process of the superior maxilla
without emerging from the bone at any point. Where
ulceration takes place, the progress of a bicuspid or tri-
cuspid upward would be very unlikely to occur, from ‘the
shape of its root. If it should occur, as in the case of
1 peer E B. : British Medical Journal, 1887, p. 873.
2 Wyeth: New York Medical Journal, November 24, 1883.
3 Griffin: New York MEDICAL RECORD, March 13, 1886.
3 aa Journal of American Medical Association, November
,1
Bs Ingalls: Journal of American Medical Association, February 23,
I
84.
* Schaeffer: Deutsch Med. Woch., No. 2, 1883.
7 it London Lancet, November 3, 1883.
2 Hall: London Lancet, November 17, 1883.
THE MEDICAL RECORD.
397
Wyeth, it would, from its situation, be most likely to be
discharged into the antrum.
The first of the cases related here is instructive as il-
lustrating the migration of an object through bony struc-
ture, while the second case was evidently orginally one of
the extra-alveolar development.
Case I.—Mary V——., aged thirty-five ; married ; came
to the Demilt Dispensary February 21, 1888. Her pre-
vious and family histories had no bearing on the case.
Four years previously she had all her remaining teeth,
nine in number, extracted from the upper jaw. ‘The last
one, 2 lateral incisor or canine, on the left side, she had
extracted during nitrous oxide narcosis. ‘The dentist told
her he thought he had left a piece behind, but could not
detect it on probing. ‘here was a good deal of gingival
tenderness afterward, which soon subsided. These facts
were elicited from direct questioning after the nature of
the trouble became evident, the patient having had no
suspicion of the connection between the tooth episode and
the nasal symptoms which followed six months later. At
that time the left side of her nose began to trouble her, by
being “ stopped up” at times, and there was a slight dis-
charge. For two years previous to her application for
treatment there had occasionally been a good deal of
bleeding, and the obstruction, together with the nasal dis-
charge, had steadily increased. For the last six months
the nose on the left side had been painful and sensitive.
An intra-nasal examination showed marked hypertrophy of
the nasal mucous membrane on the left side. It was red
and inflamed, and bled easily. A probe detected a rough,
hard surface about an inch and a half from the left an-
terior meatus, on the floor of the nose and close to the
septum. Small pieces of calcareous matter or bone could
be crumbled off with the probe. The patient was given
an alkaline wash with a syringe. ‘Two weeks later she
again presented herself, bringing with her a small, flat
sequestrum which she had washed out of her nose. After
the thorough application of cocaine, by means of a probe
and the forceps the single root of a tooth, about three-
fourths of an inch long, was extracted from the left nostril.
At one end there was some calcareous matter firmly ad-
herent. The nasal symptoms soon subsided.
Case II."—Mary F , aged eight, applied for treat-
ment to the Throat Class of the Roosevelt Dispensary on
August 17, 1888. Her father died of phthisis. The child
was undersized, and had evidently been a sufferer from
rachitis. The mother could give little or no previous
history of the case, except that the child’s nose, as far as
she knew, was in a normal condition when she was a year
old. Since then the nose had been stopped up so as to pre-
vent nasal breathing. There had been considerable of-
fensive discharge. The bridge of the nose was sunken.
The nostrils were flattened and contracted. The supe-
rior alveolar process on the left side, corresponding to the
situation of the incisor and canine teeth, was absent, leav-
ing a slight cleft. No history of accident could be ob-
tained, the mother stating that she had never noticed the
defect before. The left nostril was obstructed by a
foreign body, which gave a grating sound on the impinge-
ment of a probe. Considerable force was necessary to
extract it with the forceps. It was found to be the crown
of an incisor tooth. It was notched, as in young children,
and larger than in a child a year old. ‘There was consid-
erable calcareous matter around it and in the nostril, but
no root was found.
The patient’s nasal symptoms had very markedly abated
at the next visit, and since then she has not been seen.
ADMINISTRATION OF COD-LIVER OIL.—It is stated by
a French physician that a mixture of equal parts of cod-
liver oil and lime-water, makes a fairly palatable and per-
manent preparation. It may be flavored to suit the taste.
1 This case came under the observation of my assistant, Dr. F. A.
Manning, during my absence. To him I am indebted for the notes
of the case.
398
Clinical Department.
TUBERCULOUS PULMONARY ANEURISM—
RUPTURE—DEATH IN EARLY STAGE OF
THE DISEASE.
By J. W. KIME, M.D.,
FORT DODGE, IA.
On the morning of September 1, 1889, I was called to see
Mrs. R. M. W——,, aged forty-two, married, mother of
four children, two dead, one of diphtheria, the other of
consumption. Patient’s mother died of asthma (?), prob-
ably phthisis, at the age of sixty-one. Other family his-
tory fair. Daughter died in 1888, at the age of fourteen,
of phthisis.
During daughter's illness, in 1887, Mrs. W ’s tem-
perature constantly ranged from 994° to 100}° F., but she
would not consent to further examination at the time.
On July 13, 1889, her fourth child was bom after a
normal pregnancy and labor. Health since 1887 to birth
of child has been exceptionally good, and average weight
six to ten pounds greater than in former years. After
labor she felt stronger and better than after other preg-
nancies, and in three weeks attended her household duties.
On August 31st she had a slight pulmonary hemorrhage,
on account of which I saw her on the following day.
Examination shows very slight dulness, and coarse rales
at apex of right lung. At two inches to the right of the
sternum, in the third and fourth intercostal spaces, there
is a well-marked aneurismal bruit. ‘Temperature, 99° F.;
pulse, 100. No cough or expectoration at any time ; feels
- quite well, and is at work.
On September 4th a second hemorrhage occurred,
about one ounce of blood being expectorated.
On September 7th a hemorrhage took place early in
the morning, and again in the afternoon of the same day,
when about four ounces of blood were expectorated, and
the bronchi were nearly filled, so that patient became al-
most asphyxiated ; rallying, however, she rested quietly
till 6 a.m. the following day, when a hemorrhage, proving
fatal in a few minutes, occurred. The aneurism had evi-
dently ruptured the previous day, but a plug forming,
checked its flow until it became displaced, when fatal
hemorrhage ensued. At this time, less than a half ounce
of blood was expectorated ; the bronchi filled with blood,
resulting in death from asphyxia.
The tuberculous process could not have extended to
any considerable degree in this case, but was confined to
and about the walls of the vessel, which finally gave way.
ANTIPYRIN IN LABOR.
By J. BARAN, M.D.,
NEW YORK.
Tuis drug, to be given by rectal injection, has been lately
recommended for the relief of severe pains of labor. It
had been my intention of using it in that way, but found
no occasion for it in the cases presenting the last few
months.
Administering the drug in one of my last cases, and
observing the most striking beneficial results, I thought
it proper to bring it to the notice of the profession. Mrs.
S——., aged about twenty-two, primipara, had suffered
labor pains almost continually from the morning of August
24th to the afternoon of August 29th. She claims to have
suffered most acutely, crying for pain, so as to compel the
administration of doses of morphia, with only trifling re-
sults. The first dilatation of the os was perceptible on
the morning of August 28th, and increased very slowly.
On the 2gth, about four o’clock P.M., the woman suffer-
ing agonizing pains, dilatation about one and a half inch
in diameter, great rigidity of the cervix, I ordered twenty
grains of antipyrin by the mouth, which she took about
THE MEDICAL RECORD.
[October 12, 1889
half an hour later. When seen again, one and a half hour
after, I faund the second stage of labor fully established.
She made powerful expulsive efforts. I was prepared with
chloroform, having felt certain there would be necessity
for it, but to my astonishment, she assured me that she
did not mind the pains at all, that they were very trifling,
and very easily borne. She gave birth, half an hour later,
to a very large baby. The striking symptoms were imme-
diate great relaxation of the rigid os, and the almost en-
tire absence of suffering during most powerful expulsive
efforts after one dose of twenty grains antipyrin, given
by the mouth.
AN IMPROVEMENT IN THE TECHNIQUE OF
INGUINAL COLOTOMY.
By CHARLES B. KELSEY, M.D.,
NEW YORK.
In the last few inguinal operations I have performed, I
have adopted the following plan: The incision is that of
Crips—across a line from the anterior-superior spinous
process to the umbilicus. After getting the sigmoid flex-
ure outside the body, a hair-lip pin is passed under it in
the following manner : It is entered through the skin on
the side of the wound toward the median line, and at the
junction of the lower with the middle third of the incision.
It perforates first the skin, next the parietal peritoneum,
next the mesentery of the gut close to the bowel, and at
the junction of the lower and middle thirds of the exposed
loop, next the parietal peritoneum on the other side of the
incision, and finally, the skin. By this means the gut is
so firmly held in position that it cannot be dislodged by
any vomiting, and a perfectly satisfactory spur is formed,
which will prevent any passing of fecal matter beyond the
opening. After this procedure I have never been troubled
either by prolapsus of the mucous membrane, or the pas-
sage of fæces from the colon into the rectum. With this
modification I now adopt a running suture instead of
about fourteen interrupted ones, to join the parietal peri-
toneum to the visceral layer, and to the skin. A rapid
operator can easily, in this manner, complete the entire
technique of inguinal colotomy in ten minutes, and to this
extent reduce the necessary shock.
25 MADISON AVENUE.
AN IMPROVED WAY OF USING THE HYPO-
DERMIC METHOD.
Dr. P. G. UDELL, of Spencerport, N. Y., writes: “ Every
physician who employs the hypodermic method is aware
of the fact that painful swelling and abscess not in-
frequently follow its use. This undoubtedly arises from
the introduction of septic matter—because the method of
antisepsis has not been rigidly applied to this simple sur-
gical proceeding. ‘The sources of infection are numerous.
The syringe may be unclean ; the needle may be foul ; the
hypodermic tablet may be composed of materials that un-
dergo fermentation ; the water used as a solvent may be
impure ; the spoon employed to prepare the solution in
may furnish the septic matter, etc. I have for some time
used a method whereby the above dangers may be posi-
tively avoided. In one of the compartments of my syringe-
case I carry two small test-tubes, nested; the inner one is
converted into a vial by closing the open end with a cork,
and contains my hypodermic needles immersed in absolute
alcohol. This agent sterilizes any septic matter that may be
on the needles, and does away with the necessity of using a
wire for maintaining the patency of the same ; there is no
rusting, and the needle is always aseptic. I frequently
cleanse the syringe with a five per cent. carbolic acid solu-
tion. Having occasion to use it, I free the needle of alco-
hol by passing through it water that has been boiled. I now
dissolve one of Wyeth’s tablets in a few minims of boiled
water, and for this purpose carry the second test-tube, in
which water may be boiled quickly over any flame that
may be convenient, a match answering the purpose very
October 12, 1889]
THE MEDICAL RECORD.
399
well. After the solution is sufficiently cooled, it is drawn
into the syringe, and is ready for use. The above plan
may seem somewhat fussy in detail, but in practice is
exceedingly simple, and, if followed as directed, should
relieve the physician of those mishaps so annoying to him-
self and patient. If some instrument-maker will materi-
alize this idea, it will involve but slight increase in size of
the pocket-case now in use.”
LATE PREGNANCIES.
Dr. J. R. N. Situ, of Milltown, Me., writes: “In
accordance with your request for reports of late pregnan-
cies, I can report one in my early practice. February 14,
1868, Mrs. K , in this State, then being fifty-two years
of age, was delivered of twins. Her youngest child was
ten years of age. She had had (I think) eight children be-
fore, all living.”
Lrogress of Medical Science.
THE RESEMBLANCE OF THE MALARIA PARASITES TO
THOSE OF FEBRIS RECURRENS.—N. A. Sacharoff states that
there exists in the blood of patients suffering from fe-
bris recurrens a hematozoon which may be best observed
immediately after the temperature begins to fall, and
which then assumes enormous proportions (twenty and
more diameters of a red blood-corpuscle) (Centralblatt
für Bakteriologie und Parasitenkunde). But specimens of
lesser size are also found. ‘The parasite consists of a de-
licate amoeboid body containing a multitude of dark,
round, uniform, sharply outlined movable granules. Be-
sides these the protoplasma contains a generally grayish,
homogeneous nucleus as large as one or two red blood-
corpuscles. The protoplasma sends forth pseudopodia
(without granules) which sometimes separate from it and
- appear as small, delicate pieces of protoplasma without
granules. ‘They vary in size and are often swallowed by
red blood-corpuscles, in which they gradually grow and
finally develop into the above-mentioned large amceboid
body. In a description contained in the ‘‘ Minutes of the
Session of the Caucasian Medical Society,” in Tiflis, Sachar-
off designates the large protoplasma lumps described by
Ponfik as his parasite, Hamatozoon febridis recurrens.
He declares that the granules in the protoplasma which
Ponfik took for granules of fat are mostly pigment, not fat.
From time to time the protoplasma itself sends forth
pseudopodia in which no granules are to be found ; these
pseudopodia fall off and circulate freely in the blood. By
separating from the protoplasma, however, the parasites
become smaller, until finally only the nucleus and a nar-
row zone of protoplasma containing granules remains.
The nucleus itself is round, delicate, grayish, also reddish,
and Sacharoff thinks that it is merely a red blood-corpus-
cle. The nucleus sends forth pseudopodia, or buds,
which separate from it and also circulate freely. Sacha-
roff watched such separated speusodia and noticed suc-
cessive changes in them, #.¢., he saw spirochzetz-shaped
threads form from nucleus-pieces within from eight to ten
hours. They did not show any small undulations and
were not very thin, but large undulations were distinctly
visible. He thinks this is possibly the genesis of spiro-
chetz. Nor do the lumps separating from the proto-
plasma remain without further development. ‘They have
2 motion of their own, attach themselves to red blood-
corpuscles, send buds into them, and finally are completely
enveloped by them. Here they may assume various
shapes and may grow larger and gain granules of pigment
in the protoplasma. They distend also the blood-corpus-
cle containing them, and seem to be able to cause its dis-
appearance. On the other hand, they can emigrate with
equal facility from the blood-corpuscle. Then the para-
site becomes free and continues to grow, or decomposes,
as was shown above. Immediately after the crisis the
three first-named forms exist in large numbers ; further on,
during apyrexia principally or exclusively, the intracellular
forms are to be found. ‘This is the main difference be-
tween it and the plasmodium malariz where the intracel-
lular forms are found only during the fever. This report
is very important, and it opens new points in the etiology
of this disease. If the highly interesting discoveries of
Sacharoff should be confirmed, we should have reliable
means for the diagnosis of the disease during apyrexia, as
the intracellular forms, which can be stained with meythl
blue (at least in intermittens), are easily seen. [fn un-
colored specimens they are hard to see. ‘Ihe same pe-
culiarity might then be utilized as a means of differential
diagnosis from intermittents, with which febris recurrens
is easily confounded.—Zhe Journal of the American
Medical Association.
STROPHANTHUS AS A LOCAL ANASTHETIC.—Many of
the drugs which are useful in the treatment of cardiac dis-
ease also possess a local anesthetic action. There is, of
course, no connection, as far as can be seen at present,
between the two actions. ‘The local anesthetic action of
erythrophleine was investigated last year by many observ-
ers; the conclusions arrived at were that, although it
possessed a powerful local anzsthetic action, it causes
irritation and dilatation of the vessels of the conjunctiva,
and in some cases even severe inflammation. It was thus
much inferior to cocaine, whose action is accompanied by
a constriction of vessels and consequent pallor of the part.
Helleborin, the glucoside from the Christmas rose, 1s also
a local anesthetic and cardiac tonic; one-fortieth of a
grain in solution placed on the conjunctiva of a rabbit
causes complete anzesthesia in fifteen minutes, and there
is at the same time no interference with the movement of
the pupil and no dilatation of vessels. ‘The action of
this glucoside is therefore like that of the alkaloid cocaine ;
but it has not yet come into general use. Steinach has
lately shown that strophanthus seeds contain a body not
identical with strophanthin, which when placed on the
conjunctiva produces in twenty-five to thirty minutes com-
plete anzesthesia, lasting from two to twelve hours. ‘There
are no great signs of irritation, but if applied to the eye
of man it causes a slight feeling of burning, with a passing
hyperzemia of the conjunctiva. ‘This condition may pass
on to cloudiness of the cornea in animals. ‘The local
anesthetic action of strophanthus is, therefore, chiefly of
pharmacological interest, like that of erythrophleine.
Cocaine still holds its own when judiciously employed.—
British Medical Journal. :
EXALGINE, THE NEw ANALGESIC.—Exalgine is the
name given to a new derivative of the aromatic series,
orthomethylacetanilid, discovered by Brigonnet, of the
Cochin Hospital, and which has suddenly leaped into
extraordinary favor as an analgesic in France (St. Louis
Medical and Surgical Fournal.) The name (ex, priva-
tive, and algos, pain) is significant of its qualities. The
formula is C,H,,NO (or C,H,.C,H,O.NCH,), and the
substance is one of the three isomeric (para, meta, and
ortho) methyl derivatives of acetanilid. It occurs either
in fine acicular or long tablet-like crystals, accordingly as
it is obtained by evaporation from solution, or by fusion
thereafter. It is sparingly soluble in cold water, more
soluble in hot water, and extremely soluble in very dilute
alcohol, or in water slightly alcoholated. Physiologically
it acts very much like analgesine, having, however, more
effect upon the sensory and less upon the thermogenic
centres than this substance. Its therapeutic effects are
obtained in doses of from four to six grains, administered
at once, or from six to twelve grains taken in two doses
in the course of twenty-four hours, and are powerfully
analgesic, subduing the element of pain in all forms of
neuralgia, including visceral. Like all new remedies of
this sort, it is at present on its good behavior, as it were,
and it is claimed by MM. Dujardin-Beaumetz and G.
Bardet that it has in their hands up to the present ex-
400
-_——--— ~ = — a ih
hibited no evil sequelz, being free from the rash, cyanosis,
etc., so frequently observed after the ingestion of anti
pyrin and acetanilid. Exalgine is eliminated by the urine,
upon the quantity of which it exercises a marked effect,
acting like the antipyretics of the same group, diminishing
the quantity of the secretion. In diabetes it also dimin-
ishes the quantity of sugar eliminated. Like all of the
derivatives of the aromatic series, it is antiseptic and anti-
thermic, as well as analgesic, and possesses the latter
quality in a comparatively superlative degree, being more
efficient, in doses less than half so great, than antipyrin.
The following are the formulz for its exhibition, as given
by M. G. Bardet in Les Nouveaux Remèdes.
1. Antineuralgic potion of Exalgine.
De Ekalesia a ER 3j.
Kirschwasser ,....ossessesososoescsosseseoo 3 x.
Simple symp sesse sii iesiseisevtiboctos ei? .
Distilled water .....0....cecceecceees q s. ad $v.
Dissolve the exalgine in the kirsch water and add the
syrup and water. The dose is from one to three table-
spoonfuls in the course of the day.
2. Solution of Exalgine.
H. Exalpine oisrepatm arae uenra esauen zi.
ROUND o ak Ol aE ETNA N ES 37x.
- Distilled water 23.0ccs0sscswseeces q. S. ad 3v.
Proceed as before. The dose is the same as above.
THE MorTALITY AMONG Nurses.— The question as to
the liability of nurses to infection while in attendance on
phthisical patients is an important one, and has not
hitherto been studied with the attention it merits. The
result of a careful inquiry into the increase in Germany,
where the nurses are largely drawn from religious corpo-
rations, shows that while the mortality from tuberculosis
among the sisters who remain in the convent is from one-
seventh to one-sixth of the total mortality, among the
nursing sisters the proportion amounted to nearly two-
thirds. The death-rate from tuberculosis among the
nursing sisters attains its maximum between the thirtieth
and fortieth year, and then steadily declines. Compared
to the deaths from this cause among the population of
the towns in which they live, the mortality from all causes
among nurses between the ages of fifteen and twenty is
four times as great as outside, between twenty and thirty
three times as great, and from thirty to forty twice as
great, the explanation being the prevalence of tuberculosis
among nurses, the death-rate from this source alone being
nine times as great as among the general population. In-
fectious diseases levy an excessive tribute on nurses up to
the age of forty, after which time deaths from this cause
become infrequent. It appears, moreover, that nurses
enjoy comparative immunity from infection during the
first six months’ service, but the proportion of disease and
death then rises steadily for three years. Of course the
figures only represent an average, and do not apply to
particular hospitals and institutions, the hygienic condi-
tions of which necessarily vary very considerably. A re-
turn drawn up upon reliable data would be of very great
advantage from several points of view, and perhaps it may,
at some future time, be forthcoming.— Medical Press and
Circular.
THE COcOANUT AS A TANIACIDE.—Professor Parisi,
of the University of Athens, accidentally made the discov-
ery recently that the cocoanut possesses anthelmintic
properties. He ate the fruit of the nut after having
drank the milk. Two hours later he began to feel some-
what nauseated and had a slight diarrhoea. The follow-
ing morning he passed at stool a dead tape-worm with its
head. He was then in Abyssinia and inquired of the
natives whether they made use of the cocoanut for this
purpose, but none of them had ever known it to be so used.
Upon Dr. Parisi’s return to Athens he used the remedy
in a number of cases and found it very efficacious. It is
THE MEDICAL RECORD.
[October 12, 1889
preferable to other tzeniacides, he says, in that no prepar-
atory treatment is necessary. In all cases the entire
worm, including its head, was passed at stool on the
morning following the administration of the cocoanut.—
Schmidts Jahrbücher.
A New Form oF SUTURE BUTTON.—At a recent
meeting of the Ontario Medical Association, Dr. M. A.
Powell exhibited a suture button which he had devised.
It consists of an oval plate of block tin, about five-eighths
by seven-eighths of an inch in size, from which arises a
central post three-sixteenths of an inch in height. This
post is perforated with a round hole from the under sur-
face of the plate to its own apex and is cross-cut down
nearly to the plate. In using the button the suture, of
wire, silk, or catgut, is passed through from below, bent
into the slot, wound two or more times around the post
and then carried across the post through the slot again.
The buttons can be readily stenlized by boiling and can be
bent to fit irregular surfaces. They can, Dr. Powell says,
be instantly fastened, unfastened, tightened or relaxed,
and cannot slip or break.
TOBACCO AND INSANITY.—The essay recently read be-
fore the San Francisco Medical Society by Dr. Shiels, on
tobacco and its effects, was one deserving of exceptional
credit, as well for the thoroughness of his investigations
as for the general fairness of his conclusions. The doc-
tor addressed a series of questions to the members of a
leading New York medical society individually, and upon
their answers his deductions are mainly based. ‘The gen-
eral trend of the decisions of this medical tribunal is that
smoking in excess is bad, which few will be found to dis.
pute. ‘The question, “‘ Have you ever seen a case where
the brain was permanently affected by the use of to-
bacco ?” elicited a symphonious chorus of noes all along
the line, disturbed only by the solitary demurrer of an ex-
asylum superintendent, who claimed five cases of insanity
due to the weed. Dr. Shiels believes there must have
been some error of diagnosis here, and beyond a doubt
the large majority of asylum physicians would, if can-
vassed, sustain him in his skepticism. It is only in a re-
mote and subsidiary sense that the tobacco habit can be
considered a factor in the production of insanity. Its
opponents urge that it promotes nervousness. This de-
pends on the individual and the amount indulged in.
They also claim that it weakens moral fibre, impairs nu-
trition, fritters away a man’s time, and induces a host of
other evils. But it is not upon the brain that the penal-
ties of its immoderate use are visited ; the organs more
likely to suffer are the heart, stomach, and throat.—Occt-
dental Medical Times, July, 1889.
THE Foops oF DIFFERENT PEOPLES.—Many nations,
many dishes! Some articles that are esteemed as delica-
cies by certain nations are regarded with disgust by
others. According to the Pacific Record the Turk is
seized with violent trembling at the very idea of eating
oysters. ‘The American Indians look upon an invasion
of grasshoppers as a mark of especial favor from the
Great Spirit, and make the best of such a time to lay up
a store of provisions for the future. Buckland states that
among certain people a mixture of fish, nearly putrefied,
and soap-suds is preferred to the best butter. In Canton
and other Chinese cities rats are sold at ten cents a dozen,
and a hind-quarter of dog is more expensive than mut-
ton or beef. Some of the East Indians eat serpents dried
in the oven, but despise the flesh of rabbits. Lizard eggs
are a delicacy in the islands of the Pacific, and many
people besides the aborigines of the Argentine Republic
esteem the flesh of the skunk. Ants are eaten by many
peoples, and in Siam a curry of ants’ eggs often tickles
the palates of the wealthy. ‘The silk-worm is eaten with
relish by the Chinese, and a dessert of roast snails is con-
sidered a fitting termination of a feast in New Caledonia.
October 12, 1889]
THE MEDICAL RECORD:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Epiror.
PROPRIETORS AND PUBLISHERS
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
ei
New York, October 12, 1889.
A DISCUSSION ON THE QUESTION OF MED-
ICAL EXPERTS.
‘THE vexed question of medical expert testimony was
brought up at the recent International Congress of Foren-
sic Medicine in Paris, and was discussed and settled in a
most interesting way. The gentlemen concerned in the
debate included some of the best criminal lawyers and
judges in Paris, as well as several physicians eminent in
medical jurisprudence.
The. subject was opened with a report drawn up by
MM. Adolphe Guillot and Demange, both Judges of
Instruction.
It must be remembered that in France, in the case of
criminal trials calling for medical or toxicological experts,
a commission is appointed to whom the scientific investi-
gations are referred. The report of this commission, be-
ing presumed to be impartial, necessarily carries great
weight ; and if it is against the accused, it is almost a
fatal blow to his case.
Although, theoretically, the method seems fair and
proper, yet, practically, it has acquired unpopularity be-
cause it seems to have worked unduly against the accused.
The gentlemen above referred to seemed inclined to yield
to this popular current of opinion, and recommended, in
general terms, that there be a list of experts made out by
the State, from nominations made by learned bodies.
Then it was advised either that the prosecution and de-
fence each select its own expert, or that the judge appoint
two experts, leaving the defence the right to object to one
of them. The experts should have the same sum each,
and should be paid by the State. In case the experts
disagreed the case should be referred to a court of ap-
peal.
The views of the Congress upon these suggestions were
shown in the vote upon the nine different recommenda-
tions of the reporters.
The first, to the following effect, was carned unani-
mously: “ To guarantee the interests of society and of
the accused in all medico-legal investigations, at least two
experts shall be employed.” ‘The next sentence, “ These
shall be appointed by the judge,” was carried by a small
majority, for a large minority voted in favor of each side
appointing its own expert. A resolution giving the de-
fendant the right to object to one of the experts was lost.
The Congress next voted: “ That experts, except in
special cases requiring special knowledge, shall be chosen
from lists drawn up by the public powers and the scien-
THE MEDICAL RECORD.
401
tific bodies selected for that purpose. The system of the
plurality of experts imposed the constitution, at the seat
of the Faculties of Medicine, of a Supreme Council of
Forensic Medicine, which should act as a high and final
Court of Appeal.” With respect to this latter resolution,
it was pointed out that a similar institution had worked
very well in Germany. At first there had been many cases
referred to this court, but in a short time it was found to
act as an excellent check against careless investigation,
and now the cases sent up on appeal were not at all
numerous. The Congress then carried the following reso-
lutions without any further discussion and without any
opposition: “ That the Judge of Instruction should be
present at the post-mortem, etc., except in special cases,
so as to supply to experts such information as may guide
their researches ; and that the lawyer retained for the de-
fence may also be present, so as to point ou to the ex-
perts the objections the defence may raise.”
It was also advised that in law schools there should be
classes in criminal law, and that students should be ad-
mitted when possible to post-mortem examinations.
THE MEDICAL PROFESSION AND THE WORLD'S FAIR.
THERE is, so far as we can learn, as yet no representation
of the medical profession upon the World’s Fair Com-
mittee appointed by the Mayor. All the various trades
and business interests have one or more members, and
there are plenty of lawyers and journalists. It would
seem but just that medicine should also be allowed to
take an active interest in an event which promises to
be memorable in our civic history.
As the purposes of the Fair have so far been outlined,
there will surely be a field for medical and surgical dis-
plays of various kinds. ‘There should be historical ex-
hibits to show the progress in the care of the sick, and in
their surgical and medical treatment, with displays illus-
trating the old hospitals and the new, the old surgical in-
struments and mechanical appliances and the new. ‘There
should be illustrations also of the development of the
specialties, with displays of all new apparatus and instru-
ments of precision in every field. ‘The development of
bacteriology, the improvements in methods of teaching,
historical accounts of medical progress, and of the growth
of sanitary science, all would have a fitting place.
It is easy to see that a medical and surgical exhibit
might be made which would have great intrinsic interest,
and would be of immense educational value, not only to
the medical profession, but to the laity.
We trust that some steps will be taken soon to see
that the medical profession be given its share of the
` work.
ELECTRICITY IN GYNECOLOGY.
THE discussion over the value of electricity in pelvic dis-
orders still continues, and the views of gynecologists still
remain far from settled. ‘The method, outside of Paris,
has chiefly been tried in Great Britain and the United
States. In the former country such eminent authorities
as Sir Spencer Wells, the Keiths, and Dr. W. S. Playfair
are inclined decidedly to favor Apostoli’s method, while
Mr. Tait and Mr. Bantock are as decidedly against it.
In this country no one very prominent as a gynecologist
402
has, so far as we know, undertaken to champion electroly-
sis, but a number of men of excellent repute have reported
their results, and have as a rule spoken favorably of the
method. Useful contributions to the technique have also
been made by Martin, Goelet, and other American physi-
cians.
It is evident, from the tone of discussions upon the sub-
ject, that the older gynecologists, while not favorably dis-
posed toward Apostoli’s method, have not tried it to any
great extent.
There seems to be a tendency to use milder currents
than were formerly advocated, and a thirty-cell battery is
even stated to be amply sufficient for all purposes. It
seems, therefore, that a maximum current of one hundred
milliampéres may often be all that is needed ; while we
hear little now of the eight hundred and one thousand
milliampére currents about which discussion was first
raised.
Dr. A. Lapthorn Smith, of Montreal, has recently given
an interesting account of his experiences with Apostoli’s
method (American Fournal of Obstetrics). Dr. Smith
has abandoned punctures, and relies upon the intra-uterine
applications, using not very strong currents, apparently
not much over one hundred milliampéres. He reports
cases of endometritis, perimetritis, and fibroids cured or
greatly relieved. No exact rules can be given as to the
frequency and number of applications, or the strength of
the current. The use of the positive pole in hemorrhagic
conditions is approved by him, as by all others. It seems,
indeed, that a relief of menorrhagia is one of the things
which it is agreed electricity can accomplish. Ovarian
pains also are often cured. The exact effect of the cur-
rents upon fibroids is yet an unsettled point. They cer-
tainly often decrease in size under treatment, but whether
there is a true electrolytic action is yet hardly demonstrated.
It is noticeable that most of the older men who have
worked successfully with the knife are inclined to stick to
the tools they have been handling. But evidence is ac-
cumulating which makes it apparent that there are many
cases in which hysterectomy or ovariotomy ought not to
be performed before an electrical treatment has been
tried.
THE BLOOD-VESSELS OF THE LUNGS.
Some time ago we asserted editorially that the blood-ves-
sels of the lungs had practically no vaso-motor nerves.
"This statement was based chiefly on the fact that the
presence of such nerves had never been positively demon-
strated in mammals by physiological experiments; and
also on the well established fact that the pressure in the
pulmonary circulation is very little influenced by nervous
stimulation, or by the changes in the heart’s activity, such as
affect the systemic circulation. It 1s equally known that
the tonus of the pulmonary arteries is very slight, while
the vessels are very yielding and distensible. The result
is that a complete obstruction of a large pulmonary vessel
hardly changes the blood-pressure in the lungs at all, ow-
ing to the easy relaxation of the vessels elsewhere.
It is a fac, therefore, still holding good, that the pul-
monary blood-vessels are but feebly influenced by vaso-
motor nerves.
The actual presence of these has, however, been quite
recently demonstrated by Drs. J. R. Bradford and H.
THE MEDICAL RECORD.
[October 12, 1889
Percy Dean (‘Fournal of Physiology, vol. x., Nos. 1 and
2). ‘hese experiments were made upon dogs, and re-
sulted in showing that vaso-constrictor nerves originate in
the medulla, pass down the spinal cord, make their exit
from the second to the seventh dorsal segments, and pass
to the arteries of the lungs. Stimulation of them causes
a slight rise in pulmonary blood-pressure, but their influ-
ence is not strong.
The use of a drug like ergot in hemorrhage from the
lungs has therefore not much support on physiological
grounds.
THE PURPURAS.
PURPURA iS a name given to a class of disorders of the
most varying origin, and presenting the most divergent
types. The result is that systematic writers upon purpura
have, as a rule, treated the subject in a tentative and un-
certain manner, giving classifications and descriptions
which were admitted to be mainly provisional in charac-
ter. Under the general head of purpura, one finds sub-
divisions of purpura simplex, purpura rheumatica or
peliosis rheumatica, purpura hemorrhagica. We have,
besides, purpura nervosa or myelopathic purpura, purpura
urticans, purpura papulosa, purpura scorbutica, or scurvy,
and the various cachectic, senile, infectious, and mechan-
ical purpuras.
From all this it may easily be seen how little of definite
significance the term purpura possesses. In the attempts
at classifying its types we may abandon at once the di-
visions into idiopathic and symptomatic, for it can safely
be said that purpura is always symptomatic of some pro-
found nutritional or mechanical disturbance. We can
also exclude from the ordinary purpuras the purpura
scorbutus, since that is a well-defined malady of quite
well-known origin. The three types of purpura which are
most commonly seen in this country are probably the pur-
pura simplex, purpura rheumatica, and hzmorrhagica, and
certain cachectic forms occurring in alcoholic and de-
bilitated subjects. ‘The simple purpuras include those
mild types observed oftener in the aged, and not associ-
ated with much articular or gastro-intestinal disturbance.
There is difficulty in really separating the types known as
purpura rheumatica and purpura hzmorrhagica. ‘There
are intermediate forms which show that the disease has
the same general origin. In the purpura hemorrhagica
the mucous membranes are more profoundly involved ;
in purpura rheumatica, it is the joints. In a recent brief
paper by Dr. William A. Edwards, on “Some Forms of
Purpura Rheumatica” (University Medical Magasine,
September, 188g), illustrations are given of three types of
purpura rheumatica described by Osler. From the de-
scription of cases given it would seem quite justifiable,
however, to give up the term purpura rheumatica alto-
gether, and include all the different severe forms under
the general title purpura heemorrhagica. These may then
be further qualified by the terms arthritic, or gastro-
intestinal, or mixed. The attempts to make of purpura
a nervous disorder (Couty, Henoch, Faisans) have not
been very successful, although purpura, like urticaria and
œdema, may no doubt, at times, be the result of nervous
influences ; but where there are severe hemorrhages and
ecchymoses, a deeper disturbance of nutrition must be in-
voked.
October 12, 1889]
The belief has been that the cause of the purpura di-
rectly was a poison developed through some fault in chy-
lopoétic metabolism, and this is no doubt generally the
case. But efforts have been numerous to place the dis-
ease among those of microbic origin. Micrococci have
been found by competent observers in the ecchymotic
spots, and Guimand (Paris Médical, September 8, 1888)
has succeeded in making pure cultivations and inoculat-
ing rabbits, with the result of producing purpuric erup-
tions.
Hews of the Week.
THE MEDICAL SCHOOLS OF THIS CiTy all report un-
usually large accessions of students.
JEFFERSON MEDICAL COLLEGE.—The Jefferson Medi-
cal College and Hospital, Philadelphia, will soon add a
new building to the group already located at Tenth and
Sansom Streets.
A Maternity HospiTat.—A Maternity Hospital has
just been added to the other clinical facilities of the
Medical Department of the University of Pennsylvania.
UNIVERSITY OF MICHIGAN.—The Boston Medical ana
Surgical Journal states that the regents of the University
of Michigan, at Ann Arbor, have received an offer of two
acres of land for a hospital site from Mrs. Israel Hall.
AN ANTI-VIVISECTION HosPITAL.— The Zodphilss¢ states
that there will shortly be established in London an anti-
vivisection hospital.
A Dispensary IN Paris has just been built by the
jewels of a lady ramed Madame Edouard, André. ‘The
jewels were given to the Philanthropical Society, and were
sold for $80,000.
A STATUE has just been erected at Auxerres, of M.
Paul Bert, and one at Alfort, of the distinguished veteri-
narian, the late Professor Bouley.
A Dispensary LOvE-FEAST.—About twenty physicians
attached to the Northern Dispensary held a social re-
union at Clark’s a few nights ago.
DEATH OF ALBANY PHYSICIANS BY DROWNING.— Dr.
Otto Ritzman, of Albany, was drowned at Carrying-Place
Bay, Lake Champlain, August 19, 1889, in consequence
of the capsizing of a boat in which he was fishing with
Dr. Wiliam H. Murray and a guide. Dr. Ritzman was
born in Albany in 1857, and was graduated at the Albany
Medical College in 1879. ‘This is the fourth Albany phy-
sician who has been drowned within a few years: Dr. J.
V. Lansing, drowned May g, 1880; Dr. H. I. Fellows,
August 29, 1881; Dr. John S. Delavan, August 7, 1885 ;
Dr. Otto Ritzman, August 19, 1889.
- GETTING UP FOR MEDICINES AT NicHT.— Innumerable
mistakes have been made through persons getting up at
night to take or administer a dose of medicine. We have
heard of few sadder accidents, however, than that recorded
of the wife of a well-known physician of Harlem. She
had been suffering from insomnia, and got up to take a
dose of bromide which she had been accustomed to use.
By mistake she swallowed the contents of a bottle of Ma-
jendie’s solution of morphine, taking sixteen grains of the
drug altogether. Despite every effort she died in three
hours.
THE MEDICAL RECORD.
403
CLARK UNIvERsITY has established the rank of “ Do-
cent” as “its highest annual appointment.”
THE GERMAN DERMATOLOGICAL SociETY.—The next
annual meeting of this society will be held at Berlin, in
connection with the International Medical Congress.
Professor Caspari, of Königsberg, has been appointed
President ; Professor Neisser, of Breslau, Secretary ; and
Professor Lipp, of Graz, ‘Treasurer, for the year 1889-90.
THE REPORT OF THE STATE BOARD OF HEALTH on the
water-supply of New York City has been made to the
Governor, and its details made public. It is a most ex-
haustive study of the subject, and will be a document of
great value in studying the problems of water-supply in
cities. The investigation was made under the direction
of Professor C. C. Brown and Emil Kuichling, engineers,
with the assistance of chemical experts. A full survey of
the Croton water-shed, with a detailed description of all
the sources of pollution, natural and artificial, is given.
It is shown that the Croton water is naturally of pure
character, and all the sources of its infection or pollution
being now known the problem of keeping the water pure
is much simplified.
THE New Law REGARDING PRELIMINARY EXAMINA-
TION OF MEDICAL STUDENTS.— The imperfections in this
law were pointed out by us when its provisions were first
made public. ‘The chief defect lies in the fact that it re-
quires applicants for matriculation who come from foreign
countries or other States to undergo an examination even
if they come with certificates or diplomas from institutions
of learning. ‘The examination in English is also unfair to
students from foreign countries, who may be well educated
in their own tongue but know English imperfectly. The
Council of the University of the City of New York has ap-
pointed a committee to formulate suggestions as to neces-
sary amendments.
SPONTANEOUS Cow-Pox IN ITaLy.—The Animal Vac-
cination Committee of Milan has recently had a windfall
in the form of a supply of lymph derived from a herd of
cattle in which cow-pox had spontaneously broken out.
On August 3d the Prefect of Sondrio (Northern Italy) an-
nounced that natural cow-pox had appeared in a herd in
the commune of Cosio, in Valtellina, at a height of 2,000
metres, near the top of the Tagliata Alp. The eruption
had shown itself on the udders on June 27th, and of the
eighty cows only four had not been attacked.
RUBBER BANDAGES IN INDIGESTION.—Dr. Wettendorfer,
while using a Martin’s rubber bandage, applied round the
waist in a case of chronic eczema, became aware that this
treatment seems to be capable of acting beneficially on
the digestive organs, curing gastric catarrh and the sense
of oppression complained of by dyspeptics, and, as a result
of this action, improving in a marked degree the digestive
functions. How the bandage acts Dr. Wettendorfer is
unable to say, further than that he supposes it 1s by exert-
ing a mechanical pressure on the organs of digestion, and
possibly by causing the bodily heat of that region to be
retained. As to the particular classes of cases in which
the rubber bandage is suitable only further experience can
decide. The bandage should be worn for about an hour
after meals, and should be applied over a surface about
ten inches in depth.— Lancet.
404
THE MEDICAL RECORD.
[October 12, 1889
Bocus DipLoma MILLs AGain.—Some months ago a
practitioner of Buffalo presented as the evidence of his
medical education a diploma issued by the “ Trinity Uni-
versity of Burlington, Vt.,” an institution of learning of
which the very existence was unknown to the physicians
of Burlington or to the Secretary of State. A “ Dr.”
Bradbury, of Nashua, N. H., was discovered to be the
agent of the university ; and from him a hardware dealer
of Buffalo succeeded in obtaining a diploma for the sum
of sixty dollars, without any medical qualification what-
ever. It seems that all that is necessary to incorporate
such an institution in Vermont is to make application to
any town clerk for articles of incorporation, and they are
granted forthwith. ‘Tninity” was found to have been
incorporated in the town of Bennington, and a copy of
the articles of incorporation is published in the Boston
Herala. There was also discovered at Rutland a docu-
ment incorporating the “ Vermont Medical College or
Second Medical College of the American Health Society
for Scientific and Benevolent Purposes.” Articles of in-
corporation of the “ University of New Hampshire ” were
also discovered in the Secretary of State’s office at Con-
cord, bearing date of October 10, 1888.— Boston Medi-
cal and Surgical Fournal.
THE PRUSSIAN CHAMBERS OF PuysiciaNs.—For the
second time since the establishment of the Prussian
Chambers of Physicians their representatives have been
invited to take part in the deliberations of the highest
medical official body in Prussia, viz., the Scientific Depu-
tation for Medical Affairs. At the time when the said
Chambers were organized, the State granted them the
right to be heard by the official authorities on certain
general sanitary questions. Each chamber therefore re-
ceived the right to send one representative to the Scien-
tific Deputation, and one to the chief medical official
body of its province, and these representatives are per-
mitted to take part in the deliberations, but not to vote.
They are now regarded as extraordinary members of the
Scientific Deputation, and are invited to take part in its
deliberations once every year, viz., in November. ‘The
themes of discussion this year are to be the reform of the
midwife system, and the revision of the official text-book
for midwives. These subjects will be introduced by Pro-
fessors Olshausen, of Berlin, and Bockendahl, of Kiel.—
Lancet.
How To INHIBIT WHOOPING-COUGH PAROxysms.—In
the Correspondenzblatt fiir Schweitzer Aerzte, No. 14,
1889, p. 417, Dr. O. Naegeli, of Ermatingen, describes a
new purely mechanical method for treatment of whooping-
cough. Given a paroxysm, the author, standing in front
of the patient, firmly catches the ascending rami of the
lower jaw with his forefingers, and middle fingers placed
just in front of the lobes of the ear, places his thumbs on
the chin, and, by strong and steady traction and pressure,
pushes the jaw forward and downward. The procedure
may be very conveniently modified by making traction
with the right thumb and forefinger placed on the alveolar
process behind and below the middle lower incisors, and
the remaining fingers under the chin, while the left hand
is fixed on the child’s forehead for purposes of counter-
traction. If the patient stands with his back to the
operator, the latter places his thumbs just above the angle
of the lower jaw in front of the ears, the forefingers on
the zygomatic arches, the remaining fingers on the chin,
and then pushes the jaw forward and downward. Trac-
tion may be made still more rapidly by putting the fore-
fingers into the patient’s mouth, on the alveolar process
behind and below the back molars. No force should, of
. course, be applied to the child’s teeth. As soon as the
jaw has been moved in the way indicated, the patient is
told to inspire deeply. The procedure is said to cut short
the spasm almost instantly, which effect is explained
partly by its diminishing the muscular tone in a reflex
way, partly by its mechanically lifting up the epiglottis
(through raising the larynx with the hyoid bone) and open-
ing the rima glottidis. A systematic inhibition of the
paroxysms by means of the manipulations has a markedly
favorable influence on the course and issue of the disease.
The disease becomes milder, vomiting ceases, expectora-
tion greatly lessens, hemorrhages, as well as complications
caused by increase in the arterial tension during the spas-
modic attacks, are prevented all through, and the total
duration of the affection is shortened, while all bad after-
effects are avoided. ‘The same manipulations also give
admirable results in spasmodic cough of any origin. The
method is very simple, and may be easily learned by
nurses, mothers, etc. It is entirely painless, hence little
patients subject themselves to it very willingly, and, even
after having experienced the striking relief obtained there-
from, try to perform the manipulations on their jaw by
their own hands.— British Medical Journal.
THE TRANSMISSION OF GONORRHEA AS AN INDICTABLE
OFFENCE.—The Deutsch. Med. Zeit. relates the following :
A man was charged with rape by a fifteen-year-old girl,
at Stein-am-Anger, but at the trial he was declared not
guilty of the charge, as no force was employed. ‘The tes-
timony showed, however, that at the date of intercourse
the man was suffering with gonorrhoea, and that after-
ward the girl also had gonorrhoea, and on this basis the
prisoner was charged with inflicting severe bodily injury
upon the girl, was found guilty, and sentenced to one
month’s imprisonment. The two higher courts approved
this, but thought the punishment was too light ; one court
lengthened the term to six months ; the other and highest
authority thought it was still not enough, and increased
the punishment to one year. While such a proceeding is.
very unusual, it is not unjustifiable, and should the ex-
ample be followed the prisons would soon need enlarge-
ment. For obvious reasons there is no fear that such
will be the case.— Weekly Medical Review.
CHOLERA IN ASIATIC TURKEY.—Bagdad and Bussorah
have, according to a correspondent of Zhe Times, been
visited by an epidemic of cholera. ‘The disease was first
noticed in obscure inland spots, whence it spread to the
port of Bussorah, near the head of the Gulf of Persia. -
HOSPITAL FOR VIENNA STUDENTS.—The Association
for the Care of Sick Students at Vienna has purchased a’
house in the Laudongasse, at a cost of 55,000 florins,
which is to be opened in the course of the coming aca-
demic year for the reception of students suffering from
illness or injury. It is now being fitted up as a private
hospital, with accommodations for forty patients. It is
estimated that the cost of maintenance will be 15,000
florins a year
October 12, 1889]
Society Reports,
THE PRACTITIONERS’ SOCIETY OF NEW
YORK.
Stated Meeting, May 24, 1889.
Francis P. Krynicutt, M.D., PRESIDENT, IN THE CHAIR.
Dr. C. L. Dana exhibited some
SPHYGMOGRAPHIC TRACINGS IN A CASE OF MARKED ABDOMI-
NAL PULSATION.
‘The patient was a very nervous, delicate young woman, a
factory operative, who had suffered from several attacks
of a so-called malarial fever which is very common among
the operatives along the East Side. The affection is
called malarial, but it does not yield to quinine. After
one of these attacks had subsided, the patient began to
vomit and presented all the symptoms of an acute gas-
tritis, and was treated for that. Before this, however,
she had developed a very extraordingry pulsation, with
bruit, in the abdominal aorta, which caused her much dis-
tress. No tumor could be made out on palpation. The
vomiting was checked for a time by means of opium sup-
positories, but soon returned. After the gastric trouble
began to subside, the speaker decided that the case was
not one of gastritis but that the vomiting was largely hys-
terical. He persuaded the patient that she need not
vomit again, and the trouble soon ceased.
Dr. Dana took some sphygmographic tracings of the
abdominal pulsations and of the radial pulse. The for-
mer showed a number of serrated points at the apex, pre-
senting evidence of a very extraordinary degree of arterial
relaxation. Three days later, however, when the pulsa-
tions had subsided to a great extent, the point was a sin-
gle blunt one. The pulsations were evidently due toa
very marked dilatation of the aorta, and they are observed
very commonly, the speaker had been told, in this peculiar
form of fever. They had appeared in the same patient
during a previous attack a year before the present one.
There was an anemic murmur audible over the heart,
which disappeared as the patient got better. Dr. Dana
thought the observations of some interest as showing pos-
itively a high degree of arterial relaxation ; this being less
as the pulsation was less. The pulsation was abdominal,
not epigastric.
Dr. WILLIAM M. Pork said this pulsation was often
seen in nervous, hysterical women, even when there was no
fever.
Dr. BEVERLEY ROBINSON observed that pulsation of the
abdominal aorta was not at all infrequent. So common
was it, indeed, that it often caused considerable trouble in
coming to a diagnosis in cases of suspected abdominal
aneurism.
Dr. WiLLiAa™M H. Draper said that in febrile conditions,
especially ın children, marked epigastric and abdominal
pulsations were frequently observed. He had always re-
garded them as due to arterial relaxation.
Dr. ANDREW H. SMITH reported a case of
PERIODICAL ENGORGEMENT OF THE LIVER,
occurring in a married woman, twenty-six years of age.
‘There was no history of alcoholic indulgence, of syphilis,
or of any special illness except that she had had malarial
fever five years ago. She had had six children and no
miscarriage. Since the birth of her last child, one year
ago, menstruation had been scanty and somewhat painful.
‘Three months before admission to the Presbyterian Hos-
pital she missed her menstrual period, but had at that
time chilly sensations followed by hot flashes, and severe
pain in the right side. ‘The side became swollen and was
- very tender. These symptoms persisted for about ten
days, and then disappeared, but returned again at the next
"menstrual period with greater severity. This recurred
each month, there being no menstrual flow, but its place
THE MEDICAL RECORD.
405
being taken by the pain and swelling in the right side.
The patient was admitted six days after the beginning of
the third of these attacks. She was then suffering from
nausea and vomiting, pain in the right hypochondniac re-
gion, and anorexia. The atea of hepatic dulness was much
increased at both its upper and its lower borders, extend
ing from one inch below the nipple to a point about three
inches below the free border of the ribs. There was great
tenderness over this entire region, most marked, however,
at a point about three inches to the right of the umbilicus.
The spleen was also enlarged. Examination of the urine
gave negative results. An exploratory puncture with a
needle in the eighth intercostal space, on the right side,
showed some bloody serum, and another puncture drew
off some dark blood. Within a week after admission the
liver had become reduced to its normal proportions, and
the pain and tenderness had disappeared. Vaginal ex-
amination showed some retroversion of the uterus, but no
marked displacement.
At the next menstrual period these symptoms returned
with much greater severity than at any previous time.
The temperature rose at times to 104° F., the pulse was
almost imperceptible, and there was occasional delirium.
‘The urine was diminished in amount, and contained traces
of sugar. This attack was recovered from less perfectly
than before, the liver remained slightly enlarged and the
patient was quite weak. The following month the symp-
toms returned with increased severity, the temperature
rose to 105° F., the pulse to 160, and the woman died.
An examination of the blood, made at the beginning of
this attack, showed 2,800,000 red blood-corpuscles to the
cubic millimetre, the proportion of white to red cells
being about as one to thirty.
To summarize briefly the above report : Five successive
menstrual periods were replaced by five attacks of hepatic
enlargement with acute inflammatory symptoms. From
the first of these attacks the recovery was complete ; from
the fourth it was only partial ; and the fifth attack proved
fatal.
At the autopsy the liver was seen to be enlarged and
adherent to the surrounding parts. Its surface was
slightly roughened and dotted with yellow nodules and
small red and black spots ; its cut section presented much
the same appearance. The spleen was enlarged and con-
tained numbers of cheesy nodules. ‘The left ovary con-
tained a Graafian follicle filled with blood. Dr. Thacher,
who made the microscopical examination, reported that
the liver and spleen contained spots of congestion and
hemorrhage, and also small areas of granular matter with-
out visible structure, which were apparently necrotic.
‘There were also numerous collections of abnormal cells,
mostly of large spindle-cells with many giant-cells, which
resembled sarcoma. l
Dr. GeorcE L. Peasopy said that the case looked to
: him very much like one of leucocythzmia.
THE PRESIDENT remarked that the proportion of white
to red blood-corpuscles was not sufficiently altered to es-
tablish with certainty a diagnosis of leucocythz-mia ; it
might be regarded rather as a leucocytosis.
Dr. Witt1aM H. Draper then read the paper of the
evening (see p. 393), entitled
THE RELATION OF DIET TO URIC-ACID FORMATION.
Dr. GeorcE L. Peasopy said that he could not help
feeling that this question of uric acid and lithemia was
not so much one of chemistry as it was one relating to
the vital processes of each individual person. It was
within the experience of all that some persons, when con-
fined to an exclusively nitrogenous diet, did not do well,
and, on the other hand, a person who was getting along
fairly on a moderate diet would suffer from an attack
after taking a single glass of dry champagne. No one
could suppose that the attack was the result of the mere
chemical action of that one glass of wine. He asked Dr.
Draper what sort of food he allowed his patients when
he wished to avoid the carbohydrates.
406
THE MEDICAL RECORD.
{October 12, 1889
Dr. DRAPER said that he had distinctly stated that it
was not often necessary to withhold farinaceous or even
saccharine foods entirely, but he believed that patients
were relieved by diminishing the amount of this food
taken. It is often necessary to remove only certain kinds
of carbohydrates, such as fermented liquors, or fruits, or
starchy matters. He had not intended to open up such
a wide discussion, nor to go into the question of the
treatment of gout. The point that he had intended to
make was that uric-acid excretion is checked generally by
withholding saccharine and amylaceous food. He believed
that gout was very closely allied in some mysterious way
to diabetes. Even when lithzmia exists alone, it is often
as distinctly benefited by an anti-diabetic diet as is dia-
betes itself. Why this was so he could not tell ; it might
be due to some idiosyncrasy, to some peculiarity in a man’s
liver about which we know nothing at the present time.
When he found it necessary to restrict the diet very
greatly, he allowed spinach, salads, and the like, in ad-
dition to meat.
Dr. PEaBopy said that these green vegetables could
not be looked upon as a food, for they were chiefly water,
and the small amount that could be taken at a meal con-
tained but very little nutrient material. They might serve
to render the animal food more palatable, but that was
all, and the diet was still purely an animal one. He did not
see why fruits should be excluded, for their acids are con-
verted into carbonates and thus render the urine alkaline.
Dr. DraPeR replied that the fruit acids were converted
into bicarbonates, and these salts did not make the urine
alkaline.
Dr. WILLIAM M. Pork asked whether climate did not
have something to do with this condition. He had never
seen a negro on the Southern plantations with gout, yet
they almost lived on sugar during a part of the year.
Dr. Draper thought that climate certainly did have
something to do with it. The colored children got fat
from their saccharine diet. Under other conditions the
sugar taken might not make fat, but might instead give
rise to litheemia. It was not uncommon to observe peo-
ple take on fat for a time, then this process would stop
for some reason, and gouty symptoms would appear.
Dr. SEXTON asked what effect corn-bread had in this
condition. In those sections of the country where this
entered largely into the diet it was his impression that
gout was uncommon.
Dr. A. H. SMITH said that his clinical experience was
in accord with that of Dr. Draper, for he had often seen
patients whose gouty symptoms disappeared upon the
withdrawal of the carbohydrates. One patient, a boy,
had an immense amount of urates in the urine whenever
he took evena little piece of sugar. He believed that
the three conditions of litheemia, polysarcia, and diabetes
were closely allied. It seemed to him hardly correct to
say that green vegetables do not form tissue, for they cer-
tainly do in the lower animals. A horse will do a great
deal of work when living on grass alone.
_ Dr. Peasopy said that the herbivorous animals ate an
immense amount of grass—they ate pounds and pounds—
while a man eats only a few ounces. A man may eat
a little two or three times a day, while cows eat all day long.
Dr. KINNICUTT said that horses can do a large amount
of work on a comparatively small amount of fodder.
They do not eat all day long.
Dr. C. L. Dana thought that Dr. Draper would find it
very difficult to counteract the teachings of English physi-
cians, which exerted a powerful influence on American
practice. He could not recall a single English writer
who did not exclude nitrogenous food from the diet in
these cases. He had seen many persons, in the last few
years, who were suffering from the nervous symptoms of
hthzemia, and had systematically tried a non-nitrogenous
diet. He had had some good results and some unsatis-
factory ones, but had found usually that a nitrogenous
diet would help those who were suffering from dyspeptic
symptoms. Persons with the degenerative lesions of ad-
vancing life often do badly on a purely nitrogenous diet.
He had found that the green vegetables agree very well
“with most people.
Dr. Pork asked whether no investigations had ever
been made in these cases in regard to intestinal digestion
and the action of ptomaines in producing lithæmic symp-
toms. Until such had been carefully made, the question
could not be satisfactorily settled. In the treatment of
this condition he had always paid much attention to the
excretions, and this was the result of his observations as
to the effect of climate upon the disease. It had always
seemed to him that if we could create a Cuba for these
patients it would do a great deal for them. Of course,
he did not mean to assert that no one living in a tropical
country ever had gouty symptoms, but he believed the
disease in such cases was hereditary, and that it was
seldom if ever acquired in hot climates.
Dr. BEVERLEY Rosinson said that he did not look
upon diet in gout or lithemia as the only essential point,
and he did not believe that the retention of a certain
amount of uric acid was essential to the production of
the affection. It was necessary to watch the individual
and to ascertain: what he could digest and what not.
There was a gentleman in this city, suffering from gout,
whom he had watched very carefully. Last summer he
went to Carlsbad for a course of the waters, and was
there told that he was cured and that he would have no
more gout. Some time ago, while walking up town, he
became suddenly very short of breath. ‘The attack passed
away after resting at home, but recurred several times,
and then the patient consulted the speaker. ‘There was
nothing in the man’s urine or elsewhere to point toward
gout, but finally, other things having failed to prevent the
attacks of dyspnoea, he was put upon colchicum, and
almost immediately uric acid appeared in large quantity
in his urine. The speaker believed that gouty people did
not drink enough water, and that if they would drink
more they would suffer less from lithemic symptoms.
But they did usually eat too much, and it did not matter
so much what kind of food was cut off as it did how much
was taken. The diet should be regulated according to
the individual indications, and should not be the same
for the plethoric as for the pale, nervous sufferer.
Dr. A. A. SMITH reported a case of .
DIFFUSE PHLEGMONOUS GASTRITIS.
The patient was a colored man, thirty-four years of
age. He was admitted to Bellevue Hospital on Febru-
ary 26, 1889. The patient had suffered from no previous
sickness of any kind, excepting measles and pertussis
when quite young. Of late years he had been in excellent
health ; had never suffered from malarial poisoning,
syphilitis, or rheumatism; had never sustained any
severe injury; was not a hard drinker, and only oc-
casionally drank more than two glasses of beer daily ;
had not been drinking at all for some time preceding
his present sickness.
The patient on admission was perfectly conscious, but
suffering intense pain in the abdomen, with marked tender-
ness on pressure, especially near the umbilicus. He said
that when he arose the preceding day he did not feel so
well as usual, though he complained of no definite symp-
toms beyond loss of appetite and feeling of indisposition
to do work. Went to his place of business and fulfilled his
duties as a cook. About two o'clock in the afternoon, after
eating a light dinner, he was suddenly taken with cramp-
like pains in abdomen, pain radiating chiefly from the
umbilicus, and accompanied by vomiting of undigested
food. Pains and vomiting, both of paroxysmal character,
continued up to time of admission, viz., twenty-two hours
from the beginning of the attack. He did not have any
chill, nor experience any decided feeling of chilliness.
When admitted the patient showed signs of great ab-
dominal distress, vomiting at variable intervals a greenish-
stained fluid, and utterly unable to retain anything taken
into his stomach. ‘The bowels were constipated, though
October 12, 1889]
THE MEDICAL RECORD.
407
he had had one small movement the day before, unac-
companied by pain.
abdomen only slightly, and not unevenly distended, tym-
panites not excessive, but most marked over the ascend-
ing colon. Cephalalgia was marked, and there was much
dizziness. ‘The urine was normal in quantity and quality,
though the specific gravity was high.
February 27th.— Temperature still high ; vomiting pres-
ent ; pain and tenderness more marked ; bowels consti-
pated ; abdomen a little more distended and rather rigid ;
tympanites more marked ; pulse more rapid, 120 to 130, fee-
ble, fluttering ; respirations, 25 to 35, and rather superficial.
The patient lies with eyelids only partially closed, eyeballs
upturned, just as when first admitted ; easily aroused, and
talks coherently.
February 28th.—Condition much worse. The temper-
ature began to fall after 5 a.m., but the pulse became more
rapid and feeble; not easily ‘aroused. About g A.M. the
man went into collapse, dying at 10.45 A.M.
February 29th.—Awutopsy revealed diffuse, phlegmo-
nous gastritis, almost the entire wall of the stomach being
infiltrated with pus-cells, the mucous membrane itself being
unaffected ; no evidences of any ulcer or even break in its
continuity. There was slight recent peritonitis overlying
the affected part of stomach. The intestines and viscera
were unaffected. No evidences of any form of inflamma-
tion elsewhere ; endocardium unaffected.
This case presents several points of interest. ‘The man
gave a history of an illness beginning on rising, the day
before admission to hospital. It will be observed he was
admitted, February 26th. He was taken ill the day before,
February 25th. He died, February 28th, at 10.45 A.M.,
about seventy-six hours after the very first symptom man-
ifested itself.
The autopsy revealed a condition which is extremely
rare, and one which is seldom diagnosed except in the
autopsy-room. It would seem impossible to make an ac-
curate diagnosis unless the patient lives sufficiently long
to vomit pus. In this case a diagnosis was made of local-
ized peritonitis, but what it was due to it was impossible
to even conjecture. The peritonitis was probably second-
ary to the changes in the stomach-walls. ‘There was no
change in the intestine or liver, as is sometimes found in
phlegmonous gastritis. ‘There was no history of a blow
over the epigastric region.
MEDICAL SOCIETY OF THE COUNTY OF
NEW YORK.
Stated Meeting, September 23, 1889.
ALEXANDER S. HunNTER, M.D., PRESIDENT, IN THE
CHAIR.
Tue following nominations were made :
For Prestdent—Dr. A. S. Hunter and Dr. L. Bolton
Bangs ; Vice-President—Dr. J. Leonard Coming; Secre-
tary—Dr. C. H. Avery ; Assistant Secretary—Dr. W. E.
Bullard ; Zreasurer—Dr. John S. Warren ; For Censors
(five to be elected)—Drs. Laurence Johnson, Daniel
Lewis, G. H. Fox, N. G. McMaster, William M.
McLaury, George E. Abbott ; For Delegates to the State
Medical Soctety (twenty-four to be elected)—Drs. J. O.
Tansley, D. H. Goodwillie, William Stevens, A. S. New-
comb, F. B. Carpenter, Samuel Lloyd, P. A. Callan,
Ralph Waldo, E. M. Liell, U. G. Hitchcock, W. A. Day-
ton, Charles A. Powers, Willy Meyer, H. D. Chapin, G.
T. Elliot, John Doming, S. D. Powell, R. T. Morris,
Francis Valk, D. D. Jennings, W. C. Jarvis, L. L. Sea-
man, Malcolm McLean, E. H. Grandin, W. P. Northrup,
R. C. M. Page, R. C. Shultz, R. B. Talbot.
Dr. H. J. BoLDT read a paper entitled
SOME ABNORMALITIES OF THE CONTENTS OF THE FEMALE
P=LVIS,
being some conclusions based on personal experience,
with the diagnosis and treatment of various diseases of
the female reproductive organs.
Decubitus was dorsal, thighs flexed .
When the abnormality consisted of a tumor it had to
be determined whether it was intra- or extra-peritoneal, to
what part it belonged, whether the uterus, ovaries, tubes,
etc.; whether solid, semisolid, or having fluid contents ;
its nature ; whether likely to endanger life or disable the
patient ; what treatment, if any, was for the best interests
of the patient. The author next considered the symptoms
of ovarian cysts, which varied according to the size,
position, nature, and complications. Bladder and bowel
symptoms depended on the extent and density of the ad-
hesions, the severity of inflammation in the tumor, and
perimetritis. There was usually constipation and fre-
quent micturition, yet he had seen the reverse in some
cases of suppurating ovarian cysts in which the adhesions
were exceedingly dense. He attributed the diarrhoea in
such cases to a mild sepsis; although the temperature
was never high, still, if taken a number of days at regular
intervals, an occasional rise to 100° F. or above would be
noticed. He had never seen a patient with pus intra-ab-
dominal in whom records of the temperature for several
days did not show fever. Speaking of the physical ex-
amination, he warned against the danger of ruptures the
friable walls of the cyst by rude manipulation. He be-
lieved that one cause for suppuration might be found in
the treatment which some patients received during
months, and which, instead of allaying the localized peri-
tonitis around the cyst, increased it, suppuration eventu-
ally taking place. Cases of smal] suppurating cysts
located behind the uterus had invariably given the history
of a previous course of painful local treatment. One of
the most serious mistakes in diagnosis was to confound a
retroflexed gravid uterus with this condition, a mistake
which had frequently been made, and which was illus-
trated by one instance in his own practice.
A case was also related in which operation showed that
what had been mistaken by the patient’s former doctor for
an ovarian cyst with rupture into Douglas’ pouch was a
pyo-salpinx and intra-peritoneal exudation, the tube hav-
ing become displaced and the discharge of pus occurring
periodically through the uterus. The efficacy of cathar-
sis was most markedly manifest in this case. ‘The second
day after removal of the diseased tube and breaking up
of adhesions of the other, the temperature rose to 105° F.,
the pulse to 140. Septicazemia was evident, and he had
intended to reopen the abdomen and drain, but, remem-
bering the unfavorable result of previous experience with
this method, he ‘decided to try catharsis. Although the
patient had had two diarrhoeal movements during the day,
he gave her fifteen grains of calomel. ‘The bowel began
to move within about three hours, and by the following
morning the temperature had fallen to g9° F., and the
pulse to 110. ‘The patient quite recovered.
An ovarian cyst surrounded by perimetric exudations
and bound down firmly by adhesions to the uterus might
be mistaken for a subperitoneal or interstitial fibroid of
the uterus. A fibro-cystic tumor of the uterus of large
size could hardly be diagnosticated. Malignant degener-
ation of abdominal tumors should be: suspected if the
growth had been present a long time and was causing
emaciation. ‘The adhesions in such cases could be dem-
onstrated prior to opening the abdomen. As to the sup-
posed uselessness of operating in cases of ovarian tumors
which had already undergone malignant degeneration,
Dr. Boldt coincided with the views of Freund, who had
given the history of a number of apparently hopeless
cases in which the operation had materially prolonged
life and relieved distress. Dr. Boldt had had opportu-
nity to operate in but one such case. The patient, he be-
lieved, was yet well.
The author had seen several cases like the following : A
patient suffering for months or even years with localized
pain in one ovarian region, which had never been mark-
edly relieved by any form of treatment. A mass varying
in size from that of a hen’s egg to greater than that of
one’s fist was found on one side of the uterus, with hard,
irregular outlines, almost immovable because of firm ad-
408
THE MEDICAL RECORD.
[October 12, 1889
hesions, and in close contact with the uterus. Such of his
cases had always proven on operation to be composed of
firm perimetric exudate with a little pus in the centre, the
tube and ovary matted together and inflamed. Most
physicians treated them for cellulitis, and they had also
been mistaken for malignant disease.
The most frequent error in diagnosis was to confound
tubal disease with cellulitis and posterior displacement.
But tubal disease of infectious origin invariably had a dis-
tinct history, being traceable to either the puerperal state,
some uterine treatment undertaken for dysmenorrhcea or
sterility, or to gonorrhcea.
Dr. H. T. Hanxs opened the discussion. He said
that although the paper covered a large field, yet twenty
years ayo half of the affections mentioned would have
been grouped under one name, pelvic cellulitis or pelvic
peritonitis. He had been particularly interested in the
symptomatology of pelvic diseases, and dwelt on the im-
‘portance of a thorough study of the subjective symptoms,
which, followed by manipulation, would enable one to
make the diagnosis in most cases before opening the ab-
domen. ‘There was no question in his mind but what he-
matocele due to tubal pregnancy, pyo-salpinx due to gon-
orrhceal infection, and retroversion of the gravid uterus
had each its separate symptorns, and it was the duty of
‘the physician to ask questions and establish the exact di-
agnosis. He mentioned one case of papillomata of the
right ovary in which removal had prolonged life, although
subsequent operations had to be resorted to for renewed
growth.
Dr. E. H. GRANDIN thought the most serious error in
diagnosis was to mistake pregnancy for some other condi-
tion. Of recent years the truth had been impressed upon
him that this error need never, or very rarely, occur.
There were two signs of pregnancy of great value, yet
they were often overlooked, the one becoming of value at
the eighth week, the other at the third month. ‘The first
was Hegar’s sign, and was based on the fact that in early
pregnancy the uterus enlarged . chiefly in the antero-pos-
terior and transverse diameters, assuming the shape of a
flattened sphere, and becoming boggy. The other sign
was that pointed out by Braxton Hicks, being the rhythmi-
cal contraction of the uterus after the third month. It
might have to be waited for five or even ten minutes. It
had been said that fibrosities would give rise to this symp-
tom, but he had never felt but one which did.
Regarding free catharsis, he was satisfied that it was
one of the best means for enabling patients to withstand
the septic condition. This was true not only of sepsis in
pelvic diseases, but also in the puerperal state.
Dr. KEARNEY mentioned the fact that Hegar’s sign was
also present in extra-uterine pregnancy, and spoke ofa
case of typhlitis, with general peritonitis imminent, in
which recovery followed catharsis by Epsom salt.
Dr. W. E. Forest said it was not necessary to aban-
don opium in puerperal peritonitis while adopting the
treatment by catharsis; he gave one grain of extract of
opium, ten grains of calomel, and ten grains of quinine in
two capsules. Strange to say, catharsis was even more
free than when calomel was given without opium.
POTASSIUM BROMIDE AND BELLADONNA FOR ENURESIS.
—Dr. J. T. Richards recommends very highly a combina-
tion of belladonna with bromide of potassium in the
treatment of nocturnal incontinence of urine. He re-
ports two cases in the British Medical Fournal, of June
22, 1889, in which this mixture was effectual after bella-
donna alone and several other drugs had notably failed.
PILSNER BEER AS A DiuRETIc.—Dr. Gruss, of Vienna,
had a patient with heart trouble who was passing very
small quantities of water. He tuld him to drink freely of
Pilsner beer, and the quantity of urine passed rose almost
at once from thirteen to fifty ouncesa day. This remedy
will doubtless become very popular.
MEDICAL SOCIETY OF VIRGINIA.
Twentieth Annual Session, held in Roanoke, Va., Septem-
ber 3, 4, and 5, 1889.
(Special Report for Tua MepicaL Recor.)
(Continued from p. 384.)
THURSDAY, SEPTEMBER 5TH—THIRD Day.
Dr. R. S. MARTIN, of Stuart, read a report on
ADVANCES IN GYNECOLOGY.
Massage (Brandt’s method) is reported to be practised
with great success by Dr. Boldt, of New York, in the fol-
lowing conditions : Chronic and subacute para- and peri-
metritis; all non-acute inflammatory uterine diseases;
chronic and subacute dophoritis ; catarrhal salpingitis ;
all uterine displacements, with or ‘without adhesions, un-
less dilated tubes are present ; rectocele and cystocele;
uterine hemorrhages not dependent on neoplasms; in-
continence of urine dependent on relaxation of the visceral
sphincter ; hematocele ; floating kidney; and prolapsus
recti. It is contra-indicated, according to some, in all
acute inflammatory processes, dilated tubes, and in all
conditions where suppuratien is suspected. This treat-
ment is not useful in patients with very fat abdominal
walls. The séances vary from three minutes to a quarter
of an hour.
Dr. Martin then exhibited an Outerbridge dilator—an
ingenious instrument which acts also as a drainage-tube.
In sterility dependent on stenosis this instrument is in-
troduced, five or six days before menstruation, into the
contracted cervix uteri and allowed to remain. It is also
of value in sterility due to flexions. A full description of
the instrument and its uses was given in THE MEDICAL
Record of April 20, 1889. Electricity holds a high
place in the treatment of carefully selected cases. Engel-
mann uses galvanism for inflammatory products which
admit of restitution, indurations, deposits due to intersti-
tial inflammation, certain neoplasms. Davis, of Birming-
ham, Ala., uses faradism for subinvolution of the uterus.
It is useful in many cases of retroversion, many so-called
pelvic inflammations, in amenorrhcea due to atrophy of
the uterus, andin menorrhagia due to relaxation of the
muscles, Many think electricity (after Apostoli’s method)
of value in the treatment of uterine fibroids; but the
dangers of sepsis must be guarded against. Some think
electrolysis of fibroids uncertain.
For carcinoma uteri Brown uses the curette freely, and
applies on a tampon a saturated solution of zinc chlonde.
Mundé uses a weak solution of sesquichlonde of iron.
Schramm injects half to one grain in an ounce solution of
corrosive sublimate into the diseased mass, two or three
times a week, causing cessation of fetor and purulent dis-
charges, and lessening the frequency of hemorrhages.
The feeble absorptive power of the degenerated tissue
offers immunity from mercurial poisoning. The following
is an antiseptic and sedative suppository extensively used
in Paris.
B. Todoformi............ 0.005 cece gr. xv.
CAMPROLE o43-ae 20Gb Pan EONS EN gr. iv.
Ext. belladonnæ ............ 2.2000 gr. Ri
Ol. theobrome .......eseesses..s.
q:
M. Make one suppository. S.: Put high up in B at night.
High amputation of the tervix is advised if the disease
has not passed beyond the internal os. If disease has not
extended beyond the uterus, hysterectomy is advised. As
to uterine fibroids, Coe scrapes away the hypertrophied
mucosa. Vaginal hysterectomy has been done success-
fully. During 1888, abdominal hysterectomy was done
43 times, with only ọ deaths. Uterine anteversions and
flexions are but ae congenital, but results of previous
parametnitis. Use antisepticized laminaria tents to
soften the tissue and render intra-uterine treatment more
thorough. Use preliminary course of hot douches and
October 12, 1889]
glycerine tampons, then straighten the uterus bimanually,
and hold in place by pessary or intra uterine stem. Dil-
atation with bougies and the persistent use of hot water
will usually effect a cure. Gooddell advocates thorough
dilatation with steel-branched dilators when dysmenorrhcea
is a prominent symptom. Wylie condemns pessaries, but
dilates rapidly under thorough antisepsis. Alexander’s
operation for shortening the round ligament has grown in
favor. Mundé reports 23 cases, with excellent results.
Kellogg reports 65 successes out of 69 operations.
Schucking has devised and practised successfully vaginal
suture of the uterus in 18 cases for radical cure of retro-
flexed or prolapsed uterus. Hysterorrhaphy finds favor in
Germany, where prejudice exists against Alexander's op-
eration. A case of lacerated cervix, operated on by the
reporter in May, 1886, was delivered of twins, each
weighing eight pounds, in July, 1889, without further
laceration. Herrick pares the lips and holds them in
apposition, not by sutures, but by an elastic band shaped
like the cervix, large enough to cover the whole os and
Cervix, with a small hole in the band to allow the secre-
tions to pass. Dr. T. Gaillard ‘Thomas does not claim
that operations for diseases of women are especially liable
to cause insanity, but he mentions six very significant cases
in none of which were the kidneys at fault, nor could the
sequel be charged to 1odoform-poisoning.
Dr. CHARLES W. PRITCHETT, of Keeling, then read a
REPORT ON ADVANCE IN OBSTETRICS.
He first spoke of the vomiting of pregnancy. Hewitt
analyzes fifty selected cases, and contends that these cases
confirm his opinion that the vomiting is.in almost all cases
associated with, and dependent on, uterine displacement
and thickening or induration of the cervix. Gill Wylie
attributes it largely to induration of the cervix. Jaggard
ascribes it to endometritis gravidarum. In the treatment
of this complication Gunther, of Montreux, advises gal-
vanism. Green reports cases cured by chloride of sodium.
Collins and William Duncan report cases cured by the
application of a ten per cent. solution of cocaine to the
vagina and cervix. Rose recommends rectal injection of
carbonic-acid gas.
Anesthetics.— Recent writers accord antipyrine a very
high place-in the first stage of labor, relieving pain and
fatigue, while. the uterine contractions are not interfered
with. Chloroform holds its own in the second stage of
labor. Budin advises chloroform only to dull pain, and
not to complete anesthesia, unless to perform an operation
more severe than the application of the forceps. Swieicki,
of Posen, has used a mixture of nitrous oxide and oxygen
in the proportion of four to one. Winckel regards the
mixture as harmless, and eapecialy useful in cases of
elderly primiparæ.
Antiseptics.—The comparative results in hospitals in
which antiseptics are used, and those in which they are
not, are sufficient to show their great value in reducing the
mortality of the lying-in chamber. Corrosive sublimate
in weak solutions, and in careful hands, is still the queen
of antiseptics and germicides.
Eciampsia.—There is yet a considerable want of
unanimity as to the cause and treatment of puerperal
convulsions. Santos believes that the albuminuria is the
result of reflex irritation of the sympathetic and renal
nerves, by the enlargement, and later on the contraction
and retraction, of the uterus. Lusk says albuminuria is
caused by renal insufficiency, and is not the cause of the
convulsions. Pajot denies the dependence of eclampsia
on albuminuria, but attributes it to a reflex cause.
Mastitis.—According to Richardson, this is the result
of septic infection, and urges that the child’s mouth be
kept perfectly clean, and the nipple well washed with an-
tiseptics. Monti advises that the fissures of the nipple be
painted with a solution of gutta-percha in chloroform.
Puerperal Septicemia.—It is disputed whether this dis-
ease is dependent on one or more organisms. Vidal
claims that there are at least two, and that there is no
THE MEDICAL RECORD.
409
characteristic difference between the germs of puerperal
septicemia and erysipelas. Gusserow denies their iden
tity, and insists that erysipelas cannot cause puerperal sep-
ticeemia. Doyen says they are one and the same. Others.
assert that puerperal septicemia is of an erysipelatous
nature, and the fever typical of erysipelas.
Dr. A. S. Prippy, of Keysville, read the report on
ADVANCE IN DISEASES OF CHILDREN.
He had not found any material advance except in diseases
of the alimentary canal. The researches of Holt, Esche-
rich, afid others with reference to intestinal bacteria were
summarized, with the deduction that three factors must
be kept in mind in studying the effects of micro organisms
upon the human system: The nature of the organism ;
the dose, and numbers in which they enter; and the sus-
ceptibility of the patient. ‘The two varieties of bacteria
which have been isolated and studied in the intestines of
young children, are the bacterium lactis erogenes (found
in the upper portion of the small intestine), and the
bacterium coli commune. ‘The first decomposes milk-
sugar, with the development of lactic or acetic acid, to-
which the acidity of the intestine is due. After a full re-
view of the subjects involved, the lessons are drawn that
the infant must not be overfed, and that the milk (in
bottle-fed cases) should be sterilized, and the vessels them-
selves that hold the milk should also be sterilized. Milk
was first sterilized for food in Munich, in 1886. Dr.
Caillé, of New York, introduced sterilized milk as an arti-
ficial food into this country in 1888, and the results have
been favorably rcceived. It remains sweet for six weeks,
while boiled milk can be kept only four or five days, even
on ice. Stomach-washing for gastro-intestinal disease,
first used in Prague in 1880, was satisfactorily introduced
by Seibert in New York, in 1888—especially serviceable:
in dyspeptic disorders attended with regurgitation of food,
in cholera infantum, etc. Pass a long, soft, velvet-eyed
rubber catheter, attached to a fountain syringe, through
the pharynx into the stomach ; pour in a cupful of warm
water while the child is in the upright position; then
tilt the child forward, and the water returns through the
catheter. For intestinal irrigation, pass a Nélaton soft
rubber catheter (with a hole in the end instead of at the
side) some eight or ten inches into the bowel. ‘Through
this catheter, attached to a fountain syringe, pass a quart
or two of warm water, containing a drachm of sodium
salicylate to the pint of water. ‘Though the treatment is.
not new, it is only during the past two years that it has
become popular in this country—chiefly through the re-
ports of Dr. Booker, of Dr. H. P. Wilson’s Sanitarium, of
Baltimore. It is useful in dysentery, gastro-enteric catarrh,
acute and chronic follicular enteritis, etc. Dr. Priddy
had used the treatment satisfactorily in a number of cases
of gastro-enteric catarrh, dysentery, etc., relieving the
nausea, vomiting, tenesmus, etc., and curing his patients.
Dr. GEORGE TUCKER HARRISON, of New York, read a
paper entitled
FURTHER CONTRIBUTION TO THE STUDY OF THE ETIOLOGY
AND PROPHYLAXIS OF PUERPERAL SEPTIC INFECTION.
The doctrine of auto-infection, which has recently been
brought into great prominence, and the industrious re-
searches of the bacteriologists, with the practical deduc-
tions from them, have divided obstetricians into two par-
ties diametrically opposed to each other. The one side
attaches all importance to the disinfection of the obste-
trician (Mermann’s subjective infection); the other re-
gards it as a matter of necessity to subject the parturient
woman, in a greater or less degree, to antiseptic measures
(objective antisepsis). The writer took the ground of
those who advocate the paramount importance of sub-
jective antisepsis, in the paper read before this Society in
1885, and has had no reason to change his ground. Of
course this position does not exclude the thorough cleans-
ing and disinfection of the external genitals. ‘The views
of Kaltenbach were quoted, who insists upon it that an
410
THE MEDICAL RECORD.
[October 12, 1889
obstetrician, even with clean hands, can induce infectious
forms of disease. He believes that, as the surgeon disin-
fects his field of operation, so must the obstetrician disin-
fect the parturient canal, as well as the vicinity. Winter
(Zeitschrift f. Gyn., etc.), as the result of bacterial investi-
gation, draws the inference that it 1s necessary to disinfect
the cervix and vagina to avoid auto infection. Steffeck
and Dolderlein arrive at the same conclusion. ‘The writer
believes that if the demands made by the bacteriologists
should be generally acceded to, and it should become a
universally accepted rule of practice that the cervix and
vagina of every parturient woman should be subjected to
thorough and energetic disinfection, an immense amount
of injury would be inflicted. These disinfective proced-
ures deprive the vagina of its physiological mucus, and
render it more vulnerable. It becomes more liable to the
attack of infective germs. Moreover, labor is mechani-
cally retarded when the vagina lacks its normal mucus ;
nor must it be left out of mind that disinfection of the
vagina and cervix is a painful manipulation. Probably
the most serious objection which can be urged against the
auto-infection doctrine is, that it diminishes the personal
responsibility of the obstetrician, and that wholesome
dread of infection disappears which everyone should have
who examines a parturient woman. ‘The distinction was
made between septic infection and putrid intoxication.
Cases of so-called auto-infection are really cases of pto-
maine intoxication. The micro-organisms of septic in-
fection are streptococci. According to Bumm, the strep-
tococci of erysipelas and phlegmonous inflammations are
identical. Bumm’s careful and exact bacteriological stud-
ies lend no countenance to the doctrine of auto-infection.
Leopold’s clinical experience is very striking. Of five
hundred and ten women treated without vaginal douches,
only nine had slight febrile phenomena. When the cervix
and vagina were disinfected, there was a marked rise of
morbidity. ‘The doctrine of auto-infection is a retrograde
movement, and tends to imperil our present attainments in
the prophylaxis of septic infection.
Dr. I. S. STONE, of Lincoln, read a paper on
SOME GYNECOLOGICAL WORK OF THE PAST YEAR.
‘The paper was based upon experience of cases in the au-
thor’s sanatorium where none but gynecological cases are
received. A brief account was given of several cases of
surgical interest, among others four cases of abdominal
section. The author favors Emmet’s operation for lacer-
ated cervix, but thinks nearly all cases require the curette
before resorting to trachelorrhaphy, and very much bene-
fit may be derived from this procedure where the opera-
tion is not important. Taits flap operation has given
the most satisfactory results when required for lacerated
perineum, and can be performed in a comparatively short
time, thus simplifying a most tedious and difficult opera-
tion. Electricity came in for a brief notice only, but was
not considered of definite value. ‘The author claims ex-
ceedingly good results in neurasthenia attendant upon
pelvic disease from the use of the Weir-Mitchell method
of treatment.
Dr. Jonn W. Scott, of Gordonsville, was the reporter
on
ADVANCE IN PRACTICE OF MEDICINE.
After reviewing much of the germ theory as causative of a
number of diseases, he concludes that we must look to
local sanitary improvements rather than to quarantine
alone for the prevention of epidemics—such as Asiatic
cholera, yellow fever, etc. Gibier maintains that the ba-
cillus of yellow fever closely resembles that of cholera.
During the year ending May 1, 1889, Pasteur treated 1,673
persons bitten presumably by rabid dogs, and lost only
three by hydrophobia after the conclusion of the treat-
ment ; six died during treatment, and four developed the
disease a fortnight after leaving his institution. ‘The mi-
crobe of typhoid fever is the bacillus of Eberth and Gaffky.
It is of tenacious vitality, and may live for months in de-
composing fecal matter, increasing in numbers at a tem-
perature of 62.5° F. Drs. Kalb and Bartlett claim
(British Medical Journal, January 5, 1889) what is next
to an abortive treatment of typhoid fever by mercurial
inunction. This treatment must be commenced before
the ninth or tenth day. Cold baths are being again advo-
cated. Ehrlich’s diagnostic sign of enteric fever—re action
in the urine with one of the aniline derivatives—has been
verified by Dr. Taylor (Zancet, May 4, 1889). ‘Tubercu-
losis is a specific infectious disease, the constitutional
manifestations of which are secondary to the bacilli, and
due: to toxic influences evolved during their increase of
growth and number. ‘The number of bacilli in the sputa
bears no relation to the progress of the disease. The dry
sputa is chiefly concerned in the propagation of the dis-
ease. The disease can be transmitted only through the
medium of Koch’s bacillus. It is not in the ordinary
sense hereditary. The presence of the bacillus in the
sputa is of positive value, but not of negative value in
diagnosis. A rational prophylaxis is practicable, and we
must still look more to prevention than to the cure of
tuberculosis, as no non-injurious antiseptic has yet been
brought forth successfully. ‘The infectiousness of scarlet
fever suddenly decreases about the sixth day and increases
again about the twelfth, reaching its maximum by the six-
teenth. The telluric origin of tetanus is gaining ad-
vocates. The disease may be produced by inoculation
with earth which has recently been in contact with or-
ganic matter. The treatment of locomotor ataxia by sus-
pension is approved, but with the injunction to be cautious
in watching the effect on the patient during the operation
of suspension itself. No case of Pott’s paralysis ought to
be regarded as desperate until after failure of suspension.
Weil’s disease is due to septic poisoning, and hence it is
proposed to call it septic or infectious icterus. Dr. Scott's
observations on the treatment of whooping-cough by in-
halations of the oil of eucalyptus is beneficial in shorten-
ing the length and in ameliorating the severity of the
paroxysms, and in prolonging the intervals between the
spells. His method was to pour from one to two drachms
of the oil on sponges and suspend several of them from con-
venient places inthe room; at night, from the head of the
bed so as to let the oil be constantly inhaled. A numer
of abuses of hygienic rules were mentioned, inthe hope
of getting practitioners to properly instruct their patients
with regard to them, such as the common errors in out
schools, the aversion of wives to becoming mothers, etc.
Dr. A. Jacosi, of New York, presented a communica-
tion on
ENTERALGIA AND CHRONIC PERITONITIS.
Enteralgia is always an irritation of a branch or branches
of the sympathetic nerve. Its cause lies in the nerve or
the intestinal tissues or its contents. Hysteria, hypochon-
dria, malaria, gout, poisons, etc., may start the disease ;
or the pain may be reflected from spinal, liver, genito-
urinary or skin disease—sudden chilling of the skin being
a frequent cause. ‘The pathological changes are conges-
tion or inflammation, with their results. Acid food, cer-
tain drastics, hard scybalz, fermenting foods, etc., are the
common causes of enteralgia. The attacks are indefinite
in length or suddenness. ‘The temperature is rarely raised ;
the pulse is irregular ; the skin becomes cold and clammy ;
sometimes dysuria, nausea, vomiting, constipation for di-
arrhoea occur. The tumidity of the abdomen changes its
place under palpation, etc. Priapism and seminal dis-
charges may occur with spastic rise of the testicles.
A common cause of enteralgia, often overlooked, is
chronic peritonitis of secondary nature. New abdominal
formations, peritoneal adhesions, swelled pelvic glands,
etc., point to previous peritonitis, Floating kidney may
start peritonitis, and thus become fixed in its dislocated
position. Vertebral disease, psoas and iliac abscesses, hip-
joint abscess, etc., may cause chronic peritonitis—often-
times not recognized except post-mortem. Catarrhal
“female diseases” are frequent causes, as are violent
October 12, 1889]
THE MEDICAL RECORD.
All
cohabitation, the puerperal state, etc. Biliary calculi,
perinephritis, splenic and pancreatic diseases, infantile in-
tussusception, a preceding attack of peritonitis, etc., are
also causes. Simple intestinal catarrh grows speedily into
enteritis, Peritonitis is likewise communicated to the
muscular and mucous tissues—and thus extends the cedem-
atous infiltration, paralysis, and hence constipation.
‘Thus also diarrhoea, intestinal ulceration without perfora-
lion, etc., may cause local peritonitis. Diagnosis of
chronic peritonitis is not always easy. Respiration need
not be accelerated in pelvic peritonitis, perimetritis, and
pericystitis. Vomiting is sometimes wanting ; diarrhoea is
not infrequent, but constipation is the rule ; the abdomen
may be tumid, and the horizontal position is often wn-
comfortable. The seat of inflammation or adhesion may
sometimes be told by placing the patient on his back ;
extend and then flex the extremities, and then use press-
ure—soft, hard, sudden, and gradual. Often, however,
it is best to make deep pressure ; if no pain, relieve the
pressure suddenly when localized pain may be felt.
Change of position of the bowels may arouse pain ; sharp
pain after full meal may point to adhesions of the stom-
ach ; if painoccur three or four hours after eating, look
for chronic colitis; if after quickened inspiration, then
perihepatitis, etc. "Variability of pain depends on degree
of irritation or congestion. Extensive pelvic peritonitis
may not give pain except when waked up by defecation,
cohabitation, micturition, etc. In pericystitis, when urine
is about half voided, and the bladder begins to contract
more efficiently, a localized pain above the pubes, in-
creased by pressure, develops, much resembling the spas-
modic pain of vesical catarrh. Flatulence, etc., develops
enteralgia in chronic peritonitis ; stenosis of the bowel,
twisting, adhesions, etc., result, thus interfering with the
intestinal functions. In short, the sequelz of chronic
peritonitis are very various. ‘The indications of treat-
ment of the enteralgia of chronic peritonitis are determined
by its results and symptoms, such as intestinal sluggish-
ness, adhesions, etc. Subacute and acute peritonitis re-
quire absolute rest, support for the knees, ice or hot ap-
plications according to circumstances, opiates, etc. - Some
are now recommending large doses of magnesia sulphate
and turpentine enemata; but a treatment under which
an occasional patient may escape death must not super-
sede one which has proven to be successful in most cases,
and beneficial in all. Localized attacks, mainly in the right
hypochondrium, demand local applications ; a few leeches
occasionally and morphia subcutaneously may be required.
Old adhesions, etc., are not amenable to medicines.
Great physical exertion, pressure on abdomen, etc., must
be avoided. Keep bowels regular. Wear a snug band-
age over the whole abdomen for years after the last
complaint of pain. Generally this bandage, held down
by a perineal band, gives immediate relief. Without the
immobility given by it to the sore intestine he does not
expect a case of chronic peritonitis to do well.
Dr. W. D. DEGaRMo, of New York, read a paper
on the
SURGICAL TREATMENT OF HERNIA.
Dr. Joun RIDLON, of New York, read a paper on
SOME PRACTICAL POINTS IN THE TREATMENT OF HIP DIS-
EASE, WITH SPECIAL REFERENCE TO THE USE OF
THOMAS’ SPLINT.
The paper was addressed to the general practitioner, and
the means at his hands for the treatment of hip disease were
chiefly considered. The difficulties in the way of obtain-
ing and using the various traction splints were shown.
Plaster of Paris was considered as a convenient and com-
fortable form of dressing, but one not easy to apply prop-
erly. Traction by weight and pulley in bed was not
approved of, while Howard Marsh’s method was approved
of for those cases where traction is indicated, and rest in
bed not contra-indicated. ‘To one who was satisfied to
treat tubercular joint disease in any part of its course
without traction, or who is so circumstanced, as the gen-
eral practitioner is, that he must treat all walking cases
without traction, and to one who believes that immobil-
ization, and not traction, is chiefly indicated in the man-
agement of these cases, Thomas’ splint would prove of
great service. It can be made by a blacksmith or harness-
maker at a cost of not more than $2.50. Splints, pattens,
and wrenches were shown and their construction and
application described. ‘The writer believed that Thomas’
splint should be applied at once, and that we should not
wait to reduce the deformity by other means, and that the
patient should be kept in the horizontal position, but not
necessarily in bed, until the muscular spasm had in a great
measure subsided.
- Dr. JoserH A. WuitE, of Richmond, read the report
on
ADVANCES IN OPHTHALMOLOGY, RHINOLOGY, OTOLOGY, AND
LARYNGOLOGY,
which was rather‘a critical review of the more important
literature of the past year interwoven with some of the
practical results of his own large experience in this special
line of practice, particularly in reference to operations on
the ocular muscles in the line suggested by Landolt, Abadie,
and Stevens, of New York. His results with modified te-
notomies and resections of the recti muscles in cases of
headache, eyeache, neuralgia, confirm those of Stevens,
while he is not prepared to speak of their value in cases of
epilepsy, mental defects, etc. This method of operating
he has also substituted in his practice for the old-time
squint operation and he gets mòre accurate results than
formerly. He also emphasized the dependency of ear
diseases upon nasal troubles, and the fact that nasal ca.
tarrh was to be cured only by surgical procedures.
Dr. J. HERBERT CLAIBORNE, JR., of New York, read
a paper entitled
PRIMARY IRITIS; ITS DIAGNOSIS AND TREATMENT.
It opened with an anatomical description of the iris and
contiguous parts. It was important to remember that in
a condition of health the edge of the pupil rested on the
anterior surface of the lids in moderate dilatation. ‘The
diagnosis was to be made by the signs rather than the
symptoms of the disease. Pericorneal redness, steamy
cornea, clouded aqueous, discolored iris, small pupil, .
irregular and puckered edges of pupil, tenderness on press-
ure in the ciliary region, were the symptoms indicating
a high condition of ciliary congestion, but not necessarily
of cyclitis. Treatment was comprised under the great
‘therapeutic trilogy,” local depletion, irritation of pupil,
systematic treatment. Local depletion was best obtained
by that leech that takes deepest hold, sucks longest, and
draws most blood. Bleeding should be encouraged by
hot applications to the bites.
The position for the leeches was in the temporal fossa
in a horizontal line with the outer canthus of the eye, to
drain the temporo-malar branches of the lachrymal arteries.
Dr. Claiborne preferred to combine cocaine with mydri-
atics on account of the greater mydriatic power of such
combination and the analgesic effect of cocaine. He pre-
ferred Duboisine (ten per cent.) combined with cocaine
(six per cent.). In regard to systemic medication, use blue
ointment, salicylate of soda, and iodide of potassium, the
iodide combined with bichloride or biniodide of mercury,
antipyrine, and Russian or Turkish baths, and quinine for its
general tonic effect. He wished to lay much stress on the
value of salicylate of soda, particularly in rheumatic iritis ;
it was also of great value in the specific form, as assisting
the action of the other agents. There is no need of opium
or morphine in iritis ; if the pupil could be dilated pain
would cease ; if it could not, antipyrine was a good substi-
tute for morphine. Too much stress could not be laid on
the importance of the early treatment of iritis with regard
to preserving the sight. The responsibility rests wita him
who sees the case first.
412
THE MEDICAL RECORD.
[October 12, 1889
Dr. Lewis G. Pepico, of Roanoke, read a report on
ADVANCES IN NEUROLOGY AND PSYCHOLOGY.
He regarded the development of the suspension treatment
of locomotor ataxia aś the most important step of pro-
gress in neurology in the past twelve months and devoted
considerable time to the consideration of this subject.
Other items of progress in neurology were reviewed; the
problems of asylum management and general care and
treatment of the insane received due attention. A brief
allusion was made to Stephen Smith’s project of a law for
commitment and detention of the insane. ‘The present
status of various questions of medical jurisprudence was
presented at length.
The latter portion of the paper was devoted to hypno-
tism and allied phenomena. ‘This portion of the paper
was illustrated by actual experiments before the society
on a subject who, the doctor claims, is one of the very
best and, in some respects, most remarkable hypnotic sub-
jects in the world. He succeeded by his own modifica-
tion of the Bernheim and Charcot methods in throwing
this subject into the hypnotic trance in about one-third the
time required by Bernheim to hypnotize his very best sub-
jects. La petite hypnose and la d hypnose (in its
three stages), as delineated by Charcot in Salpêtrière,
were demonstrated in clear and rapid succession.
Dr. E. M. MaGRUDER, of Charlottesville, reported two
cases of
NEURECTOMY FOR FACIAL NEURALGIA, WITH RECOVERY.
His first case was a gentleman, seventy-one years of age,
who had had persistent neuralgia for fourteen years, that
no medicine cured, although he had consulted eminent
specialists. Seven drops of fluid extract of gelsemium,
every three hours, gave greater relief than any other med-
icine except morphia. But all medicines failing, the pa-
tient was chloroformed, and, with strict antisepsis, an
incision was begun just below the lower orbital margin,
over the infra-orbital foramen, straight downward, parallel
with the nose, toward the lip, and ended on a level with
the lower border of the ala nasi—about an inch incision.
The fascia and fibres of the levator labii superioris were
torn through with the handle of the scalpel, and the nerve
exposed at its exit, where it divided into two branches.
Each branch—the palpebral, the nasal, and the labial—
spreading into a far-shape as it neared its destination, was
dissected out as far as it could be followed without muti-
lating the face too much. The main trunk was then
seized with forceps at the foramen, drawn out as far as
possible without breaking it, and cut off close to the bone,
after which the various branches were divided at their
farthest point of dissection. ‘The wound was closed with
fine silk sutures. ‘There was at first considerable paraly-
sis of the side of the face, and loss of sensation, but these
disappeared, except from the nght half of the upper lip,
which is still without motion or sensation. ‘There has
been no recurrence of the neuralgia. The patient feels
like a new man.
Case II. was a lady, fifty-eight years of age, who has
had facial neuralgia for ten years. At first it was con-
fined to the left lower jaw, never passing the middle line
of the chin; but afterward extended to the left external
ear, temple, and side of head above and behind the ear
(auriculo-temporal), to the left side of the tongue (gusta-
tory), and then to the left side of the floor of the mouth
(mylo-hyoid). ‘The diagnosis was neuralgia of the in-
ferior dental nerve, with reflex and sympathetic phenom-
ena exhibited by the auriculo-temporal, gustatory, and
mylo-hyoid nerves. As to treatment, teeth had been ex-
tracted, analgesics had been used, etc., and, finally, total
neurectomy of the inferior dental nerve—including its
branches—was done, with cure. In the operation, avoid
injury of the facial artery and Steno’s duct. Entering the
scalpel just in front of the posterior border of the ramus,
just below the parotid duct and lobe of the ear, a curvi-
linear incision was made downward, half an inch in front
of the inferior maxillary angle, then forward a little above
the lower border of the ramus, and upward just behind,
and avoiding the facial artery, stopping short of the line
of Steno’s duct above. ‘The flap thus shaped was raised
by shaving the masseter muscle from its attachment to
the outer surface of the ramus, and the bone laid bare.
With a half-inch trephine cut out a button of bone from
the centre of the outer plate of the ramus, exposing the
nerve in its bony canal. Seizing the proximal end of the
nerve with forceps, strong traction was made from the
direction of its origin; it was then cut off with scissors,
close to the bone, as it entered the circular cavity made
bythe trephine. Then, the wound being stuffed with moist
antiseptic cotton, and the hemorrhage stopped with press-
ure, a second incision was made, an inch long, horizontal
In direction, over the mental foramen (below the root
of the second lower bicuspid tooth), beneath the depressor
anguli oris, disclosing the mental nerve and its branches
beneath the last-named muscle. ‘The nerve was grasped
with forceps and pulled upon, but broke off at its point
of exit. The branches were then dissected out and cut
off as far as possible from the foramen. Then returning
to the first wound over the ramus, and chiselling away the
wall of the dental canal, or one-eighth inch from the cir-
cular cavity in the ramus, so as to expose this end of the
nerve which had been divided by the distal side of the
trephine, it was drawn out of the dental canal with forceps,
in its entire length from the ramus to the foramen. In
all, three and three-eighths inches of nerve-structure were
removed. ‘The wounds were closed, and the patient was
perfectly relieved, without any return of neuralgia since.
The paralysis of the left side of the face disappeared in
about two weeks.
The lesson learned is, in all operations for facial neu-
ralgia remove as much of the troublesome nerve and its
branches as the anatomical formation of the parts will
possibly allow without rendering the procedure too grave.
Dr. C. R. Cutten, of Waldo, Fla., read a paper on
RAILROAD INJURIES,
He reported eight parties injured by railroad accidents—
several had ribs fractured ; two had hands crushed ; one
besides broken ribs, had cystitis, fractured arm, and ab-
scesses ; one had fractured femur, which was finally re-
moved, and the foot on the other leg badly crushed. Sev-
eral bones and pieces of bone were successfully removed,
with full restoration to health. Dr. Cullen urged that
doctors not engaged in the service of railroads insist upon
the same compensation, when they are called upon for
such service, that is received by doctors engaged in rail-
road service.
Mr. HucuH BLAIR, of Richmond, read, by invitation, a
paper on
DIAGNOSIS BY MEANS OF URINARY ANALYSIS.
Harley says the state of the urine is a key to the condi-
tion of the body. While some diseases may not affect
the urine, morbid urine indicates disease. Renal inade.
quacy (notable absence of urea and other solids), due to
want of the necessary nervc-influence. is shown by the low
specific gravity of the urine, other causes being excluded.
In overworked nervous systems, excess of alkaline phos-
phates in the urine occurs. Probably the nervous system
is fed with phosphorus by licithin. The best way of
supplying phosphorus to licithin is to give hypophos-
phites. If indigestion and improper metabolism occurs,
deleterious matters accumulate in the blood ; if of nitro-
genous character, the kidneys excrete them if they are
eble. Destructive metamorphosis of albuminoids in the
liver forms urea. Uric-acid crystals—easily recognized
by the microscope—appear in the urine in some function-
al hepatic disorders and lesions, causing gout, chronic
nephnitis, renal calculi, etc. If the crystals do not ap-
pear, excess of urates, acid urine, with high specific grav-
ity, are present. Lithzmia (uric.acid in the blood) is a
chronic condition of the overworked and over-anxious, is
October 12, 1889]
THE MEDICAL RECORD.
413
not so serious as gout, but is ever active in causing ob-
scure and distressing symptoms. It points to chronic
functional disturbance of the portal circulation, and is
recognized by the high specific gravity of the urine, its
acidity, excess of lithates and phosphates, and, often, ox-
alate of lime crystals, and especially pigments in the urine.
It gives a peculiar change in color in the urine dunng
Pavy’s copper test for sugar. Diabetes indicates grave
systemic disease ; but it should be differentiated from
hydruria and polyuria. Icteric urine stains white cloth
yellow ; but its diagnostic value is not of practical use.
In short, the value of urinalysis extends to every disease
characterized by pathological urine, as the Bright’s dis-
eases, pyelitis, cystitis, etc. Numerous urinalyses made
by him for physicians had enabled practitioners to deter-
aoe their diagnosis, and oftentimes save the lives of pa-
ents.
Dr. A. F: Kerr, of Williamsville, reported a case of
EXTERNAL GLANDERS, OR FARCY, IN MAN.
_ The rarity of the disease, especially in mountainous re-
gions, justified, he thought, a note or two about the case.
Glanders is an infectious disease, principally of domesti-
cated equine animals, and communicated to other ani-
mals and to man by inoculation of the glanders bacillus.
It originates in solipeds, although it has been known to
originate in cloven-footed animals. Having originated,
infection occurs only for a short distance through the at-
mosphere, or the disease may be communicated through
the ingestion of infected matter, or through the seminal
secretions to the female in coitus, etc. In man, the chief
source of infection is the horse—being rarely communi-
cited from man to man. ‘The point of attack is usually
an abrasion upon the skin or mucous membrane. ‘The
incubative period is from one to four days in inoculated
cases. ‘The wound becomes tense, swollen, painful, with
a dark or yellowish erysipelatous redness, and the edges
become puffy and everted. A sanious matter issues, and
the surrounding lymphatics become swollen and red, and
the glands become enlarged and tender. Constitutional
disorder sets in in a few days—languor, extreme weakness,
and prostration, with aching in the limbs and head, rigors
alternating with fever, or a continued fever after the first
violent chill; sometimes there is nausea and vomiting,
and even diarrhoea. When not due to external inocula-
tion the febrile symptoms appear first, and then the other
conditions which have been noted first in the description
of cases due to external inoculation. ‘The phlegmonous
swellings along the lymphatics become abscesses, and dis-
charge small quantities of a thick slimy pus. ‘The result-
ing sores become ulcerous, with grayish base. ‘Tempera-
ture rises perhaps to 104° F. |
His case was a young healthy man,in 1886. He con-
tracted glanders from treating a mare supposed to have
“ greased heel,” or “ scratches.” He first noticed a pain-
ful swelling on the point of the second finger of the left
hand, which had been slightly cut with a penknife. The
swelling was yellowish, edges of wound everted and puffy,
and discharged a thin, sanious material ; the surrounding
lymphatics became enlarged, and all the fulness of the
history of glanders in man was complete. Treatment be-
gan with a brisk purge, followed by quinia and muriated
tincture of iron, and an exclusive milk diet. ‘The swell-
ings on the forearm were freely laid open and cauterized
with nitrate of silver, all diseased tissues removed, and
the resulting sores packed with iodoform, over which was
laid medicated jute. Subsequent washings were made
with carbolized water. Recovery was prompt.
Dr. W. W. PARKER, of Richmond, presented a paper
on
A FEW ORIGINAL OBSERVATIONS ON BLOOD GRAVITATION
IN HEALTH AND DISEASE,
of which the following were the conclusions :
1st. The first wound ever inflicted upon the human
body was probably upon one of the extremities, and the
relief following the elevation of the wounded member was
‘the first illustration of blood gravitation in disease.
2d. A case reported of the wonderful curative power of
elevation—the leg 80°—of a boy struck in the tibia bya
base-ball.
3d. A singular case of death from the application of a
mustard-plaster to the ankle, being an exception to the
rule, yet establishing it.
4th. The gravitation of blood in the stomach made use-
ful in preventing emesis in certain cases.
sth. A remarkable case of acute inflammation of the
neck of the bladder, in a woman, with retention of urine,
at once removed by the forcible elevation of the hips of
the patient. Other cases reported.
6th. The avoidance of varicose veins of the legs in
shopkeeping men and women by sleeping on a double in-
clined plane, and the importance of those predisposed to
apoplexy sleeping with the head well elevated.
qth. The effect of the position of the body in phthisis,
in liver, and other congestions. A case of an infant, with
suffocating catarrh, at once relieved by the elevation of
the head and chest.
8th. A beautiful illustration, found especially in the
herbivorous or grazing animal, of nature’s plan of counter-
acting the hurtful gravitation of blood to the brain.
gth. A lesson suggested from these considerations and
facts to those unwise doctors and deluded people who
think “a man cannot die till his time comes.” That me-
chanical law in the body is as inflexible as the same law
in the machine, and loss and ultimate destruction will
come. as certainly, from the neglect of these laws, to the
one as to the other.
Dr. A. C. PALMER, of Norfolk, presented a paper on
OUTLINE TESTS FOR MUSCULAR INSUFFICIENCIES OF THE
EYE.
Leaving out of consideration cases of strabismus and the
like, he devoted attention to the more minute forms of in-
sufficiencies known by the term heterophoria. In stra-
bismus one eye soon accustoms itself to see the object
looked at, while the other is idle, as to effort at vision.
But in heterophoria there is acute normal vision, in which
every detail of an object is seen; but the external rectus
of one or both eyes is too weak to prevent the internus
muscle from turning the ball in, just past the normal axis.
Eyes such as these have to swing a very little way to make
the image seen with one eye a little to one side of that
seen with the other; and the confusion resulting is all the
worse from the very fact that each eye sees so clearly that
neither image can be ignored. ‘The patient has before
him two similar images, which are continually receding
from, and blending with, one another. But he will invol-
untarily overcome this blurring of outlines, if he can pos-
sibly spur up the externus muscle to pull the eye out to
its proper place. Just these insufficiencies, or strains,
produce more mischief than true strabismus.
Heterophoria is subdivided into esophoria (eyes tend to
turn in too far), exophoria (tend to turn out too far), and
hyperphoria (where one eye swings on a higher level than
its fellow). Prisms deflect an image toward their apices
or their edges. ‘The relative strength of each of the four
recti muscles, in their normal condition, is presumed to
be ascertained. ‘Thus the externi should diverge the eyes
sufficiently to make the image single when prisms of 8°
are placed before them, with their bases in. ‘The interni,
after a little trying, should converge sufficiently to single
images when prisms of 50° are placed before them, bases
out. If a patient with neurasthenia presents, place him
in an erect position, and direct his vision on a lighted
candle twenty feet off. Then cover each eye alternately,
and notice whether the light moves up or down, or to the
right or left. ‘This parallax test, introduced by Dr. Alex-
ander Duane, of New York, often establishes at once
the form of insufficiency. But should it not do so,
then use the prism tests, which the paper described in de-
414
THE MEDICAL RECORD.
[October 12, 1889
tail.
to overcome each of the insufficiencies.
Dr. Henry V. Gray, of Roanoke, read a paper on
THE THERAPEUTIC POSITION IN SEXUAL CONGRESS.
Many husbands will not keep their promise of continence
even when the wound is inflamed. What is to be done?
Advise the husband that if he will have intercourse, to do
so with the wife in the position for introducing Sims’
speculum. For in this position the womb rises up beyond
the reach of the largest penile organ. ‘The perineum
gradually relaxes in the effort, and the womb does not re-
ceive a bruise or a jar. He has in several instances ad-
vised this mode of sexual intercourse, greatly to the relief
of his patients with womb and ovarian diseases.
Dr. D. Mayer, of Charleston, W. Va., delegate from
the Medical Society of West Virginia, read a paper on the
USE AND ABUSE OF OBSTETRIC FORCEPS.
He showed that when the forceps are properly used
they are not damaging; that harm may come when used
too late; that the time has arrived in obstetric advances
when the practitioner will be compelled to use them be-
cause intelligent women demand their application to
shorten their period of suffering.
Dr. L. B. ANDERSON, of Norfolk, Va., presented the
REPORT ON HYGIENE AND PUBLIC HEALTH,
in which he classed etiological factors into 1, those which
are known ; 2, those which are purely hypothetical and
chimerical, such as malaria, vegetable parasites, bacteria,
etc. ; 3, those that are partly demonstrable and partly
hypothetical, namely, ptomaines and leucomaines—from
which sanitary laws are deduced.
Dr. J. G. WILTSHIRE, of Baltimore, Md., read a paper
on
ANSTHETICS,
but retained his manuscript for some revisions, etc., be-
fore presenting it to the Committee on Publications.
After the session had been adjourned the members and
guests met to enjoy a magnificent banquet, given by the
profession and citizens of Roanoke.
AMERICAN PAEDIATRIC SOCIETY.’
first Annual Meeting, held at the Army Museum Build-
ing, Washington, D. C., Seplember 2@ Gnd 21, 1889.
First Day, FRIDAY, SEPTEMBER 20TH— MORNING SESSION.
THE Society was called to order by the President, Dr.
A. Jacosl, of New York.
ADDRESS BY THE PRESIDENT.
He briefly outlined the history of pzdiatrics, its rela-
tions to other branches of scientific medicine, and its claims
to be considered a speciality, viewing it in the light of in-
ternal medicine, surgery, neurology, physiology, psychol-
ogy, embryology, and public hygiene. The following ex-
tract from this address will enable the reader to gain some
idea of its scope and great value. “ The most vital ques-
tions of public hygiene are most intimately connected with
pediatrics. It is mainly two subjects that attract the at-
tention of those wħo take an interest in children. Ial-
lude to the school and to constitutional diseases. My re-
marks to-day can be but fragmentary, but still I must not,
both in the interest of our science and human society,
omit to emphasize the fact that it still appears that our
schools were establishments organized to produce near-
sightedness, scoliosis, anzemia, and both physical and in-
tellectual exhaustion. Contrary to the treatment a colt
receives at the hands of its owner, human society or the
State permits or directs that the powers of a child should
be rendered unfit for its future functions, physical, mental,
and moral, for these three are indelibly interwoven. It
1 Organized in Washington, D. C., September 18, 1888.
Dr. Palmer then explained the application of glasses
requires physical and mental education to fertilize the soil
for the evolution of morals. Thus the physician, and
especially he who makes pzediatrics his special study, is a
pedagogue by profession. ‘The question of school-house
building and school-room furniture, the structure of bench
and table, the paper and the type in the books, the num-
ber of school hours for the average child and the indi-
vidual pupil, the number and length of recesses, the hours
and duration of intervening meals, the alternation of men-
tal and physical training, the age at which the average and
the individual child should be first sent, have been too
long decided by school boards consisting of coal mer-
chants, carpenters, cheap printers, and under-taught and
over-aged school mistresses; not, however, of physicians.
The health and vigor of the American child in early years
seem, according to Bowditch, superior to those of the
European ; why is the youth and maiden, particularly the
latter, so inferior? Why is it that anemia and neuroses
eat the marrow of the land, and undermine the future of
the country by degenerating both the workers and the
thinkers of the community, and the future mothers? If
there is a country in the world with a great destiny and a
grave responsibility, itis ours. Its self-assumed destiny is
to raise humanitarian and social development to a higher
plane by amalgamating, humanizing, and civilizing the
scum of all the inferior races and nationalities which are
congregating under the folds of our flag. Unless the edu-
cation and the care of the young is carried on according
to the principles of a sound and scientific physical and
mental hygiene, neither the aim of our political institu-
tions will ever be reached, nor the United States fulfil its
true manifest destiny. ‘That destiny is not so much the
political one of excluding Europeans from our continent,
North or South—for indeed the participation of European
civilization in the gradual work of removing barbarism
ought to be very welcome—but of raising the standard of
physical and mental health to possible perfection, and
thereby contributing to the welfare and happiness of the
eople.”
: Dr. FRANCIS Huser, of New York, reported
TWO CASES OF DOUBLE EMPYEMA.
‘The writer gave the details and the results of his cases,
and presented a very complete list of all the cases ot
double empyema which he could find in the literature of
the subject.
Dr. CHARLES WARRINGTON EARLE, of Chicago, read a
paper entitled
SUBCUTANEOUS EMPHYSEMA IN CHILDREN.
He gave the details of a very interesting case which fol-
lowed a catarrhal pneumonia, and resulted in death. The
subcutaneous tissues of the forehead, cheek, neck, and of
the entire trunk, anteriorly to Poupart’s ligament, and pos-
teriorly to the iliac crest, were filled with air. It ap
in the neck first, and rapidly extended to the other parts.
No autopsy could be obtained. He gave the histories of
many cases, and discussed the causes of this condition
and its treatment. He said that, as a local affection, tt
was found after operations and injuries in the vicinity of,
or involving, the respiratory tract; or by the introduction
of air through a tube in the loose subcutaneous tissue.
General emphysema was rare in children, and was caused
by interference with, or obstruction to, the respiration.
Prognosis was good, unless the preceding disease had
brought about great depression.
Dr. A. CAILLÉ, of New York, reported a case of
MEMBRANOUS CROUP (LARYNGO-TRACHEITIS) IN A GIRL OF
TWELVE YEARS OF AGE—TRACHEOTOMY—RECOVERY.
There were no visible signs of membrane in the nose or
pharynx. Digital examination of the larynx revealed a
stiff and thick epiglottis, and a marked flattening of the
funnel-shaped laryngeal entrance. The treatment before
operation consisted of small doses of bichloride of mer-
cury in a watery solution with wine of ipecac. ‘There was
October 12, 1889]
a piece of pseudo-membrane coughed up nine hours be-
fore the operation, after which there was temporary relief
to the dyspneea.
Auscultation showed little respiratory murmur in the
left lung, and during inspiration a short “flap” sound
could be heard, which was thought to be due to detached
membrane. After the operation, the temperature rose to
102°, 103°, 104° F., and this febrile condition persisted
for one week. During this time a large amount of mem-
brane was removed through the tracheal opening. (A
bottle containing this membrane was exhibited.) A con-
tinuous spray, salt-water being the most acceptable, was
absolutely necessary to insure comfortable breathing. ‘Ihe
tube was removed on the fourteenth day, and the child
made a good recovery.
Dr. CalIL_é also read a paper on
PERSONAL PROPHYLAXIS IN DIPHTHERIA.
He said that the acceptance of the principles governing
antiseptic wound treatment has given a new stimulus to
the study of disease prophylaxis. At the present stage of
our knowledge, specifics for diphtheria are an illusion, and
the medical profession should admit to the public that
the treatment is entirely symptomatic. From a study of
the subject, Caillé has come to the conclusion that mu-
nicipal control of diphtheria is inadequate and impossible,
just as the municipal control of infectious wound disease
would be impossible. A good surgeon will find it possi-
ble to secure aseptic wound healing in filthy and infected
localities, by directing his efforts to the parts liable to be
infected. ‘The physician’s efforts to prevent and check
diphtheria must lie in the same direction, though tempered
with the full understanding that methods of occlusion
such as in antiseptic surgical dressings are not applicable
to the usual sites of diphtheria. It is positively known
that diphtheria is infectious—is due to germs—and is first
a local deposit, and a hyperemic or defective mucous
membrane favors its localization. The germs looked
upon by many authorities as pathogenic, have been found
in the naso-pharynx, buccal cavity, in carious teeth, etc.,
of persons in ordinary good health, who may harbor them
for a time without becoming infected. When, however,
a favorable condition of the mucous membrane is present
infection takes place. In order to prevent diphtheria,
therefore, we must seek to carry away putrid matter and
keep in a healthy condition such parts as are liable to be-
come diseased. ‘That this can be done by nasal insuffla-
tions and gargling of non-irritating antiseptic liquids, and
by reducing large tonsils, and filling or removing bad teeth,
had been shown in a previous report by the writer. He
has instructed many families in the employment of per-
sonal preventive measures during the past five years, and
is firmly convinced of their value and easy application.
He uses salt, alum, boric acid, potassium permanganate,
potassium chlorate, and Labarraque’s solution in water,
which is dropped lukewarm into the nose, and is used
as a gargle by older children and adults, two or three
times a day. The same measures are adopted to pre-
vent secondary diphtheria in every case of scarlet fe-
ver, measles, whooping-cough, etc. The author cited a
number of cases, and gave instances in which the views ex-
pressed in his previous communication were corroborated.
He suggested to his colleagues that a trial of this method
would convince them of the great value of personal pro-
phylaxs in diphtheria.
Dr. C. W. EARLE, of Chicago, read a paper entitled
THE NECESSITY OF PROLONGED REST AFTER SOME ATTACKS
OF DIPHTHERIA.
He said that he desired to call special attention to this
class of cases, and to obtain the endorsement and influ-
ence of this Society, so that we can go before the great
general profession and convince them that these cases re-
quire special care and prolonged rest in bed. He often
keeps them in bed two or three weeks after all symptoms
have subsided. This may not be necessary in every case,
THE MEDICAL RECORD.
415
but it is safer. It is absolutely demanded, however, in
all cases in which symptoms of paralysis are present, and
should be insisted upon until every sign denoting it has
disappeared. He urged that in the treatment of these
cases the point of most importance, and most to be in-
sisted upon, was prolonged rest in the recumbent position.
AFTERNOON SESSION.
Dr. J. H. FRUITNIGHT, of New York, read a paper en-
titled
THE TREATMENT OF SCARLET FEVER AND ITS COMPLICA-
TIONS.
In the treatment of the febrile condition, he obtained the
best results from the administration of the tincture of
aconite root in doses of one drop every two hours. His
experience with antipyrine and antifebrine had not been
such as to lead him to continue their use; and, although
he had had no experience with the hydropathic treatment,
he would hesitate to employ it except in desperate cases.
In milder cases, he treated the angina and pharyngeal
symptoms with tincture of chloride of iron. In those
cases in which a deposit had formed, he added the hypo-
sulphite of soda, and in very severe cases the bichlonde of
mercury. When the exudate was extensive, he used tryp-
sin in spray, alternating with a weak preparation of Lugol's
solution or carbolic acid. The adeno-cellulitis, which is
not uncommon, he treated with absolute rest, all manipu-
lation of the parts being positively forbidden. If sup-
puration occurs, it is encouraged, and as soon as pus can
be detected it was evacuated.
He treated the nephritis by rest in bed, warmth, and a
generous milk diet. Hot vapor bath and digitalis were
given when there was much dropsical effusion. There
tincture of chloride of iron was not withheld, and when
needed hydragogue cathartics were given, and for their
diaphoretic effect the muriate of pilocarpine and jaborandi
were used. He treated the otitis by warm fomentations
to which an anodyne was added. After suppuration was
established, he used antiseptic injections followed later by
astringent ones, and for the pain he dropped into the ear
a weak, warm salt solution. When the inflammation was
severe, he applied leeches to the tragus, and when the
mastoid cells threatened to be involved, leeches were also
employed. ‘The rheumatism complicating scarlet fever
was treated the same as a simple rheumatic attack, 1.¢.,
with the salicylate or salol and alkalies. Other complica-
tions were treated pro re nata. |
A general principle of treatment was to keep up the
strength of the patient, hence cardiac stimulants were em-
ployed early in the course of the disease, combined with
good, nutritious, and easily digested food, The sick-room
should be cool and well ventilated, and the isolation of
the patient should be insisted upon as a prophylactic
measure. Inunction of the skin was not advised, as it is
thought to interfere with desquamation, but instead the
writer recommended warm baths impregnated with an an-
tiseptic solution.
Dr. JosePH O’Dwyer, of New York, read a paper en-
titled
THE APPARENT PHYSICAL CONTRADICTION INVOLVED IN
THE REINFLATION OF A COLLAPSED LUNG WHILE AN
OPENING REMAINS IN THE PLEURAL SAC.
He said that this was a physical paradox, which none of
the laws either of physics or of physiology could appar-
ently account for. After discussing in detail all the various
theories advanced for the explanation of this phenomenon,
he showed their weak points, and demonstrated that they
did not explain the problem. He considered the power
of the normal lung to inflate the collapsed lung by cough-
ing and sudden forcible expiration ; but this did not offer
a complete explanation, because in such cases the lung
should immediately recollapse, which it did not do, and
again because, in cases of double empyema with an open-
416
ing in both pleural cavities, there should be immediate
death from asphyxia, while as a matter of fact the lungs
expanded under such conditions very well.
DISCUSSION.
Dr. NORTHRUP made some animal experiments to de-
termine whether the force of cohesion between the two
pleural surfaces was sufficient to maintain the lung in
complete expansion, the parietal pleura having been punc-
tured. Samuel West, in his Bradshawe Lecture, 1887,
had claimed that such force was sufficient. In five suc-
cessive operations upon dogs’ pleurz, the lungs collapsed
the instant a pin-hole opening was made, thus contradict-
ing the statements of Samuel West. Further experiments
were reported, in which a dog’s two pleurz were fitted
with double-flanged cannulz, stoppered with corks. Un-
til the dog recovered from ether the two corks were left
in place. When fully recovered one cork was withdrawn,
and the dog scarcely suffered dyspnoea on moderate exer-
tion. When both corks were removed, the dog travelled
about for two minutes and succumbed to severe: dyspncea,
which again entirely disappeared on replacing the corks.
Other experiments to determine the behavior of the lungs,
the chest having been fully opened, were reported, illus-
trating the expansive force of strong expiratory effects.
is DiLLon Brown, of New York, read a paper en-
title
NOISY RESPIRATION IN CHILDREN.
It was a paper on diagnosis, in which the author related
« number of curious cases, and after briefly giving an out-
line of the different diseases in which noisy respiration is
a symptom, considered the differential points by means of
which a diagnosis by exclusion could be made.
Dr. H. Kop tix, of New York, read a paper entitled
TUBERCULOSIS OF THE TESTIS IN CHILDHOOD.
Including his own case, the author could find in the liter-
ature of the subject only twelve cases of primary tubercu-
losis of the testis occurring in infants and children. ‘The
disease in some of these cases was noticed at the birth
of the patients, and in others it was clinically diag-
nosed at the second month, and up to the third year of
life. The right testis was the selected organ in most of the
cases. In some cases the epididymis, and in others the
testis, was first noticed to be the seat of the disease. In
one case general tuberculosis followed the testicular
trouble, and in another case a secondary cerebral tumor
(tubercle) was the cause of death. In some a favorable
result 1s recorded following castration; in others, no such
record is made. In four cases the spermatic cord was
affected ; in one case the disease had spread to the pros-
tate and seminal Vesicles. In no case could a traumatism
be clearly demonstrated, and in most of the recorded his-
tories the parents were the victims of tuberculosis, thus
lending additional support to the theory of a congenital
osigin. In these cases the author advocated early extir-
pation, even when the tubercle bacilli could not be satis-
factonly demonstrated in the scrapings of a sinus. Delay
tended to increase the chances of a return after castra-
tion.
The author’s case was that of a child aged twenty-two
months, with an hereditary history of phthisis. The di-
agnosis was made by establishing the presence of the
tubercle bacilli in the scrapings of a discharging sinus.
A return of the disease occurred at the site of the opera-
tion after three months. Disease of the other organs
could not be established clinically. ‘The diagnosis in
these patients is always to be made between syphilis and
tuberculosis. The author presented a detailed micro-
scopic examination, histological and bacteriological, of
the diseased testis and epididymis in this case. Micro-
photographs were shown, illustrating the following histo-
logical changes: Diffuse tubercle, interstitial changes,
acute miliary eruptions both in the testis and epididymis.
THE MEDICAL RECORD.
[October 12, 1889
Dr. Francis Huser, of New York, read a paper en-
titled
ACUTE SUPPURATIVE PERITONITIS FOLLOWING VULVO-VAG-
INAL CATARRH.
The patient was seven years of age, and the symptoms
simulated a case of perforation of the appendix. Lapa-
rotomy was performed by Dr. Bull, of New York, the ab-
domen being opened by a lateral incision over the colon.
Considerable sero-purulent fluid was found in the perito-
neal cavity ; the intestines were distended with gas, con.
gested, and here and there coated with lymph. The ap-
pendix was perfectly normal in appearance, and no
concretions could be detected through its walls. The
right Fallopian tube, however, with its extremity, was in-
flamed, thickened, and evidently had formed the channel
by means of which the infecting process had gained en-
trance into the peritoneal cavity, and thus gave mse to a
train of symptoms simulating closely a case of perforation
of the appendix. The abdomen was then washed out
with hot water, the wound sewed up, and an antiseptic
dressing applied. Twenty hours later death occurred
from heart failure, the pain and vomiting persisting to the
end.
Dr. W. P. Norrurup, of New York, read a paper en-
titled
SCLEREMA NEONATORUM ; REPORT OF A CASE.
A twin, female, died on the ninth day after birth with
typical sclerema of the new-born, as observed in the
foundling asylums of Germany and France. Its temper-
ature four days before death was 964° F. in the rectum.
There was subcutaneous hardening where the fat was
most abundant about the buttocks and thighs, shoulders
and arms, cheeks, and other parts of the body in less de-
gree. The hip- and shoulder-joints became immovable,
the knee- and elbow-joints stiff. The child was of a dirty
yellow color, hard and cold as though frozen, the tem.
perature gradually descending until it could not be
measured on the register of any clinical thermometer.
‘The subcutaneous tissues were examined microscopically
and showed no change in either blood-vessels, connective
tissue, or fat. The writer had not been able to find -
more than two other cases occurring in American litera-
ture which presented the characteristics so often observed
in France and Germany. Many theories had been pre-
sented to account for the subcutaneous hardening, but
only one offered any satisfaction, and that was the in-
creased proportion of stearine and palmatine compared
with oleine always present in children’s fat. On exposure
to cold in case of a weak foundling, the body-heat might
become sufficiently lowered to inaugurate the process of
hardening of the stearine and palmatine.
Dr. L. Emmett Hott, of New York, read a report of
a case and presented a specimen of
CONGENITAL MALFORMATION OF THE HEART, COMPLETE
ABSENCE OF THE SEPTUM VENTRICULORUM, PULMONARY
STENOSIS, AND PATENT FORAMEN OVALE.
The child lived to be eighteen months of age, and died
of acute pneumonia, having been under observation for
two months. Marked cyanosis had existed from birth.
During life the apex-beat was one-half inch to the left of
the right nipple, and a loud systolic murmur was present
at the apex, but louder at the junction of the left second
intercostal space and the sternum, and transmitted to-
ward the left shoulder. It was not heard behind. The
normal area of cardiac dulness gave pulmonary resonance.
At the autopsy the heart showed: 1. Absence of the
septum ventriculorum, the division being marked by only
a slight ridge. 2. Very marked pulmonary stenosis, the
orifice being about one-fourth inch in diameter. 3. Pat-
ent foramen ovale, the opening easily admitting one finger.
4. A shallow pouch, which was the rudimentary left
ventricle. 5. A right ventricle, very much hypertro-
phied, out of which opened both the pulmonary and aortic
October 12, 1889]
arteries, and into which opened both the mitral and tri-
cuspid orifices. The heart was deflected to the right
about as much as usually to the left. The border of the
right lung was hollowed out for its reception, that of the
left being straight.
EVENING SESSION, HELD AT THE ARLINGTON HOUSE.
Dr. A. V. Meics, of Philadelphia, read a paper entitled
THE ARTIFICIAL FEEDING OF INFANTS.
The author said that, after a long experience, he had
seen no reason for making any radical change in the arti-
ficial food which he had previously recommended. He
had found that mother’s milk never contained more than
one per cent. of casein. This food was based upon the
dilution of cows’ milk, for the reason that it contains too
much casein ; the further need of the addition of cream
because, in diluting, the fat was reduced to too small an
amount ; the addition of sugar, to make it equal to the
amount contained in human milk ; and of lime-water, to
change it from being an acid to an alkaline fluid. How-
ever, he had fallen upon several improvements to render
it easier to get together the required amounts of the differ-
ent constituents, and thus simplifying the work of the
nurses. He directs that instead of taking cream and milk
in the proportion, respectively, of two and one in eight,
three parts of a weak cream be used, which is obtained
as follows: One quart of good ordinary milk is obtained
and placed in a high vessel, and allowed to stand in a cool
place for three hours. Then one pint is poured slowly
from this, care being taken that the vessel is not agitated,
the object being to obtain the upper layer of fluid, rich in
fat, and leave the lower comparatively poor portion be-
hind. When the child is to be fed, there is taken of this
weak cream three tablespoonfuls, of lime-water two table-
spoonfuls, and of sugar-water three tablespoonfuls. The
sugar-water is to be made in the proportion of eighteen
drachms of milk-sugar to one pint of water. This is an
improvement upon the food recommended previously by
the author, because it 1s more economical (cream being
expensive) and the food 1s less likely to ferment.
Dr. J. A. JEFFRIES, of Boston, read, by invitation, a
paper entitled
A CONTRIBUTION TO THE STUDY OF THE SUMMER DIAR-
RHCEAS OF INFANCY.
He held that the cases formed a group or genus of dis-
eases, all closely related, but rarely just alike, and rejected
climate, heat, foods, and the like, as direct causes. He
then reported the results of his bacteriological examina-
tions of the stools. In these he found thirty-one kinds,
but no kind sufficiently often to suggest a specific germ.
The writer then reported a series of experiments upon
young cats. Cats fed with pure cultures of the various
bactena remained perfectly well. Cats fed with pure cult-
ures of several kinds in milk contracted summer diar-
rhoea which ran on to a fatal issue, though the food was
changed to fresh milk. The species fed in the milk were
rarely found in the intestines. Kittens fed with milk af-
fected by the bacteria, but not curdled, and then sterilized,
died in the same way.
From an examination of all the data, he held that the
complaint in the kittens was the same as in children, and
that it was due to the products of the growth of many
forms of bacteria in the food, both before and after con-
sumption. Most bacteria were probably unable to make
head against healthy digestion, but flourished if this were
disturbed in any way. Probably species not found by
him also existed, which were able to thrive without any
favoring conditions. Lastly, he pointed out the close
relation between summer diarrhoea and that group of
symptoms first brought into prominence by Panum—pu-
tnd infection. From the therapeutic side, he pointed out
that the first thing to do was to keep germs out, and also
their products, and that, so far as known, sterile food re-
THE MEDICAL RECORD.
417
duced the number of germs in the stools as much or more
than any drug
Lastly, that it must ever be borne in mind that serious
changes were being produced in the intestines, and must
be considered apart from all bacteria. Kill every germ
in the body, and the eroded and swollen gut must still be
attended to.
Dr. JoserH O’Dwy er, of New York, read a paper en-
titled
CASE OF DIAPHRAGMATIC HERNIA, WITH OPERATION.
The physical signs closely simulated those of an empyema,
and a positive diagnosis could not be made until the chest
was opened. By removing portions of the two lower true
ribs, the false ribs could be pushed down out of the way,
and ample room for operation was obtained. After a
great deal of difficulty, the intestines were pushed back
into the abdominal cavity, and the edges of the opening
through the diaphragm, after being refreshed, were brought
together and held in place with sutures. The pressure
from below on the stitches was so great that it was neces-
sary to keep up counter-pressure from above with a large
pad of antiseptic gauze. ‘The child rallied from the oper-
ation, but died later on, suddenly, when apparently doing
very well. ‘This was the only case on record in which this
operation was done. The author exhibited the diaphragm
with portions of the chest-wall.
Dr. A. CAILLÉ, of New York, reported a case of
PROLAPSUS RECTI, DUE TO LARGE STONE IN THE BLADDER,
IN A GIRL OF THREE YEARS.
‘The patient had been presented at many of the clinics of
New York as a case of inveterate prolapse. The gut was
usually out two inches, but came down fully seven inches
by straining. Micturition was painful, and the urine con-
tained pus. ‘The sphincter ani was relaxed so as to admit
three fingers. On careful examination a large stone was
found free in the bladder, and removed by suprapubic
cystotomy. In extracting the stone the bladder wound
was slightly lacerated, in consequence of which the blad-
der suture leaked slightly on the fourth day. The process
of healing took place without fever, and the child was dis-
charged cured in three weeks. ‘The prolapse of the gut
was due to the straining caused by the stone in the blad-
ber, and its removal was followed by a complete cure of
the prolapse.
SECOND Day-—SATURDAY, SEPTEMBER 21ST—MORNING
SESSION.
Held at the Fohns Hopkins Hospital, Baltimore.
Dr. H. N. VineBerc, of New York, read a paper en-
titled
SOME PRACTICAL POINTS ON THE DIAGNOSIS AND TREAT-
MENT OF MALARIA IN CHILDREN.
‘The author said that the same vagueness in the diagnosis
of malaria in early life was met with as in adult life.
There was no good reason for using the term as a cloak
of ignorance, for malaria was due to a definite poison and
was attended with characteristic symptoms. It was the
aim of the writer to bring the most reliable and prominent
symptoms under review, and discuss each symptom sepa-
rately, thereby endeavoring to show its diagnostic value.
His remarks were based upon a careful study of eighty
cases that came under his own observation, and the pe-
rusal of the literature pertaining to the subject.
The signs of acute malaria in early life were chills, con-
vulsions, fever, sweating, enlargement of the spleen, and
hzematozoa in the blood. He carefully analyzed each of
these symptoms and their characteristics in malaria, and
determined their diagnostic value. He said that the spleen
enlarged more rapidly and to a greater degree than in the
adult; and that this enlargement was constantly present
in the malaria of children. That it must be made out by
percussion, and not by palpation as in the adult, because
418
THE MEDICAL RECORD.
[October 12, 1889
in early life the enlarged spleen pushed its way upward
and backward, and was prevented from descending by the
costo-colic ligament, which at that period of life was very
rigid. If the dulness did not extend above the upper
border of the ninth nb, an accumulation of fæces in the
colon should be suspected.
The weight of evidence is in favor of the pathogno-
monic value of the plasmodium malanz, but unfortunately
it is present only in the more pronounced and severe
cases, and is difficult of detection when present.
Chronic malaria was made to include the milder forms
of malarial poisoning, which might at first be expressed
by acute symptoms, but generally the affection began in-
sidiously. ‘The symptoms in this condition were lassitude,
- drowsiness, headaches, vertigo, wandering pains in various
parts of the body, anorexia, bloody diarrhoea, emaciation,
a peculiar tint of the skin, anzmia, urticaria, night-sweats,
asthmatic attacks, and pain over the region of the spleen.
None of these symptoms were characteristic of malaria,
but were also present in a number of other chronic affec-
tions. Here, even more than in the acute forms, enlarg-
ment of the spleen was a sine gua non in the diagnosis of
malaria. He called attention to the presence of night-
sweats and of attacks of syncope, as symptoms of this con-
dition, which are not mentioned in the literature of the
subject.
The treatment of malaria in early life was not the easy
matter that some authors led us to suppose. In the acute
form, quinine in full doses was most to be depended
upon. It was best given in solution with aromatic sul-
phunc acid and syrup of lemon, or coffee. In private prac-
tice the chocolate tablets were valuable. In the chronic
variety, it was well to combine the quinine with arsenic.
Ergot was found very valuable to reduce the splenic tu-
mors, which often persisted long after the other symptoms
had subsided. Pure nitric acid, well diluted, was service-
able in preventing the relapses to which children are so
subject.
Dr. ‘THomas S. LATIMER, of Baltimore, showed two
CASES OF SPASTIC PARAPLEGIA.
Both occurred in the same family. In one case the con-
tracted muscles were cut, which gave her marked benefit
and improved her walk. In spite of this, however, she is
progressively growing worse, and the disease, a cerebral
sclerosis, is still active.
Dr. W. D. Booker, of Baltimore, read a paper en-
titled
A STUDY OF SOME OF THE BACTERIA FOUND IN THE
DEJECTA OF INFANTS AFFECTED WITH SUMMER DIAR-
RHŒA (SECOND COMMUNICATION).
This article is the continuation of one read at the
Ninth International Medical Congress. It contains a
description of 17 varieties of bacteria, isolated from the
fæces of 14 children affected with summer diarrhcea.
Bacteria have thus been isolated from the fæces of
30 infants affected with summer diarrhoea, 11 of whom
had cholera infantum, 14 catarrhal enteritis, and 5 dys-
entery. With the exception of bacterium lacti zrogenes
and bacterium coli commune, the two constant milk
feeces bacteria, no species appear with much constancy,
taking the cases asa whole. If the different forms of
bacteria are cultivated separately, in the cases classified
under the head of cholera infantum, the proteus group
has been found in 7 of the 11 cases examined. In the
four cases in which no member of this group was found,
agar was used exclusively as the separating medium, and
in the other case a number of cultures were lost before
being identified.
Not only do the proteus bacteria possess in a high de-
gree the power to excite putrefaction ; but on account of
their extensive and frequent occurrence, they belong to
the most important and ordinary putrefactive exciters.
‘The prominent symptoms of the cases of cholera infan-
tum in which the proteus bacteria were found, were
drowsiness, stupor, emaciation or great reduction of flesh,
more or less collapse, frequent vomiting and purging,
with watery and generally offensive stools. Experiments
on lower animals with proteus vulgaris and bacillus A.
gave about the same results. Bouillon cultures injected
into the veins of rabbits caused death in a few hours.
There was drowsiness and stupor, and finally convulsions,
in all cases; and in some diarrhoea, the latter very pro-
fuse in two cases. Cultures directly injected into the in-
testine, when exposed in a bath of normal salt solution at
38° C., caused active peristalsis. Cultures fed to young
animals resulted generally in death, and in some diarrhoea
occurred.
The frequent occurrence of this widely spread group of
putrefactive bacteria in the most serious cases of summer
diarrhoea, in which toxic symptoms are more or less prom-
inent, cannot be without significance. In cases of diar-
rhoea free from toxic symptoms, no member of this group
of bacteria has been found, nor were they found in the
healthy fæces of sucklings.
Another species of bacteria which liquefies gelatine and
possesses pathogenic properties on lower animals, was
found in a large quantity in three cases of cholera in-
fantum and one fatal case of dysentery. In two of the
cases of cholera infantum, the proteus vulgaris was also
found. ‘These two cases were especially grave, and had
decided stupor.
No variety of bacteria appeared to be associated espe-
cially with the cases of catarrhal enteritis and dysentery.
‘The fæces in catarrhal enteritis often contained an enor-
mous quantity of bacteria, chiefly varieties of colon bac-
teria and bacterium lactis zrogenes, with a number of
inconstant varieties.
In conclusion, it must be understood that the work is
too incomplete to admit of positive conclusions, and as
referring to the examination of but a limited number of
cases, in which not even all the varieties of bacteria con-
tained in the fæces that can be cultivated on our present
nutritive media are supposed to have been separated, and
those separated had been but incompletely studied.
Dr. A. SEIBERT, of New York, read a paper entitled
TWO YEARS OF EXPERIENCE IN THE MECHANICAL TREAT-
MENT OF GASTRO-INTESTINAL DISORDERS IN INFANTS.
He said that, as we now admit that these affections are
caused by bacteria and chemical poisons getting into the
digestive organs of the children, it appears but rational to
follow the first logical therapeutic indication, and empty
the stomach and intestines of these noxious substances.
The profession, here and abroad, has been too conserva-
tive in following this imperative and clear indication.
Calomel and castor-oil do not cleanse sufficiently. Ep-
stein’s method of stomach washing in infants, and Bagin-
ski’s proposed bowel washing in all cases of diarrhcea,
have long been overlooked entirely, and are still ignored
by the majority of practitioners. Seibert reports on 1,404
cases of gastro-intestinal disorders in children under three
years, treated within the last two years. Stomach wash-
ing was done in 521 cases, and bowel washing in 1,309
cases. ‘The majority of the cases in which stomach wash-
ing was employed suffered from acute gastro-intestinal
catarrh, nearly all of a severity to produce more or less
pronounced collapse. Of these 6 died. Besides, cases
of entero-colitis with true intestinal inflammation were
treated by both methods, and also all cases of chronic
gastro intestinal catarrh. All cases of diarrhoea, whether
mild or severe, were treated by bowel washing. In all
cases of infantile dyspepsia the stomach was washed.
MORTALITY.
Acute gastro-intestinal catarrh, about five hundred cases
with six deaths. Entero-colitis with peritonitic irritation,
eight cases with six deaths. Chronic gastro-intestinal
catarrh (with atrophy and marasmus), about one hundred
with one death (in this case the mcther had tuberculosis).”
In cases of acute simple diarrhoea, including follicular en-
October 12, 1889]
teritis, no deaths occurred. ‘The youngest child stomach
washing was practised on was a day and a half old, the
author’s own baby. All children felt better after stomach
and bowel washing. Collapse in cholera infantum is the
strongest possible indication for stomach washing; the
deeper the collapse, the sooner the stomach and bowel
ought to be cleansed. ‘The writer never saw collapse get
worse after washing, and never had any accident.
The following papers were read by title: “ Aneurism
in Early Life,” by Dr. A. Jacobi, of New York; “Scarlet
Fever,” by Dr. I. N. Love, of St. Louis; “ Recent Im-
provements in Infant Feeding,” by Dr. J. Lewis Smith, of
New York ; “Two Cases of Hepatic Cirrhosis in Chil-
dren,” by Dr. M. P. Hatfield, of Chicago ; “ Notes on a
Case of Ataxia in a Child of Ten Years,” by Dr. A. D.
Blackader, of Montreal; “ Carpo-pedal Contractions,
One Manifestation of Tetany,” by Dr. C. W. Earle, of
Chicago; “Two Cases of Nystagmus Associated with
Choreatic Movements of the Head in Rachitic Babies,”
by Dr. A. Caillé, of New York ; “ A Case of Simple Mus-
cular Atrophy of the Facio-scapulo-humeral Type,” and
s“ Cerebral Sclerosis in Children,” by Dr. William Osler,
of Baltimore.
The following officers were elected for the ensuing year :
President—Dr. J. Lewis Smith, of New York; First Vice-
President—Dr. A. V. Meigs, of Philadelphia ; Second Vice.
Presittent—Dr. F. Forchheimer, of Cincinnati; Secretary
—Dr. W. D. Booker, of Baltimore; Recorder—Dr. W.
P. Watson, of Jersey City; Zreasurer—Dr. C. W. Earle,
of Chicago; and Council—Dr. T. S. Latimer, of Balti-
more, Dr. J. M. Keating, of Philadelphia, Dr. i. N. Love,
of St. Louis, Dr. S. C. Busey, of Washington, Dr. C. P.
Putnam, of Boston, Dr. A. D. Blackader, of Montreal,
and Dr. L. E. Holt, of New York.
Army und Ravy Hews.
Official List of Changes in the Stations and Duties of Cfi-
cers serving in the Medical Department, United States
Army, from September 29 to October 5, 1889.
ADAIR, GEORGE W., Captain and Assistant Surgeon.
Leave of absence granted for one month. S.O. 90, Head-
quarters Department of the Platte, September 25, 1889.
POINDEXTER, JEFFERSON D., Assistant Surgeon.
Granted leave of absence for one month. S. O. No. 113,
coreg uaren Department of Dakota, September 30,
1889.
Pope, BENJAMIN F., Surgeon. Relieved from duty at
Fort Clark, Tex., and will report for duty to Command-
ing Officer, Whipple Barracks, Arizona Ter. Par. 11,
S. O. No. 230, A. G. O., October 3, 1889.
BILLINGS, JOHN S., Surgeon. Detailed as delegate to
represent the Medical Department of the Army at the
annual meeting of the American Public Health As-
sociation, to be held at Brooklyn, N. Y., October 22, 18869.
Par. 10, S. O. No. 230, A. G. O., October 3, 18809.
TREMAINE, WILLIAM S., Surgeon. Relieved from tem-
porary duty at Fort Leavenworth, Kan., and will return
to his home (Buffalo, N. Y.). Par. 13, S. O. No. 230,
A. G. O., October 3, 1889.
KENDALL, WILLIAM P., Assistant Surgeon. Granted
leave of absence for one month. S. O. 93, Department
of the Platte, October 2, 1889.
Oficial List of Changes in the Medical Corps of the United
States Navy for the week ending October 5, 18809.
Harmon, Georce E. H., Surgeon. Detached from
the U. S. S. Constellation, and ordered to Naval Acad-
emy.
THE MEDICAL RECORD.
419
Lownes, C. H. T., Assistant Surgeon. Detached from
the U. S. S. Constellation, and ordered to Naval Academy.
WınsLow, GeorcE F., Surgeon. Ordered to Marine
Rendezvous, Boston. a
HENRY, CHARLES P., Assistant Surgeon. Ordered
before the Retiring Board for examination.
Medical Items.
ConTacious DISEASES—WEEKLY STATEMENT. — Re-
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending October 5, 1889:
Cases. | Deaths.
Typhus fever. 64 occ iccp cea lcd cae eeeeeeeeees o O
Typhoid (OVER neccs estorn errn E ian 62 14
Scarlet (EVER esse isses stew as ne ss aaie enn eared 40 5
Cerebro-spinal meningitis................-ssceee 2 2
Measles 25g oa Se coke cirdean eaa ai 23 2
Diphtheliaics ceca 4 v's bet as yates aceon ee ii 61 13
Small- Pot usecase i icies arn tive ee cece eee, sare o o
Yellow févr s5.03.0:0 seescwes ser eiie Seen ia aaae o o
Chole rs co iicaccdewes Svein o00 0d ox ee eeu awe ee o o
‘THE PATHOLOGICAL BEARINGS OF HEREDITY.— Animals,
including man, have arrived at their present state of de-
velopment by the combined, but rival, forces of heredity
and evolution, the latter term including the effects of sur
rounding environment. Evolution without heredity, as
Ribot observes, would render every change transitory, and
every modification, whether beneficial or not, would dis-
appear with the individual. 'The results of heredity
without evolution, on the other hand, would give us the
monotonous conservation of the same types fixed once
and for all. With heredity and evolution we have life
and variation. Evolution produces physiological and
psychological modifications, habit fixes these in the in-
dividual, and heredity fixes them in the race. These
aphorisms apply as well to diseased conditions as to
health, and in endeavoring to unravel the mysterious bear-
ings of heredity upon disease we have to bear in mind the
conflicting influence of stability with this tendency to
variation. The operation of hereditary tendencies is
perpetually disturbed by innumerable circumstances un-
appreciable by our means of observation, but capable
nevertheless of producing varieties infinite alike in extent
and degree. It is well known that sensitiveness, whether
to general or special impressions, varies extremely in dif-
ferent individuals. An operation which involves pain
amounting to agony to one person will be borne by an-
other with comparative indifference, and the tissues of
one person will react to stimuli to such an extent as to
cause violent inflammation, while those of another prove
quite passive under similar circumstances. It is this
varying irritability which explains the fact that no two
cases are exactly alike of the same disease. ‘These dif-
ferences are distinctly transmissible from parent to off-
spring, and when the inherited quality is a tendency on the
part of certain tissues to react more readily than normal
to morbid influences, we say that a person has a diathesis.
What we term, for the want of a better word, idiosyncrasy,
is in reality a diathesis or part of a diathesis—a peculiar
susceptibility of the individual to react unduly, either in
excess or otherwise, to certain stimuli. Idiosyncrasies
may be transmitted, as they very frequently are, but they
are in any case congenital. These peculiarities of tissue
and function often remain latent until some morbid pro-
cess emphasizes the fact that a particular proclivity exists
in the individual. We cannot better illustrate this point
than by quoting the well-known story, that of several
hunters who were thrown at the same time into the same
stream of water, no two were affected alike. In one an
attack of rheumatism marks the tendency of joint-tissues
420
THE MEDICAL RECORD.
[October 12, 1889
to take on a certaip process of inflammation. In another
an attack of inflammation of the lungs points out the
pulmonary apparatus as the organ least endowed with
powers of resistance, while a third simply yets a cold in
the head. As for the horses, they very probably escape
scot free in the absence of any special or general variation
in the tissue tendencies. While we recognize clearly
enough that certain diseases are largely influenced by ine
herited tendencies, there are others, and these the majority,
in which the influence of heredity is more or less in-
distinct, but it is as certain as anything of the nature of
a deduction can be that the conduct of a particular organ-
ism, in the face of morbid influences, is determined largely
by inherited qualities of tissue, even when the suscept-
ibility is difficult or impossible to make out. The prob-
lem before us is to discover and elucidate the natural laws
which govern and regulate the transmission of mental and
physical qualities, or, in the words of Mr. Lewis, “ the
paths along which forces travel to their particular results.”
We are already in possession of a large number of facts
and observations bearing upon the “how,” though the
“ why ” still remains, and is likely to remain, unfathom-
able. These relative individual differences of bone tissue-
cell, organ, membrane, and vessels, which are admitted by
all competent authorities, really form the foundation of
all sound views in pathology, and the more they are rec-
ognized and appreciated the more will the art of medicine
acquire scientific exactitude and increased usefulness to
humanity. In the words of Sir James Payet, better
treatment will follow better diagnosis, and better diagnosis
will certainly follow a more exact pathology.— Zhe Med-
tcal Press.
IMMEDIATE RELIEF OF HOARSENESS.—The first Na-
poleon is said to have been subject to sudden attacks of
severe hoarseness, for the immediate relief of which his
physician was in the habit of prescribing the following,
known as Foreau’s syrup :
B. Liquor ammoniz fortioris ....... . 2c. cco M x.
Syrupi erysimi. 6.0 6. cs Gases edie News aie soso 3 iss
Infusionis tiliz florum......... ccc cece eee Z iiss.
* M. To be taken at one dose.
- Erysemum officinale (sisymbrium offic.), or hedge mps-
tard, is no longer officinal, but is easily obtained. It is a.
small annual growing almost everywhere in the United
States and Canada, as well as in Europe. The infusion
of linden (tilia) is used simply as an agreeable vehicle, and
may be dispensed with or supplanted by any other pleas-
ant vehicle.—S¢. Louis Medical and Surgical Fournal.
AN HISTORICO MEDICAL COINCIDENCE.—In Rome,
- where the Sacred Way descends into the Forum, stands
the interesting old church dedicated to Saints Cosmas
and Damianus, two Christian physicians who for their
services and sufferings in Arabia were canonized by the
Pope. Damianus, or, as he is called for brevity’s sake,
Damian, became a power in Italy, where more than one
house of prayer was reared in his honor, notably that one
in the Umbnan hills. It was there that St. Francis of
Assisi devoted himself to the spiritual life, and in a spec-
ial manner to the cure of leprosy, a disease which by that
time (the latter half of the twelfth century) had been in-
troduced by the Crusaders from the East into all the
countries washed by the Mediterranean. A ritual was
compiled to celebrate with awful solemnity the isolation
of the leper from his fellow-Christians—“ a pathetic and
melancholy service, in which the sternest interdict was
softened by words of consolation and pity.” Moved by
their forlorn condition, St. Francis becai.e the constant
associate of the leprous and the inmate of their asy-
lum at Assisi, where he washed their feet and dressed
their sores—to which, indeed, in one case he applied his
lips with such effect that the poor leper instantly became
whole. So, at least, says St. Bonaventura. But the inter-
esting point is this: that his care and cure of these victims
to a loathsome malady was practised “ sub invocatione
Sancti Damiani” (under the invocation of St. Damian),
fluence present very decided changes of color.
a saint who six centuries thereafter was to find a counter-
part in a Belgian priest of almost identical name —the
Pére Damien, whose noble life and death in the leper
island of Molokai will never fade from the annals of his
church, or, indeed, from the history of the world. The
Vatican, it is understood, has taken the preliminary steps
toward the canonization of this true martyr in the service
of mankind, and though the prescriptive period required
for admission into the saintly calendar will not expire till
well on into the twelfth century, there may be those now
living who will survive to witness the Church of Rome’s
invocation of St. Damienus, closely allied in merit as in
name with that other St. Damianus, who inspired St. Fran-
cis to his life of philanthropic self-sacrifice. — Zhe Lancet.
CuicHa Poisoninc.—The Anales de la Instrucción
Publica en la Republica de Colombia contain an interest-
ing account of the effects produced by over-indulgence
in a certain popular drink called “ chicha,” which is pre-
pared by the fermentation of malted maize, with the ad-
dition of the leaves of the primum payaca, or “ sandino,”
as it is called in the country. ‘This beverage, when taken
in excess, produces a feeling of extreme weariness, ren
dering the patients totally unfit to follow any kind of em-
ployment. There is also observed a loss of the power of
co-ordination, which may make it possible on a cursory
inspection to mistake the case for one of locomotor ataxia
or spasmodic tabes; but “chichinism” can be distin-
guished from these conditions by making the patient shut
his eyes and stand or walk, and touch his toes with his
hands, all of which he is able to do. The course of
chichinism, too, 1s quite short, and it may terminate in
trophic changes and acute diffuse myelits. Another symp-
tom which is frequently observed is an erythema of the
dorsum of the hand, similar to that seen in pellagra.
Physiological experiments also show that the chicha has a
special action on the skin; for frogs subjected to its in-
With
chronic alcoholism there is a good deal of affinity, but
there does not seem to be any liability to excitement or
hallucinations.— The Lancet.
THE DREAD OF Deatu.—Sir Lyon Playfair, in a letter
to Junius Henri Browne, author of a paper with the above
title, says: “ Having represented a large constituency
(the University of Edinburgh) for seventeen years as a
member of Parliament, I naturally came in contact with
the most eminent medical men in England. I have put
the question to most of them, ‘ Did you, in your extensive
practice, ever know a patient who was afraid to die?’
With two exceptions they answered ‘No.’ One of these
exceptions was Sir Benjamin Brodie, who said he had seen
one case. The other was Sir Robert Christian, who had
seen one case, that of a girl of bad character who had a
sudden accident. I have known three friends who were
partially devoured by wild beasts under apparently hope-
less circumstances of escape. ‘The first was Livingstone,
the. great African traveller, who was knocked on his back
by a lion which began to munch his arm. He assured
me that he felt no fear or pain, and that his only feeling
was one of intense curiosity as to which part of the body
the lion would take next. The next was Rustem Pasha,
now ‘Turkish Ambassador in London. A bear attacked
him, and tore off part of his hand, and part of his arm
and shoulder. He also assured me that he had neither
pain nor fear, but that he felt excessively angry because
the bear grunted with so much satisfaction in munching
him. ‘The third case is that of Sir Edward Bradford, an
Indian officer now occupying a high position in the Indian
Office. He was seized in a solitary place by a tiger, which
held him firmly behind the shoulders with one paw and
then deliberately devoured the whole of his arm, begin-
ning at the end and ending at the shoulder. He was
positive that he had no sensation of fear, and thinks that
he felt a little pain when the fangs went through his hand
but is certain that he felt none during the munching of
his arm.— Zhe New Idea. i
‘The Medical Record
A Weekly Fournal of Medicine and Surgery
Vol. 36, No. 16
Original Articles,
A PATHOLOGICAL CONDITION OF THE
LUNGS, HITHERTO UNDESCRIBED - IN
THIS COUNTRY, BUT WHICH IS NOT IN-
FREQUENT.
By F. PEYRE PORCHER, A.B., M.D.,
ONE OF THE PHYSICIANS TO THE CITY HOSPITAL, CHARLESTON, S. C.
Durinc the course of a very prolonged service in hos-
pitals I have repeatedly observed a condition of the lungs
which is markedly distinct and characteristic, which I
have not seen described. I speak of it at present only as
a pathological condition, leaving it to others to decide
whether it should take rank as a distinct disease.
Certain patients presented the following symptoms:
Dulness, or subdulness, generally at the middle, lateral,
or posterior portions of the chest; there was always im-
perfect respiration ; scarcely any rales were present, or if
so, they were sparsely disseminated, and generally the sub-
crepitant ; or, perhaps, in lieu of rdles there was only
rough breathing. The condition was consequent on ante-
cedent morbid states, and there was not necessarily ele-
vation of temperature; there did not exist evidence of
any acute inflammation, or any of the well-known classic
diseases of the chest—no phthisis, pneumonia, bronchitis,
pleurisy, emphysema, hydrothorax, etc. The positive
physical signs of these several diseases were all absent—
there was no crepitant, or sibilant, or crackling rales ;
neither was there pain nor rubbing sounds. So all the
diseases which these signs indicated had to be excluded,
and a name was wanted for the new condition which had
been isolated.
But to continue the citation of positive and negative
symptoms: The respiratory murmur, though not normal,
was not completely absent, for the lung was still pervious
to air; the vocal resonance—or what I prefer to term
the reverberation of the voice—was slightly affected ; some
complementary respiration might be present, but this was
not very decided, because there was no absolute consoli-
dation ; scarcely any dyspnoea may exist, and the cough
may be moderate or absent.
Constantly, also, when an autopsy was afferded in such
cases, the physical evidences of the diseases above cited
were absent, and there was invariably present a large
amount of bloody serum exuding from the cut surfaces, and
tt would flow most freely when the lung was squeezed.
Here was plainly a gross morbid fact, which had to be
noted and ‘accounted for.
No disease of the heart coexisted, to the obstruction
produced by which might be ascribed the collection of
bloody serum ; and though I have not yet been able to
associate the two, I would not be surprised if cases were
found to be dependent upon diseases of the heart.
In a hepatized or in a solidified lung the dulness is
complete, and there is bronchial, and often puerile, res-
piration in the healthy areas, so that kepatization and so-
lidification were also excluded. It was not cedema, for
this is general over both lungs, and Laennec had taught us
that the crepitant rile is as characteristic of cedema as it
is of pneumonia. I have heard, as it were, a shower of
fine crepitation over the entire lungs in a case of cedema
consequent upon measles; the cedema was detected by
means of the rales. ‘The crepitant râle was not pres-
Whole No. 989
ent, nor the am etc., essential to pneumonia ; neither
was there any rusty-colored sputa.
The conditions with which our cases would be most
likely to be confounded would be the hypostatic conges-
tion, or the hypostatic pneumonia of recent authors—if
such a disease exists. But these will be referred to again.
I long since began to designate the condition, or dis-
ease, referred to as “ Engorgement of the Lungs” —serum
being always mixed with blood. I was compelled to use
these terms, because they were true and applicable, and
were essential in describing and interpreting the condition.
I felt satisfied that others must frequently encounter a like
pathological state, especially in hospitals ; but I could get
no response or support from authorities in this country.
I wrote to Professor Austin Flint upon the subject years
ago. The loss of his letter is regretted, together with the
notes of cases with autopsies, though I possess the record
of one observed in 1879, and had been observing and
demonstrating the condition long anterior to that period.
Some illustrative cases will be inserted at the conclusion
of this paper.
My cases of engorgement of the lungs exist for days
and weeks, and do not depend wholly upon the acciden-
cies of position, stasis of the blood, age of patient, or
want of vitality. The powers of life are not specially en-
feebled. ‘They do not seem to depend on Brights dis-
ease, dropsy after scarlet fever, measles, infectious dis-
eases, etc.—as is the case with congestion of the lungs and
cedema. I did not for a moment dream of calling them
hypostatic congestion—certainly not in the old sense of
the use of the term, for the condition is hot necessarily
hypostatic in cause.
The term infiltration 1s not very inapplicable, and the
diagnosis may be attended with difficulty ; but I have seen-
lungs infiltrated after severe pneumonias, and tubercular
infiltrations exist ; but in neither case is there often a large
flow of serous fluid when the lung is cut, as is constant in
engorgement of the lungs. ‘This I have repeatedly ob-
served in autopsies—some of them quite recent, and ex-
amined with a view to determining this question. Yet
Ihave also recently seen serum with bloody and purulent
matter exuding from the lungs in a well-marked case of
general tuberculosis. The presence of fever, purulent ex-
pectoration, rise of evening temperature, and other signs
of tuberculosis must be used to aid in their distinction
from engorgement of the lungs.
I consulted, almost accidentally (1888), Ziemssen’s “ Cy-
clopzedia,” vol. v. . “ Diseases of the Respiratory Organs.”
In Juergensen’s paper therein, entitled “ Hypostatic Pro-
cesses of the Lungs” (p. 236), I found that I was support-
ed by one writer, he a master-mind (M. Piorry) ; and the
simple fact may now be stated that I had indicated a dis-
eased condition besides those usually recognized by the
profession; and this had in a great measure corresponded
with what Piorry has pointed out as a distinct form of
disease, to be recognized and treated by the general prac-
titioner. I had noticed and had endeavored to attract at-
tention to a most marked and characteristic morbid con-
dition, which physicians in hospital practice must have met,
and must now meet, but failed to recognize, name, and
separate from others.
Juergensen writes as follows, /oc. cit. sup. : “ Hyposta-
tic pneumonia and hypostatic conditions of the lungs were
first recognized as a distinct form of pulmonary diseas |
through the labors of French writers. Pre-eminent among
them 1s Piorry, who handles the subject with great clear-
422
THE MEDICAL RECORD.
[October 19, 1889
ness, and whose teachings are based upon a rich expe-
rience. He likewise gave the disease its name.”
“ Piorry proved by experiment that a hypostatic condi-
tion diagnosticated during life did not alter its location
after death, under the laws of gravitation. As Piorry
made his diagnosis long before death, it was evident that
this condition did not result during the death-struggle.
By means of these experiments Aypostasis ceased to be a
condition of but little pathological significance. If it oc-
curred during life, then it must have an influence on life.”
To quote still from Juergensen: “ Does an inflamma-
tion of the lung actually exist? Is the term ‘hypostatic
pneumonia’ correct? Here we must agree with Piorry,
who answered this question in the negative in his nomen-
clature, and afterward still further confirmed this opin-
ion.” “ He calls this form of disease preumonémie hyposta-
figue, and gives as a synonyme engouement pulmonaire”
(vol. v., p. 238).
So I am sustained by Piorry, not only as regards the
existence of a special disease and in the non-existence of
an inflammation of the lung, but also in the use of the
identical designation engouement pulmonaire, which may
be equivalent to “ engorgement of the lungs.” |
Pneumonémie, under Piorry’s peculiar phraseology, it
will be observed, isnot to be confounded with pneumonia ;
it is equivalent to congestion. Juergensen, in going on to
describe “ the conditions which give occasion to the rise of
hypostatie infiltrations of the lungs,” makes no difficulty
whatever regarding the existence of the condition, but de-
scribes its pathological anatomy, symptomatology, etc.
I need only quote the following, which may be com-
pared with my own observations: “ The /ocal symptoms of
hypostasis demonstrable by physical examination are the
following : At first diminished resonance on percussion, be-
ginning at the lower angle of the scapula, and on auscul-
tation a lessening, sometimes almost a cessation of the
respiratory murmur, which is vesicular, or may be quite
indefinite in character. At the point of attack the vocal
fremitus is weak. If hypostasis is complicated with a
coexistent catarrh, new features foreign to the former
disease will appear. Mucous rales, for example, are usu-
ally absent in simple hypostasis. The dulness on per-
cussion and the auscultatory signs, as a rule, extend slowly
f:om delow upward. ‘There is a period at which abso-
lutely no breathing is to be heard over the consolidated
portion (Piorry). Then mucous rales gradually become
audible, those in the larger tubes appearing first. In case
of a fatal termination extensive oedema of the lungs super-
venes, accompanied by the auscultatory sign peculiar to
that condition.” I have not been able to confirm the
supervention of cedema ; certainly never got the crepitant
rile, or other signs of oedema, just before death, nor at
any period.
However, both of us recognized and marked out a col-
lection of symptoms which are often found associated, but
which had not previously been designated as character-
izing a special diseased condition. ‘This collection can
have no other name than Engorgement of the Lungs; and
all such terms as pneumonias, in any form, hyperzmias,
cedemas, etc., must be rejected, as I will endeavor to
show later on.
The merit of Piorry consists in his freeing hypostatic
processes from the imputation—ancient and deep-grounded
in all writings—of occurring only just before death ; and
giving it its true place as a diseased condition of variable
duration, to be recognized during life. What he has done
we have just read from Juergensen’s paper.
If my cases of engorgement of the lungs were proved
to be only forms of hypostasis, yet I also recognized them
as unconnected with position, or with the death-struggle ;
as existing, and to be studied and treated long before dis-
solution. But I do not regard “engorgement of the
lungs” as dependent altogether upon hypostasis, there-
fore my observations do not conform strictly to Piorry’s.
Woillez, in his “ Dictionnaire de Diagnostique médi-
cale,” Paris, 1870, citing “ the diseases of the lungs which
can be diagnosticated during life,” does not even refer to
such a disease ; he includes only : Congestion, Pulmonary
Apoplexy, Pneumonia, Gangrene of the Lungs, Œdema,
Tubercles (Phthisis) ; Lardaceous Degeneration, or Amy-
loid ; Cancer, Hydatid or other ‘Tumors, Vesicular Em-
physema, Accidental Perforation of the Organ (Fneumo-
thorax).
I quote one passage from his rather elaborate descrip-
tion of “ Congestion of the Lungs,” to show how far re-
moved this also is from the disease we are considering :
“ Congestion du Poumon : 1°. Eléments dela diagnostique,
considérée comme maladie au même titre que la bronchite
franche et la pneumonie ; l'hypérémie pulmonaire débute
subitement par une douleur du côté de la poitrine, avec
fièvre le plus souvent légère, parfois intense, une dyspnée
très variable, avec absence de toux, ou toux assez rare, sèche
ou suivie a’expectoration mugueuse, transparente, parfois
un peu teinté: de sang.” 7
All he has to say under the head of Engorgement:
(“ Engouement” ) is as follows: “ This word is applied
principally to the lungs and to the intestines. It expresses
in the first case a state of inflammatory congestion still ill
defined.” This was in 1870.
Professor John Guitcras, late of this city, informs me
that Woillez has recently (1889) written a paper on “ The
Acute Diseases of the Chest,” published in one of the
New York medical journals, with six cases of acute fatal
congestion of the lungs from exposure to cold.
In view of the claims which I have ventured to make,
the burden of proof is upon me to show that engorgement
of the lungs as a disease, though not infrequently met
with, is not described or recognized by the prominent au-
thors in this country. One or two of these must therefore
be examined.
But first, as to the literature of the subject in this coun-
. All that we have is a paper by the present writer
(which had wholly passed out of his mind) published in
the American Journal of the Medical Sciences for Octo-
ber, 1869, being one section’ of an article entitled
“ Certain Pathological Conditions.”
It is true that the so-called “ hypostatic pneumonia” has
been refeired to in the edition of 1886 of “ Flint’s Prac-
tice,” by Flint, Jr., and Welch, but this is a comparatively
recent publication. The existence of such a disease is
regarded as problematical.
Flint writes as follows : “ Passive hyperzemia occurring
in the dependent portions of the lungs is called hypostatic
1 This being brief, 1 insert here, as follows : °
AL iaer of Serous LEngorgement of the Lungs.—! have very fre-
quently met with a condition of the lungs which I have been in the
habit of designating in my clinical: teaching before students as ‘‘se-
“rous engorgement,” or simply pulmonary engorgement.
The lower lobes on either side are the parts usually implicated.
There is some dulness on percussion, some deep-seated respiration,
with rough breathing, and at times a little crepitation. Coexisting
with such a condition there is neither pneumonia, bronchitis, tubercu-
losis, phthisis, ner any cavity. ‘he post-mortem examinations have
repeatedly disclused the unmixed character of the pathological state.
t is a result of neglected catarrhs, previously existing bronchitis or
pneumonia in a chronic form, and sometimes the engorgement is
partly hypostatic ; but this term should be reserved for post-mortem
changes, or those occurring just before death. I think the term used
above can often be safely and properly used as a distinctive one, mark-
ing a substantive condition. The term “congestion " should be ap-
plied only to active determination of blood to the lungs, as in apo-
plexy,etc. In ‘‘ serous engorgement " there is often a large amount
of serous fluid mixed with air, which escapes on cutting into the lungs,
and the dulness is not absolute when the patient is examined before
death, as the lung tissue is still partly permeable to air.
This serous engorgement often also accompanies tuberculosis of the
lungs, as, for example, when cavities or granular tubercular matter is
found in the upper portion of the organs, the lower and more depend-
ent portions are simply engorged with serum, and furnish correspond-
ing auscultatory and percussional signs, But the morbid alterations
referred to as existing at the base or more dependent portions of the
lungs are not ‘‘ tubercular infiltrations,” which almost always have
their seat under the clavicles.
If" serous engorgement " is one and the same with ‘' edema,” then
it exists much more frequently than the books would teach us to be-
lieve it does, and Laennec was wrong in stating that the crepitant rdle
characterized three conditions, namely : The forming stage of pneu-
monia, the congested tissues around a hemorrhagic spot, and œdema
(in which he is correct as far as my experience goes), for in the serous
engorgement described above the crepitant rále is rarely if ever heard.
In true ‘‘ oedema " of the lungs consequent upon measles, the crepi-
tant rale is heard over the entire region of the chest.
October 19, 1889]
congestion. The conditions which favor the production
of hypostatic congestion are enfeebled heart’s action and
the maintenance of the body in one position for a long
time. It is met with in acute infectious diseases, in the
aged, and in the course of chronic diseases which occasion
general debility. ‘The higher grades of hypostatic con-
gestion result in a transudation of bloody serum. The
condition of lung thus produced has been called spleniza-
tion. i
Now, our cases are not pneumonias—there is no true
snlenization, they @d not necessarily depend upon acute
infectious diseases, did not exist in the aged; the term
congestion is not applicable, as I have shown, nor were
they dependent upon debility, as before stated. Refer-
ences also to these points have apparently only been made
in editions of recent years.
Professor S. C. Chew has an able paper, written in his
usual style of excellence, in vol. iii. of Pepper’s “System
of Medicine,” entitled “ Congestion and C&dema of the
L (Hypostatic Pneumonia).” What is said below
will include all the arguments I have to offer in the effort
to show that he also does not include Engorgement of the
Lungs in the subject-matters treated by him, and I refrain
from a minute analysis only on account of want of space.
The work on “ Practice,” third edition, 1885, by so
deservedly conspicuous an authority as Dr. Loomis, must
also be examined ; but having the greatest respect for his
character, ability, and experience, I write in no undue
critical or controversial spirit. The terms “engorgement,”
or “serous engorgement,” are nowhere found, either in
the index or in the body of the work; nor is there any
other disease referred to by him which can be confounded
with “ engorgement of the lungs,” as I will endeavor to
show by a careful analysis.
‘The nearest approach thereto will be discovered in the
section entitled “ Hyperzemia of the Lungs,” which is di-
vided by Loomis into “ Active Hyperemia, or Fluxion,
and Passive Hyperzemia, or Pulmonary Congestion.”
With the first, active hyperemia, our disease, “ en-
gorgement of the lungs,” will not be confounded. The
second, passive hyperemia, embraces a subdivision, viz.,
hypostatic congestion, which somewhat resembles “ serous
engorgement,” but if the diagnostic differences are closely
scanned, the mcompatibilities can readily be exposed.
In justice to the author we quote as follows (p. 113):
“ Passive hyperemia or pulmonary congestion depends
upon an obstruction to the return circulation. It occurs
with varying appearances and anatomical characteristics.
that have led to its subdivision into splenization, brown
induration, and hypostatic congestion. A form of active
hyperzemia has, because of its physiological cause and
situation, been called compensatory hyperemia. Other
divisions are sometimes made, but all the varieties can
probably be classified under these heads.”
I have explained elsewhere why “engorgement of
the lungs” cannot be confounded with splenization, with
hypostatic, or any other active congestion ; still less is
it possible to confound it with “ brown induration,” or
“ compensatory hyperemia ”—this will be admitted with-
out hesitation by everyone. But I must recur to “ hypo-
static congestion.” This, unless in a modern and changed
sense of the term—and Loomis fails to say that views
have changed with regard to it—is not to be confounded,
as I explained, with “ engorgement of the lungs;” un-
less it is assented to that hypostatic congestion (laying
aside for the present any objection to the term conges-
tion) is not necessarily associated with the position of
the body or with post-mortem changes, as Piorry’s re-
searches have proven. It is still a grave misnomer to
apply the term hypostatic to a disease where there is no
necessary hypostasis. If the characteristics are aban-
doned which make it a case of hypostasis, then we had
better change the name for one more appropriate, and
call the disease engorgement of the lungs, which is far
the most applicable, as it is descriptive of the true con-
dition. But, finally, our “ engorgement of the lungs” is
THE MEDICAL RECORD.
423
not Aypostatic congestion! and Piorry himself called his
hypostatic congestion “engoument pulmonaire.” He en-
countered the same diseased condition that I did, and
the difficulty was met in each case by the application of
analogous terms.
Let us see what the leamed author (Loomis) says of
“ hypostatic congestion ”—I quote verbatim et literatim:
« Hypostatic congestion isa term apphed to that form
of hyperæmia which occurs in the most dependent parts
of the lungs; it is usually bilateral in those dying of dis-
eases which have confined them to bed for a long time,
It very closely resembles splenization, but the lung-tissue
is very friable instead of doughy, and the httle whitish or
reddish points which are seen in splenization are absent in
hypostatic congestion. The lung-texture itself is but
little altered. Low forms of pneumonia are liable to oc-
cur in hypostatic congested parts of the lung, and hence
some call it ‘hypostatic pneumonia,’ and others again
call it splenification (differing from the above described
splenization).”
Our disease has nothing to do primarily or essentially
with hypostasis, nothing to do with being “confined in
bed for a long time ;” there is also no splenification ; it
has nothing to do with any form of pneumonia. The
crepitant râle, fever, or rusty-colored sputa—one or more
—should be essential to every morbid state to which the
term pneumonia is applied. I have repeatedly stated
that none of these symptoms characterize engorgement of
the lungs. Besides, the description by the able patholo-
gist quoted above is entirely too inadequate ; there is not
enough relating to the morbid anatorhy, symptomatology,
etc., of hypostatic congestion to prove that it agrees with
“engorgement of the lungs,” and hence that the latter
1S no new disease.
As I have satisfactorily disposed of the subdivisions of
“ passive hyperzemia,” I might well be dispensed from con-
sidering the characteristics of passive hyperemia itself.
But I will state that this is not to be confounded with
“ engorgement of the lungs.” Loomis gives some of
the characteristics of passive hyperzemia by which the
identity of the two will be proven to be irreconcilable.
For example, he does not mention serum as exuding,
but only “dark blood;’’ ‘bronchial tubes and pleura
show post-mortem staining.” ‘“ Engorgement of the lungs”
has nothing to do necessarily with post-mortem staining ;
it is not dependent upon the position of the body—for a
long or a short period; or upon the accidencies of disso-
lution—upon recumbency or decubitus ; it bears no rela-
tion whatever to death or the death-struggle—it has,
indeed, existed for weeks or months before death.
In “engorgement of the lungs” there is serum and
blood mixed—so the term Ayferemia, also, would, for
this reason, not be comprehensive enough.
Here are some cogent additional reasons: Dr. Loomis,
in speaking also of the different varieties of pulmonary
hyperzmia (p. 115), says, “ blood-stained, watery expecto-
ration is the prominent objective symptom of pulmonary
congestion. The advent of active hyperæmia is usually
very sudden.”
I have already shown that “engorgement of the
lungs” is not congestion ; and also that it is never active
and sudden in its onset—as is congestion. In “ engorge-
ment of the lungs” “ watery expectoration is not a prom-
inent symptom.” In fact it does not exist in cases oI
engorgement of the lungs.
Dr. Loomis again repeats (p. 116) that the “ diagnosis
of pulmonary congestion is not difficult if one considers
the circumstances under which it occurs, and the two
prominent symptoms, viz., the dyspnoea and the copious,
watery, blood-stained expectoration.” He also says that
“oedema” is characterized by “ blood-stained sputum”
(p. 116).
These admissions by a pathologist of great experience
settle the question that neither of these diseases is synony-
mous with “engorgement of the lungs,” in that blood-
stained sputum has not been seen by myself in the latter,
424 ©
THE MEDICAL RECORD.
[October 19, 1889
nor referred to in the statement of the pathology of the
diseased condition with which the researches of my old
master, Piorry, have been so promiently associated.
Résumé. — The pathological condition referred to
should be best designated and known as Engurgement of
the Lungs ;
Because, 1st, Hagorgement of the lungs may include
blood and serum, both being invariably present. i
2d. Term “ ypostatic” objectionable ; becayse con-
dition does not depend on hypostasis.
_ 3d. “Congestion” objectionable ; because congestion
is an acute condition (see body of paper).
4th. “ Hyperemia” objectionable ; because it necessi-
tates the presence of blood, and does not include serum,
which is always present.
5th. “ Pneumonia,” or “ pneumonic,” objectionable ;
because the crepitant râle, fever, rusty-colored sputa, |
bronchial respiration, and heyatization, are all aġsent.
6th. ‘ Edema” objectionable ; because “in cedema
the expectoration is always frothy and watery in char-
acter and abundant” (Loomis), and there is dyspncea.
These do not occur in engorgement of the lungs, and
in the latter there is, also, no blueness of lips, lividity,
cold extremities, etc.,as are found in extreme cases of
oedema.
Lllustrative Cases.—During the past year the following
(which was a tolerably fair specimen, but the records are
meagre) occurred during my attendance upon the Marine
Hospital wards :
Case I.—E. O——., white, aged thirty, admitted August
7, 1888, with a diagnosis of bronchitis. Evening temper-
ature, 100° F.; morning, 987° F. His condition was as
follows : Dulness over front of right lung; left lung re-
sonant ; no rales; vocal resonance almost amounting
to pectoriloquy in the right lung posteriorly, above
the scapula. No indication of phthisis, fibroid phthisis,
bronchitis, or pleurisy.
Diagnosis.— Engorgement of the lungs.”
Note.—Similar symptoms naturally occurred in a man
who died from drowning a few days previously.
August 11th.—Revulsives were employed ; much less
dulness observed at the base of right lung anteriorly and
posteriorly ; temperature ranges from 97° to 1o1° F.
From physicians present, when invited to express their
opinions based on a consideration of the symptoms, the
replies varied, as follows: “ Incipient phthisis,” “ Ca-
wll pneumonia,” “ Hypostatic congestion,” “ Œdema,”
etc.
There had been no evidence of catarrhal symptoms or
pneumonia, no crepitant rales, rusty-colored sputa, etc.
Hypostatic congestion was the closest approach ; but this,
as we then interpreted it here, is a condition character-
izing the very latest ante-mortem state, results from a pro-
tracted recumbency upon the back, occurs in the aged or
when the powers of life are enfeebled. It was not con-
gestion of the lungs, for attacks of this are sudden and
violent, and there is active hyperzemia.
The next case is extracted verbatim from my notes,
under the date 1879, and therein entitled “ serous en-
gorgement,” which term was used here as synonymous
with “ engorgement of the lungs.”
Case I].—Woman, colored, aged fifty, entered hospital
October 5, 1879. Complained of some derangement of
chest and stomach ; no active disturbance of stomach ;
enlarged liver, which was hard; no fever or dyspneea ;
cough, but no expectoration; dulness over heart ; reso-
nance over apices of both lungs, but at back of right and
left lung partial dulness, with subcrepitant rdles, espe-
cially in right lung ; dulness more marked at inferior mar-
gin of lungs.
Diagnosis.— Serous engorgement ;” possibly water in
pericardium, but no pleuritis.
Death occurred rather suddenly—subject complaining
of oppression of the chest; pulse normal. All the post-
mortem phenomena corresponded with the diagnosis.
Autopsy.—Above thoroughly sustained, as follows:
Fluid in pericardium ; liver large, hard, thickened ; spleen
medium size. Right lung engorged, and poured out se-
rum when cut ; dilatation of right ventricle and general
enlargement of the heart, no special valvular disease ;
veins of right side of the neck enlarged—the jugular was
more than an inch in diameter.
Note, 1879.—I make a distinction between “ engorge-
ment,” congestion, and also cedema—the justness of which
this case confirmed. Drs. Rhett, Andrews, and Wana-
maker, house physicians, were present.
Case III.—A. K——,, colored, aged twenty-five, ad-
mitted May 22, 1389. Had had pneumonia; base of
both lungs dull anteriorly and posteriorly ; no swelling,
no rales. sks
May 23d.—Same condition as on previous day ; no fever,
no rales; base of both lungs dull, but not absolutely, as
would be if there was water on the chest ; no pleurisy, no
bronchitis.
May 28th.—Examined. No fever ; back of both lungs
dull, dulness also extending in front; respiration not
quickened ; no rales, cough, or pleurisy. So:
Diagnosis.—Engorgement of lungs.
This case presented also a rare example, which I have
recently seen repeated, of greatly diminished respiration,
without quick breathing. Entered hospital with a diagnosis
of “ pneumonia of right lower lobe.” If so, the pneumo-
nia is well, and is followed by serous engorgement. l
Case IV.—E. J , admitted February 14, 1877,
aged twenty-two. Had spitting of blood; no dulness
under either clavicle, and anterior portions of both sides
of chest resonant, respiration loud. Puerile respiration
at back of left lung; percussion dulness over back of
right lung, extending to diaphragm and liver, and absence
of respiration ; subcrepitant rales posteriorly.
Diagnosis.—Serous engorgement of right lung ; spleen
somewhat enlarged; respiration not quickened ; pulse
120; temperature, 100° F. Ordered, B. Calomel, gr. 4;
digitalis, gr. j.; ipecac, gr. 4; squill, gr. ij. in each pill.
One t.i.d. ; chest to be rubbed with iodine and mercurial
ointment (U. S. D.), and cod-liver oil and whiskey, on ac-
count of weakness.
February 25th.—Still weak. Subcrepitant riles very
evident over right lung, with dulness—the serous engorge-
ment involves whole of right lung. Dulness exists still at
back of nght lung also—not so marked as formerly, and
crepitation on inspiration also diminished. Applied em-
plast. cantharides, 4 by 5, back of nght lung.
Died April 3, 1877:
Case V.— P. B——, admitted 1888. Engorgement of
lungs (or hypostatic congestion) ; had been in bed for
three weeks on his back; no rdles, partial dulness; all
signs of hypostatic engorgement, viz., impaired respiration,
posterior portion of lower lobe of lungs, mostly base and
centre, dull.
Left hospital September 24th completely well. Took
stimulants, milk diet, etc. In the above case “ hypostatic
congestion ” and “ engorgement of the lungs ” are convert-
ible terms.
Case VI.—P. M—, colored, aged sixty; admitted
September 7, 1888, with a diagnosis of “ chronic gastritis
and malaria with anzemia.”
September 8th.—Examined. Physical signs: Dulness
on right side of chest, anteriorly, extending up to fifth in-
tercostal space, and to about the seventh posteriorly ;
respiration in this region not good; left lung healthy ;
heart-sounds normal, but somewhat labored.
A tumor, about four inches in diameter and hard to
the touch, found in the region of the stomach, just below
the ensiform cartilage ; no pulsations, but with consider-
able constriction of the abdominal walls just above the
umbilicus—supposed cancer of stomach! Patient, about
eight to ten hours after meals, vomits a considerable
quantity of partially digested blood, or black vomit ; pain
considerable in the region of the tumor, which had been
observed for one month past; patient anemic. Dulness
October 19, 1889]
and impaired respiration extend to the rear of the right
lung ; probably “engorgement of the lung.”
Two cases may be added ; one of “acute engorgement
of the lungs,” with recovery, and one, for comparison,
an example of acute congestion of the lungs, with an au-
topsy. :
Case VII. Acute Engorgement of the Lungs (from
notes, 1886).—D. G , white, aged eight ; suffered ap-
parently from acute engorgement of the lungs, without
crepitant rales; rusty-colored sputa, etc. ; a.“ click” and
dulness were present at the back of the right lung, middle
region. Recovery took place after eight days’ treatment.
Temperature 101° to 102° F.; on the fifth day it was
103° F., even after using the following mixture: B. Sirup
of squills, ipecac, and soda with nitre. This combination
failed. Then the following: R. Calomel, gr.4; Dover's
powder, gr. 4; soda, gr. j. Six powders, each containing
the above. S.: One every three or four hours. Did not
resolve the inflammation. Then local applications of mus-
tard, followed by a thapsia plaster, with flaxseed tea as a
drink. As fever became higher, employed, successively :
B. Muriate of ammonia, 3 j.; carb. of ammonia, 3 j.;
acetate of potash, 3ij.; tinct. aconite, gtt. xx.; tinct.
singuinaria, 3 1ij.; fluid extr. licorice, 3 ij.; water. to
živ. S.: Teaspoonful every two hours. Gave also a
stimulating diaphoretic tea, made with senega and ser-
pentania, t.i.d.
Before the last mentioned was given, had used also, in-
effectually, the following sedative and relaxant expecto-
rant: RB. Wine of antimony, 3 iij.; sirup. squills, sirup
senega, a&, 3ss.; tinct. digitalis, 3j.; sirup wild cherry
bark, 3 j.; tinct. lobelia, 3 iij.; water to Ziv. S.: Tea-
spoonful, t.i.d., and oftener if cough is troublesome.
He never had much expectoration, but his cough was
troublesome, with constant fever; no pain; pulse, always
120, and respiration, 28. Under the aconite mixture, which
is an excellent combination for pneumonic (?) engorgement,
the temperature went down to 97° F. To-day, March 16th,
sitting up ; temperature, 984° F. On the fifth day I used
an oil-silk jacket over his flannel ; the latter was wet with
perspiration every night, and was changed. e
It is instructive to compare a case like the above with
our cases of “ engorgement of the lungs.” In the latter,
which is not acute, there is no such high temperature.
The absence of the crepitant råle, rusty-colored sputa,
etc., in the above case, make its relations to pneumonia
doubtful. Therefore I consider it a case of acute en-
gorgement—not congestion, not pneumonia.
Case VIII. Congestion of Lungs; with an Autopsy
(from notes, December 5, 1880).—This case is intro-
duced for comparison with cases of “engorgement of
the lungs” and to show the acute nature and rapid in-
vasion of congestion.
S. A. , white, aged twenty-five, entered City Hos-
pital, July 3, 1880, two days before death. Not very ill, ap-
parently ; said to have intermittent fever, and that on the
previous night fever was very high. I could not ascertain
that he had any congestive chills, or any prominent symp-
Saa after close inquiry from nurses and those lying near
im.
When I saw him, July 4th, at 9 A.M., his respiration
was slow and oppressed, and gradually becoming more so.
He died in ten minutes after, though his pulse was not
feeble—explained by the fact that death was caused by
an apoplectic invasion of the lungs, while the heart was
less involved.
Autopsy, July 5th. The cavities of the heart contained
some blood ; the pericardial sac held mucli bloody serum ;
much blood free in cavity of the thorax—a quart or more;
both lungs hepatized or black with blood; 4/o0d was pour-
ing from his nose at the autopsy (there had been white
froth upon his lips at death, in striking contrast with his
dark face). The spleen was soft and friable—not large,
. four by five inches ; liver enlarged.
This man had not been severely purged (colliquative
diarrhoea, whether natural or artificial, being, in my opin-
THE MEDICAL RECORD.
such a diagnosis I have ever seen.
425
ion, a frequent cause of congestive chills from diminished
power of reaction which they give rise to). He must
have died after brief sickness of congestion of the lungs—
this being the most decided post-mortem confirmation of
Have never seen so
bloody a lungs and thorax; the structure of the heart also
seemed softened and infiltrated with blood.
I cannot discover that this man had been purged be-
fore or after his admission. It is stated by the house
physician that his fever had been very high the previous
evening ; no testimony showing the existence of any cold,
chills, or excessive sweating. I regard diarrhoea, and high
temperature, which liquefies the blood, as the dangerous
symptoms. He had had ten grains or more of quinine,
given him t.i.d. since his entrance into hospital.
JABORANDI AND PILOCARPINE IN BRIGHT’S
DISEASE.
By P. R. EGAN,
ASSISTANT SURGEON, U.S.A., EAGLE PASS, TEX.
THE leaves of Pilocarpus pinnatus have been used to pro-
duce sudorific effects for centuries. The alkaloid has
been before the profession for the last twelve years.
Nevertheless, the truth of a recent statement will be
readily admitted. Willoughby says (7 he Lancet, May 25,
1889) : “ There are few drugs of which the physiological
action is so direct and palpable, but of which the thera-
peutic uses are so undetermined.”
In the discussion which followed the reading of Dr. C.
S. Wood's paper on “Some Points in the Treatment of
Chronic Albuminuria, or Bnght’s Disease” (THE MEDICAL
REcorpD, March 24, 1888), pilocarpine was mentioned by
but one speaker. Dr. Page’s faith in the drug was not of a
very exalted nature. “ Pilocarpine,” he added, “ has been
recommended for the purpose of eliminating this so-called
uremic poison. The chief objections to this remedy are
its depressing effect upon the heart, and sometimes it
causes such a profuse salivary secretion that the patient
almost strangles.” So, too, Heither, of Vienna: “ He had
never seen any good result follow the use of pilocarpine
in renal disease after ascites had once set in. He ad-
mitted that it produced its physiological effects of in-
creased perspiration and urination, but believed these to
be purely temporary, and to have no beneficial result;
whereas the depression consequent upon the use of the
drug was not seldom alarming.”
Before the New York Academy of Medicine (Birming-
ham Review) Dr. Francis Delafield brought forward a
paper on the “ Treatment of Acute and Subacute Nephri-
tis” (THE MEDICAL REcoRD, March 23, 1889). It was
discussed by seven representative physicians of that great
medical centre. But one referred to the use of pilocar-
pine—in truth, the remedy was almost ignored.
On the other hand, the general consensus of recent
authorities on materia medica is that expressed by Stillé
(“ National Dispensatory ”) : ‘‘ When dropsy arises in con-
nection with desquamative tubular nephritis (especially
scarlatinous), or even with interstitial nephritis, the med-
icine is very efficient ; in the former case often leading to
a cure, in the latter to a prolongation of life.
From Professor Wagner's clinic at Buda-Pesth comes the
following : “ When used according to the above-mentioned
principles (guod vide), pilocarpine will be found in most
cases of Bright’s disease, even when hot baths and other
diaphoretics prove useless, always to diminish dropsy to
such an extent that the patient is more or less protected
against dangerous uremic suffocative attacks. In this
way it may be possible to obtain a relative cure ; that is, in
secondary granular contracted kidney” (British Medical
Journa:).
In Zhe Lancet for December 22, 1888, J. G. Marshall,
B.A., M.B. Cantab., writes : “The value of jaborandi and
its derivatives in the treatment of the dropsy of Bnght’s
disease cannot be overestimated. By its use I have re-
426
— o m
THE MEDICAL RECORD.
[October 19, 1889
lieved in several cases some of the most distressing feat-
ures of this complication, and prolonged or rendered less
painful the termination of life in others, but in none has
the drug been exhibited with such satisfactory results as
in the following case.” Mr. Marshall then details the his-
tory of a fisherman, aged nineteen, who contracted Bright’s
disease, for which he was unsuccessfully treated at home
and in hospital. When he again saw him “his face was
livid, and the swollen condition of the cellular tissue of
his neck made it almost as broad as his shoulders. He
coughed incessantly; there was copious intra-thoracic ef-
fusion, and the subcutaneous tissue all over the chest was
‘doughy’ to the touch. His abdomen was as big as a
barrel, and there was extensive cedema of the genitals.
His legs and thighs were enormously swollen, and water
was exuding from them. He was passing a small quan-
tity of urine, which was of a dirty color and loaded with
albumen.” Mr. Marshall treated him with hypodermic
injections of one-fourth of a grain of pilocarpine hydro-
chlorate. In a fortnight he was relieved of his dropsy,
and passing his usual quantity of urine, which still con-
tained some albumen. Mr. Marshall adds: “I think the
almost miraculous improvement which followed the use
of the pilocarpine is worthy of recording, and (when one
considers the usual helplessness of a condition such as I
have descnbed in a patient of this age, and from such a
cause) that jaborandi and its alkaloids must occupy the
first place among therapeutic agents in the treatment of
cases of this kind.”
Although we may not agree with the statement of a
recent authority that in puerperal eclampsia “ nephritis
is usually, if not always, present” (B. Holmes: Medical
News, September 14, 1889), still it is sufficiently akin
to acute and subacute Bright’s disease to merit our con-
sideration. Here, too, the same ambiguity prevails. The
London Obstetrical Society cordially indorsed the opinion
of Dr. John Phillips, that “although good effects were
produced in twenty-eight cases, yet in nine such danger-
ous symptoms manifested themselves that he was bound
to warn others against its use, especially when coma was
pronounced ” (The Lancet, October 13, 1888).
On the other hand, Zhe Lancet for 1885 and 1886 con-
tains an account by Dr. Horrocks, of Guy’s Hospital, of
two very severe cases treated successfully by the injection
of one-third of a grain of pilocarpine, repeated to obtain
its physiological effects. Cessation of convulsions almost
immediately followed the use of the injection; the os
rapidly dilated, and the children were quickly expelled,
-but did not survive. The maternal mortality is generally
thirty per cent. A recent writer, however, gives twenty-
three cases and no death (THE MepicaL REcorp, Septem-
ber 7, 1889). Zhe Lancet for 1886 also contains an account
of five cases equally happily treated by Dr. Murphy, with
similar injections of pilocarpine. One case so treated by
him had thirty-three convulsions in the seventh month of
pregnancy, but was afterward successfully delivered at
term of a living child.
The writer desires to add two cases to the contribution
of Mr. Marshall—one almost similar to his, but in which
the result obtained by the use of jaborandi was better ;
the other a well-marked case of acute Bright’s disease,
with total loss of vision, which was restored in one hour
and a half by the use of pilocarpine. Jaborandi and pilo-
carpine would seem to be especially indicated in all forms
of Bnght’s disease. Its sudorific effect promptly elimi-
nates the poison pent up in the system. Its well-known
power of relaxing nervous tension in status epilepticus
and kindred conditions (S. B. Lyon, Journal of Nervous
and Mental Diseases, April, 1889 ; Willoughby, ut supra)
is of the greatest service when eclampsia is threatened, or
convulsions have already taken place. In a five years’ ex-
perience (1882 to 1887) with jaborandi and pilocarpine in
large doses, we have never seen, among non-debilitated sub-
jects, any worse results than emesis, which at one time or
another has attended almost every drug we have used. In
Case I., instead of increasing the cedema of the lungs,
as it is said to do, it relieved it after other remedies had
failed.
Case I.—J. R-——, colored, aged twenty-four. Was
seen on April 27, 1885, when he gave the following ac-
count of himself: About three months ago he began to
swell in his legs and abdomen. Found that he could not
easily button his “pants.” Says he has never had any
venereal disease, but has been a hard drinker. ‘That two
nights since, while camping in the valley, with insufficient
covering, he, suffered very much from cold. ‘That he
then began to cough, and rapidly to swell up.
Has anasarca of legs and body as high as his neck.
His genitals and abdomen are very much swollen. A
percussion wave cannot be obtained, but there is dulness
on the flanks, changing with change of position. His
heart is normal, but beats rapidly—-120 per minute.
Over his lungs are heard sibilant rales, and fine crepita-
tion, but no dulness. He coughs almost constantly, and
ejects mouthfuls of serous fluid. Says he has passed
scarcely any urine during the last two days. A sample
obtained is very dark colored, and became almost solid
on heating. Under the microscope it was found to con-
tain blood-corpuscles and granular casts. There were no
nervous symptoms. Suffers from constipation. He was
given pulvis purgans, acetate of potash in infusion of
buchu and digitalis, and Stokes’ mixture for cough. He
passed about twenty ounces of urine each day, until May
ist. ‘The albumen was slightly diminished, but otherwise
there was no change. He was then given, morning and
evening, ext. jaborandi, fl. 3 j.; aq. menth. pip. 3). Sig:
To be taken at a dose; repeat in one hour if sweating 1s
not produced. This dose produced its physiological ef-
fect without causing emesis. Pulvis purgans and Stokes’
mixture also continued.
Next day there was a slight improvement.
Or May sth the following note was entered : Much
better. Only few crepitant rales over lower part of chest.
(Edema only noticeable over sternum. Passed thirty-four
ounces of urine of light color; sp. gr., 1.015. No albumen
or casts. On the following day it was noted—swelling
gone from over chest. His recovery was uninterrupted.
Ten days later he was given Basham’s mixture alone, and
in the first days of July he resumed his ordinary occupa-
tion. Seven months afterward, when last seen by me, he
was found to be slim, wiry, and in excellent health.
There had never been any return of his cedema, and al-
bumen had not been detected after May sth.
Case II.—M. G——, aged twenty-eight. Was seen
December 24, 1888. He had been suffering from sore
throat for two days prior to seeking medical aid. Tonsils
very much swollen and filling almost the entire pharynx.
There is marked difficulty in swallowing, and some slight
fever present. He was treated by ammoniated tincture
of guaiac, aconite, and steam inhalations. On December
30th an abscess of the right tonsil was evacuated, all medi-
cine discontinued, and a gargle of boric acid in hot water
directed. He progressed favorably until January Io,
1889. On the morning of that date he complained of
severe headache, and his face appeared swollen. This
was thought to be due to a severe cold. During the fore-
noon he vomited twice—the vomited matters being bile-
stained. About mid-day he fell into a sleep which lasted
a couple of hours. At 3 P.M. he was assisted to the cham-
ber, and then discovered that he was unable to see. He
wanted to be told whether it was night or day. On my
arrival I found him talking incoherently His legs and
face were sufficiently swollen to leave a slight depression
when firm pressure had been applied. His headache was
very severe, and he was unable to distinguish daylight. A
small quantity of urine obtained at the time gave a de-
posit equal to about two-thirds of its volume. He was
given one drop of croton-oilin glycerine, but this was soon
rejected. A rectal injection of one drachm of glycerine, re
peated in twenty minutes, produced a slight watery evacua-
tion. A hypodermic injection of one-sixth of a grain of
pilocarpine hydrochlorate produced a free perspiration,
October 19, 1889]
THE MEDICAL RECORD.
427
beginning ten minutes after its administration and lasting
nearly an hour. In one hour and a half he could distinguish
the faces of those around him, and at 7 p.m. he could dis-
tinguish a light about one hundred yards away. His urine
under the microscope was found to contain granular tube-
casts. The pilocarpine was again injected at 8 P.M. and
produced a free perspiration.
January 11th.—Passed a small quantity of water twice
during the night. Vomited twice. Swelling has gone
from the face and almost wholly from the lower limbs.
Can see everything about him, but distant objects seem
misty. Passed twenty ounces of urine, containing about
one-third albumen and some casts, during the last twenty-
four hours. Was given one drop of croton-oil in glyce-
rine, which acted freely. Pilocarpine injected night and
morning. His recovery, from this point, was uneventful.
He was given the pilocarpine night and morning until
January 13th, when he passed thirty ounces of urine con-
taining no albumen or casts, and having a specific gravity
of 1.022. It was then injected once a day until January
- 15th, when he passed fifty ounces of normal urine. The
swelling had all disappeared, and he expressed himself as
feeling quite well. Seven months afterward I learned
that he successfully passed the physical examination re-
quired for one of the government services.
Kemarks.—From the symptoms, but more especially
from the history of Case I., a diagnosis of chronic paren-
chymatous nephritis was arrived at. Mentally a fatal prog-
nosis was registered. It appeared wholly similar to several
acute exacerbations in chronic Bright’s disease, observed
while interne to a large hospital, and in which every remedy
Save Jaborandi was known to have been unsuccessfully
used. Imagine our surprise at the result of the treatment.
The Philadelphia Medical News for December 5, 1885,
contains a résumé of a paper by Dr. Flint on “The Ele-
ments of Prognosis in Bright’s Disease.” (I am indebted
to the kindness of Assistant Surgeon Ogden Rafferty,
U.S.A., for copying and forwarding this article at my re-
quest.) He considered that, as a rule, acute and sub-
acute Bright’s disease does not tend to become chronic. .
That chronic Bright’s disease may remain latent for a long
time, which fact he considered of great importance. In
v:ew of these opinions the questions arose :
I. Can a case of subacute Bright’s disease have a grad-
ual onset lasting for three months ?
2. Can a case of chronic Bright’s disease remain latent
for seven months?
To solve these interesting problems an attempt was
made to learn the after-history of this patient, but unfort-
unately without success. However, relying on the well-
known incompetency of the average member of the
colored race to observe or define his symptoms, the case
is deemed to have been one of subacute Bright’s.
FAT IN THE Faces oF DysPepTic CHILDREN. — Dr.
Tschernow, of Moscow, has published his analyses of the
fæces of dyspeptic infants, which he found to differ both
physically and chemically from the fæces of healthy in-
fants. Dyspeptic fæces contain eighty-five per cent. water
and fifteen per cent. solids, and nitrogenous, fatty, and
inorganic salts. The solids of normal fæces consist of
from twenty-five to thirty per cent. fat, thirty to thirty-two
per cent. albuminous matter, ten per cent. salts, and
twenty-eight per cent. carbohydrates ; while the solids of
dyspeptic fæces contain forty-five to sixty per cent. fat,
and fourteen to twenty-five per cent. albuminous matter.
The carbohydrates do not differ very much. In dyspep-
tic fæces fat increases at the expense of albuminous mat-
ters. This proportion was observed alike in children at
the breast and in those fed on artificial food. All dys-
peptic fæces contain, as above mentioned, more fat than
normal fzeces, and the quantity of fat does not depend on
the degree of indigestion. Dr. Tschernow concludes
from these results that Demme’s and Biedert’s so-called
“ fatty diarrhoea” was simple dyspepsia.— Zhe Lancet.
LEGAL MATTERS OF INTEREST TO THE PHY-
SICIAN.
By HENRY A. RILEY, Esq.,
NAW YORK.
THERE are some accident policies which do not seem
to insure against accidents. Here is one of them, as found
in a New York case where the Preferred Mutual Accident
Association was defendant. ‘The policy stated that pay-
ments would be made to a member injured through “ exter-
nal, violent, and accidental means,” provided said member
shall “ sustain bodily injuries by means as aforesaid which
shall, independently of all other causes, immediately and
wholly disable and prevent him from the prosecution of
any and every kind of business pertaining to the occupa-
tion under which he receives membership.” The insured
was a retired gentleman having no occupation, who in-
jured himself while operating a buzz-saw at the shop of a
wagon manufacturing company of which he was a stock-
holder and director. As a result of the injury he was
obliged to carry his arm in a sling, and was deprived of its
use to some extent for several months. Under these cir-
cumstances the cempany refused to pay the policy, and in
a lawsuit the court declared they need not pay it.
Two reasons were given for this adverse decision. The
first was that the accident did not prevent his carrying on
the business of a “retired gentleman,” and the reasoning
will make most retired gentlemen wish they were some-
thing else, provided their dependence is placed upon a re-
covery under an accident policy. The court said: “ Can
it be said that a man with his hand in a sling, and suffer-
ing a degree of discomfort from a painful wound in that
member, is wholly disabled and prevented from the prose-
cution of every kind of business pertaining to the condi-
tion of a retired gentleman? The question is one which
does not seem to admit of much discussion, but it would
be easy to suggest many duties and even pleasures, per-
taining to the domestic, social, and business relations of a
retired gentleman, from which he would not be wholly de-
barred by a disabled hand. He might still, it would
seem, keep an eye upon his investments, collect and dis-
burse or reinvest his income, attend the meetings of
the boards of directors of which he was a member,
superintend repairs and improvements upon his prop-
erty, and generally devote considerable attention to the
care of himself, his family, and his estate.” The “ retired
gentleman” must have, however, it appears, no accidents,
for he cannot be protected against them, unless the dis-
ability is so entire that he could not even advise about
his property. ‘he second reason given by the court is
that operating a buzz-saw is not the ordinary occupation
of a “retired gentleman,” and that if he voluntarily placed
himself in such a position that he might come in contact
with its rapidly revolving periphery, he had only himself
to thank for any injury that might follow. He could not
share his sufferings and sorrows with the insurance com-
pany. The policy, it seems, only permits a loss to the
company when the injury is incurred in carrying on the or-
dinary occupation of a person. But as a “retired gentle-
man” has no very accurately defined occupation, it is dif-
ficult to see how there could ever be a loss which the
company would pay. Possibly, if the “ retired gentleman ”
were injured in some remarkable manner by the scissors
with which he was cutting off his coupons, he might be
able to recover; but if he were run over while passing
along the streets he might be unable to get a cent, for how
is it part of the occupation of a retired gentleman to be
on the streets at all? Such refinements as these seem
highly absurd, and if a person can get no protection from
accident policies under like, or even somewhat different,
circumstances, it would be well to let the accident com-
panies alone.
How, indeed, can a railroad accident have anything to
do with the occupation of a dry-goods clerk? Is not his
occupation continually behind the counter, and what busi-
ness has he ever to go on a railroad train? We wonder
428
THE MEDICAL RECORD.
[October 19, 1889
how accident insurance companies can get business if
they hedge themselves in from any possible loss by such
conditions. ‘The Indiana Supreme Court holds that
shaving on Sunday is not a work of necessity, and is-
therefore illegal when performed for pecuniary compensa.
tion. This was the decision in Indiana fifty years ago,
and the court holds that the reasoning and the conditions
of life are the same now as then.
What constitutes necessity is well stated as follows:
“ The law contemplates that the community has a gen-
eral need that all should rest on Sunday. Most of the
affairs and doings of week-days are less important than
this need of a rest-day, but some few are superior. To
keep the body physically sustained by food; to provide
the facilities for worship during some hours of the day,
and for restful mental occupation during others ; to nurse
and heal the sick ; to provide prompt burial for the dead ;
these and some other objects are superior to the need of
general repose. Necessary work includes all that is in-
dispensable to be done on Sunday in order to secure the
attainment of whatever is more important to the com-
munity than its day of rest.”
The law of nuisance has been invoked many times to
prevent an exceeding variety of acts, sounds, or smells, and
every little while some new word is added to the long
catalogue of nuisances actual or alleged. Some which
have occupied the attention of the courts are steam
whistles, squealing of pigs, bleating of sheep, singing, ring-
ing of bells, playing of pianos, hand-organs, and brass bands,
tenpins, trundling of baby carriages, beating of drums, blow-
ing of fifes, hammering of anvils, children at school, etc.
One of the latest cases, and one of the most curious, is
found in the English courts, and the object was to pre-
vent a gentleman who was suffering from softening of the
brain, and who was a rather noisy invalid, from living next
door to a boarding-house.
The court decided, however, that noisy invalids require
attention and must have some place of shelter or home.
It was said by the judge: “I have not been able to dis-
cover any precedent which is precisely applicable to the
state of things presented by this case. Sick people must
live somewhere, even if they make a noise. When we
consider how the great majority of people in this country
have to live, and in what houses, it would be absurd to
hold that a man or woman who had a painful wound,
and who screamed when it was dressed, or that a hysteri-
cal woman, or a person subject to fits during which he
makes a noise, was only to live in an isolated house, or
one the walls of which are of a certain thickness.” There
are some noises we must pu‘ up with, such as the playing of
a neighbor’s piano, or the noise of children in the nursery,
and now it would seem that sick persons in a neighbor’s
house must be added to the list.
Physicians do more travelling in carriages than almost
any class of persons, and they are therefore interested in
many cases of damages for street runaways, and accidents
occurring through excavations on the highway.
In a recent case in West Virginia, a horse driven by a
physician fell into a hole near the travelled track of the
street, and the question was whether the city of Hunting-
ton was liable in damages, the hole being unprotected and
not marked.
The evidence was quite conflicting, but the vital part
was contained in the physician’s own testimony. He said
“that he turned short in Third Avenue, and drove across
the sidewalk for the purpose of hitching horse and buggy
to the fence on a lot by the side of the house he was
going to, which fence was outside the line of the street,
and some thirty feet from the north line of the street, and
he knew he was driving toward the fence.” The court
held that the point was whether Dr. Beardsley was in the
street which the authorities were under obligation to pro-
tect, or had left it for his own convenience and without
necessity. The jury in the first instance decided in favor
of the doctor, but the appellate court reversed this de-
cision and held that he must bear his own loss.
THE PROPOSED NEW LUNACY LAW.
By FREDERICK PETERSON, M.D.,
FORMERLY FIRST ASSISTANT PHYSICIAN AT THE HUDSON RIVER STATE HOSPITAL
FOR THE INSANE, POUGHKEEPSIE, N. Y.
Tuts lunacy bill, drafted under the advice and direction
of a committee of the National Conference of Charities,
the chairman of which was Dr. Stephen Smith, ex-com-
missioner in lunacy of New York State, was introduced
into the Legislature at Albany last winter by Mr. Gallup.
It passed both the Assembly and the Senate, and would
have become a law had not the Governor failed to affix
his signature to it. As the same bill is to be reintroduced
at the coming session, it is well that medical men in gen-
eral should become acquainted with its more important
features.
There is much to reform, much to improve, in existing
lunacy laws, and most of the provisions of this bill are so
excellent and. admirable that it is to be hoped they will
be favorably acted upon within the year. |
The method of commitment of the insane to institu-
tions contemplated by this bill is the only portion upon
which there can be any discussion as to its advisability, and
that point will be last considered in this article.
The really invaluable features of the new measure are,
in brief, as follows :
Removal to Asylum.—It is provided that attendants of
the same sex as the patient shall accompany the insane
person to the institution. ‘This applies more particularly,
of course, to cases upon public charge. Under the pres-
ent system, it has been my misfortune to see many a fe-
male patient brought to the asylum by one or more half-
drunken deputized officials.
Voluntary Patients.—It is not uncommon for an insane
person, cognizant of his mental condition, to desire to
enter an asylum voluntarily. Under existing laws he can-
not do so without recourse to the usual two medical cer-
tificates approved by a judge; and although easy to get
in in this way, there may be difficulty in getting out. The
new bill provides for the admission of such a case upon
his written application, together with a corroborative cer-
tificate of his family physician; and he can leave the asy-
lum at any time upon giving six days’ written notice to
the asylum superintendent, and two days’ notice to the
family physician who recommended his voluntary com-
mitment.
Emergency Cases.—Patients requiring immediate care
and protection can be received by institutions for three
days without procedure of any kind by provision of
the new bill. The evil that has resulted from the lack
of such provision in our present laws is well known to
asylum physicians and to those who have had to do with
the commitment of suicidal, homicidal, violent, destruc-
tive, and nearly moribund cases, which, because of some
trivial defect in the medical certificates, could not be le-
gally received at asylums, and have been either returned
to their homes or spent a night in a poor-house or jail
until the flaws in the papers could be remedied.
Confinement of the Insane in Jails.—It is common in
country-districts for a disturbed case to be placed tempo-
rarily in jail, often along with criminals, where he may,
however, be detained for an indefinite period. The new
bill forbids his confinement in the same room with crim.
inals, and limits the detention to ten days at furthest.
Home Furloughs for Asylum Cases.—Under the exist-
ing law no provision has been made for patients who may
be benefited by occasional visits at their homes during the
period of their stay at the asylum. But in some institu-
tions in the State, visits of ten days have been granted by
the superintendents, on the ground that the medical cer-.
tificates are legal for that period of time. I have known
patients returning on the eleventh day, to be refused re-
admission without new certificates. The new measure
arranges for furloughs of indefinite duration, according to
the discretion of the superintendent of the asylum, the
October 19, 1889]
commitment papers remaining in force during the whole
of such leave of absence.
The Boarding-out System.—The boarding out of i insane
persons in private families at the expense of counties is
permissible under the Gallup Bill, the superintendents of
the poor to be fully satisfied of the good character of such
familes, and to visit the patients every three months. This
applies more particularly to chronic cases taken from asy-
lums, the superintendents of which must furnish a certifi-
cate as to the adaptability of the patients for care of this
nature. This system is successfully practised in Scotland,
some Continental countries, and in Massachusetts.
The above are the most important and valuable features
of the Gallup Bill, and will appeal to everyone having at
heart the welfare of the insane.
Commitment to the Asylum.—The manner of commit-
ment contemplated in the new law is, in my opinion,
positively harmful. The following is an outline of the
method proposed :
When a person becomes insane, and it is necessary that
he should go to an asylum, a justice of the peace, super-
intendent of the poor, or some judge of a court of record
must be formally notified in this wise (Form B) :
To Esquire, one of the Justices of the Peace of the
Town of in the County of , State of
Sır: Your informant respectfully represents that one
residing at is insane and a fit subject for
custody and treatment in a Hospital for the Insane, be-
cause ; and he therefore asks that the necessary
steps be taken to investigate condition, as the law
provides in such cases.
Whichever one of these officials has been notified then
directs two physicians (in all probability political adherents,
who will be thus rewarded for partisan services) to exam-
ine the alleged insane person, and report to him within
one day, exclusive of Sunday, the result of the examina-
tion. ‘The order issued to the physicians to make such
investigation is as follows (Form C) :
STATE OF
?
COUNTY. l OFFICE OF THE
To , a legally qualified physician and Examiner
in Lunacy, of County, State of
Information in due form of law having been laid before
me, alleging that one residing at is insane,
and is a fit subject for custody and treatment in a hospital
for the insane, you are hereby appointed to visit or see
said person, and make a personal examination touching
the truth of such allegations, and touching actual
condition.
The physicians make each an exhaustive report accord-
ing £0 a form provided for in the bill, too long to repro-
duce here, but to the thoroughness of which none can
have objection, since the usually meagre details of our
present certificates are as a rule decidedly unjust to the
patient and useless to the asylum physicians about to un-
dertake his treatment and care.
If the physicians report the patient not insane the case
is dismissed ; but if they find him insane and a proper sub-
ject for commitment, and make their report to a justice of
the peace or to a superintendent of the poor, such official
must himself also personally visit the patient and certify
to the correctness of the proceedings and to his personal
visitation, and must then deliver the medical certificates
to a judge of a court of record within two days with the
following certificate of his own (Form E) :
To the Hon. , Judge of the
County of , State of
Sir: 1 transmit herewith to you two medical certificates
of insanity, in the case of , in the Town of
in the County of , State of , made respec-
tively by , M.D., and , M.D., Medical Exam-
iners in Lunacy, qualified i in accordance with the laws of
Court, in the
THE MEDICAL RECORD.
429
this State, and acting under Commissions severally issued
by me. I hereby certify to the correctness of these cer-
tificates and approve of their finding, which I have verified
by a personal examination of said
, Justice of the Peace.
,18 +
Upon receipt of these three papers, the judge “ may or
may not visit the alleged insane person, or require that he
be brought into court,” but must state, in the order of com-
mitment he then makes, whether he saw the patient or
not, and if not, his reasons therefor. He may take
further testimony or call a jury at his discretion. His
order must read thus (Form F):
STATE OF ;
County. Í OFFICE OF
To the Superintendent of the for the Insane.
On the receipt of the certificates of two duly qualified
examiners in lunacy, transmitted by , Esquire,
one of the justices of the peace of the ‘Town of
in the County of , certifying to the insanity of
of the Town of , and approved by the
said justice, by whom said was personally visited
and examined, I have seen and examined said
respondent alleged to be insane, because it was not
deemed necessary or advisable to do so, for the reason
that ; and said respondent has been duly notified
of proceedings taken inh case and of the time and place
appointed for hearing, and had an opportuity to be heard
thereon. The motion to take further testimuny or to
have a jury summoned was denied for the following
reasons :
It appears to me, upon a full hearing and considera-
tion, and upon evidence, statement, and certificates re-
quired by law, that a respondent is an insane
person, and a proper subject for the treatment
and custody of , a State insane asylum; and I so
find. Therefore, it iS ORDERED that e be committed
to the , there to be detained until discharged ac-
cording to law.
, Justice of the
This order must be issued within five days after the
last medical certificate. But before issuing this order,
the judge is required to cause the alleged insane person to
be fully informed of “ the action about to be taken against
him” (against him, forsooth, as if it were not for him, as if
he were a malefactor instead of an invalid) and presum- ©
ably such notifitation must be served personally upon the
patient by a police officer deputized by the court.
In addition to the order to incarcerate the culprit in
the psychopathic hospital, the judge issues a warrant either
to the hospital superintendent or a proper county official
to remove the offender to the institution he designates.
If the warrant be issued to the former, he must send from
the asylum attendants to convey the patient to the institu-
tion. When received, the medical officer of the hospital
notifies the judge of the date of admission, persons at-
tending the patient, etc., which paper the judge must
cause to be filed with the commitment papers by the
county clerk.
~ A brief summary of the steps in the complicated pro-
cess may be presented thus :
1. A formal paper is made out by somebody (family
physician ?) notifying a public officer that a person is in-
sane, and requires asylum care.
2. The official directs two physicians (very likely politi-
cal on-hangers), in a formal paper to each, to examine the
patient.
3. The two physicians make out two documents certify-
ing to the insanity.
4. If said official be a justice of the peace or superin-
tendent of the poor, he, too, must visit the patient, ascer-
tain if the doctors were correct in their diagnosis, and, if
so, approve of their finding and make out a formal paper
430
certifying to these facts. He then presents the three
papers to a judge of a court of record.
5. The judge, if he does not care to bother about
‘bringing the sick man into court, visiting him himself, or
‘trying him by jury, merely makes out three more papers—
‘one to be served upon the invalid, one an order com-
mitting him to some institution, and one a warrant for his
transfer to the asylum.
6. Then the asylum officer gives formal notice to the
judge of the receipt of the patient, and the judge must
file this paper with the county clerk.
q. The judge must cause copies of the medical certifi-
cates tọ be filed in the office of the county clerk. He
must also take proof as to the estate of the insane person,
and file a certificate as to these facts with the clerk of the
county.
Thus the papers requisite to the procedure are thirteen
m number—one furnishing information of insanity ; two
notices to physicians; two medical certificates; two
copies of the latter; one certificate from justice of the
peace or poor-superintendent to judge ; one notification
to patient from judge ; one order of commitment; one
‘warrant for transfer to asylum; one notification of re-
ceipt of patient at the institution ; one certificate as to
patient’s estate.
This may be slightly simplified by avoiding the justice
of the peace and superintendent of the poor, and having
‘a judge of the court of record first informed of the insan-
ity, which will reduce the number of documents to twelve
-only, and, what is still more important, will dispense with
-one more annoyance to the sick man, viz., the personal
visit of one of these officials. l
To me the proposed law is somewhat confusing on one
important point. I cannot quite clearly apprehend what
becomes of the original medical certificates. The copies
-are to be filed with the county clerk. Nothing is said
-about the originals accompanying the patient to the asy-
Jum, which they surely ought to do; possibly their dis-
posal has been forgotten in the multiplicity of details.
One’s first query on looking over the Gallup Lunacy
Bill would naturally be, “ Is a sick man to be treated as
if he were a criminal?” When his abdominal or thoracic
viscera are acutely affected, and hospital treatment is
required, he. can be transferred without delay to the
gentle ministry of a sick-ward ; but when the most deli-
cate organ of his body is diseased—his brain disordered—
he must suffer visitation from two strange physicians, a
public officer, and a policeman with a legal notification of
. his being a lunatic about to be taken to an asylum. It is
unmerciful. It is pernicious. The law.upon commit-
ment is difficult enough of execution in its present form,
and the truth is that the treatment of diseased brains in
hospitals for the insane should, if anything, be rendered
easier of attainment. Isan insane man an outlaw, to be
thus treated, or rather maltreated? Rather make the ac-
cess to asylums easy, and egress still more easy, and no-
harm will be done by wrongful detention! Rather throw
open the general hospitals also to the curable insane, as
they have recently done in far-away Victoria, Australia.
It is clearly to be seen that the framers of this law had
in mind only the protection of a few cases, such as are
often (generally unwisely) freed from asylums on writs
of habeas corpus, and the prevention of the possible in-
carceration of a sane person in ar asylum, But it is a
narrow view to have this only in mind. To protect one
doubtfully insane person, who is more than likely a troub-
lesome paranoiac, nine hundred and ninety-nine are made
to suffer.
‘That commitment upon the certificates of two physi-
cians, sworn to, and approved by a judge, as now prac-
tised, is an efficient obstacle to the wrongful confine-
ment of a sane person is attested by the fact that no sane
person has ever been sent to an asylum in this State against
his will. It is no argument to adduce the cases of “‘ Nellie
Bly” and other reporters, as has been done, who, for the
_aske of writing sensational newspaper articles, have sought
THE MEDICAL RECORD.
[October 19, 1889
entrance to institutions for the insane. Such persons
would need but exercise a little more patience to run the
gauntlet of åll the provisions of the Gallup Lunacy Bill.
I need but quote the following from a recently printed
letter of Dr. John B. Chapin, who for many years was
connected with asylums in this State :
“ I have been familiar with admissions to four asylums
for the insane during portions of thirty-four years that I
have been connected with them, and I have never known
of a single instance of the intentional commitment of a
sane person as insane, nor of a single attempt to make
such commitment ; and I have no cases to report a8 com-
ing within my personal knowledge.”
And Dr. J. B. Andrews, superintendent of the State
Asylum at Buffalo, formerly first assistant physician at
Utica, writes:
“It has never been my misfortune to find in any case
an effort on the part of medical men to declare a man
insane and commit him to an asylum from any improper
motive.”
Here is the opinion of Dr. G. Alder Blumer, the pres-
ent superintendent of the Utica Asylum, as to the adequacy
of the law now in force:
“ The present lunacy statute “of New York State, if fully
and conscientiously complied with, affords sufficient pro-
tection, in my judgment, against improper commitment.”
Let the truly superior qualities of the Gallup Lunacy
Bill, as above described, be amalgamated with the existing
law as to commitment, and we shall have advanced a long
step toward perfection in the elaboration of humane meas-
ures with regard to the insane.
aor West Firry-rourtTH STREET, New YORK.
@iinical Department.
ANTIFEBRIN IN THE TREATMENT OF HEAD-
ACHES.
By HARVEY B. BASHORE,
WEST FAIRVIEW, PA.
ABOUT a year ago I began a study of the analgesic effects
of antifebrin in the various headaches, and my treat-
ment has been so gratifying that I wish to record it. In
headaches of the nervous type, in facial and supra-orbital
neuralgias—not very severe—lI prescribe five grains e
half-hour, and in severe cases I give ten grains, to be fol-
lowed by a similar dose in three-quarters of an hour, if
necessary ; to be most effectual, the dose must be grad-
uated according to the severity of the case and the pecu-
liarities of the individual, and when this is accomplished
the administration of the drug becomes very safe and its
effects exceedingly reliable. Of five hundred or more
cases of these affections which I have treated I have given
relief to all but a few, snd in most cases the entire dis-
appearance of pain followed the administration of the
remedy. But it is in sick headaches that antifebrin seems
to me to be the best of all remedies, not even excepting
antipyrin, which I have used with excellent success ; an-
tipyrin will do well enough in the prodromal stage, but
in the later stages may cause gastric disturbances and
provoke that distressing symptom rather than allay it;
in simple migraine, antifebrin is, I think, the remedy in-
dicated, and if given in the beginning will almost certainly
abort an attack. I have treated fifty cases at least of pure
migraine, and I know of no failure to ameliorate the symp-
toms when the drug was properly administered, and here,
too, the dosage is important; in the prodromal stage of
an ordinary attack, five grains every half-hour was gen.
erally sufficient—if the case was further advanced, large
doses at longer intervals are better, such as ten or fifteen
grains every hour for two or three doses. If there is much
gastric disturbance the dose should be placed directly
upon the tongue and very little liquid used in taking it;
but it must be remembered that antifebrin will not so
October 19, 1889]
much cure an attack as abort it, hence the necessity for
the early administration of the drug. I may add that I
have lately used phenacetin as an analgesic, but found it
in no way superior to antifebrin.
In regard to acetanilid-poisoning, I have only noted it
once in all my cases, and in that instance a much larger
dose than prescribed was taken. From my year’s work,
then, and its results I conclude that antifebrin is
1. A most effectual analgesic for headache.
2. The remedy, par excellence, for sick headache.
3. And that, when used with the precautions neces-
sary in the use of all drugs, it is absolutely without danger.
SNAKE-BITE AND ALCOHOL.
By HOWARD H. HOPKINS, M.D.,
NEW MARKET, FREDERICK COUNTY, MD.
On August 16th I saw a colored child, four years of age,
who, the day before, had been bitten three times on the
leg, between the ankle and knee, by a copperhead snake
(Anctstrodon contortrix).
The snake measured thirty-seven and a half inches.
Two of the wounds showed the imprint of but one
fang ; the other one showed the marks of both fangs.
The mother told me she had given the child, just after
it had been bitten, about half a pint of common whiskey.
At the time of my visit the leg was much swollen and
very painful; the effect of the whiskey was beginning to
disappear, and, as the heart’s action was good, I directed
the application of cloths, wrung out in hot water, to the
limb, but gave no medicine. In four days from the re-
ceipt of injury the child was running about as usual, and
the swelling had almost entirely disappeared.
Being much interested in the effects produced by snake-
bite, I made the inquiry, several years ago, among a num-
ber of the older physicians of this (Frederick) county,
some of whom had been in active practice for over fifty
years, and I could not find one who knew of, or had ever
heard of, a well-authenticated case of death from snake-
bite.
The only poisonous snakes in this section are the rattle-
snake and copperhead.
Those cases of snake-bite occurring in my own prac-
tice have always responded promptly to moderate
stimulation (alcohol or ammonia), and I am very much
inclined to believe the guanżity (to say nothing of the gual-
ity) of the whiskey generally given before medical aid
arrives is frequently responsible for the alarming symp-
toms occasionally met with, rather than the venom, which,
in this country at least, I believe is rarely injected in
sufficient quantity to prove dangerous to life, unless it is
received immediately into a vein.
I shall be under obligation to any of your numerous
readers who will kindly furnish me with cases known to
them where death has Hes Hee from snake-bite.
THE DANGER OF ANTIPYRIN.
A CORRESPONDENT, H. B., writes: “I wish to report a
case of antipyrin-poisoning that lately came under my
observation, and enter a protest against its general and
indiscriminate use by the public.
“The patient, Mrs, A——, had taken thirty grains of the
drug, in three equal doses, six hours apart, for the relief
of a facial neuralgia, as she had occasionally done before
without any untoward effect. I found the patient half an
hour after the third dose was exhibited (which, by the
way, was taken at the soda-water counter in a druggist’s)
in a condition approaching coma. ‘The train of symp-
toms that occurred in the ensuing hour seemed all out of
proportion to the amount of the drug administered: tem-
perature, 103° F.; vertigo, chill, marked convulsion,
nausea and vomiting, and decided impajrment of respira-
tory function. On cessation of these fees the pa-
THE MEDICAL RECORD.
431
tient complained of her eyes feeling like live coals burning
in their sockets. The heart’s action during this time was
in no way disturbed. Ought not the sale of this drug to
be prohibited, except by prescription ? ”
Brogress of Medical Science.
THE TREATMENT OF Eczema.—Dr. Unna says that, .
even before the experimental cultivation of bacilli, exact
clinical observation had distinguished a number of entirely
different types of eczema, and he thinks that each differ-
ent type will be found to require a different mode of treat-
ment. The type most frequently seen in Hamburg is
seborrhoeic eczema, and the parasite causing it is the same
which in the first instance produces pityriasis capitis.
Those persons who suffer from seborrhoeic eczema of the
head, including those affected with pityriasis capitis, are
apt to suffer from the same kind of eczema on other parts
of the skin. Dr, Unna has repeatedly pointed out that
we possess a series of valuable remedies for the treatment |
of seborrhceic eczema in all its forms—viz., sulphur,
resorcin, chrysarobin, and pyrogallol. Of these remedies’
resorcin is the best, as being the least likely to produce
local or general ill effects. It may also be used in an
‘alcoholic or watery solution, or in the form of ointment,
paste, soap, or powder. Dr. Unna’s favorite formula is a
solution of three drachms of finely powdered resorcin,
with an equal quantity of glycerine, in six ounces of
spirits of wine, diluted with four times the quantity of
water or camomile-tea, A thin layer of cotton-wool well
moistened with the solution is applied, covered with some
waterproof material, and fastened by a bandage. These
applications are particularly useful when the treatment is
prolonged, or when it is carried out by night. They are,
of course, impossible in general eczema of adults, but not
in that of infants. Dr. Unna describes an especially im.
portant effect following the application of resorcin#~viz.,
a swelling of the epidermis, by which all painful fissures
are healed in a single night. In order to insure healing,
he advises that the skin should be anointed after the re--
moval of the bandage, and that washing with soap should
be avoided. A few people suffer from a resorcin idiosyn-.
crasy which necessitates the immediate cessation of this
treatment, and the application of powder to the affected
parts. This idiosynctrasy is, however, very rare, as he has
only met with it ten times in five years observation, dur-
ing which time he has seen two thousand cases. He re-
marks that his treatment is not adapted to those cases
of long-existing eczema in which strongly infiltrated or
thickly indurated patches occur.— Zhe Lancet.
DiTHI0-SALIcyLic AciD.—While working in the chemi-
cal laboratory of the Society of Physicists in Frankfort-
on-the-Main, Herr H. Baum, chemist, recently discov-
ered a substance which is likely to compete with salicylic
acid as a remedy and antiseptic. ‘This new substance,
dithio-salicylic acid, consists, as it were, of two molecules
of salicylic acid concatenated into one molecule by two
atoms of sulphur (Zhe Lancet). The well-known bacteri-
ologist Professor Hueppe, of Wiesbaden, has ascertained
that a twenty per cent. solution of sodium-dithio-sali-
cylate kills anthrax spores.in forty-five minutes, whereas
sodium-salicylate under the same conditions has no per-
ceptible effect. Its effect on chplera and typhus bacteria,
on the bacterium of green pus, and on the staphylococ.
cus aureus, is much stronger than that of sodium-salicy-
late. Sodium-dithio-salicylate II. (there is a similar sub-
stance called sodium-dithio-salicylate I.) has been tried in
many cases of acute rheumatic fever in Dr. Knoblauch’s
wards in the city hospital of Frankfort. In the slighter
cases a dose of three grains was given every morning and
evening ; in the severer ones the same dose every mom-
ing, and two, three, or four times an hour every evening.
In slight cases pain, fever, and swellings disappear after
two days; in severer ones, after six days at most. As
432
compared with sodium-salicylate, sodium-dithio-salicylate
possesses the following advantages: Stronger effect and
consequent adequacy of smaller doses, no bad effects on
stomach, heart, and vessels, no collapse, no humming in
the ears. A Frankfort physician had given a patient, who
was suffering from acute rheumatic fever, six ounces of
sodium-salicylate without any essential alleviation. He
then tried the new remedy, giving the patient four doses
of three grains daily, which cured him in five days.
THE GERMICIDAL ACTION OF BLoop.—Drs. Nuttal and
Buchner (“ Ueber die bacterientédtende Wirkung des zell-
enfreich Blutserums,” Centralblatt für Bakteriologie und
Parasitenkunde) have added materially to our knowledge
of the germicidal action of blood. Both defibrinated and
freshly drawn blood manifest a decidedly deadly action
upon bacteria, for more than four hours after it has been
drawn from the body. This is most marked toward the
pathogenic bacteria. For example, the number of an-
thrax bacilli in a given quantity of material was reduced
in two hours from 4,800 to 56 by being mixed in a test-
tube with defibrinated blood; and three hours later only
three living bacilli remained. Almost as remarkable a
germicidal influence was manifested toward other patho-
genic bacteria. The destruction of putrefactive bacteria
1s, however, much less marked, and against some of them,
at least, the blood manifested little germicidal influence.
This is in accord with the latest ideas of the origin of
parasitism. These investigations open up a new field of in-
quiry and thought, which promises a reorganization of our
ideas of infection. We are brought back to consider
the anitnal body a colony of individual cells, the integrity
of which, when attacked by parasitic bacteria, depends
upon the issue of the struggle for existence between in-
dividuals of the invading parasites and the individual
cells of the body.— The Journal of the American Medical
Association.
Tue First SouND OF THE HEART.— Dr. Krehl, from
investigations conducted in the Physiological Institute of
Leipsic, has arrived at the conclusion that the contraction
of the cardiac muscular fibres is the principal cause of the
first sound, instead of being, as is now generally admitted,
merely an accessory cause, or, as some will have it, en-
tirely inoperative (Zhe Lancet). The part played by each
of these factors in the production of the sound can only
be finally determined when the intensity of the full sound
is ascertained, as well as the intensity of the several pos-
sible factors. But the difficulties of the case are well
known ; for while, on the one hand, the systole of the
heart is found to consist of a single and sudden contrac-
tion, which it is held can produce no sound, since it pro-
duces only a single wave, and while it is rendered indis-
tinct by the incompetency of the auriculo-ventricular
valves, on the other hand, such experienced observers
as Ludwig and Dogiel have satisfied themselves that under
circumstances in which the sudden tension both of the
auriculo-ventricular valves and of the vascular walls is
impossible the first sound is still indubitably audible,
from which it would appear that one, if not the chief,
agent in its production is the muscular sound. The re-
searches of Krehl were undertaken to test the truth of
Ludwig and Dogiel’s observations under conditions in
which the play of the valves was still more stringently
prevented, and this he believes he has accomplished by
the employment of an ingeniously constructed little ap-
paratus, consisting of a tube, from the extremity of which
an expanding crown can be protruded, and by this means,
when the instrument is introduced into the cavity of the
heart, the valves can be firmly pressed back against the
walls of the arteries. The animals used were dogs, and
while after the insertion of the instrument one observer
auscultated the heart, another alternately pressed in and
withdrew the crown. The results obtained were that
when the auscultator knew that the crown was thrust out
and the, valves compressed against the arterial walls, he
perceived that the systolic sound was duller and a liftle
THE MEDICAL RECORD,
[October 19, 1889
less strong; but when with averted face he was unaware
of the position of the crown, he was unable to distinguish
any difference between the periods when the valves were
acting and when they were not acting. This result ob-
tained incidental confirmation by the fact that in all in-
stances as the animals bled to death the second sound
disappeared, while the first sound was still for some time
distinctly audible ; and additional evidence is to be found
in the circumstance that, when in such cases the ventricle
had ceased to contract and the auricle alone acted, a
sound was clearly perceptible—that is, when the play of
the valves had certainly ceased. He does not consider
that he has been able to determine from his investigations
whether the cardiac contraction is a simple convulsion or
a tetanus, but he thinks that the sound may arise from the
friction of the muscular fibres against each other; and
this is supported by the observation or Dr. MacWilliam,
that a sound is audible on simple convulsion or spasm of
the voluntary muscles.
DIETETIC TREATMENT OF BRIGHT’S Diısease.— The
treatment of chronic renal affections by special forms of
diet has recently been the subject of a series of investiga-
tions by Professor Schreiber, of Königsberg, whose results
are of some interest in view of the present position of the
question. He traverses Senator's statement that one ought
in cases of albuminuria to forbid the use of eggs, holding
that their injurious influence is open to question (Zhe
Practitioner). He took for the purposes of experiment
eight people suffering from kidney disease, to whom he
gave along with their ordinary diet six to ten eggs daily.
Before the beginning of the experiment they had been ure
der observation from four to eight days, on the usual diet,
until the fluctuations in the amount of albumen in the
twenty-four hours had been determined’; the estimations
being likewise made for several days after the eggs were
discontinued. In four of the cases the eggs were admin-
istered boiled ; in the others, raw. In the former group,
the patients received six eggs daily, and in none of them
during the period of administration of the nitrogenous
food could any fluctuation or increase in the amount of
albumen be determined. In the second group, six to ten
raw eggs daily not only did not show an increase in the
excretion of albumen, but actually led to a considerable
diminution. Similar results have also recently been re-
corded from Leyden’s wards. ‘These observations also
agree with those of Oertel, who has stated that the addi-
tion of a great quantity of albuminous food may affect
albuminuria favorably. Schreiber maintains that none of
the three forms of diet—mixed, meat, or milk—appears to
be capable of influencing constantly and unmistakably the
excretion of albumen in kidney disease—a result, he thinks,
although really negative, to be nevertheless received with
satisfaction when one considers that patients can never
stand for any time a one-sided diet. In discussing the
question how a patient suffering from Brght’s disease
ought to be dieted, Schreiber recommends that to an ordi-
nary mixed diet should be added fluid or coagulated albu-
men, meat and other nitrogenous substances, and as there
is not less albumen passed under a pure milk-diet than
under a nitrogenous one, it succeeds better to combine
the two and adds to the body-weight. A special diet for
Bright’s disease is not in the least indicated ; it ought to be
founded on the broadest basis, bearing in mind that the
disease is an affection gradually and steadily consuming
the bodily strength; while the forms of diet should be
given according to the want and necessity, and without
the unjustifiable and exclusive endeavor to compensate or
change the loss of albumen by the urine.
DANGER IN SILK THREAD.—Silk thread is soaked in
acetate of lead to increase its weight, and persons who
pass it through the mouth in threading needles, and then
biting it off with he teeth, have suffered from lead poi-
soning.— Sanitary News. |
October 19, 1889]
THE MEDICAL RECORD.
433
THE MEDICAL RECORD:
A Weekly Fournal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., EDITOR.
aeee
PROPRIETORS AND PUBLISHERS
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
New York, October 19, 1889.
THE DISEASED-MEAT SCARE.
"THE Nineteenth Century recently published as its pièce
de résistance an article on the diseases conveyed by
butchers meat. The author, Dr. Behrend, is unknown
to us as a pathologist or sanitarian, but he seems to have
collected industriously all the facts obtainable regarding
tuberculosis of cattle and the dangers to human beings
of infection therefrom. He quotes a statement recently
made before the Berlin Medical Society to the effect
that in-some parts of Germany one-half the cattle are tu-
berculous; and adds that the only Continental town in
which “a systematic inspection of all dead meat is en-
forced” is Hanover, where a careful examiration of the
various organs is made by experts who are continuously
employed, and meat cannot be sold unless it bears a
stamp affixed by them. In one month, at Hanover, 8,000
pounds of meat were condemned as tuberculous.
Eight thousand pounds means, however, only nine or
ten cows. ‘“ But,” says Dr. Behrend, “if we apply the
Hanoverian standard, we shall find that 7,500 head of
cattle thus affected are eaten by Londoners every year,
and that, at the ordinary rate of computation, at least
375,000 of the inhabitants of the metropolis run the risk
of being tainted with consumption.”
Now all this is very interesting and important, and Dr.
Behrend’s article has excited much talk and learned edi-
tonal writing in the daily press. But it is yet entirely
unproved that the meat of tuberculous cattle ever caused
tuberculosis in man. Bovine tuberculosis is generatly
pulmonary. Tuberculous bacilli are found sometimes in
the glands, but practically never in blood or muscle, ex-
cept in acute general infection. Evenif the bacilli do get
in meat-muscle, Nocard, who is an ingenious and skilful
bacteriologist, has shown that they are destroyed or di-
gested in the tissue. And Nocard has positively affirmed
that one can safely eat the. flesh of tuberculous animals
the tubercles of which are limited to the viscera and lym.
phatics. High temperatures destroy the bacillus also, and,
therefore, thorough cooking would make even tuberculous
tissue safe.
Dr. Behrend ought to know, also, that tuberculous meat
can only infect the body through the alimentary tract ;
but Koch has shown that adult bacilli are destroyed in
the stomach, and that the spore bacilli can only get
through alive by a narrow margin.
But, furthermore, if tuberculous meat were so danger-
ous there should be more primary intestinal tuberculosis
In adults this disease is a great rarity, and, practically, it
may be ignored. Even including infants, it does not make
up ten per cent. of tubercular diseases.
We venture to say, therefore, that the 375,000 Lon-
doners who possibly ate the presumably tuberculous meat
digested it and its bacillus, and were the better for their
repast. It must be very evident, we think, that the
danger to adults from eating flesh of tuberculous cattle
is so extraordinarily remote that it may be practically
ignored. The liver, “ lights,” and glands of such cattle,
however, are perhaps not so safe, and sausage made up
from meat seriously affected may not be free from
danger. We advise, therefore, as we have done, the
governmental inspection of slaughter-houses ; but we
much more seriously urge the supervision of milk. This,
it is known, can carry the tuberculous virus, and, being
consumed uncooked by delicate and growing children, is
a far more dangerous product than the flesh of tuber-
culous cattle.
THE CORONER SYSTEM.
EFFORTS are periodically made to abolish the coroner sys-
tem in thisand other States. These efforts have not been
entirely futile, for they have caused the remedying of some
abuses and have, perhaps, educated the people a little
upon the question. | |
The last attempt to upset existing metho ls was made,
we believe, by the Medico-Legal Society aid Mr. Clark
Bell in 1881. At that time the evils of te present cor-
oner system, the political corruption, the gross stupidity
and ignorance often shown in connection with its work-
ings, were depicted, and our State Medical Society was
asked to take some action in the matter. No material
changes, however, were secured. |
Lately the Society of Medical Jurisprudence has taken
the subject up, and we learn that a committee has been
appointed to investigate the matter.
The trouble heretofore has been that the State Consti-
tution has stood in the way. This requires that each county
appoint four coroners, and, with the powerful author-
ity of this instrument to back them, adherents of the pres-
ent system seem to have easily defeated attempts at reform.
It has been shown, however, that the Constitution,
while calling for four coroners per county, does not ex-
plicitly lay down or limit their duties, and it is quite
possible tor the Legislature to arrange details so as to
make their duties very slight and limited to other things
than the examination of cases of sudden death. ‘These
latter duties, together with such others as are cognate,
could be easily given by legislative action to medical ex-
aminers, as has been done now in Massachusetts for over
ten years.
THE DEADLY CURRENT.
Tue death, within a short time, of three men by the elec-
trical current has justly aroused a great deal of public
excitement; and it is a grim commentary on the state-
ments made not long ago regarding the uncertainty of
electricity as a lethal agent.
In the indignation occasioned by the recent accidents,
it is well to bear in mind that there are two sides to the
question of electric-light currents, and that by carrying
out measures for public safety too stringently an impor-
434
THE MEDICAL RECORD.
[October 19, 1889
tant and useful industry may be crippled. It is possible
that by careful insulation and underground wires even
the thousand-volt currents may be made safe.
We should not forget that the railroads, and gas, and
mines have a regular and large contingent of fatal acci-
dents, which the public ignores unless inexcusable neglect
and carelessness are shown. ‘The same position should
be taken as regards electric-light currents.
THE FIRST PHYSIOLOGICAL CONGRESS.
THE First International Congress of Physiology, which re-
cently met at Basle, was attended by a number of eminent
physiologists, and many interesting communications were
made. These will after a time reach medical readers in
detail ; meanwhile, we would call attention to some of the
more important topics that were discussed. Of course,
Professor Goltz was present with his dogs and his theory
of non-localization of the functions of the brain. This
year Professor Goltz gave the history of a dog from which
he had removed nearly the whole of the cefebral cortex.
The dog lived fifty-one days, and though the animal had
been rather stupid while in its anencephalic condition, it
could still raise itself up and walk about. A dog was
also shown in which nearly all the left half of the brain
had been removed ; yet it could walk, and use the mus-
cles of the right side. All this, however, proves nothing
against the clinical facts of cerebral localization, and it is
time for the Antivivisection Society to protest against
the further use of dogs, at least for futile experimentation.
Professor Heidenhain reported the results of a study of
the formation of lymph, and claims to have proved that
it, like glandular secretions, is the product of the activity
of the cells of the capillaries. Heidenhain looks upon
lymph as a fluid secreted for a purpose preliminary to the
formation of urine. The lymph, he thinks, is a sort of
reservoir in which are accumulated products to be used
in urinary excretion. At the proper moment the lymph-
products re-enter the blood, and are carried to and elimi-
nated by the kidneys.
- Educationists and sanitarians should be interested in
an alleged discovery of Dr. Mosso, of ‘Turin. By means
of an instrument, called the ergograph, he is able, he says,
to measure the condition of the brain by that of the mus-
cles. His instrument serves to diagnosticate and dose
the amount of mental work performed.
Professor Bowditch, of Boston, showed some composite
photographs of doctors, car-drivers, and conductors. We
are glad to learn that a distinct difference in the degree of
intelligence is shown by the composites, but the reporter
does not say in which class the highest form prevails.
Drs. Dastre and Loge, of Paris, have been making some
experiments in order to determine what is the last reflex
which persists in profound anzsthesia. This, it has been
usually thought, was the oculo-palpebral, but Dastre and
Loge say that it is the labio-mental. * In other words, even
after the oculo-palpebral reflex is gone, if one irritates the
mucous border of the lower lip, there appear movements
of the chin.
M. Minkowski described some experiments with dogs
from which the pancreas was entirely removed ; the result
was a permanent diabetes.
A number of other communications of a somewhat
more technical and purely scientific character were made
at the Basle Congress. But it will be seen from the fore-
going that physiological scierice is each year giving us new
and fruitful advances.
THE HYDERABAD COMMISSION ON THE ACTION OF
CHLOROFORM.
THERE is still a doubt, in some scientific circles at least,
as to whether chloroform first paralyzes the heart or the
respiration. In Edinburgh, for example, we are told that
failure of respiration is regarded as the chief or only dan-
ger in administering chloroform, while in London it is
failure of the heart which is mostly feared. We have re-
ferred already to the experiments and experience of Sur-
geon-Major Laurie in Hyderabad, from which he has
deduced very positive conclusions as to the innocuousness
of chloroform so far as the heart is concerned. Some
criticism having been made upon these views, his High-
ness the Nizam of Hyderabad has placed the sum of
$5,000 at the disposal of Zhe Lancet, for the purpose of
paying the expenses of a commission to repeat the ex-
periments and test the validity of the Scotch-Indian view
of chloroform.
We are glad to learn that so distinguished a physiol.
ogist and pharmacologist as Dr. Lauder Brunton has
consented to undertake the work, and has already sailed
for India. The result of his trip will be watched for with
much interest, though we doubt if anything can be found
in India which will change the views which American
surgeons have reached as the result of long experience.
Mews of the Week.
RESOLUTIONS OF SYMPATHY FOR Drs. IRWIN, FERGUSON,
AND Hance.—At the recent meeting of the Society of
Medical Jurisprudence and State Medicine, a resolution was
unanimously passed denouncing the unjust persecution of
Drs. Irwin, Ferguson, and Hance in the Bishop autopsy
matter, and expressing sympathy with and confidence in
these gentlemen. This is as it should be, and is in per-
fect accord with the sentiment of the profession here and
abroad. These gentlemen are beyond the suspicion of
wrong-doing, the charges against them are absurd, and the
proper thing for the prosecuting parties would be to ex-
onerate the defendants promptly and effectually. Let us
have an end to this uncalled-for and unjust persecution.
COMPULSORY NOTIFICATION OF INFECTIOUS DISEASES.
—The new Act of Parliament providing for the compul-
sory notification of infectious diseases comes into force
at the end of next month. In London, the act is com-
pulsory ; in the provinces, its adoption is* optional, and it
rests with the local authorities to determine whether they
will apply the act to their district or not. The bill was so
“ rushed ” through the House of Commons at the last that
no adequate discussion of the question of “ dual notifica-
tion” was possible. ‘That system, therefore, remains an
integral part of the bill, although it is one vigorously op-
posed by no inconsiderable section of the profession. In
accordance with it, both the medical attendant and the
patient’s representatives are bound to notify to the medical
officer of health for the district any case of infectious dis-
October 19, 1889]
ease. A list of the infectious diseases to which the act
will apply is given, but local authorities are empowered
to make additions to the list at their discretion. Those
named are the following: Small-pox, cholera, diphtheria,
membranous croup, erysipelas, and the following fevers,
viz., scarlet, typhus, typhoid, enteric, relapsing, continued,
and puerperal.
ANOTHER CONFIDENCE Man.—A smooth-spoken in-
dividual, of good address, and possessing a phenomenal
familiarity with the “ Medical Register,” has been re-
cently engaged in victimizing members of the profession
in this city, representing himself as secretary of the
“ Commercial Travellers’ Association.” On the strength
of his references (such as cards from reputable physicians)
he seeks to interest doctors in a scheme for giving medical
assistance to commercial travellers, stating that he has
been commissioned to engage physicians in each town
and city in the State to attend sick drummers and their
families. The credulous victim is induced to advance a
few dollars to purchase blank forms.
THE MEDICAL SOCIETY OF THE STATE OF NEw YORK.—
The next annual meeting will be held in Albany, February
4to6, 1890. The Business Committee has been appointed
as follows: Dr. George H. Fox, 18 East Thirty-first Street,
New York; Dr. Henry Flood, Elmira ; Dr. Herman Ben-
dell, Albany. Application should be made before January
1st by those desiring to read papers, in order to secure the
proper arrangement of time and subjects. Papers should
not exceed fifteen minutes, and the title should accompany
the application, which may be made to any member of the
committee.—DaniEL Lewis, President, 62 Park Avenue,
New York.
THE AMERICAN PUBLIC HEALTH ASSOCIATION meets in
Brooklyn next week, and New York physicians have been
asked to help in entertaining the guests. We trust that
the profession in this city will generously respond.
MASSAGE OF THE HEART, whichis Dertel’s latest de-
vice in mechano-therapy, consists essentially in causing
the patient to make slow, forced expirations, while the
masseur, with his hands upon the nibs, assists the expira-
tory effort, pressing the hands forward toward the ensi-
form cartilage. The patient then takes a deep inspiration.
The process increases.the strength of the heart’s systole
and helps the diastole.
Tue DIGITALIS OF THE LunGs is a name fancifully given
to quebracho by Dr. E. M. Hale (W. A. Practitioner).
This is a drug which has failed to hold its place in thera-
peutics, though occasionally it seems useful. Dr. Hale
says that the alkaloid aspidospermine, in doses of gr. +4,
to sy, has a better action.
A New COLLEGE oF PHARMACY.—The Kings County
Pharmaceutical Society has had under consideration
‘plans for the establishment of a college of pharmacy in
Brooklyn. It is reported that the preliminaries have all
been agreed upon, and that before many months a fully
equipped school will have been launched.— N. Y. Med-
ical Fournal.
SCARLET FEVER IN LONDON is still on the increase, and
it is thought that another of the hospitals of the Metro-
politan Asylums Board will shortly have to be opened.
THE MEDICAL RECORD.
435
A POST-GRADUATE Course FOR LONDON is projected,
to commence in January next. Several so-called “ post-
graduate ” courses have already been held in London, but
in every one of those hitherto held the venture has been
in connection with one particular hospital, to which the
instruction given has been confined. The new scheme is
for a course comprising clinical teaching at several hospi-
tals, which have arranged for joint action in the matter.
The first course is to be given by members of the staffs of
the following hospitals: The Brompton Consumption
Hospital, the Hospital for Sick Children (Great Ormond
Street), the National Hospital for the Paralyzed and Epi-
leptic, the Royal London Ophthalmic Hospital, and the
Hospital for Diseases of the Skin (Blackfriars). It will
be noted that these are all special hospitals without med-
ical schools (though all are at present available for clinical
study), and this marks a new departure, for all the “ post-
graduate” courses hitherto given in London have been in
connection with one of the general hospitals to which med-
ical schools are attached. Should the new scheme suc-
ceed, it will doubtless be largely extended by arranging
for other hospitals to join it. Otology and gynecology
will then probably receive attention also. It is somewhat
remarkable that a course omitting them should have been
announced. Three courses a year are to be given. These
will commence in January, May, and October, respective-
ly, and each occupy eight weeks. The duration of the
courses is, perhaps, the weakest part of the scheme. A
fee of ten guineas will be charged, or three guineas for the
demonstrations at any one hospital.
A ConreEsT has been going on in Brooklyn between Dr.
George R. Fowler and Dr. Nelson B. Sizer as to who
should be head of the medical staff of the Bushwick and
East Brooklyn Dispensary. It is asserted by Dr. Fowler
that Dr. Sizer was elected president at a packed meeting.
The matter has been brought before the courts.
Dr. THoMaS SNOWDEN, one of the leading physicians
of Peekskill, N. Y., died in this city on October 11th.
Dr. Snowden came to this city on October 3d to arrange
for the admission of his son to college. He was suddenly
struck down by apoplexy. ` Dr. Snowden graduated from
the College of Physicians and Surgeons in 1849.
THE DIAGNOSIS OF EXTRA-UTERINE PREGNANCY.— Dr.
J. M. Baldy, of Philadelphia, writes: “In my article on
‘The Early Diagnosis of Extra-uterine Pregnancy,’ in THE
RecorpD of September 21st, J made the statement: ‘ Also
of Janvrin, who stated at the Washington meeting of the
American Gynecological Society that the diagnosis of ex-
tra-uterine pregnancy was easier than that of normal preg-
nancy.’ Dr. Janvrin writes me that he never made such
a statement, or anything that could be so interpreted. I
had thought I had heard him make the statement myself,
but of course must have been mistaken. I wish, therefore,
to withdraw the quotation.”
‘THE AMERICAN ACADEMY OF MEDICINE is endeavoring
to make as complete a list as possible of the Alumni of
Literary Colleges, in the United States and Canada, who
have received the degree of M.D. All recipients of both
degrees, literary and medical, are requested to forward
their names, at once, to Dr. R. J. Dunglison, Secretary,
814 North Sixteenth Street; Philadelphia, Pa.
436
THE MEDICAL RECORD.
[October 19, r889
New YORK STATE MEDICAL ASSOCIATION, OFFICERS
ELEcT.—The following were elected on the last day of the
session of the Association : President—John G. Orton, of
Broome County; Vice-Presidents—Douglas Ayres, of
Montgomery County; W. H. Burton, of Rensselaer
County ; E. Mott Moore, Jr., of Monroe County, and
William B. Eager, of Orange County ; Secretary—Everard
D. Ferguson, of Rensselaer County ; Director of Libra-
ry—John W. S. Gouley; Members of the Council—First
District—C. M. Klock and W. H. Biggam, of Mont-
gomery County. Second District—’Thomas Wilson, of
Columbia County. ‘Third District—H. O. Jewett, of
Cortland County. Fourth District—Simeon T. Clark,
of Niagara County. Fifth District—John G. Truax, of
New York County.
THE “ MEDICAL Warr” has been wafted into the em-
braces of the North American Practitioner, which es-
teemed journal has absorbed and extinguished it.
“DIPHTHERITIC SORE THROAT.”—The editor of the
Indiana Medical Fournal truly and forcibly says, regard-
ing the above expression: “ There is no such disease
known to medical science. An individual either has or
has not diphtheria. If the former is the opinion of the
physician, let him say so ; if the diagnosis is uncertain, it
is also best to say that or nothing. Surely there is no ex-
cuse for the use, under such circumstances, of terms
which are both professionally and popularly misleading,
and which imply a belief that there is a condition which
has a diphtheritic element and yet is not diphtheria.”
A TRAINING SCHOOL FoR Nurses has been opened in
connection with Johns Hopkins Hospital.
MANHATTAN Eye AND Ear Hospitat.—Dr. W. M.
Leszynsky has resigned from the Manhattan Eye and Ear
Hospital.
SOME OF OUR ESTEEMED Chicago contemporaries are
worrying over the meagre show which the medical profes-
sion can make at a World’s Fair. “ What,” says the JV.
A. Practitioner, “ have we got to show the medical men
of the world?” We think that our contemporaries and
colleagues are feeling unnecessarily disturbed.
A New Source oF MorPHINE.—MM. Adrian and
Bardet, after investigating the properties of the California
plant Eschscholtsia Californica, say that it contains an al-
kaloid identical with morphine. ‘The Occidental Medical
Times publishes an account of the plant written by Dr.
W. P. Gibbons. It is therein stated that the plant be-
longs to the Papaveraceæ. Years ago he made some ex-
periments with it, but got no definite results.
THE GREAT COMPOSER.—Being asked the name of the
world’s greatest composer, a smart university young man
said: “ Chloroform.”—Philadelphia Record.
Docror—“ Not so well to-day, eh? Have you kept
him quiet and given him his medicine regularly?” Mrs.
Richard Bevylin Buckner—“ Dey ’ain’t been nobody in
de room wid him ’cept me an’ de children, so he’s been
nice an’ quiet ; an’ I give him de med'cine like you tole
me—three spoonfuls every hour.” Doctor—“ Great
heavens, woman, it’s a wonder he’s alive! I said one
spoonful every three hours.” Mrs. Buckner—“ Well, now,
Doctah, dey ain’t no diffrence between one three an’ three
ones. Count ’em fo’ yo’self an’ see."— Harper's Bazar.
Reviews and Rotices of Pooks.
A MANUAL OF DISEASES OF THE EAR, FOR THE USE OF
STUDENTS AND PRACTITIONERS OF MEDICINE. By
ALBERT H. Bucx, M.D. Pp. 420. New York: Will-
iam Wood & Co. 188g.
THE present volume is more or less a revised edition of
Dr. Buck's previous work, entitled “ Diagnosis and Treat-
ment of Ear Diseases” (1880), and is, as the title states,
especially intended for students and practitioners of med-
icine. This book is, however, a more systematic and
scientific essay than the author’s former volume.
Among the more especially revised portions of the
work may be mentioned the treatment of different forms
of acute and catarrhal inflammation of the middle ear.
Here considerable space has been devoted to the im-
portance and manner of removal of adenoid vegetation
from the vault of the pharnyx, and to the application of
other local remedies to the naso-pharyngeal mucous mem-
brane. Chapter XII., dedicated to diseases of the mas-
toid process, is a very comprehensive sketch of the
subject, and well supplied with excellent illustrations.
The writer goes very elaborately into the treatment with
the drill, chisel, etc., of which procedure he is a well-
known advocate. Chapter XIV., on syphilitic and tu-
bercular disease of the deeper parts of the ear, will
be found interesting reading. In the appendix is given
a short and concise anatomical and physiological sketch
of the ear, with numerous well-selected illustrations.
The index is unusually complete.
DISEASES AND INJURIES OF THE EAR: THEIR PREVEN-
TION AND CurE. By CHARLES HENRY BURNETT, A.M.,
M.D. Pp. 154. -Philadelphia: J. B. Lippincott Com.
pany. 1889.
Dr. BURNETT'S little book forms one of a series entitled
“ Practical Lessons in Nursing,” the contributions of
several different authors, and published by the above-
named firm. The writer presents to the public a very
readable little work, and which, owing to the absence of
technical terms, will be easily understood by most per-
sons. The object of the author has been to show the
public how ear diseases may be avoided by care, and, in
case they have contracted affections of the hearing
organ, to warn them against the numerous experimental
forms of treatment so much in vogue and so often dis-
astrous. Dr. Burnett has certainly carried out his idea
in a very successful manner. Especially good is the ad-
vice he gives in relation to foreign bodies in the exter-
nal auditory canal, where meddlesome treatment so
frequently results in disaster. Equally valuable are his
remarks about the effect of diseased teeth, dental plates,
and fillings, in the causation and maintenance of aural
troubles. The author goes quite fully into a detailed
description of the causative influences in chronic catarrh
of the middle ear, and gives many valuable hints and
suggestions from an hygienic point of view. The book
contains a few illustrations of the anatomy of the ear,
sufficient for explanatory purposes, and an excellent
index.
TRAVAUX D’OBSTETRIQUE DU Dr. A. ANVARD. Tomes
I.-III. Paris: Lecrosnier et Babé. 1889.
OBSTETRICAL WorkKS OF Dr. ANVARD. Three volumes,
Paris.
In these rather bulky volumes Dr. Anvard has embodied
most of the doctrines and methods of practice now cur-
rent in the department of obstetrics in France. With
some unimportant exceptions, those doctrines agree with
what is taught in ourowncountry. Antiseptic accouche-
ments, or rather aseptic ones, are the aim and object of
French obstetricians, as well as those of other civilized
countries,
October 19, 1889]
THE MEDICAL RECORD.
437
Society Reports,
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, October 3, 1889.
THE PRESIDENT, ALFRED L. Loomis, M.D., IN THE
CHAIR.
Dr. C. L. Dana read a paper entitled
THE PATHOLOGICAL ANATOMY OF CHOREA—A CASE, WITH
AUTOPSY.
It dealt chiefly with the pathological anatomy of the
nervous centres. , Those occurring elsewhere, particularly
in the heart, had often been described. There was pretty
definite agreement that the most uniform condition in
cases dying with chorea was fibrinous deposits on the
valves of the heart, usually the mitral. It occurred in
ninety per cent. of the cases. Turning to the nervous side,
he first gave his own case. The patient was a Swiss, aged
eighteen, single, whose family history was unknown. He
was admitted to the hospital, December 15, 1888. He
had always been weak and sickly as a child ; no rheumatic,
venereal, nor alcoholic history. He began to have choreic
movements twelve years ago, or at the age of six years ;
cause unknown. The movements at first were not severe.
He had had so-called epileptic attacks at occasional inter-
vals for several years. Formerly they occurred at night
only ; later they came on during the day also. They be-
gan with a shrill cry.
PHYSICAL EXAMINATION AT ‘THE HOSPITAL.
The patient lay abed, unable to walk or help himself be-
cause of the violence of the choreic movements. He was
dull, but answered questions intelligently. Speech slow
and jerky. There was the mark of a former trephining
for epilepsy. There was no paralysis, no heart murmurs ;
lungs and abdominal viscera normal; urinary examina-
tion negative. The movements were so severe that he
could not feed nor help himself. He had several epilep-
toid attacks daily and nightly. The fits were of a hyste-
roid character, seemingly not strictly epileptic. Dr. Dana
had not himself seen an attack. .
The patient improved considerably under chloral hy-
drate and other treatment until January, 1889, when he
contracted pneumonia and died. The autopsy showed
the lesions of pneumonia. The heart was normal, and
showed no vegetations on the valves. ‘The skull was un-
usually thick, seven-eighths of an inch on section through
the occipital bone. ‘The pia mater was thickened, not
markedly adherent ; the cortex of the brain appeared nor-
mal to the eye except for very superficial softening on the
under-surface of both temporal lobes. ‘The cord was ap-
parently normal. Sections were made of the brain, cord,
` and several of the nerves for microscopical examination.
Two or three cuts were made vertically through the
brain when it was fresh, and appeared to be slightly con-
gested, but there appeared to be no spots of softening and
no hemorrhages. However, the deeper parts of the brain
did not harden well for microscopical study. Under the
microscope pieces were examined from the motor, tempo-
ral, and biparietal convolutions, corpora striata and thala-
mus, bulb and cord, and some of the nerves. There was
a slight amount of lepto-meningitis, the gray matter was
considerably injected, the neuroglia was not markedly in-
creased, occasionally a cell was seen undergoing pigmen-
tary.degeneration. The nerve-fibres could be seen run-
ning up into the cortex, and the transverse fibres of the
cortex were also present. The chief changes were just
beneath the cortex where the white matter was honey-
combed, the change in some places being apparent even
to the unaided eye. The walls of the blood-vessels were
somewhat thickened, but not markedly so. There was no
real arteritis or endarteritis, but the -vessels had been
much distended by exudates of blood-cells, with dilatation.
of the perivascular spaces. The process, though chronic,
could not be looked upon as inflammatory. It was due
rather to flabbiness and loss of tone of the vessel-walls.
There were no colloid bodies. At the base and tip of the
temporal lobe, however, there wis softening, a severer
grade of meningeal inflammation, the white matter beneath
was more excessively honey-combed, while there was evi-
dently an increase of the neuroglia-cells. The basilar
ganglia and internal capsule did not appear to the unaided
eye so much involved as did the subcortical tissue, al-
though some portions of the internal capsule, the deeper
parts particularly, did not harden well and sections could
not be made. The optic thalamus and anterior part of
the caudate nucleus showed the same honey-combed ap-
pearance from vascular dilatations, though less marked
than in sections higher up. The lenticular capsule showed
more serious degenerations, the walls of the blood-vessels
were even degenerated and seemed to fall to pieces, and
some of the nerve-fibres seemed swollen and disorganized,
although some of these changes may have been post mor-
tem. ‘The nucleus of the fourth cranial nerve seemed de-
generated.
The spinal cord showed some congestion ; the distended
and thickened vessels were most numerous, apparently, in
the lateral columns. It had none of the honey-combed
appearance found in the brain and pons. In the lumbar
cord a double canal was present, arid for a short distance
one could see three canals, apparently, with epithelial
lining. The anterior and posterior roots showed no de-
generated fibres. Macroscopically, the cerebellum seemed
n : .
The severest changes existed under the surface of the
temporal lobes, in the internal capsule, in adjacent parts
of the corpora striata; the pons Varolii and medulla
showed the same condition, much less marked. There
was slight connective-tissue increase in the pyramidal
tracts, the spinal cord showed slight lepto-meningitis and
congestion in the lateral tracts, a double canal in the lum-
bar region.
The author then reviewed cases reported by other
writers. The mortality from chorea, he said, seemed to
be much greater in England than anywhere else. In the
English hospitals three or four per cent. of all the cases
ended fatally. He knew of only three fatal cases in
America, reported in detail. He had examined and tab-
ulated the post-mortem records in over eighty cases.
Eliminating the duplicated ones, he had found on record
nearly two hundred reports of autopsies. The large
majority were of no value as indicating the nervous lesions.
Indeed, he had found only thirty-nine cases in which a
satisfactory account had been given of the nervous sys-
tem, and even here, in some instances, the examination
had not been complete.
They had shown congestions, extravasations, emboli,
and softening in the nervous centres; they had also prov-
en the great uniformity of heart-lesions. It was, how-
ever, only by very minute and critical microscopical ex-
amination that light had come. But the records of the
complicated, of the uncomplicated, of the acute, and of
the chronic cases should be studied separately. It was.
only the acute and chronic chorea of the Sydenham type
which one ordinarily met, and it was this disorder in which
the pathological anatomy should be especially studied.
Among the thirty-nine cases with autopsies of the ner-
vous system, there were twenty-five in which the disease
was the acute chorea of Sydenham, uncomplicated with
other serious disorders. Leaving out six cases, for special
reasons, there remained nineteen in which a careful
microscopical examination had been made. In sixteen
there was a record of intense cerebral hyperzemia, peri-
arterial exudations, spots of softening, and minute hemor-
rhages, and, occasionally, aneurisms. Of the remaming
three cases, in one absolutely no changes were recorded,
but Dr. Dana thought some must have been overlooked.
In five chronic cases, lasting from four to twelve years,
there were found dilatation and thickening of the arteri-
438
oles, with necrotic changes, spots of sclerosis, fungus
growths along the vessels in one case. The cord was
somewhat similarly involved, though less in extent.
Dr. Dana thought we were not far from obtaining an
anatomical basis for chorea. In the acute types there
was hyperzemia of the brain, and of parts of the cord. In
the brain it was not meningeal, but affected the deeper
parts; it was more than an ordinary congestion. The
arterial walls were paralyzed, dilated, badly nourished,
and an exudation took place. Sometimes there were
thromboses and spots of softening, or the vascular walls
gave way and some small hemorrhages took place. On
the other hand, the lymph-spaces around the nucleated
cells and neuroglia were not dilated; no proliferation of
connective-tissue cells, no distinct sign of inflammation.
The process was one of vaso-motor paralysis. “ Inflam-
matory,” or “subinflammatory,” was not strictly a correct
term to apply to it. In the older cases the vascular
changes were more marked, the small arteries were per-
manently dilated, a little thickened, varicose, and the
other peculiar changes which had been described took
lace.
ý Admitting that there were the vascular and degenera-
tive changes already indicated, we had yet to learn the
cause before we could know the pathology of chorea.
Several theories had been advanced, as the humoral, the
embolic, the subinflammatory, the functional or agnostic,
and the infectious theories. After briefly considering
these, the author said there were three things at least
which had been well determined in chorea, namely, the
existence of an abnormal state of the blood, an intense
cerebral hyperzemia in certain parts, and a neurotic history.
He asked if we must not logically combine a humoral
and a neurotic theory to explain chorea. The disease
was a kind of traumatic neurosis occurring in children
with impoverished blood. Repeating, he said that in
chorea there was a neuropathic and a humoral state, the
preponderance of the two varying in different cases, and
giving indications for treatment.
Dr. L. C. Gray being asked to open the discussion,
thought little remained to be said except to congratulate
the author on his excellent and exhaustive treatment of
the subject.
Dr. M. ALLEN STARR made some remarks on the
theories of the causation of chorea, and said he had in-
clined toward the infectious theory, although it had not
been proven, and there were some objections to accept-
ing it, at least in all cases. As Dr. Dana had said, three
cases had been recorded in which a micro-organism had
been found, and he therefore thought all cases should be
studied in this regard. Rheumatism and heart complica-
tions favored the infectious theory.
It might be questioned, he thought, whether, in the cases
of chorea which lived, the pathology was exactly the same
as that in the cases which died. Nerve-cells had the
power of discharging their energy, and consequently of
causing spasmodic manifestations under a great variety of
conditions ; it was not nece that the cell be irritated
by a micro-organism, or an irritant in the blood. It was
noticeable sometimes after fatigue and exhaustion; he
therefore believed that some cases of chorea must still
be regarded as functional, and that we could not lay
down for all cases a definite pathology such as was found
in cases that died.
Dr. M. PuTNAM-JACOBI cited two cases published in
the last issue of Brain, in which the pathological changes
had been described, and said it seemed scarcely possible
that the ubiquitous bacteria should lie in wait just at the
time when the child fell down the cellar, or experienced
a strong emotion, which was immediately followed by
chorea. Dr. Dana’s case seemed to imply a congenital
defect in the nerve-centres, indicated by the three canals
in the lumbar cord.
Dr. W. R. BIRDSALL admitted the importance of the
pathological findings described by Dr. Dana, but he thought
it equally important to give_the proper interpretation of
THE MEDICAL RECORD.
[October 19, 1889
those findings. It might be a question whether the chorea
had been caused by the lesions, or whether the lesions had
not been caused by deranged action in the nerve-centres
attending chorea. With functional disturbance in the be-
ginning sufficient to cause convulsive action, it was but
natural that vaso-motor paresis should follow, and, in time,
more decided vascular changes. He thought a variety of
conditions might produce disturbances of a choreic charac-
ter, and finally lead to the pathological changes described.
He also mentioned a family in which several of the mem-
bers developed chorea, and the cardiac and exophthalmic
symptoms of goitre.
THE PRESIDENT made some remarks on the very
common presence of chorea, rheumatism, and cardiac
symptoms in the same subject, and was disposed to think
with Dr. Birdsall that the lesions described by Dr. Dana
were to be found in other nervous diseases of a functional
nature of considerable duration, although the location of
the lesions might not closely correspond.
Dr. Dana closed the discussion, and said he knew of
no other disease in which the same pathological changes
had been found as in chorea.
AMERICAN ASSOCIATION OF OBSTETRICIANS
AND GYNECOLOGISTS.
Second Annual Sesston, held at the Burnet House, Cincin-
nati, O., September 17, 18, and 19, 1889.
WittiaM H. Tayor, M.D., PRESIDENT, IN THE CHAIR.
AFTER an address of welcome, by. Dr. Comegys, of Cin-
cinnati, the following papers were read: ‘ Congenital
Sinus of the Urachus: Abdominal Incision, Recovery,”
with remarks, by Dr. A. Vander Veer, of Albany, N. Y.;
“A Case of Extra-uterine Pregnancy: Operation and
Recovery,” by Dr. L. S. McMurtry, of Danville, Ky.;
“ Intra-uterine Cord Amputations of the Foetal Extrem-
ities,” by Dr. Joseph Price, of Philadelphia, Pa.; “ Flap-
splitting in Perineorrhaphy, with Special Reference to
Tait’s Operation,” by Dr. X. O. Werder, of Pittsburg,
Pa.; ‘ Vaginal Hysterectomy,” by Dr. E. E. Montgomery,
of Philadelphia, Pa.; ‘ Supra-vaginal Hysterectomy :
Extra-peritoneal Dry Treatment of the Pedicle,” by Dr.
Joseph Price, of Philadelphia, Pa.; ‘‘ Successful Removal
of a Fibrous Tumor of the Right Ovary during Preg-
nancy,” by Dr. J. H. Carstens, of Detroit, Mich.; “ A Re-
markable Case of Nymphomania,” by Dr. W. S. Stewart,
of Philadelphia, Pa.; “A Few Considerations on Peri-
toneal Effusions after Intra-peritoneal Operations,” by
Dr. W. H. Meyers, of Fort Wayne, Ind.; The President’s
Annual Address; ‘Reasons for Drainage in Ovarioto-
my,” by Dr. Hampton E. Hill, of Saco, Me.
On the afternoon of the third and last day the session
was given up to the discussion of the subject,
IS CRANIOTOMY JUSTIFIABLE ON THE LIVING CHILD ? AND
ITS ALTERNATIVES.
Listerism received some hard knocks, as did also elec-
tricity in gynecology. One gentleman who was especially
severe, and a good deal more positive than our science
will allow, said electricity was used only by the ignorant,
and those who had never been in the abdomen. He cited
as a specimen a doctor in his city who was a great advo-
cate of electricity, and he scarcely knew whether the pubis
or the sacrum was before. ‘This same speaker, after hav-
ing vented his venom on Listerism and electricity, turned
to compliment a fellow who had agreed with him in his
paper, and said he described a case as perfectly as Mozart
could have painted it. If his ignorance of Listerism and
electricity was as profound as his familiarity with music
and painting, it is not to be wondered that he avoids them.
Another antagonist of electricity made a boast that he had
not a battery in his office. Drainage was discussed freely,
and as a general thing warmly endorsed. One gentleman,
Dr. Hill, reported twenty-six ovariotomies in which he
used the drainage-tube twenty-four times and had twenty-
October 19, 1889]
THE MEDICAL RECORD.
439
five recoveries. He made twelve ovariotomies without
losing a case before he ever saw the operation done.
His work was highly praised by the members. Flap-split-
ting in perineorrhaphy was severely condemned. Abdom-
ina] surgery was lauded to the skies, and should be lim-
ited to the hands of the specialist.
Socially the Association was very kindly entertained.
The city of Cincinnati was thrown open to them. Dr.
and Mrs. Taylor gave a reception, to which the Associa-
` tion was invited to meet the local profession. ‘This was
a very enjoyable occasion, and the Cincinnati doctors
made themselves as agreeable as possible. The local
members took the Association to see “ Montezuma, or the
Conquest of Mexico,” which was also very much appre-
ciated.
The election of officers resulted as follows: President
—Dr. E. E. Montgomery, of Philadelphia; First Vice-
President—Dr. W. H. Meyers, of Fort Wayne, Ind. ;
Second Vice-President—Dr. R. L. Banta, of Buffalo ; Sec-
retary—Dr. W. W. Potter, of Buffalo; Zreasurer—Dr.
X. O. Werder, of Pittsburg ; Executive Committee—Dr.
A. Vander Veer, of. Albany; Dr. C. Cushing, of San
Francisco; Dr. W. H. Wathen, of Louisville, Ky.; Dr.
C. A. L. Reed, of Cincinnati; Dr. H. B. Hill, of Saco,
Me. -
The Association on meeting in Cincinnati numbered
thirty-eight members of whom twenty were present. Fif-
teen new members were added at the Cincinnati meeting.
Place of next meeting, Philadelphia, third Tuesday, Wed-
nesday, and ‘Thursday in September, 1890.
THE PRESIDENT’S ADDRESS.
The President, Dr. WiLLIAM H. TAYLOR, of Cincin-
nati, in his annual address, congratulated the Association
on the success of its first meeting at Washington, and on
the valuable publication made, and thanked the medical
journals for their kindly comments on the work of the
Association. He had experienced much difficulty in
finding fit topics for remark before a society where all
were pursuing the same line of study and similar work.
Among the many suggestions and proposed changes offered
the profession many were ephemeral and lost their interest
as soon as something newer was presented. Others hada
permanent value and were incorporated into the creed
and practice of scientific medicine, while some were use-
ful m revealing error, though they may not discover the
truth.
One very satisfactory feature of the year’s progress in
our department of medecine is the successful effort at
increased accuracy in diagnosis, and to more definitely
determine the indications for operative procedure. The
condemnation of laparatomy is much less frequent than
formerly, because of more accuracy in diagnosis, and in-
creased experience has determined proper cases for oper-
ation.
The recent lecture of Sir T. Spencer Wells and the
statistics of Munchmeyer show the propriety of uterine
extirpation, and Wells’ terse words, “ The best means to
prevent return is to operate early,” must become an
aphorism for our guidance ; the very essential factor, abil-
ity of early diagnosis, is still a desideratum.
The low death-rate of myomata and the great mortality
from operation for their removal suggest the propriety of
rare resort to such operation. ‘Ihe brilliance of operative
procedure obscures other work, and the apparently greater
gravity of a case justifying an important operation diverts
attention from suffering less severe ; such minor ailments
are, however, just as needful of care.
Schultz's and Herman's recent publications regarding
uterine displacements are likely to improve our manage-
ment of such cases.
Subjects which seem to be definitely settled are again
revived and become the theme of active controversy, of
which fact the discussion of the phenomena and conduct
of the third stage of labor is an instance. We all know
that debate on this topic has continued for several years
in Germany, apparently with little benefit either to the
combatants or to science, but the subject assumes much
practical importance after the statement recently made by
Duhressen, that “one woman dies every day in Prussia
from post-partum hemorrhage.” ,. Remembering that
this fatality can occur only among a limited portion
of our population this would seem a large mortality.
Assuming the period during which it could occur to be
between the age of fifteen and fifty, we should have, ac-
cording to our census reports, one death from hemorrhage
after delivery in less than two hundred from all causes
among women in the period mentioned. i
The great confidence we have had in the usual method
of dealing with the placenta might lead us to the belief
that we should be exempt from such disaster, but just now
our idols are being shattered, and a man as eminent as
D. Berry Hart has said, “ I consider the Credé the most
dangerous plan possible for the separation of the pla-
centa.”
With these facts and these statements so much at vari-
ance with the generally accepted opinions, certainly it is
the part of wisdom to survey the ground carefully upon
which our confidence is built.
The very satisfactory results of Cæsarean section,
recently, establish it as an operation which must be re-
sorted to if the obstetrician would escape censure, and
the success of the Porro operation modification must
lead us carefully to determine to which cases it is adapted
and to which Saenger is the more appropriate.
Ectopic pregnancy, pelvic suppuration, and craniotomy
have occupied such large place in our recent literature,
and are to have such consideration in our programme, that
it would be superfluous to devote time to their discussion
here.
A review of the progress in our branch of medicine
during the past decade is a source of astonishment and
a cause of congratulation, for no department can show
such additions to life and comfort, but I need only make
the assertion to elicit your assent that there yet remains
very much land to possess. With the intelligent restless-
ness which characterizes the educated mind we must press
forward, and no prophetic power is required to predict
that great progress will be made.
The recent advances in all departments of science, and
the wonderful practical application of newly acquired facts
disarm incredulity, and we dare to place no limit on the
possible acquisitions of the near future.
The Utopias of to-day rnay be the familiar dwelling-
places of to-morrow, and actuated by the noble sentiment
which so characterizes our profession, of seeking the truth
for the truth’s sake, we may be sure of grand additions to
our knowledge and skill, and I can utter no better bene-
diction than the hope that this Association may bear its
full share in making these acquisitions.
Dr. R. B. HALL, of Cincinnati, O., read a paper en-
titled
SOME POINTS IN THE DIAGNOSIS OF PYOSALPINX.
The author believes the importance played in the produc-
tion of suffering by this disease has not received the at-
tention which it merits. The general practitioner sees
and treats the great majority of these cases before they
are seen by the operator, and if it is hoped or expected to
affurd relief to a great number of suffering women all over
the land the subject of diagnosis must be better under-
stood than at present. The importance of septic infection
in the production of inflammatory disease of the uterine
appendages is the cause of these diseases in a large per-
centage of cases. Repeated attacks of acute exacerba-
tions from perhaps trivial causes, finally produce complete
closure of the ends of the tubes. As a consequence the
normal secretions of the tubes soon become pathological
and by repeated attacks of inflammation may become
changed into pus, producing the typical pyosalpinx. The
speaker is convinced that this affection frequently follows
puerperal diseases and gonorrhceal infection, but does not
440
THE MEDICAL RECORD.
[October 19, 1889
consider these the most common causes of the disease.
He believes pyosalpinx to be contracted in two different
ways: (a) By a chronic process, causing dropsy of the
tube, which, by repeated attacks of inflammation, is
changed to pus; (4) it may be rapidly produced by an
acute process following gonorrhcea and puerperal diseases.
A history of almost constant suffering for years, directed
to a certain locality, perhaps originating in an attack of
pelvic or abdominal inflammation, connected or not with
parturition. To this may be added sterility, and we have
a most important aid to a correct diagnosis in the history
of the case. Diseased appendages can usually be recog-
nized by a vaginal examination, yet this is not always pos-
sible. In most cases it is difficult, and in many impossible,
to make out the exact disease of the appendages except
in cases of pyosalpinx. We usually have an irregular
ovoid tumor, showing swellings and contractions not found
in any other pelvic tumor but tubal collections. This tu-
mor is generally of small size; it may be in the retro-
uterine space extending toward the pelvic brim on the one
side, with a second tumor on the other side higher up ;
or it may be distinctly felt as a narrow furrow, which is
occasioned by a portion of the uterine end of the tube re-
maining undistended by pus, while the distal end of the
tube is enlarged to form the tumor. This furrow is not
so plainly felt in those cases where there is a periodical
discharge of the pus through the tube into the uterine
cavity. ‘This is a very valuable sign to help in making a
diagnosis. If we have all the other symptoms of pyo-
salpinx with a history to confirm them, where we can feel
the enlarged tube before a discharge of pus from the
uterus, and immediately after the discharge has occurred
we find that the tube has collapsed, then we have proof
positive of the existence of pyosalpinx.
If the previous history of the case be carefully learned
and given due weight and consideration, the author be-
lieves the diagnosis is not so difficult as usually thought.
The uterus is more or less fixed and misplaced. In the.
majority of cases seen by him there has been pain during
defecation—particularly where the tumor occupied the
retro-uterine space. Most cases gave a history of dys-
pareunia. If pain has long been a prominent symptom
and it is evident the tube contains pus, the case must be
looked upon as serious and demanding prompt relief.
Delays are dangerous, asthe bursting of the tube may
cause fatal peritonitis, and escape should be afforded the
offending pus by removal of the tube.
AMERICAN ORTHOPEDIC ASSOCIATION.
Third Annual Meeting, held at Boston, Mass., September
17; 18, and 19, 1889.
First Day, ‘TUESDAY, SEPTEMBER 17TH—MORNING
SESSION.
THE Society was called to order by the President, Dr. E.
H. BRADFORD, of Boston, who read an address on
AMERICAN ORTHOPEDICS.
Dr. V. P. Gisney, of New York, read the first paper,
entitled
THE TYPHOID SPINE.
He called attention to a group of symptoms pertaining to-
the spinal column as a sequel to this fever, and as an
anatomical diagnosis used the term “ perispondylitis,”
meaning an acute inflammation of the periosteum and the
fibrous structures which hold the spinal column together.
He gave the details of three such cases, all of which were
acuté and ran a benign course. As pertinent to this sub-
ject he spoke briefly of a similar condition in which the
hip was affected, and presented the photographs of a
second case in which the thighs were sharply flexed upon
the pelvis, and the legs on the thighs, so that the heels
touched the buttocks.
“its share in the work of locomotion.
Dr. L. A. WEIGEL, of Rochester, by invitation, read a
paper entitled
THE RELATION OF THE THORACIC AND ABDOMINAL WALLS
TO THE SPINAL COLUMN, CONSIDERED WITH REFERENCE
TO THE TREATMENT OF ANTERIO-POSTERIOR CURVA-
TURE.
His conclusions were as follows: 1. The spinal col-
umn in its general upright position is supported by the
abdominal viscera, or rather by the resistance of the ab-
dominal walls. Following the force of gravity, the spinal
column sinks downward until a resistance is met with.
This resistance may be produced by a direct support upon
the viscera, or indirectly by pressure exerted through the.
elastic thorax and diaphragm upon the abdominal organs,
which are thus forced against the muscular walls until an
equilibrium of forces is established. 2. By the support
which the abdominal viscera give to the spinal column
and thorax, the abdominal muscles very materially sup-
plement the action of the erector muscles of the spine, by
increasing the resistance which the viscera offer to the for-
ward inclination of the spine and thorax. 3. The back-
ward inclination of the spine is limited by the tense ab-
dominal muscles and the firm linea alba to which they are
attached.
Dr. DILLON BROWN, of New York, read a paper en-
titled
PSOAS CONTRACTION AS A SYMPTOM.
He briefly outlined the various diseases in which this con-
dition may be found, and gave their diagnostic points,
especial attention being paid to those phenomena by
means of which each disease could be excluded.
Dr. A. B. Jupson, of New York, read a paper on
THE PREVENTION OF THE SHORT LEG OF HIP DISEASE.
He set forth the importance of inducing the patient who
wears the hip-splint to observe the natural rhythm of the
gait in walking, dividing the time on the ground equally
between the two feet, or rather between the well foot on
one side and the hip-crutch of the splint on the other side.
He believes that if the patient, by precept and drill, is in-
duced to walk habitually in this way the affected limb will in-
cline toward abduction, in order to reach the ground and do
Adduction and flex-
ion, which constitute the dreaded short leg of hip disease,
are caused by the patient's efforts to keep the limb off the
ground, partly to guard against concussion, and partly to
keep the limb out of the way of its fellow, which is charged
with the chief part of the work of progression. If the af-
fected limb, protected from concussion by the splint,
habitually seeks the ground and is active in locomotion,
the cause of adduction and flexion isremoved. He cited
cases illustrating his views.
Dr. BERNARD Bartow, of Buffalo, read a paper en-
titled
THE IMMEDIATE DISREGARD OF MALPOSITION OF THE
THIGH IN THE TREATMENT OF HIP DISEASE.
He employed the following method in the earlier stage
of the disease. It was a fixative dressing of plaster of
Paris, which was applied while the patient was suspended,
as during the application of the plaster jacket in spondy-
litis. The well foot is allowed to rest on a block from
four to six inches in height, so that the affected limb will,
by its own weight, exert traction’ upon the muscles about
the hip-joint. The plaster of Paris is applied over the
trunk, hip, and leg, extending above to the sixth nb and
below to the middle of the leg. The dressing is strength-
ened by strips of thin malleable steel. No attention is
paid to the malposition, which is gradually overcome by
the weight of the leg as different splints are applied, the
rest afforded the joint during these intervals removing
each time much of the spasm. The author reported his
cases, and showed photographs of them.
October 19, 1889]
—
AFTERNOON SESSION.
Dr. C. C. Foster, of Cambridge, read a paper en-
titled
A CASE OF CARIES OF THE ANKLE TREATED CONSERVA-
TIVELY.
After giving a detailed report of the case and its treat-
ment, he exhibited the patient and plaster casts of the
foot before and after treatment. He maintained that
such treatment is not nearly so quick, so easy, or so strik-
ing as a successful resection, but that the final result is
far superior, and well repays the extra time and great pa-
tience which must be devoted to the case. He did not
claim that all cases should be treated in this manner, but
that in many cases an intelligent, enlightened conserva-
tism, properly carried out, will produce the best final re-
sults.
Dr. C. L. SCUDDER, of Boston, by invitation, read a
paper (with exhibition of patients) entitled)
A REPORT OF CASES OF CARIES OF THE ANKLE TREATED
BY EXCISION.
From the study of his cases, he drew the following con-
clusions: Excision is safe, and the mortality is not great.
The convalescence and time of after-treatment are short.
The disease in the foot is ended, and the prognosis is
sure. Profuse suppuration and its consequences are
avoided. ‘The likelihood of septic infection is at a mini-
mum. ‘The partial operation of curetting is of very little
value. There is no mutilation of the foot, and its use-
fulness is very great dfter excision. ‘The question of
tubercular infection after operative interference is yet
unsettled. Excision of all the diseased bone should be
resorted to earlier in the treatment of chronic ankle-joint
and tarsal disease. .
Dr. Jonn Ripon, of New York, read the report of a
CASE OF CONGENITAL DISLOCATION AT THE HIP.,
The patient, a female, aged ten and one-half years, came
under observation nineteen months ago. The right great
trochanter was two and one-half inches above Nélaton’s
line, and it required a blocking under the foot of three
inches to make her stand fairly erect. The old pattern
of the Taylor extension hip-splint was applied, and the
leg elevated on an inclined plane. For one year the child
did not leave her bed, and no relaxation of the traction
was once permitted. At the end of this time it was pos-
sible to locate the head of the femur, which was found to
be displaced upward and forward, lying almost directly
below the anterior iliac spine, and the difference in the
length of the legs was found to be reduced to half an
inch. A jointed splint was applied, February 1, 1889, and
the patient was allowed up.
Dr. J. E. GOLDTHWAITE read a paper prepared with
Dr. R. W. Lovett, of Boston, entitled
ABSCESSES IN HIP DISEASE: THEIR PREVENTION, SIGNIFI-
CANCE, AND TREATMENT—A CLINICAL STUDY.
‘Three hundred and twenty cases were analyzed with ref-
erence to the number of abscesses occurring and the
effect of treatment. In these cases, seventy-five abscesses
occurred, which very small percentage is attributed to
long-continued treatment with the long traction splint in
the line of deformity, if present, and fixation in bed. The
majonty of the abscesses occurred in patients in whom
there had been insufficient and careless treatment at home.
The abscess in fifty-nine per cent. came early in the course
of the disease, /.¢., within one year of the bezinning of treat-
ment, and in forty-four per cent. the abscess came on before
treatment had been begun. He concluded that the pre-
ventive treatment in hip abscess was an exceedingly im-
portant matter, and that the abscess may be averted in a
large proportion of the cases under efficient treatment by
confinement of the patient to bed when symptoms of de-
formity or joint tenderness arise. But that when this
smaller proportion of abscesses had occurred, in them the
THE MEDICAL RECORD.
441
ee ee a
mortality was exceedingly high and the prognostic outlook
very much more serious than in suppurating hip disease in
general. Operation, in all of these cases, was not accom-
panied by anything approaching septicemia, nor did it
prevent the occurrence of tubercular meningitis or amyloid
degeneration ; and, finally, it was stated that thorough opera-
tion is followed in a fair proportion of all cases by speedy
closure of the sinuses, a closure which remains permanent.
SECOND Day, WEDNESDAY, SEPTEMBER 18TH—MORNING
AND EVENING SESSIONS.
These sessions were devoted to the reading of short
papers on hip disease, which were followed by a general
discussion of the subject by the members of the Associa-
tion.
Dr. H. G. Davis, of Everett, exhibited a
HIP-SPLINT
which showed many valuable modifications of the original
splint which he invented many years ago, and which has
formed the basis of all the traction hip-splints.
Dr. N. M. SHAFFER, of New York, read a paper on
THE PRINCIPLES OF TREATMENT OF HIP-JOINT DISEASE.
He held that hip-joint disease is a tubercular disease char
acterized by an insidious invasion and by a limp, and a
muscular splinting of the diseased joint. The muscular
splint, acting in the direction of the long diameter of the
muscles, made a direct interarticular pressure, and was
nature’s method of affording protection to a diseased
joint. Dr. Shaffer illustrated the action of traction in pro-
tecting a diseased hip by calling attention to the effect of
manual traction in a child suffering acutely from ‘ip dis-
ease, and he further illustrated the subject by showing
that it subjected the patient to severe pain if we used the
| lever principle, making the joint a fulcrum to overcome
the muscular deformity, thereby still further increasing the
interarticular pressure. He spoke only on the general
principles, and mentioned no particular form of apparatus.
He stated that his experience had led him to say that the
lever principle of treating hip disease was crude and un-
scientific. Certainly it was not the correct mechanical
principle to apply to an already overburdened and over-
taxed joint. And that true rest, real immobilization, and
perfect fixation, when these elements were required in
the treatment of hip-joint disease, were best obtained by
some form of apparatus employing the traction principle.
Dr. A. J. STEELF, of St. Louis, discussed
THE EARLY LOCAL TREATMENT.
He said that the earlier correct treatment was com-
menced, just so much better would be the result. The
reason we had fewer deaths, less deformity, and better
average results to-day than formerly, was because the
cases were recognized earlier, were subjected to treatment
at an earlier stage, and because of our improved therapeu-
tics. He said that the members of this Association could
not too often or too emphatically instruct the profession
at large regarding the serious import of lameness and
pain in the child. Our ideas upon the correct treatment
of this affection turn upon what we believe to be the
pathological process going on within or near the joint.
The means by which the needed rest may be furnished
the joint, without interfering with the proper hygienic
treatment, was obtained, he thought, by the “stretcher
splint,” which consists of an iron frame covered with can-
vas upon which the child lies. By movable attachments,
extension and counter-extension may be obtained, and
the trunk is fixed to the frame by straps. Perfect im-
mobilization can be thus secured, and at the same time
the patient may be moved from place to place in the
open air and sunlight. He exhibited his apparatus, and
stated that cases seen early and thus treated had no ab-
scesses, and obtained useful joirts.
442
THE MEDICAL RECORD.
[October 19, 1889
Dr. De F. WiLLARD, of Philadelphia, spoke upon
THE OPERATIVE TREATMENT.
His conclusions were: 1. Mechanical measures that
enforce strict and long-continued restriction of the joint
are preventatives of operative procedures. 2. That an
operation is in itself a confession of failure to arrest the
inflammation. 3. Antiseptic aspiration of the joint is
advisable when it is distended with serum, and sometimes
when it is full of pus. 4. Ignipuncture, trephining, and
drijling give great relief, provided the focus of disease is
not extensive. 5. If in doubt as to the presence of pus,
use rest and fixation, and wait ; or aspirate antiseptically,
and, if no true pus is found, continue the immobilization.
Should the aspirator disclose a thin sero-purulent material,
continue the aspirations as needed until absorption takes
place, or until positive signs of pus are present. 6. When
certain that pus is present, and in those cases in which
the patient is doing badly, make an exploratory incision,
open the abscess, and follow by one or the other of these
tw plans: (a) Wash out the abscess-cavity antisepti-
cally, but on no account attempt, by pressure, to expel
the pus, lest fissures be produced in its walls, and bacil-
lary infection occur; or (4) continue the exploratory in-
cision down along some sinus, thoroughly examine the
joint, and remove thoroughly every particle of tuberculous
tissue of both hard and soft parts. 7. Do a formal in-
cision only when the bone disease is found to be too ex-
tensive to be removed in any other way. 8. Always
follow operative procedures by the most thorough atten-
tion to fixation and protection of the joint for years.
Dr. R. H. Sayre, of New York, discussed i
EXCISION OF THE HIP.
He said that with proper mechanical treatment, com-
menced early in the disease, and with good hygienic sur-
roundings, the vast majority of cases recover without ex-
cision and recover with limbs as good or better than those
resulting from excision. The primary focus of the disease
1s usually so situated that it cannot all be removed without
excising the joint. About half the primary excisions re-
lapse, a number are followed by general tuberculosis, and
the result is not equal to that of mechanical treatment.
Therefore do not excise in the onset of the disease. The
development of an abscess is the last step in nature’s pro-
cess of exfoliating the diseased tissues, and in such cases
to excise is a mistake, and the abscess alone requires
treatment. In other cases, however, the patient, in spite
of treatment, does badly, and it is in such cases that it is
necessary for the surgeon to interfere and excise the joint,
not delaying until the patient is worn out with fever and
suffering from amyloid changes. But, even in such cases,
when the diseased tis;ue is removed, the patient may re-
cover. The author then gave the technique and the after-
treatment of the operation. |
Dr. A. B. Jupson, of New York, discussed
THE TREATMENT OF HIP DISEASE.
He had been unable to recognize the trauma which is
said to be caused by reflex spasm. It implies a vicious
circle in which spasm causes inflammation, and inflamma-
tion, in its turn, causes spasm. He was also sceptical in
regard to the alleged counteraction of the muscles by trac-
tion. He believed it mechanically impossible to make
useful traction on the muscles which cross the line of the
joint with adhesive plaster applied over the skin. The
great relief comes from the fact that traction is attended
by practicable, comfortable, and beneficial fixation of the
joint. He raised the question whether we are not respon-
sible for the apathy with which the profession regards the
treatment by the hip-splint. We claim so much for it and
the things we try to do with it are so mysterious and re-
quire such nice and fanciful adjustments that the practical
common-sense of the profession in general is likely to con-
tinue to neglect an apparatus of the greatest utility and
value. He doubted the permanent efficacy of operations
on the femur for the correction of any except the most
extreme deformities, ‘The angle established in the bone
after osteotomy is of course permanent, but he would ex
pect adduction to recur at the point of fibrous anchylosis.
Dr. Joun Ripon, of New York, read a paper entitled
FIXATION AND TRACTION IN THE TREATMENT OF HIP-JOINT
DISEASE.
He believed that the treatment of inflammation in and
about the hip-joint should in a general way be governed
by the same principles which govern the inflammation of
like character in other parts of the body, and that physi-
ological rest of the inflamed structures is the chief end
to be obtained. By physiological rest he meant relief
from the performance of the normal functions. The
functions of the hip-joint are motion and the sustaining of
weight ; therefore, as applied to the hip-joint, rest is relief
from motion and from the sustaining of weight. The
problem, then, would seem to be, in so far as it is possible,
to immobilize the joint so long as any inflammation re-
mains. ‘To remove the superincumbent weight until con-
valescence 1s well established and to counteract the effect
of muscular spasm, so long as that spasm is in any way
harmful, are the indications. He discussed the means of
fulfilling these indications and urged that fixation should
be made as perfect as possible, depending upon the sur-
rounding circumstances of the patient. If traction be
used at all, it should be constant and in the same line.
Traction at right line at one time and at right angles at
another, as is permitted by most forms of traction appara-
tus, cannot be free from harm, and the push and pull
action of all traction hip-splints during locomotion must
be seriously condemned.
Dr. V. P. GIBNEY, of New York, discussed ;
MECHANICAL VS. OPERATIVE TREATMENT,
and în a very complete comparison gave the indications
and limitations of each line of treatment.
AFTERNOON SESSION.
Dr. E. G. BRACKETT, of Boston, read a paper entitled
AN EXPERIMENTAL STUDY OF DISTRACTION OF THE HIP-
JOINT.
The points in this paper include the consideration of the
counteracting influence of the bony formation of the
joint, of atmospheric pressure, and of the assisting force
of ligaments and muscles. In adults, owing to the bony
formation of the joint, traction is mainly expended in pull-
ing the most dependent portion of the head of the femur
down on the bottom of the acetabulum, which offers a
mainly horizontal surface. When separation occurs it is
denoted by a widening at the hips as well as by lengthen-
ing of the leg. The child’s joint offers no such resistance
to the traction force, but allows a separation nearly in the
line of traction and is shown principally by a lengthening
of the limb. Experiments showed that atmospheric press-
ure played but a very unimportant part in preserving
contact while the parts were intact. It was shown that
the counteracting force of muscular action was the most
important influence, and this must be accomplished either
by muscular tonicity or muscular contraction. ‘The claim
was not made that distraction is an inevitable result of
traction, nor even that it is possible under all conditions,
but that this does occur in children under favorable con-
ditions when the power is properly applied.
Dr. Joun H. HupDDLEsSTON, of Boston, read a paper
entitled
AN ANALYSIS OF TWENTY-ONE CASES OF HIP DISEASE
TREATED BY THE THOMAS SPLINT. .
No attempt had been made to choose cases for the splint.
It had been applied in all stages of the disease, and in
some cases it was kept on throughout the course of the
disease and in others until the interests of the patient de-
manded a change. Cases were seen once a month or
October 19, 1889]
oftener and were taken from the ordinary class of out-
patients. It was found difficult to fit the splint, and
more difficult to fix the splint after being fitted. Of
the twenty-one cases, satisfactory notes were obtained
in fourteen, and notes sufficient to explain the use and the
result of the splint in five more. One patient died shortly
after the application of the splint and one had not been
heard from. The results obtained were stated as follows :
Good position with both flexion and adduction, but
great shortening, great atrophy, and very constant eleva-
tion of the trochanter above Nélaton’s line with a remark-
able percentage of abcesses.
The Society then inspected the Boston Children’s Hos-
pital, and were shown by Dr. H. L. Burrell many cases of
great interest.
THIRD Day, THURSDAY, SEPTEMBER I9TH—-MORNING
SESSION.
Dp GeEorGE W. Ryan, of Cincinnati, read a paper en-
titled
WHEN MAY TREATMENT BE DISPENSED WITH IN SPONDY-
LITIS ?
It was a matter which had a wide interest to every ortho-
pedic surgeon, and was never an easy question to deter-
mine. He believed that as a rule the orthopedic surgeon
left the apparatus on too long, and that the general sur-
geon removed it too early. He had seen many cases of
spondylitis in which the appliance had been removed too
early, and many others in which he was satisfied that it
was kept on too long. He stated that a slight increase in
a kyphos which is already well marked makes a very great
change in the gait, the appearance, and the growth. He
believed that when the disease was no longer present the
appliance was a foreign body and retarded muscular
growth and exercise. He believed that no general rule
could be laid down concerning the time when treatment
could be dispensed with, but that some indications might
be pointed out. He thought that the type of patient
largely influenced the course of the disease. Absence of
pain was of little value, as efficient support always relieved
that. The speaker often found the compensating de-
pression beneath the kyphos indicative of cure. Many
cases of cervical and lumbar disease get well without
treatment and with fairly good results. ‘The matter re-
quires a great deal of care, and the apphance should be
slowly dispensed with. Massage, cold baths, and faradism
were of great service at this time.
he W. R. TOWNSEND, of New York, read a paper en-
title
ACUTE ARTHRITIS OF INFANTS.
It was essentially an osteo-myelitis, the difference in path-
ological conditions being largely due to differences in
anatomical conditions and relations of the epiphysis to
the joint. Various forms of staphylococci were found in
some cases, notably S. aureus and albus.
The symptoms are quite constant—flexion of the joint,
production of abscesses, involving the joint and soft
parts, and constitutional symptoms of pyzmia. The
treatment was early and complete evacuation of the in-
flammatory products and heart-stimulants ard tonics.
Most cases occur in patients under one year of age, and
about fifty per cent. of them result fatally. He 1eported
seventeen cases, and from the experience of these and
others found that the joints most affected were the hip,
knee, and shoulder.
Dr. A. J. STEELE, of St. Louis, showed a
NEW EXERCISE IN THE TREATMENT OF LATERAL CURVA-
TURE OF THE SPINE.
He showed an apparatus for fixing the feet firmly to the
ground, thus securing fixation both below and above.
THE MEDICAL RECORD.
443
—— ~~
The Secretary read a paper by Dr. T. H. Meyers, of
New York, reporting a case of
TRAUMATISM OF THE HIP SIMULATING THYROID DISLO-
CATION.
It was the result of a fall in a child nine'years of age. The
patient struck upon the left hip and the injury was im-
mediately followed by a limp, but little pain, and presented
the following condition : The patient stands with the left
thigh advanced, the knee slightly flexed, and the foot in
equinus with 45 degrees of outward rotation of the thigh.
In the supine position there was flexion at the hip of 160
degrees and abduction of 30 degrees ; and when the legs
are approximated the left leg is apparently one and one-
quarter inch longer than the right, but there is no real dif-
ference in the length. There is marked depression over the
trochanter major, and the trochanter is three-eighths of
an inch above Nélaton’s line. On flexing both thighs to
go degrees the left knee is an inch higher than the nght,
but all these facts seem to be due to the abduction. Ad-
duction and extension are impossible. Rotation, abduc-
tion, and flexion are allowed to a considerable extent, and
when limited there is not the reflex spasm of joint disease.
Under ether the flexion and abduction disappeared, but
adduction and extension were still restricted. It was
_probably a separation to a greater or less degree of the
cotyloid ligament and the bone.
Dr. V. P. Gisney, of New York, presented a paper
entitled
A CONTRIBUTION TO THE STUDY OF FLAT-FOOT.
In some cases painful flat-foot was accompanied by in-
growing toe-nail, and he reported one case and referred
to two others in which the removal of the offending nail
resulted in a marked improvement in the condition of the
flat-foot. l
AFTERNOON SESSION.
Dr. N. M. SHAFFER, of New York, read a paper en-
titled
THE ‘'REATMENT BY PORTATIVE APPLIANCES OF UNUNITED
FRACTURE OF THE FEMUR.
The writer reported three cases. In the Grst a long
traction splint with a felt coaptation splint was applied
and traction was maintained, the patient walking about on
itin the meantime. In two and a half months it was united,
with three-quarters of an inch of shortening. ‘The second
was also a case of ununited fracture of the shaft of the
femur, following treatment by Buck’s extension. The
long traction splint was applied, and this was followed
by a traction splint which permitted knee-joint motion
and also independent traction to the thigh and leg. In
this way passive motion to the knee was given during
treatment and the union was completed in two months,
with practically no shortening. In the third case there
was an ununited fracture of the neck of the femur, with
three inches of shortening. A traction splint like that in
the second case was applied, with the addition of a
“surcingle,” which was buckled tightly about the tro-
chanter. Union was completed in three months, with
five-eighths of an inch of shortening.
Dr. R. W. Lovett, of Boston, reported
A CASE OF FUNCTIONAL TORTICOLLIS, PROBABLY DUE TO
DEFECTIVE EYESIGHT, WITH EXHIBITION OF PATIENT.
The patient was three years of age, and the torticollis was
noticed by the parents six months before the patient came
under treatment. ‘There was an internal strabismus, and
as soon as the recti were cut there was a decided improve-
ment in the wry neck. The recovery from the torticollis
was not complete, but, as a slight internal strabismus still
remains, it was expected that after another operation for
the insufficient recti the recovery would be complete.
444
THE MEDICAL RECORD.
[October 19, 1889
Dr. W. N. BuLLARD, of Boston, read a paper, prepared
in conjunction with Dr. H. L. BURRELL, the title of which
was
OPERATIONS UPON THE SPINE FOR THE RELIEF OF PRESS-
URE PARALYSIS.
‘Twelve cases were reported, and the summary was as fol-
lows: Contra-indications—1, Those cases in which an
operation would not be advisable, from the general health
or other general surgical considerations; 2, the presence
of tuberculosis in other parts of the hody ; 3, the pres-
ence of an abscess with the caries which can be otherwise
evacuated; 4, acute exacerbations without symptoms
referable to the cord, and not threatening life. ‘The in-
dications in favor of an operation were: 1, General good
conditions and favorable surroundings—(a) when the dis-
ease 1s gradually and slowly progressing to an unfavorable
termination, and (4) when the patient has more or less loss
of motion and sensation in the portions of the body below
the level of the lesion and incontinence of urine and
fæces, and when these conditions have lasted for a suff-
cient length of time to render spontaneous recovery im-
probable, and not so long as to produce permanent
destruction of all recuperative power in the cord; 2,
when acute symptoms threatening life appear, and when
there is reasonable expectation that they may be relieved
by the removal of the compression.
Dr. Homer Gace, of Worcester, by invitation, re-
ported
A CASE OF CONGENITAL ABSENCE OF FIVE RIBS, WITH
RESULTING DEFORMITIES. .
The sixth to tenth inclusive on the left side were absent,
and in consequence of their absence there had developed
a rotary Jateral curvature of the spine, a hernia of the
stomach, and a displacement of the heart on to the right
side. Photographs showing these conditions accompanied
the paper.
It was decided to hold the meeting next year in Phil-
adelphia, and the following officers were elected: Pres-
tdent—Dr. De F. Willard, of Philadelphia ; First Vice-
President—Dr. A. J. Steele, of St. Louis; Second Vice-
President—Dr. A. B. Judson, of New York ; Secretary
and Treasurer—Dr. G. W. Ryan, of Cincinnati ; Corre-
sponding Secretary—Dr. Samuel Ketch, of New York.
The following statement was adopted as expressing the
opinion of the Association in regard to the treatment of
hip-joint disease: 1. In the painful stage, complete rest
to the joint is of the first importance. 2. Early excision
is to be condemned. 3. ‘The weight of the body should
be remoygd from the affected joint until complete recov-
ery has taken place. 4. ‘Traction is an important element
of treatment.
Some DomeEsTIC REMEDIES IN THE ‘TRANSVAAL.—
Mr. Walter H. Haw, in a letter to Zhe Lancet upon
medical practice in the ‘lransvaal, gives the following
list of remedies in which the Boers have the most implicit
faith, and to which they recur in many of the ills of them-
selves and their families: 1. Cow-dung poultices. 2.
Stink blaar (Datura stramonium) \eaves applied for the
relief of pain. ‘These act well, and are often used. 3.
Prickly-pear leaves skinned and applied. 4. For chil-
dren: A young goat killed and opened, the child being
put in bodily after removal of the viscera. A good poul-
tice, I fancy. 5. Rimpis (threads) of eel-skin worn
round the painful joints in chronic rheumatism. This
was described to me by a man who was wearing one
round almost every joint of his body as being a splendid
remedy. 6. Rimpis of the tanned skin of a tame goat
worn as above for sprains, etc. 7. The finely chopped
hair of a black cat, which should not have the faintest
trace of white about it. A remedy for convulsions. 8.
A spoonful of dog’s blood taken from the ear for “ buur
en de mag” (inflammation of the bowels). 9g. For snake-
bite, repeated fowl poultices.
New Znstruments.
THE QUESTION OF THE POCKET-CASE.
By ROBERT H. M. DAWBARN, M.D.,
LECTURER IN OPERATIVE SURGERY, NEW YORK POLYCLINIC.
In common with many others I have felt interested in the
letters from various medical men which have appeared in
these columns of late, discussing the question of the ideal
pocket-case for surgical instruments. Considerable space
in these communications has been devoted to the case
itself, and not so much as I could have wished to its con-
tents.
This is a subject upon which I have had to think some-
what, for each year there are a dozen or more men about
entering professional life who ask me, as their preceptor,
what is best for them to purchase at the outset in the way
of tools of the trade, so to speak.
It is an unfortunate fact, which I think no surgeon will
deny, that the pocket surgical cases and contents now on
the market are, almost without exception, an abomination
in the eyes of the surgically cleanly ; and the instruments
are, furthermore, in many respects inefficient in point of
proper selection to meet the needs of any emergency op-
eration much graver than lancing a boil. ;
Surgery has advanced; but, with few exceptions, the
cases we carry upon our persons are those familiar to our
fathers.
The leathern receptacle is prettily lined with velvet,
and cannot by any possibility become purified when, in
process of time, it has become strong with sweat and
grimy with dust which a tap of the finger will bring forth
from the lining.
Into this the instruments go. And what “instruments !
The knives have baby-blades—fit only for playing at
surgery. ‘There is the inevitable curved, sharp-pointed
bistoury, the pet of those whose idea of surgery 1s to stab
in the dark and cut out. Of course no one is brutal
enough nowadays to incise a felon or a boil without some
kind of local anzesthesia ; hence this bistoury loses its one
poor excuse of completing at a stroke its incision when
the patient in agony shrinks suddenly away from the sur-
geon. ‘These knives, at the best, have some patent ar-
rangement whereby, although they close up, the blade can
be detached, permitting the handle to be cleansed—with
difficulty. And at the worst, and usually, they are as
hard to disinfect as the ordinary pen-knife.
Sometimes we actually find the jointed metallic catheter
in our case. A little use always makes its joints misfits.
I wonder how many physicians would be willing to have
their water drawn by one of these things which was not
fresh from the instrument-maker ?
Will someone of an intellectual turn of mind inform
me why it is generally considered de rigueur to limit the
number of artery-forceps in the pocket-case to one? Out
of dozens of these cases I have never seen any with more
than two hemostatic forceps, which number is all too
little. If an emergency case demands treatment of
hemorrhage at all, it will almost surely need more than
one or two clamps for bleeding vessels. ‘The custom, I
find, is to kill two birds with one stone by making the
other end of the artery-forceps a needle-holder—or some-
October 19, 1889]
thing else—and the combination is, of course, difficult to
clean.
In this latter regard I cannot refrain from expressing
my admiration equally for the business thrift which in-
duces the instrument-dealers to stamp their names as an ad-
vertisement into the metal of our tools, and for the Chris-
tian resignation with which a long-suffering profession has
tolerated this means of propagating filth. If a surgeon’s
time is of any value he does not wish to waste it in dig-
ging particles of foreign matter with a needle out of the
letters stamped into his scalpels and scissors, and which the
brush will not entirely remove ; and if he is not thus
careful he will probably have “laudable pus” in his
wounds—to his shame.
_ How about our ligatures and sutures? These we shall
find in the form of a strand of silk wound on a card and
placed in a pocket of the case. Woe to the wound !
The essence of primary antisepsis is asepsis, and asep-
sis 1s strict cleanliness. ‘Therefore let us use only tools
which are easily kept surgically clean. If possible, we
should have each tool of one piece of smooth metal, shaft
and blade. If two parts are essential, these should be
smooth too, and easily detachable for cleansing. Cross-
hatching upon handles, etc., is worse than useless. The
idea, of course, is to give security to the grip; but no
one needs to grip these instruments.
To surgeons all the foregoing will be trite, and as a
many-times-told tale. But that it needs repetition for the
profession as a whole a visit to the nearest instrument-
shop will convince anyone. The dealers keep in stock
what is found still salable.
Among the correspondents of THE MEDICAL RECORD
is one gentleman who advocates a case made of chamois-
skin, as being easily cleansed by washing, and readily
made at home. ‘This is a step in the right direction, but
has two objections: First, the bulk is about as great as
that of the leathern wallet ; second, with the scalpel which
I have advocated, and which is not a claspknife, the
blade would probably cut its way through the chamois-skin.
My object in writing this article is not alone to criticise ;
it is also to offer a case of my own for criticism, and, I
hope, for approval. First let us discuss the case, then its
contents.
I. An ideal case should be of smooth, plated metal,
that it may be easily cleansed ; may be boiled, if thought
desirable.
leathern pocket-case ; hence the metal must be very thin.
It should be as small as possible, and of such a shape as
not to cause the pocket in which it is carried to bulge,
and thus make a coat fit badly.
These points are covered in my case. Of course the
idea of a metallic case is not new. It originated in Ger-
many, I believe. But generally they are too thick and
heavy. They should be as wide as the top waistcoat-
` pocket will carry, and this width permits them to be of
less depth than otherwise.
The cut of the case shown herewith is, of course, re-
duced in size. ‘The actual case has no name upon it (dif-
fering from the cut), neither is there a name or an un-
necessary scratch upon any instrument. A close-fitting
chamois-skin cover goes over the case, for use, if thought
best, to prevent the slipping of so smooth an object from
the pocket.
The case and instruments are made by Welker, next
door to the Polyclinic.
II. The following is the list of instruments: 6 stout
artery-clamps; 1 pair of scissors, straight, with French-
lock ; 1 needle-holder (French-lock), which is also a dress-
ing-forceps and a sequestrum-forceps; 1 very narrow-
bladed scalpel; 1 straight, blunt- pointed bistoury ; 1 pair
of two-hooked retractors; 1 Peaslee’s needle (long, with
handle, eye in point); 2 pairs of dissecting-forceps; 1
metacarpal saw; 1 Volkmann’s sharp spoon, medium size ;
I grooved director and aneurism-needle; 2 silver probes,
_ one of them eyed; 1 small metal box with tight cover—
this contains a silver porte-caustigue, an assortment of
THE MEDICAL RECORD.
It should not be appreciably heavier than the
445
needles, including Hagedorn’s, and in a small compart-
ment a few bichloride tablets wrapped in rubber-tissue ; 2
bottles, tightly corked, in a metal frame; one contains
catgut, the other silk, each tightly wound on a small reel,
and in an antiseptic solution; 1 rubber soft catheter,
medium size. ‘This serves three purposes : that of a cath-
eter, a means of bloodless operation upon the smaller
members, and, in the case, as a buffer, preventing by elas-
tic pressure any noise or rattling of instruments.
The knives have long blades and as short handles as
compatible with good work. No more than one good
scalpel is really needed in an emergency pocket-case ; and
the surgeon can do things with a narrow-bladed scalpel
that he could not with a wider blade—can use it as a
tenotome if he needs one.
It seems to the writer that, odan the object we
have in view, the list given about covers the ground. . As
the instruments are all made as light as possible, the total
weight is trifling. If more were added the case would
have to be larger, and would then become clumsy and
bulky, like the leather one. And I hardly think that any
of these tools could well be spared. It has been suggested.
that one pair of thumb-forceps is engugh. But when
working in a dangerous region it is safer to use two pairs
of forceps than a grooved director, in many cases.
In the bottles the antiseptic liquid preferred is—fol-
lowing the experiments of Dr. G. de Ruyter—one com-
posed of a saturated solution of bichloride-washed iodo-
form in equal parts of alcohol and ether. The silk is
first boiled in a 1 to 500 watery solution of mercuric
bichloride, and is then immersed and kept in the iodo-
form-alcohol-ether. ‘The commercial catgut is first placed
for a few days in ether, to remove all the fat thoroughly
from its pores, and is then immersed in the same solution
(iodoform-alcohol-ether) and kept there permanently. I
know of no method compatible with strict antisepsis where-
by the strength of catgut and silk is better maintained.
There are very few operations, except some unusual
ones upon bone, which really need other mechanical aid
than the contents of this case and one or two things al-
ways at hand. Exsanguination of a major member needs
no Esmarch apparatus in an emergency ; elevation and
“ milking ” of the limb, followed by the thorough applica-
tion of the extemporized “ Spanish windlass” suffices ad-
mirably. A clean sheet is always to be had; and torn
in pieces of proper size, and bichloride-soaked, makes
pledgets in lieu of sponges, and also supplies dressings.
Still other rolled-up strips oi the sheet form bandages.
Bichloride tablets we have, wherewith to disinfect
hands, patient’s skin, and the dressings, and to irrigate.
The instruments, being scrupulously clean, need only be
put in pure water. If this needed demonstration, Mr.
Lawson Tait has demonstrated it.
There is no need to carry or procure carbolic acid.
Carbolic acid is at present little more than a means ,
whereby surgeons testify to their distrust of their assist-
ants, therewith trying to sterilize dirt upon instruments
which may have been carelessly cleaned.
EFFECT OF CANNON-FIRING ON THE EIFFEL TOWER.— Of
all the indispositions (and there are many) created by the
Exhibition, the most curious is that which is caused by the
firing of the cannon on the Eiffel tower. Every evening,
at ten o'clock, when the gun is fired for the last time in
the day, it is not unusual to see produced a sort of frenzy
among the young female visitors to the Exhibition. Un-
der the already strong impression produced by the illumi-
nations, the luminous fountains, etc., when the gun is
fired, they seem to be seized with a veritable panic. It
appears to them that a sudden catastrophe, such as a great
fire, has taken place. Cries of admiration escape from
some, and of terror from others, when fainting, attacks of
hysteria, and of prostration occur. The subject has at-
tracted the attention of Professor Charcot and other phy-
sicians.—Paris Correspondence of Zhe Lancet.
Army and Dany Hews.
Official List of Changes in the Stations and Duties of Off-
cers serving in the Medical Department, United States
Army, from October 6 to October 12, 1889.
STEINMETZ, WILLIAM R., Captain and Assistant Sur-
geon. Ordered for examination for promotion. Par. 3,
S. O. 236, A. G. O., October 10, 1889.
CARTER, Epwarp C., Captain and Assistant Surgeon.
Granted leave of absence tor twenty days. Par. 6, S. O.
234, A. G. O., October 8, 1889.
SMITH, A. K., Lieutenant-Colonel and Surgeon. Leave
of absence extended twenty-one days, on surgeon’s certi-
ficate of disability. Par. 7, S. O. 234, A. G. O., October
8, 1889. .
Munpay, BENJAMIN, Captain and Assistant Surgeon.
Granted four months’ leave of absence. Par. 2, S. O.
233, A. G. O., October 7, 1889.
Official List of Changes in the Medical Corps of the United
States Navy for the week ending October 12, 18809.
BRIGHT, G. A., Surgeon. Detached from temporary
duty at the Naval Academy, and placed on waiting orders.
Medical Items.
CONTAGIOUS DIsEASES—WEEKLY STATEMENT. — Re-
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending October 12, 1889:
| Cases. | Deaths.
Typhus fever s6oce 24.54 dd oid bb aad caved eehnds |
Typhoid fever occ 5 eos secae case eae heeadt sseroos
SCArIet LEVET sE ieee anes E a
Cerebro-spinal meningitis....................000.
MCASIES 4 getter die de eyo wis a aa meee
Diphtheria iorra torsos sadeetaeinaiwetenes
SMAM-POX oc fase eines eee case tee a ceeeaeea sels
W GOW: (EVER cose iss nanai a AERAR AEE |
Choleraen eene E ERE NENEDA |
COODH ORDO
o
85
36
o
8
73
o)
o
o
PULMONARY DISEASES CauseD BY Dusty OCCUPATIONS.
—Dr. Kunze, in his inaugural thesis for the M.D. degree
of the University of Kiel, publishes as a contribution to
the diseases caused by the inhalation of dust a series of
examinations of lungs so affected. In all these dust was
found microscopically, and after chemical tests in the
various anatomical and histological parts of the lungs and
in the interior of the lymphatic vessels, numerous leuco-
cytes were found covered with the dust. Being arrested in
its progress it causes inflammation, producing hyperplasia
of connective tissue, especially where a dense net-work of
lymphatic vessels exists. Dr. Kunze also proved that the
degree of alteration in so-called “ dust lungs” depends not
merely on the quantity of the dust inhaled, but also on
its greater or less morphological power of injuring the tis-
sue. He concludes from his experiments that even the
greatest alterations in these lungs—such as nodes, indura-
tions, and vomicz—are mainly produced by the inhaled
dust, and that tuberculosis is only an occasional coinci-
dence. ‘The least serious alterations in the lungs resulted
from the inhalation of lamp-black, the particles of which
are very fine and little injurious ; the most serious, from
the dust inhaled by earthenware manufacturers and stone-
masons. The lungs of a locksmith showed only a moder-
ate hyperplasia of connective tissue, the dust consisting
partly of the finest particles of iron. In a worker in
oxides of iron the lungs were found full of small granules,
THE MEDICAL RECORD.
[October 19, 1889
and the morbid changes in the tissues were very consider-
able. The lungs of gold miners were generally indurated
and atrophied ; the dust in these cases is exceedingly fine.
Sand produced numerous circumscribed hard nodules and
thick indurations. In cloth manufacturers the lungs, in
spite of the contact with an enormous quantity of organic
dust, presented but few indurations. In the lungs of two
stone-masons induration and tuberculous disintegration
were observed; all the other lungs were entirely free
from tuberculosis of any kind, an observation which. was
verified by the absence of tubercle bacilli in the muco-
pus in the vomice.— Zhe Lancet.
AMERICAN PuBLIC HEALTH ASSOCIATION, 1889.—The
American Public Health Association will convene at
Brooklyn, N. Y., Tuesday, October 22d, at ro o'clock
A.M., and continue four days. The meetings will be held
at the Brooklyn Institute. The Executive Committee
have selected the following topics for consideration at
said meeting: I. “ The Causes and Prevention of Infant
Mortality.” II. “ Railway Sanitation. (a) Heating and
ventilation of railway passenger coaches ; (4) water-sup-
ply, water-closets, etc.; (¢) carrying passengers infected
with communicable diseases.” III. “Steamship Sanita-
tion.” IV. “ Methods of Scientific Cooking.” V. “ Yel-
low Fever. (a) The unprotected avenues through which
yellow fever is liable to be brought into the United States ;
(4) the sanitary requirements necessary to render a town
or city proof against an epidemic of yellow fever ; (c) the
course to be taken by local health authorities upon. the
outbreak of yellow fever.” VI.“ The Prevention and Re-
striction of Tuberculosis in Man.” VII. “ Methods of
Prevention of Diphtheria, with Results of such Methods.”
VIII. “ How far should Health Authorities be permitted
to apply known Preventive Measures for the Control of
Diphtheria?” IX. “Compulsory Vaccination.” X. “Sani-
tation of Asylums, Prisons, Jails, and other eleemosynary
Institutions.” Partial list of papers to be presented.—The
following is a partial list of papers to be presented—a
full list will appear in the daily programmes: “ Address
of Welcome,” by Hon. Alfred C. Chapin, Mayor, on
behalf of the City; “ Address of Welcome,” by Alexander
Hutchins, M.D., on behalf of the Medical Profession ;
“ President’s Address,” by Professor Hosmer A. Johnson,
M.D., Chicago, Ill.; ‘The United States Census in its
Relation to Sanitation,” by Dr. John S. Billings, LL.D.,
Major and Surgeon U.S.A., Washington, D.C.; “ Re-
cent Researches relating to the Etiology of Yellow Fever ”
(illustrated with the stereopticon), by George M. Stern-
berg, M.D., Major and Surgeon U.S.A., Baltimore, Md. ;
“ More Yellow-Fever Problems,” by Jerome Cochran,
M.D., State Health Officer, Montgomery, Ala.; ‘ Forms
of Statistics,” by Henry B. Baker, M.D., Secretary State
Board of Health, Lansing, Mich.; “ A Suggestion for the
Limitation and Detection of Adulterations in Food and
-Drink,” by Henry Leffmann, M.D., Philadelphia, Pa. ;
“ The Prevention of Consumption,” by J. N. McCormack,
M.D., Secretary State Board of Health, Bowling Green,
Ky.; “The Necessity for a More Rigorous Inspection of
Meat-producing Animals at the ‘Time of Slaughter,” by
D. E. Salmon, D.V.M., Chief of Bureau of Animal In-
dustry, Washington, D. C.; “ The Causes of Infant Mor-
tality,” by Dr. R. O. Beard, Assistant Commissioner of
Health, Minneapolis, Minn., and Professor of Physiology
in the Medical Department of the Minnesota State Uni-
versity ; “ Causes and Prevention of Infant Mortality,” by
Jerome Walker, M.D., Brooklyn, N. Y.; “The Utiliza-
tion and Purification of Sewage,’ by John H. Rauch,
M.D., Secretary State Board of Health, Chicago, IIL ;
“The Art of Cooking,” by Edward Atkinson, LL.D.,
Boston, Mass.; *“ New Method of Dealing with the
Dead” (illustrated with the stereopticon), by Rev. Charles
R. Treat, New York City; “ Report of the Committee
on the Disposal of Garbage and Refuse Matter,” by S. S.
Kilvington, M.D., Commissioner of Health, Milwaukee,
Wis. ; ‘A Suggested Minimum Basis of Compensation tu
October 19, 1889]
THE MEDICAL RECORD.
447
Local Health Officers,” by George Homan, M.D., Secre-
tary State Board of Health, St. Louis, Mo.; “Do the
Sanitary Interests of the United States demand the An-
nexation of Cuba?” by Benjamin Lee, M.D., Secretary
Pennsylvania State Board of Health, Philadelphia. ;
“ Railway Sanitation,” by Samuel W. Latta, M.D., Medi-
cal Examiner Pennsylvania Railroad Voluntary Relief
Department, ‘Trenton, N. J.
PUNISHED FOR MAKING AN INCORRECT DIAGNOSIS.—
A surgeon of high rank in the French military service was
recently retired on a pension because he had treated a
soldier for mental disease who was in reality suffering
from the results of a beating at the hands of one of his
comrades.
SoME CHINESE Docrors.—Colonel Cheng-Ki-Tong,
military attaché of the Chinese Embassy in Paris, has
written several books to instruct the Western barbarian
concerning the ways and customs of the inhabitants of
the Flowery Kingdom. In one of them he relates some
tales of medical practice in that land, the two following
being noted by the Medical Recorder: A certain physician
having advertised that he had an infallible remedy for curva-
ture of the spine, a hunchback applied to him and asked
if he could straighten his back. ‘The doctor undertook to
do so, and placed the unfortunate patient on his back on
a flat board. He then placed a similar board on his
chest and abdomen, and loaded it with heavy weights and
stones. The result of this novel orthopedic surgery was
that the patient was straightened out so effectually that
he died on the spot. ‘The quack claimed his fees on the
ground that he had kept his promise; the bargain was
that he should straighten his patient’s back, but nothing
had been said about his life! In China, it appears, the
distinction between physicians and surgeons is more sharply
defined than with us, and every man is expected to stick
to his own branch of the profession. A rich merchant
was struck by an arrow, which remained fixed in the
wound. The principal surgeon of the place was sent for,
and after insisting on pocketing his fee in advance cut off
the projecting end of the arrow, leaving the point buried
in the patient’s body. On being asked to extract it, he
said medical etiquette would not allow him to trespass on
a brother practitioner’s province ; the arrow being inside
the body, the case was clearly one for a physician !
SPONTANEOUS RUPTURE OF THE HeEarr.—Dr. Mallet,
of Paris, described before the Société Anatomique of that
city a case of this accident which occurred last May in
the Hôpital Tenon. The patient was a man aged
seventy-nine, with pulmonary disease. He died suddenly
after rising to micturate. A rent, almost vertical and over
two inches long, was discovered in the anterior aspect of the
wall of the left ventricle. ‘The pericardium was full of
blood, the aorta atheromatous, and the left coronary
artery nearly obliterated. All the valves were normal.
Dr. Mallet quotes Odriozola’s statistics of spontaneous
rupture of the heart. That observer could only collect
176 authentic cases. In many instances the patient was
old, being between sixty and seventy years of age in 36,
and between seventy and eighty in 45. ‘The accident
appears most frequent in women. As a rule, the escape
of blood into the pericardium is considerable. The rent
in the wall was unusually large in Dr. Mallet’s case. In
nearly every instance in Odriozola’s statistics the rupture
was in the anterior part of the left ventricle. The origi-
nal report of the case deserves study. The rupture ap-
parently took place fifty-three hours before death, when
the patient was seized with dyspnoea and epileptiform con-
vulsions marked in the upper extremities ; his face turned
pale. ‘The exertion of rising to micturate caused imme-
diate death, probably by sudden escape of blood into the
pericardium. A similar history has been recorded in other
cases of spontaneous rupture of the heart.— British Medi-
cal Journal.
FORMUL# FOR THE USE OF CREOLIN.—During the
last few years none of the more recent remedies has had
such a rapid success as creolin, identical with a patent
fluid, of which a refined preparation has been named
“ Liquor Antisepticus.” When creolin was suddenly rec-
ommended in Germany as an unsurpassed non- poisonous
disinfectant, many voices were heard which objected to
the use of a remedy that was a “ patent article ;” but the
hesitation was soon overcome when it was found that the
preparation really fully deserved the claims made for it.
In many hospitals, clinics, and in private practice, creolin
has completely superseded the use of corrosive sublimate,
carbolic acid, 1odoform, etc., in antiseptic surgery. Au-
thorities like Von Nussbaum, Von Esmarch, Professor
Fréhner, Dr. Kortum, have given such favorable verdicts
on creolin that it has now become a generally used dis-
infectant—for instance, for sterilizing instruments before
operations, for irrigation of wounds after operation.
Creolin is especially convenient for the disinfection of
the hands. In the ophthalmic, aural, and gynecological
practice its use has become general. For prevention of
the formation of pus, and for deodorizing large carcino-
mata, profusely discharging ulcers, creolin has proved
very successful. The following are the daily formulz in
Germany (Zhe Provincial Medical Fournal) :
No. 1.—Solutio Creolin (half per cent. ).
delivery.
No, 2.— Solutio Creolin (two per cent. ).
P: CHOOT cig Sakae agent eae Mowe eee ee Zj
Ague dest So 5's cars coe Maio Sa ie aaa
Sig. : To be well shaken before use. For the preparation of
poultices and all dressings, for sloughing wounds, and for the disin-
fection of hands and instruments; also as a hemostatic.
No. 3.—lnjectio Creolin,
Bar ceolin: acco esa eek an
Aquæ dest isss uresa etenee ad 3 iv.
Sig. : The injections. Asan injection for gonorrhcea, leucorrhea,
and catarrh of the bladder.
No, 4.—Pulv, Creolin,
Be Creolut, se: iink coli wsesaeuukes M xxv, to 3).
Acid. boraciC.......es.s.ssocescseo s S Aij:
Sig. : Antiseptic powder. For dry bandaging ; for eczema in
the neck or nose.
No. §.—Oleum Creolin,
B. Creolin ......ccccceee EPEE S eo M xv.
Olei Oliva, 2... cccesecese Preece’ ‘Reale
M. Sig.: Antiseptic oil, For inunction of the hands in gyneco-
logical practice.
No. 6.—PF ilula Creolin,
H. ClOOlitic ins b0ou nese oh dneeeew es e T xvije
Extract. et pulv. glycyrrh......... aa q. s.
Make roo pills. Coat with collodion, Sig.: Two pills to be
taken night and morning.
No. 7.—Ungt. Creolin,
B- Creolen e n a o M xij
Lanolin. 2 sc¢006 choses kauati giint % ss.
M. F. ungt
ConjuGaL DiaBeTES.—Dr. Debove read a note at the
Société Médicale des Hôpitaux on the coexistence of dia-
betes in the husband and in the wife. Of fifty cases of dia-
betes, Dr. Debove observed five which existed simultane-
ously in the husband and in thewife. Thesame coincidence
was established by Dr. Lecorché, who thought that this
coincidence can only be explained in two ways: by the
use of the same defective alimentation, or by the cares of
life shared in common by husband and wife. Dr. Debove
said that he could not accept this explanation, as women,
from the nature of their habits and the exigencies of their
sex, do not live exactly as their husbands. Hence it
448
THE MEDICAL RECORD.
[October 19, 1889
is that gouty couples are rare. He would therefore
ask if diabetes were contagious; but for the present we
must rest contented to register the fact. If new facts
should show that conjugal diabetes is not a simple coin-
cidence, it is only then one could propose a theory, which
for the moment would be premature. Five or six other
members also cited one ur more cases in which they ob-
served the coexistence of diabetes in the husband and
wife.—Paris Correspondence of Zhe Lancet.
IODINE IN THE TREATMENT OF WartTs.—<According to
Dr. Imossi, the tincture of iodine, given to adults in doses
of ten drops twice daily, has proved very successful in
preventing the further development of warts, and causing
those already present to disappear. Dr. Imossi noticed,
in the ten cases which had come under his observation,
that the treatment produced striking emaciation, a fact
which he has since turned to account in the treatment of
obesity. He has thus succeeded in procuring a diminu-
tion of weight of about twelve pounds in three weeks.
TREATMENT OF GONORRHGAL RHEUMATISM.—Dr. Buf-
fet, of Elbeuf, has published some interesting observations
on the course and treatment of gonorrhceal rheumatism,
and concludes his paper with the following considerations :
1. Gonorrhceal rheumatism, often monoarticular, may affect
several joints. 2. The small joints may be affected as
well as the larger joints. 3. The malady may attack the
tendinous sheaths, muscles, nerves, and cellular tissue. 4.
The clinical difference with articular rheumatism consists
in the absence of fever, of sweats, and in the fixity and the
tenacity of the lesions. 5. ‘The malady may terminate by
anchylosis, suppuration, or by muscular atrophy. 6. The
treatment reduces itself to placing the limbs in a good posi-
tion, employing revulsion, massage, and electricity. The
salicylate of soda and the anti-gonorrhceal medication have
no action whatever.
- VACCINAL SyPHILis.—On August 6th last, Dr. Hervieux,
director of the vaccination department at the Academy
of Medicine, reported that five cases of vaccinal syphilis
had come under his observation among the children that
had been vaccinated at the Academy. The most minute
inquiry could not discover the source of the accident, as
the two subjects from which the vaccine lymph was taken
were, to all appearances, perfectly healthy. Dr. Fourmer,
the well-known syphilographer, however, believed that he
found in one of the subjects some induration of the epi-
didymus and of the testicle, which would lead to the sup-
position of the existence of hereditary syphilis. The anti-
vaccinators would, of course, try to make good capital out
of this unfortunate, though happily extremely rare, cir-
cumstance, and would denounce the whole system of vac-
cination as being most dangerous to public health. But
Dr. Hervieux, anticipating this, declared at the Academy
that for the sake of a few regrettable cases vaccination,
whether in man or- animal, should not he condemned,
when it is considered that millions of persons have been
benefited by vaccination since its discovery by Jenner. A
short time ago a few cases of suspected vaccinal syphilis
occurred among some children who had been vaccinated
at Motte-en-Bois, in the Department of the North. An
inquiry was held, and Dr. Hervieux read the report at the
last meeting of the Academy of Medicine of the result,
from which it would appear that it was a false alarm, that
nothing proved that the accidents or ulcerations which
appeared on the children’s arms were of a specific charac-
ter. ‘The appearance of the ulcerations eight or ten days
after the vaccination would show that one was in presence
of ordinary non-syphilitic accidents.
DEAF-MUTISM.—In a very interesting note by Dr.
Baratoux (Paris) on deafness, the writer makes out that
there exists more than 200,000 deaf-mutes spread all over
the surface of the globe. For France, the proportion
is 6.25 deaf-mutes per 10,000 inhabitants; and in
1880 the enlisting committee of the Department of the
Seine had to reject sixty-seven young men affected with
diseases of the ears, while only sixty were rejected for
pulmonary phthisis, and sixty-five for diseases of the heart.
It is lamentable to think, says the author, that. more than
half of the cases of deafness proceed from the negligence
of the laws of hygiene, and can be easily prevented if
proper measures be taken to remedy the morbid causes
which prepare the deaf-mutes. It has been demon-
strated that, notwithstanding certain statistics, deafness at
birth is rare, that it represents at the most one-fourth of
the total number of deaf-mutes. But it is in the early
part of the life of the child that the deafness most fre-
quently occurs, resulting from lesions more or less un-
perceived, and thus appears to be congenital. Deaf-mut-
ism at birth is caused by consanguineous marriages, mar-
riage; between deaf-mutes, and certain foetal malformations
little known. Infantile deaf-mutism is caused by lesions
which may be produced by the improper application of
the forceps, nasal catarrh of the new-born babe, falls on
the head, tight compression of the ear by a cap, exposure
to cold, negligence of cleanliness, introduction of foreign
bodies into the ear. Among the causes of deaf-mutsm,
heredity plays a rôle much less important than is gener-
ally supposed. The proof is that deaf-mutes almost
always give birth to children who hear and speak well.
The proportion rises a little when one of the parents is
a deaf-mute and the other hears. Consanguineous mar-
riages, which represent in France about two per cent. of
marriages, produce about one-fifteenth of congenital deaf-
mutism. Dr. Ladreit de Lacharriére, a well known aurist,
has laid it down as an axiom that whenever a child loses
its hearing during the first eight years of its existence, it
becomes dumb by its forgetfulness of language, and until
the age of four years this mutism is fatal.
MEDICAMENTOUS ERUPTIONS.—In his inaugural thesis
for the doctorate, under the title of “ Medicamentous
Eruptions,” Dr. Deschamps thus sammarizes the common
characters and the course of the eruptions which may fol-
low the administration of a medicament. Among the me-
dicaments the employment of which may determine ery-
thematous eruptions the list is headed by copaiba, then
follow belladonna, the sulphate of quinine, turpentine, stra-
monium, the protoiodide of mercury, the bromide of po-
tassium, the syrup of poppies, the preparations of arsenic,
etc. Those which produce vesiculous affections are the
bromide of potassium, the alkaline iodides, cubebs, the san-
tonate of soda. Those which give rise to pustulous affec-
tions are the iodides, arsenic, the bromide of potassium.
The papulous affections are produced by Fowler's arsen-
ical solution, by the hydrochlorate of morphia in hypo-
dermic injections. Bullous affections are produced by
copaiba and the sulphate of quinine. Hemorrhagic af-
fections are produced by the sulphate of quinine and the
iodide of potassium. It may be seen from the above enu-
meration that the same medicamentous substances may give
rise to different cutaneous affections, whence it may be
concluded that the effects which are always due to the
same physiological procedure, viz., the elimination of the
medicament by the skin, vary a good deal as regards the
different forms of eruption, according to the aptitudes of
receptivity of individual idiosyncrasies. It goes without
saying that the treatment of these eruptions should consist
in the momentary cessation, or at least in the diminution
of the doses of the medicament, its suppression not being
effected always without grave inconvenience.
DÉBUT oF A LADY Proressor.—Signorina Giuseppina
Cattani recently read herself in as incumbent of the newly
founded chair of bacteriology in the University of Bologna.
The subject of her lecture was bacteriology in its relation
to modern pathology. She was received with great ap-
plause. The learned lady is thirty-one years old, and has
been assistant in the Bologna Pathological Institute since
1884.— British Medical Journal.
The Medical Record
A Weekly Fournal of Medicine and Surgery
Vol. 36, No. 17
—_—_ -n
Original Articles,
KNOTS, LIGATURES, AND SUTURES.'
By B. FARQUHAR CURTIS, M.D.,
ATTENDING SURGEON TO ST. LUKE'S HOSPITAL, NEW YORK.
——— ooo’
IT is well, sometimes, to review the groundwork of our
practice in order to see what advances have been made,
what old ideas have proved worthy of being retained, and
what old methods should be discarded : and this must be
my excuse in presenting the trite and elementary subject
here considered.
Knots.—The foundation of ligatures and sutures is, of
course, the knot, and several forms of knots are used in
surgery. It may seem to be scarcely worth while to em-
phasize the necessity of tying even a simple knot properly,
and yet I have seen some good surgeons to whom it ap-
peared to be more natural to tie a “ granny-knot ” than a
square knot. If the knot is wrongly tied, it cannot be
made strong by any number of additional turns. The
best verbal rule for tying the square-, or reef-knot, is to
pass the same end over the other in both turns; thus, if
the end held in the right hand is passed over and turned
around the end held in the left, it naturally passes into
the left hand ; and, in making the second turn, the same
end (now held in the left hand) must be passed over and
Fic. 1.—Surgeon’s Knot.’
around that held in the right. Thus the motion of the
hands is reversed, and it 1s here that the tendency to error
appears, for it is more natural to make the same motion
of the hands in both turns. When there is much tension,
as in bringing the edges of a widely gaping wound to-
gether, an extra twist is given to the strands in the first
half of the knot, the second half being then tied as usual,
and the same rule applying—to always pass the same
strand over. This makes the surgeon’s knot (Fig. 1).
The extra twist simply keeps the first half of the knot
from slipping while the second half is being tied. The
surgeon's knot should never be used for ligatures, because
it cannot be drawn tight enough ; nor for tying sutures of
fine silk, for the thread will break before the edges of the
wound can be brought into contact.
When the tension is extreme, and a slippery catgut is
used, it 1s well to tie a third turn after the square knot is
completed, and the same rule must still be followed.
This additional turn should always be employed in tying
the surgeon’s knot in catgut, for the double turn of the
first twist does not correspond with the second turn made
in the ordinary way. In tying knots there is one practical
point which is not often enough insisted upon, namely,
the greatest tension must always be exerted upon the first
turn, for that is tied around tissues which are more or less
elastic and yielding, and the encircling luop of thread
1 Read before the Surgical Section of the New York Academy of
Medicine, October 14, 1889.
New YORK, OCTOBER 26, 1889
Whole No. 990
helps to take up the extra strain, so that the material may
be safely put to its fullest stretch. In the second turn,
however, there is no such safeguard, and a pull which the
thread bore well enough in the first turn will easily break
it in the second.
Another knot which is sometimes useful in surgical work
is the “clove-hitch” (Fig. 2), which
is made by throwing two half hitches
over any object. As it does not slip
easily, it is employed for securing a Ñ
catheter in the bladder ; or for fasten-
ing a scarf upon a limb in order to {
get a good purchase for reducing a
dislocation, or the deformity of a
fracture. ‘The “Staffordshire knot” san
will be considered later. W N
Ligatures.—For ordinary ligatures — pio. 2.—Clove-hitch.
the thread is merely passed around
the vessel or stump of tissue to be l'gated, and tied with
a square knot. In ligating a thick pedicle when the
tissues are very elastic, and a slippery catgut is used, the `
surgeon’s knot may be employed, but, as a rule, it should
not be used for ligatures. When a ligature is to be
tied around a vessel, the points of the thumbs or of the
fingers should be carried down the thread close to the
knot, so as to make a direct pull upon the knot itself, and
to avoid drawing the tissues out of place, or pulling the
enclosed mass of tissues off, or at least displacing the
artery-forceps. When a clamp or forceps has been ap-
plied to a large surface or mass of tissue, it is well to take
it off after the first half of the knot is drawn tight, for
then it can generally be drawn tighter before the second
half is made. In the same way, if two or more artery-
clamps have been applied close together, and it is desired
to include them all in one ligature, it is best to take off
the clamps one by one, as the first half of the knot is
drawn up, at least until only one clamp is left. By adopt-
ing this method in all cases, a great deal of time can be
saved, the assistant removing the clamp as the first half of
the knot is tied, and being ready to cut the thread when
the knot is completed.
When there is difficulty in securing a bleeding point on
account of the friable nature of the tissues, or because the
latter are too dense to be pinched up by the forceps or
ligature, the hemorrhage can be arrested by passing a sut-
ure deeply underneath the bleeding vessel, and tying the
thread so as to include it. It is thus that Horsley controls
hemorrhage in his extensive operations upon the delicate
tissue of the brain, where it is impossible to apply ligatures
in the ordinary way. Before excising any part of the cere-
bral tissue, he surrounds it by a series of these deep suture-
ligatures, and the operation is then practically bloodless.
This method is greatly superior to the old one of tying
under a tenaculum hooked under the bleeding point, or
under a needle similarly placed and allowed to remain for
some hours 7” situ.
When an artery is to be tied in its continuity, catgut is
now almost exclusively employed for the ligature. It is
not necessary to draw the thread tight enough to divide
the internal coat of the artery (as used to be the rule), for
the lumen of the vessel will be obliterated by simple ad-
hesion of the internal surfaces. But if it is necessary to
obtain a permanent obliteration of the vessel, it is wiser
to apply two ligatures, and to divide the artery between
them, for, with an aseptic course of the wound, there is
so little new tissue and blood-clot formed that the vessel
450
may become permeable again, even if the ligature has been
applied tightly enough to divide the intima.
If a vein has received a small wound which can be
picked up by forceps without entirely occluding the lumen
of the vessel, a ligature can be thrown around the forceps,
and these lateral ligatures have been frequently applied
without destroying the permeability of the vein. ‘This is,
of course, a matter of great importance in those large
veins which are almost the only channels for the return of
the blood from a limb.
In tying off large pedicles of tumors, especially those
which are to be dropped into the abdominal cavity, it is
not safe to depend upon a ligature simply tied around the
pedicle as a mass, and it is necessary to transfix the pedi-
cle with the ligature before tying, and to tie it in two
or more portions. In this
way the ligature encircles
a smaller mass, and, each
loop being passed through
the tissue of the pedicle
itself, it is less likely to slip
over the end. The thread
is passed through the pedicle
with some blunt instrument,
such as an aneurism-needle,
and it is well always to hold one end of the thread in the
hand along with the handle of the needle, allowing the. other
to hang loose, so that, when the loop has been picked up
from the needle and the latter withdrawn, the surgeon may
be sure that the two threads are not twisted in each other.
- The loop is then cut, and the two halves of the thread are
made to twist around each other, lest the pedicle should
split at the point of puncture and hemorrhage occur where
it would not be controlled by either ligature, and each
thread is then tied around its half of the pedicle (Fig. 3).
In tying the ligatures the greatest amount of compression
will be obtained by placing the knot directly opposite the
point of transfixion, and this is especially true of the
broad, flat pedicles, in which, if the knot is properly
placed, it will gather the comparatively thin, free edge of
the pedicle toward the centre like a curtain. Instead of
twisting the two threads, they may be tied together ina
square knot at about the middle of their length, which is
drawn firmly against the point of transfixion, and the two
halves of the ligature tied as before.
Tait has introduced a very good method of applying
ligatures to pedicles (called by him the “ Staffordshire
knot”), which combines all the advantages of the method
just described, and requires less time to apply it. When
the loop is picked up and the needle withdrawn, after
transfixing the pedicle, the loop is drawn upon until it is
large enough to slip over the tumor, then it is thrown
over, so that it lies upon the same side as the free ends of
the ligature. One of the ends is passed through the loop,
and both ends are then drawn upon until the proper
amount of constriction has been
obtained, when they are secured ,
by tying them across the loop in £
an ordinary square knot (Fig. 4). 4
A somewhat similar ligature may Ñ
be tied without drawing the loop
out and passing it over the tumor,
by throwing one of the free ends
around one-half of the pedicle, passing it through the loop,
and then tying it with the other end around the other
half of the pedicle ; but great care must be exercised in
drawing the first half very tight before the second half of
the pedicle is constricted, or there may be difficulty in
drawing it sufficiently tight afterward.
A small pedicle may be transfixed with a single thread,
which is first tied around one-half, and the ends then
carried around the entire pedicle, and tied upon the other
side. If the tissues of a pedicle are very resistant, it will
be well to apply a clamp temporarily where the ligature
is to be placed, and to tie the ligature in the groove made
by the clamp. ‘Ihe best material for ligatures, for pedi-
I Fic. 3. — Interlacing Ligature (three
oops).
Fic. 4.—Staffordshire Knot.
THE MEDICAL RECORD
[October 26, 1889
cles of any size, is undoubtedly silk, for catgut is too
readily absorbed, and is too bulky when sufficiently thick
to be strong ; but some surgeons prefer catgut. The silk
becomes incapsulated, and gives no trouble.
Sutures, Interrupted and Continuous (Fig. 5).—It s
unnecessary to describe the interrupted and the continu-
ous sutures, but a few words
may be allowed as to which
form is the better suited to any
given case. Where there is
much tension, the interrupted
suture is to be preferred, for if
it should yield in any place the
integrity of the other stitches would not be impaired,
whereas if one or more of the line of stitches in the con-
tinuous suture should break or cut out, the entire line
would be slack. When very accurate apposition is desir-
able, as in wounds upon exposed parts of the body, the
interrupted suture is also the better, for, with the con-
tinuous, one is apt to find on reaching the farther end
that there is a surplus of material in one edge, especially
if they were unequal to begin with. With the interrupt-
ed suture, on the other hand, even if one lip of the
wound is longer than the other, by putting the first stitch
in the middle and then halving the distance on each
side with each succeeding stitch, the superfluous length of
one side can be so evenly distributed that the inequality
entirely disappears under the préssure of the dressing
and in the process of healing. In using the continuous
suture, it is well to have an assistant lift up a fold and
make tension on both ends, so that the edges shall be
evenly stretched ; or, if no fold can be raised, he should
hook a tenaculum in each end of the wound and thus
make tension while the sutures are inserted.
‘The great advantage of the continuous suture lies in
the ease and rapidity with which it can be applied, and
consequently it is to be employed for almost all other
wounds than those just noted.
The continuous suture can be finished very neatly by
taking the last stitch with the thread double (the tree end
of the thread being left long enough to remain in the
stitch), and when the stitch has been pulled tight the free
end of the thread ‘on one side is tied with the needle-loop
on the other. If the thread should be too short for this
manoeuvre, the loop of the last stitch is left long and tied
(using the double thread as one strand) with the free end
of the thread after the needle has been removed ; or an
interrupted suture may be put in with another thread, and
one of its ends tied with the free end of the continuous
suture.
Glover's Suture (Fig. 6).—An irregularity of the seam
is often seen in the continuous suture, owing to the fact
that, although the needle is passed at right angles to the
incision at each stitch, there is an oblique pull upon the
lips of the wound when the _. P
suture is finished, because æ%
the thread passes obliquely
across the incision fromone ff
stitch to the next. ‘This &
can be avoided by passing
the needle after each stitch
through the loop of the preceding one, thus making a
sort of chain-stitch, called the “ glover’s suture,” and mak-
ing each stitch partially independent of the rest. This
expedient allows of very accurate apposition, and is also
useful when the tension upon the suture varies in different
parts of the wound, for it enables one to keep the stitches
tighter in one part than in another.
Mattress or Quilt Suture (Fig. 7).— Another variety
of the continuous suture is the mattress or quilt suture, al-
though the latter may be so applied as to be rather a modi-
fication of the interrupted form. ‘The mattress suture is
designed to bring broad surfaces into apposition, the
needle being passed in the ordinary way for the first stitch
and the thread tied, but instead of carrying the needle over
the wound, and introducing it in the same direction as be-
Fic. 5.—Continuous Suture.
Fic. 6.—Glover’s Suture.
October 26, 1889]
THE MEDICAL RECORD.
451
fore, it is inserted upon the same side as it emerged, and
passed through both lips of the wound in the opposite di-
rection. Thus the direction of the needle is reversed at
each stitch, and the external loops of the stitches, instead
of lying across the incision, lie upon the skin on each side
of the latter, and parallel with it, as seen in the figure. It
is evident that the same pripciple may be used as to passing
the needle, but by cutting
the external loops upon one
side and leaving the ends
long, each stitch can be tied
as in the interrupted suture,
care being taken not to tie
so tightly as to cause slough-
ing. This suture has a tend-
ency to cause great eversion of the edges of the wound,
and this peculiarity makes it an excellent suture where the
skin is thin (as in the eyelids or the scrotum), for here the
skin has a natural tendency to inversion ; and also when
the skin is bound down by cicatricial tissue, as around old
fistulæ. It is a capital suture for bringing the deeper
parts of a wound in contact, as a sort of tension-suture,
and has been especially recommended for this reason for
the abdominal wound in laparotomy.
Cobblers Suture (Fig. 8). — Another variety of the
continuous suture is the ‘“cobbler’s stitch.” ‘This is best
applied by a needle set in a handle with an open eye near
the point. ‘The needle is passed through both lips of the
wound, and one end of the thread caught and pulled
through on the withdrawal of the needle. ‘The thread is
allowed to remain in the needle, and the latter is again
passed through the lips of the wound for the second stitch,
when the thread is removed from the eye and the other
thread is caught up in its place and pulled through by
withdrawing the needle. ‘Thus both threads pass through
Fic. 7,.—Mattress Suture.
Fic. 8.—Cobbler’s Suture.
each puncture of the needle, but in opposite directions.
When the entire wound has been closed the ends of the
thread are tied together. ‘The external loops of the
stitches form a continuous line on each side of the incision
and parallel to it. Of course, the same suture could be
made by a thread with a needle at each end, the needles
being passed in opposite directions through the tissues at
the same point ; but one must be passed and its thread
drawn tight before the other is introduced, for the second
will probably pierce the thread of the first and prevent it
from being drawn any tighter. ‘This suture is very useful
for covering in broad, oozing surfaces in pedicles which
it is iapossible to ligate en masse.
Lead-plate Suture (Fig. 9).—When there is great ten-
sion of the skin, or when there is a tendency of the deeper
parts to fall away from each other and to leave a cavity,
some deep sutures are passed at a distance from the edges
of the wound to assist the ordinary sutures in closing the
gap. Sutures of heavy catgut, or silk, or wire may be
employed for this purpose, but most useful are the
lead-plate sutures. ‘The lead-plate suture consists of a
wire with a lead plate about an inch in diameter fastened
to each end, thus distributing the pressure over a consider-
able area of skin and permitting the wire to be drawn
very tight. In placing these sutures, which are always
passed at some distance from the wound, it is well to put
a little of the iodoform or other gauze used in the dressing
between the plate and the skin te lessen the danger of ex-
coriation. The wire is secured to the lead plate by
twisting it around little projections which are cut in the
edge of the latter; or a perforated shot is. slipped over
the wire at each end, pressed against the plate, and
clamped when the desired tension has been obtained ; or
Fic, c.—-Lister’s Tcad-plate Suture
the wire is passed through and twisted around a bead
slipped over its end. An ordinary flat button can be used
instead of the lead for the plates. ‘Two of these lead-
plate sutures will usually be found sufficient.
Quill Suture (Fig. 10).—The old quill suture has almost
entirely disappeared from use, being replaced by these
lead-plate sutures, and by the method of buried sutures ;
but in some cases it wi!l still be found useful. The quill
suture was employed where it was desired to get close ap-
position of broad surfaces, as in the old-fashioned opera-
tion for repair of a lacerated perineum. ‘The necessary
number of sutures are passed, the needle, carrying a double
thread, being entered far from the edge of the wound and
passed very deeply, as if for interrupted sutures. A quill,
orapiece of rubber or
glass drainage - tube is
laid along each side of
the wound where the
threads emerge, the
double threads of each
suture are separated,
passed on each side of
the tube, and tied to-
gether over the latter. All the threads on ore side of the
wound are tied, then those on the other are drawn tight
and secured over the other tube in the same manner.
Hare-lip Suture.—Finally, we must notice the hare-lip
or twisted suture, which consists of a pin passed through
both edges of the wound, and a soft thread twisted around
the projecting ends of the pin and across the edges of the
wound, approximating the latter, and also pressing down
the margins so as to prevent eversion. ‘The ends of the
pin are then cut off close to the threads. In three or
four days the pins are withdrawn, being loosened from the
threads by gentle rotation, and the latter are left for a
few days longer adhering to the wound and holding it to-
gether. ‘This method of closing wounds is especially
adapted to cases in which the tension is great and there
is a lack of support from underlying tissues, and it is most
frequently employed in operations for hare-lip. In pass-
ing the pins through the lips they are entered half an inch
or more away from the edge of the wound, and passed
obliquely so as to issue on the raw surface of the wound,
just avoiding the mucous membrane; then they are
entered on the opposite raw surface at the same point,
and made to issue from the skin at the same distance from
the wound on the other side, so that nothing is exposed
on the mucous membrane of the mouth. A few fine, in-
terrupted sutures secure exact apposition of the skin and
Fic, 10.—Quill Suture.
452
THE MEDICAL RECORD.
[October 26, 1889
the vermilion border of the lip, and it is well also to in-
sert one of these where each pin is passed, removing the
thread temporarily for the purpose.
Buried Sutures.—The formation of cavities may be pre-
vented in wounds in another way—by the use of the buried
suture. ‘The buried suture is made with fine catgut and
a curved needle, by picking up a little tissue on each side
of the wound near its bottom, and tying the stitch. Then
the operator picks up a little tissue with his needle on
one side of the wound, and then on the other, keeping
close to the angle at the bottom, and making a continuous
suture, each stitch being drawn tight as soon as made.
When one end of the wound has been reached, he turns
back and adds another tier of sutures in the same way,
each tier reducing the depth of the wound about half an
inch, until the two raw opposing surfaces have been as
thoroughly united to each other as the cloth upon the two
sides of a quilted cloak, and the cavity of the wound has
been entirely obliterated. ‘The continuous suture ıs the
best for this purpose, but in some cases interrupted sut-
ures will answer instead. With thorough antisepsis it is
sometimes possible to sew up the entire cavity of an ab-
scess in this way without drainage, after clearing the walls
of granulations by the curette, and to obtain primary union.
‘The buried suture is most useful in plastic operations for
lacerated perineum, or after excision of anal fistula.
Wire Sutures —When wire is used for sutures it is in-
troduced by a strong needle with a large eye; or a needle
is threaded with both ends of a stout silk thread, and the
end of the wire is sharply bent and hooked into the loop
thus formed, by which it is drawn through the tissues.
Wire sutures are secured by twisting, and forceps are gen-
erally used for this purpose, a “ shield” (an instrument
with a slot in it like a tongue-tie) being slipped down over
the ends so as to compel the twisting to begin near the
wound. When the proper tension has been obtained by
twisting, a couple of tenacula are hooked under the loop
of wire, and by drawing them apart the wire is bent at a
right angle where it enters the tissues, and the external
loop is made to lie smoothly on the surface. ‘This is
technically called “ shouldering.”
Suture of Tendons.—' Tendons are sutured, primarily, in
some wound ; or, secondarily, after the original wound has
healed, or after subcutaneous rupture. In the first case
the wound is already present, and at most only requires
to be enlarged in order to reach the tendon. In the sec-
ond, the surgeon has a choice as to the wound, and in such
cases the best means of gaining access to the tendon is
undoubtedly by a curved incision, parallel to the course
of the tendon, marking out a flap, with its base lying over
the latter. When the tendon has been united and the flap
returned to its proper position, the line of the incision will
not lie directly over the tendon, and there will be less
danger of cicatricial adhesions forming between the latter
and the skin. When the tendon has retracted into its
sheath, it is not wise to try to drag the ends down by for-
ceps, for that is hable to lacerate them and to carry infec-
tion up into the sheath. ‘lhe better plan is to open the
sheath by a lateral incision as far as the end has retracted,
for a few sutures will close the wound, and as it is placed
upon the side it will be out of the direct line of tension,
and even if immediate union is not secured, there will
still be synovial membrane between the tendon and the
tissues above it.
The most difficult part of the operation is the suture
of the divided ends of the tendon, for the tension is often
very great, in spite of all the relaxation that can be obtained
by placing the limb in the most favorable position, and
the tissue is so easily split by the thread that the tissues
tear out. Some have employed a sort of quilt suture,
made as follows: A thread is provided with a needle at
each end, the ends of the tendon are made to overlap for
about a quarter of an inch, and the needles are passed
through both ends at once, from below upward, one near
each edge of the tendon. When the stitch is drawn tight
he loop of the thread forms a transverse suture on the
lower surface, and the two ends are tied together across the
upper (Fig. 11). When the two ends of the tendon cannot
be made to overlap, a modification of this suture can be
used. In this case the two needles are passed through
one end from above downward, one near each edge, and
then they are passed through the other end in the reverse
a Emar,
oS #8 neoe
FıG. 11.—Suture of Tendon.
direction, from below upward, and the knot made across
the upper surface of the latter end, holding the cut surfaces
of the ends in close contact (Fig. 12). Of course both of
these forms of suture can be made with a single needle,
by beginning and ending the stitch where the knot is to be
tied, and taking care to pass the needle in the proper di-
rection at each puncture. ‘This quilt suture answers very
well for broad, flat tendons, but is altogether inapplicable to
the small, round variety, which barely give holding ground
for one thread. A theoretical objection of doubtful
weight is the danger of cutting off the blood-supply of the
ends.
But the greatest advances have been made in the suture
of tendons since the proposition of Nicalodoni, to relieve
tension by passing acupressure needles through the ten-
dons above and below the point of division, suggested to
Witzel the more practical idea of accomplishing the same
object by relaxing sutures inserted in the ends of the ten-
Fic. 12.—Suture of Tendon,
don in the wound (Volkmann’s Sammi. klin. Vorträge,
No. 291). He passes a stout catgut thread through each
of the divided ends, about half an inch away from the point
of division, thus making a loop in each end which serves
to hold them in apposition during the operation. Deli-
cate catgut sutures inserted at the point of division are
sufficient to insure contact of the divided ends, and the
relaxing loops are then tied together across the point of
division, thus relieving the fine sutures of all strain, for the
heavier sutures are passed so far back that they are not
likely to tear out. If a tendon has been divided close to
its insertion into a bone, the distal relaxing suture is
passed through the periosteum of the bone near the point
of attachment of the tendon, and then the sutures are in-
serted in the same way. `
Suture of Nerves.—It is to the French surgeons of the
early part of this century that we owe the clinical dem-
onstration that suture of nerves could be’ practised with-
out danger of tetanus from “irritation,” and with the
growing proof that tetanus is due to a specific infection all
fears of the procedure have disappeared, leaving us free to
adopt bolder and securer methods of applying the sutures.
At first the only suture considered allowable was the “ para-
neurotic,” which included only the sheath of the nerve,
with a portion of the surrounding cellular tissue. In
most cases accurate adaptation of the ends of the nerve
cannot be obtained by such sutures. ‘I'he obstacle to suc-
cessful suture of nerves, however, lies not so much in the
mechanical difficulties as in the degenerative changes which
are at once set up in both ends when a nerve has been
divided, so that even with immediate restoration of phy-
October 26, 1889]
THE MEDICAL RECORD.
sical continuity, functional restoration is delayed until the
nervous tissue can be regenerated. It is true that some
recent cases seem to show that immediate functional
restoration is sometimes possible, but the evidence is not
yet conclusive, and for most cases, at any rate, the older
theory holds good. In fact, the functional results of
secondary nerve-suture have been almost as good as when
the ends have been immediately united.
If the ends of the nerve can be brought together so that
the raw surfaces of the recently wounded nerve, or its
freshened ends if the operation is secondary, are in con-
tact, a simple suture or two of fine catgut will generally
suffice ; but if there is much tension, a quilt suture similar
to that used for tendons may be employed, and perhaps
relaxing sutures would be of advantage here also. But
the true nervous tissue must be in contact, so that it will
not answer to have the ends overlap. Nerves do not re-
tract much when divided, but the operation is so often
undertaken secondarily, when the ends of the divided
nerve have degenerated into fibrous tissue, that it is neces-
sary to remove a considerable portion before any real
nervous tissue can be found, and thus a considerable gap
is made. Various means have been adopted to overcome
this difficulty, such as grafting the nerve into some neigh-
boring nerve ; cutting a flap from each end with its base
toward the point of division, turning them into the gap
and uniting them ; replacing the lost tissue with fibres of
catgut, decalcified bone, or even rubber drainage-tubes ;
transplanting into the interval portions of another nerve,
or of a nerve from some animal; or even shortening a
limb by resecting its bones so as to bring the separated
ends together. But the simplest and best expedient is to
stretch both ends of the nerve, and this will serve for
most cases; for a nerve will bear a considerable amount
of stretching without losing its functional powers, and
even if a tesnporary suspension of these were caused, the
final result would not be affected. A gap of an inch in
the median nerve, for example, has been easily overcome
by stretching.
Suture of Veins and Arteries—Longitudinal wounds
of veins have frequently been united by suture without
occluding the vessel. Horoch (Allgem. Wien. med. Zig.,
1888, 263, 279) has lately reported some experiments
upon animals which prove that veins may also be circu-
larly sutured after complete division, with preservation of
the lumen, and that longitudinal and circular suture (after
complete division) can even be applied to arteries; but
the artery becomes gradually occluded by endothelial
growth. Since the establishment of the fact that a clamp
forceps can be applied laterally in case of wound of a
vein, and removed in a few hours without secondary
hemorrhage, so that the calibre of the vessel can be pre-
served, it has become unnecessary to suture the wound,
and even the lateral ligature is falling into disuse. But
circular suture, if it can be accomplished in man with
preservation of the lumen of the vessel, would offer a new
and welcome escape from the ligature of veins when the col-
laterals are insufficient. Suture of the arteries would also
be useful, in spite of the fact that the vessel remains per-
meable only a short time, in cases where it was desirable
to give the collateral circulation more time than usual to
develop. I believe that the crewel needle, to be de-
scribed below, would be excellent for the suture of ves-
sels which were not so deeply placed as to make the use
of acurved needle imperative, a double thread of fine
silk being used which would completely fill the needle
punctures and prevent oozing.
Suture of Intestine and Stomach.—The only available
forms of suture for the intestine and stomach are those
which bring the peritoneal surfaces together, for only in
this way can union be obtained quickly enough to pre-
vent leakage of the contents. ‘This requirement is most
simply fulfilled by the Lembert stitch, whether applied as
an interrupted or continuous suture. ‘The Lembert stitch
is made by entering the needle about three-sixteenths of
an inch from the margin of the wound, picking up the
serous and muscular coats only, and leaving the mucous
membrane untouched, and bringing the needle out about
one-sixteenth of an inch from the edge. ‘The needle is
then made to pick up the serous and muscular coats
on the other side of the
wound, being entered one-
sixteenth of an inch from
the margin, and made to
issue three-sixteenths of an
inch from it (Fig. 13).
On tying the two ends of
the thread, the edges of
the wound will be rolled
in, and the two strips of
peritoneum, about one-
eighth of an inch wide, un-
der which the stitch passes
on each side, will be
brought into contact (Figs.
14 and 15). After one
line of such sutures has
been inserted around the
wound, a second is often
advisable, which will turn
in still more of the perito-
neum and give additional
security.
In the dog’s intestine the submucous coat is developed
into a strong aponeurosis (first pointed out, so far as I
know, by the simultaneous papers of Halstead and my-
self, American Fournal of the Medical Sciences, October,
1887, although it must have been known to all experi-
menters), and if the point of the needle is made to scrape
over the surface of this membrane so as to pick up some
of its fibres, the stitch holds much more strongly than
Fic. 13.—Lembert. Suture.
_
REGGE re GOI RO TEN
aie Ro once oie ; RREN
P
Í
pauna
Fic. 15.—Continuous Lembert Suture.
FIG. 14. —Lembert Suture,
when only the brittle and soft serous and muscular coats
are included. But in man, where the submucous coat is
mere soft cellular tissue, the stitches will not bear any
very great strain, and it is difficult to pass them without
wounding the mucous membrane. (Greig Smith writes
as if the submucous coat were also fibrous iu man, but
this is not the case.) In general, the interrupted suture
is to be preferred in intestinal work, for there is great
danger that the continuous suture would be loosened by
the premature cutting out of one of its links ; but the lat
ter is useful for the second (re-enforcing) line of sutures,
as it requires less time to apply it.
One of the greatest difficulties in circular suture of the
intestine, is the treatment of the mesenteric attachment
at the wound. It requires great care to cover the raw
surfaces here with the ordinary Lembert suture, even
when the two peritoneal layers of the mesentery have
been fastened together by a stitch at the wound, and a
passageway of non-serous surfaces is very apt to be left
in the wound communicating at one end with the interior
of the bowel, and at the other with the fatty cellular in-
terspace between the two layers of the mesentery. ‘This
forms an easy route for infection, and it is here that the
suture most frequently gives way.’
1In a series of experiments upon dogs (loc. cit.), I used a rather
454
Senn has lately revived the old idea of protecting the
line of sutures with a strip of the omentum stitched
around outside, and claims good results.
The best needles for use in intestinal work which I
have been able to find, are the fine needles with long eyes
that are used by ladies for embroidering in crewels.
They can be obtained from an inch and a half to an inch
and three-quarters long. ‘They carry a very large thread
in proportion to their size, and are much more easily
threaded than the cambric needle, or the milliner’s needle
recommended by Halstead. A straight needle held in
the fingers is far better than a curved needle, which re-
quires forceps, except in some situations where the sutures
have to be applied to a wound deep in the abdomen.
For such cases the slender curved needles of Schramm,
or the Hagedorn intestinal needles, can be used, the latter
having the advantage in the size of their eyes. ‘Fine silk
is the best material to employ in suturing the intestine |
and stomach, for catgut of the same strength would have
a greater bulk, and necessitate a larger needle; more-
over, catgut is difficult to obtain, while silk can be had
anywhere, and soon sterilized by boiling. As the silk be-
comes encapsulated in serous exudation, it remains harm-
less. |
More complicated methods of suture are in favor with
some surgeons. ‘The edges of the mucous membrane are
Fic, 16.—Wé6lfler’s Internal Suture.
frequently united with a line of sutures before applying
the Lembert stitches outside, and in operations upon the
stomach this is advantageous, to protect the raw edges of
the inverted wound from the action of thé gastric juice.
But in the intestine it seems to be an unnecessary
refinement, except, perhaps, for a short distance
at the mesenteric border. ‘The Czerny suture is
of this kind, and the Gussenbauer, as well as the “
suture advocated by Wölfler, shown in Fig. 16. xaf
In the latter about three-fourths of the sutures
are tied with the knot free in the lumen of the
bowel, but the rest must be tied with the knot
outside, where it lies in the wound between the
submucous and mucous coats. Halstead rec-
ommends a quilt suture, made by taking a Lem-
bert stitch as usual, and then making another
about one-twelfth of an inch from the first, but in
the opposite direction, so that the end of the
thread is brought out again upon the same side
of the wound as it started from, and the two ends are tied
there. ‘The disadvantage of this suture is, that instead of
turning in the broad surface of peritoneum under which
the thread passes, as the Lembert stitch does, it turns in
only the narrow strip along the edge of the wound which
has been left free from sutures. ‘lhe stitch, however, is
not likely to tear out, and the first objection could be
complicated but reliable method of suturing this point, but it is un-
fortunately not often applicable to the human bowel, because the in-
terstitial fat in the mesentery extends so far, not being limited toa little
triangular interval near the intestine, as it is in dogs.
THE MEDICAL RECORD.
|
[October 26, 1889
overcome by inserting a second line of sutures, if the pro-
longation of the operation were not considered an objec-
tion.
Intestinal Anastomosis.—A very great advance in intes-
tinal surgery has been made by the proposition of Senn
(Annals of Surgery, vii., 1888), to employ perforated
plates of decalcified bone when it is desired to make an
anastomotic connection between two adjacent loops of
Fic. 17.—Inserting the Ring.
bowel, instead of the tedious operation of uniting the
edges of the openings in the two loops to each other
by sutures. ‘The plates have a large opening in the centre
to allow the contents of the intestine to pass while they
remain in place. One is passed into the opening in each
loop, and the two are then tied together by the silk
threads attached to them, and hold the edges of the open-
ings in contact. Abbe has suggested (Wew York Medical
Journal, March 23, 1889) oval rings of catgut, the latter
being coiled until it is about of the thickness of a lead-
pencil, and then flattened by pressure between two pieces
of glass, for the decalcified bone plates are difficult and
tedious to prepare, especially the large sizes, and the
opening in them is in some danger of being too small.
Brokaw, of St. Louis (Weekly Medical Review, August
17, 1889), has experimented successfully on dogs, with
rings made of short pieces of rubber tubing threaded on
catgut strands, to which the silk threads are attached.
The method of application is in all cases the same.
Each ring has six silk threads attached to it, one at each
end and two on each side, each provided with its own
needle. An incision is made in the bowel at the desited
place, and the ring with its needles having been spread out
upon a towel near by, the operator passes one of the end
needles through the wall of the gut from within outward,
about one-fourth of an inch from the end of the incision.
The ring is then inserted into the bowel through the
wound and the thread drawn tight; the other end can
then be passed through the bowel at the point which cor-
responds to its attachment to the ring. With these two
Fic. 18.—T ying the Threads.
threads drawn tight, the rest are easily passed at exactly the
proper points (Fig. 17). ‘The other ring is then inserted
into the other loop of the intestine in the same way, and
while an assistant holds the loops of the gut and the rings
(easily felt through their walls) in apposition, the six pairs of
threads are tied together (Fig. 18), but care must be taken
not to exert so much force as to break the thread. Should
one of the threads break, a needle armed with a thread
which has a large knot on its end, can be through
the ring and the wall of the bowel, so that the knot will
catch in the former, in place of the broken thread. Half
October 26, 1889]
THE MEDICAL RECORD.
455
a dozen Lembert sutures are placed around the anasto-
mosis, to diminish the strain on the rings, and to secure
closer apposition of the serous surfaces. ‘The operation
requires only about fifteen minutes, and the rings can be
applied in situations which would be inaccessible to ordi-
nary sutures. (Fig. 19 shows a section through the open-
ing and the rings 77 situ.)
This method is also applicable to the formation of a
fistula between the stomach and bowel. But perhaps the
most important development of the use of the rings is
SOWA
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Fic, 19.—Section through Opening and Rings, in the Long Axis of the Bowel,
their use instead of circular suture of the intestine. In
such cases the two ends of the divided bowel are closed
by turning in the edges and uniting them by a continuous
Lembert suture, which only takes a few minutes. Then
the ends are made to overlap, slits cut in the side of each
about an inch from the end, and the rings applied. ‘The
entire proceeding requires less than half an hour, and
gives a-much safer union of the two ends than the most
skilfully applied intestinal suture, and if the rings and
openings are made sufficiently large the functional results
are just as good. A considerable number of cases are
now on record in which the rings have been used success-
fully for entero-enterostomy, gastro-enterostomy, and as a
substitute for circular suture of the bowel.
Gastrostomy.—We must mention here a very ingenious
suture introduced by Greig Smith (“ Abdominal Surgery,”
London, 1888) for securing the stomach to the abdominal
wall for gastrostomy, and available also for securing any
cyst to the abdominal wall for drainage (Figs. 20 and 21).
JA Fa
/ `
t \
t \
/ Sohn p
Cy T
\ ;
FIG. 20.—Fixation for Gastrostomy.
Having passed two wire sutures in the wall of the stomach,
without penetrating the mucous membrane, and using it to
steady that organ, he takes six long stitches in the wall of
the stomach, surrounding the wire suture, passing the
needle under the serous and muscular coats only, and in-
cluding a hexagonal space large enough to contain the re-
quired opening. Each stitch is about half an inch long,
and the needle is entered for the next stitch close to where
it emerged from the last, leaving a loop four inches long
hanging between the two. The abdominal wound is then
partly closed to reduce it to the proper size for the fistula,
and the peritoneum and skin are sewed together around the
edges so as to cover in the raw edges of the remainder.
While the wire suture holds the stomach against the wound,
the other loops are picked up in.turn by a needle set in a
handle with an open eye at its point .(like the needle in
Fig. 8), inserted through the entire thickness of the abdom-
inal wall from without inward at corresponding points, so
that the six loops are drawn outside and lie upon the skin
of the abdomen. A drainage-tube is then passed through
the loops and coiled in a ring around the wound, the
loops are drawn tight in succes-
sion, and the last one (consisting
of the two free ends of the
thread) is then tied over the
tube. ‘lhe wire sutures are also
twisted over the tube, for they fj
are useful subsequently in open- $£
ing the stomach. In a case ¢
of gastrostomy in which I tried
this suture it answered very
well, but instead of the needle
on a handle, I found it more
convenient to usea large curved
needle with a carrying thread of
coarse silk, by which the loops
attached to the stomach were
drawn through the abdominal wall by passing the necdle
from within outward. I also found it very difficult to
draw the thread of the loops even and tight after they had
been passed over the drainage-tube, so I cut each loop
and tied the ends together over the tube.
The Abdominal Wound in Laparotomy.—The greatest
difference exists in the methods adopted by surgeons in
closing the abdominal wound made in laparotomy. All
are agreed upon the necessity of bringing peritoneal sur-
FIG. 21.—Gastrostomy, Fixation
Suture.
_faces in contact, but some surgeons use only a single row
of sutures passing through all the layers of the abdominal
wall, while others apply several series, uniting each layer
independently. For small simple wounds, where the
edges have not been exposed to much stretching or con-
tusion, the simplest method will save time and will give
perfect results, if care is-taken to insert the sutures prop-
erly. In closing the wound in this way, a coarse silk is
to be preferred (although silver wire, silkworm gut, or
even a heavy, hard catgut may be used), introduced witha
large straight needle. ‘The edges of the wound are kept
upon the stretch so as to prevent uneven retraction or
protrusion of any of the various layers, and the needle is
inserted about half an inch from the margin of the wound
and carried obliquely toward it, so as to emerge upon the
serous surface only one-eighth of an inch from the edge ;
it is then passed through the other lip of the wound at a
point exactly opposite, in a reverse direction. Some sur-
geons use a thread with a needle at each end, and pass
both ends of the suture from within outward. In tying the
sutures, which are placed one-third of an inch apart, care
must be taken to see that the serous surfaces are really
brought in contact, but too broad a strip of peritoneum
must not be turned up into the line of the wound, for it
might become interposed between the tendinous and mus-
cular structures, prevent their union, and result in hernia.
When several tiers of sutures are employed, the peri-
toneum is united with a fine thread and continuous suture
for the whole extent of the wound. ‘The transversalis
fascia must be included in this stitch when there is much
tension, or the suture will tear out. ‘Then the tendon or
muscle is secured by a second tier of stitches, made with
a stout thread, and finally the integument is united over
all. It is very advantageous to make a separate suture of
the peritoneum, except in the simple wounds mentioned
above, for if any septic trouble arises in the wound, the
early and accurate union of the peritoneum shuts it off
from the abdominal cavity. But the majority of opera-
tors make only two tiers of sutures, one for the peritoneum
and one for the skin and muscular layers together, and
this seems the most common-sense practice. Sometimes
it may be necessary to use lead-plate relaxing sutures when
the tension is great, but such cases seldom occur except
in laparotomy for intestinal obstruction.
456
Artificial Anus.—In performing lumbar colotomy, it is
well to draw the bowel into the wound and secure it to
the skin around the entire incision before opening it, if it
be possible to do so, in order to cover in the exposed sur-
faces and to shield them from infection. In making an
artificial anus elsewhere, the peritoneum is drawn out of
the wound with artery-clamps and sutured to the skin, so
as to cover the raw surfaces here also, and the intestine is
then drawn out of the wound and secured in the method
preferred by the operator—a loop being drawn out and
fastened by a few sutures to the skin, or by passing a rod
or some other object through the mesentery ; or by stitch-
ing the lips of the wound together in the middle with the
mesentery between them, so that the central portion of
the loop rests upon a bridge of skin. Or the presenting
bowel is left inside of the abdomen, and simply secured to
the wound by a circular suture, or several interrupted
sutures. A method similar to that just described for
gastrostomy might also be employed.
Fixation of Abdominal Organs.—When any of the or-
gans in the abdomen become displaced or too freely
movable, such as the kidney, spleen, or a lobe of the liver,
they may be secured by sutures, and the same method has
been employed for correcting malpositions of the uterus.
The suture is in these cases of some coarse material,
passed so as to include the capsule and more or less of
the tissue of the organ, lest it should cut out. In all cases
except fixation of the uterus, it has been found advisable
not to depend merely upon the suture, but to tampon the
wound, and thus secure an anchoring of the organ to a
mass of cicatricial tissue embedded in the abdominal wall.
In securing-the uterus, after it has been restored to its
proper position through a small wound just above the .
pubes, it may be stitched by separate sutures to the inner
surface of the abdominal wall, or the sutures which close
the abdominal wound (silk, or wire) may be made to pass
through the fundus also, and to hold it up against the
Inner aspect of the wound.
Any organ or cyst may be secured to the abdominal
wall by a couple of sutures, in order to evacuate the con-
tents of an abscess or cyst through the wound. Some
prefer a ring of sutures of fine material, but in the case of
solid organs (liver, spleen) two deep sutures will answer.
For some cases Greig Smith’s suture for gastrostomy
might be used. If the sutures hold well it will not be
necessary to wait for adhesions to form. I recently
evacuated an abscess of the liver through the pleural
cavity by resecting a portion of the tenth mb, sewing the
two layers of the pleura together as they lay in contact
(but not adherent) over the diaphragm, making a circle of
continuous sutures, and immediately opening the abscess
through the diaphragm by an incision ın the centre of the
ring. No pus and no air entered the pleural cavity.
Suture of the Bladder.—Since the revival of the supra-
pubic operation upon the bladder, many surgeons have
been studying the best method of closing the wound in
that organ. Where the walls of the bladder are covered
with peritoneum, a Lembert suture will secure union as
in any other peritoneal wound, and wounds of the blad-
der have often been closed in that way ; hence one bold
surgeon has even suggested that every cystotomy should
be performed intra-peritoneally, so that primary union
could be obtained—a suggestion which is not likely to ob-
tain favor, for the results of the ordinary operation are
too good, even if an occasional fistula does prove obsti-
nate. It is necessary, in the first place, that none of the
material used for suture should project into the bladder,
for it forms a nucleus for stone formation, and even cat-
gut cannot be used in this way. Von Antal suggested
(Centralol. f. Chir., 1885, 297) to bevel the edges of extra-
peritoneal wounds of the bladder externally, so as to in-
crease the extent of surface which could be brought to-
gether by sutures, as is often done in vesico-vaginal fistula,
for instance. Brenner (Arch. f. Chir., xxxv., 33) has
lately recommended a suture passed around the wound in
the bladder like a purse string, so as to pucker it up when
THE MEDICAL RECORD.
[October 26, 1889
drawn tight. Two sutures are employed, one being
passed in the submucous layer, and one in the muscular,
each about one eighth of an inch from the edge of the
wound. ‘The inner one is tied first, the mucous mem-
brane being turned up into the wound, so that epithelial
surfaces are éverywhere in contact ; then the muscular
suture is tightened over that. In experiments on animals
he has obtained excellent results. The usual method is
to unite the wound in a linear manner, with fine thread
and continuous or interrupted sutures, passed so as not to
include the mucous membrane. But it is very exceptional
to obtain complete primary union, although partial union
is sometimes secured, and the sutures always do good by
preventing the exit of the urine for a couple of days, and
by that time the wound is granulating and the danger of
urinary infiltration has been reduced to a minimum.
In speaking of the urinary organs we must not forget
that brilliant results have recently been obtained 1n sutur-
ing the male urethra after rupture, or after resection of a
strictured part. Successful cases of transplantation of
skin or mucous membrane in the place of the excised lis-
sue have also been reported. The material used for the
sutures has been fine silk or catgut, but there are no
special technica] points to be noted in their insertion.
Caesarean Section —One more peculiar problem in ab-
dominal work remains to be described, and that 1s the
treatment of the uterine wound in the Cesarean section,
the successful solution of which by Sanger has resulted in
restoring that old operation to favor instead of the mutil-
ating Porro and Miiller operations. ‘The advance lay in
applying the principle of the Lembert stitch here also,
and the most approved method at the present day is but
little more than an ordinary Lembert suture. A row of
sutures is passed first, including all the tissues except the
mucous membrane, the peritoneum being inverted into
the incision when the knots are tied. A second is then
passed, picking up only the peritoneum, which can be
made to slide over the subjacent tissues and to cover in
the first line of sutures. Primary union is easily obtained
by this method.
NoTE.—bigs. 1, 2, 5, 6, 7, 9, 10, 14, 15, and 16 are
taken from Esmarch’s “ Handbook of Surgery ” (translat-
ed from the third German edition by B. F. Curtis, M.D.) ;
and Figs. 3, 13, 20, and 21 are from J. Greig Smith's
“« Abdominal Surgery.”
APPARENT CANCEROUS TRANSFORMATION
OF SYPHILOMA OF THE TONGUE—EXCI-
SION OF THE TONGUE BY THE GALVANO-
CAUTERY.’
By G. FRANK LYDSTON, M.D.,
LECTURER ON GENITO-URINARY DISEASES IN THR COLLEGE OF PHYSICIANS AND
SURGRONS, CHICAGO, ILL.
THE possibility of the existence of a combination of syph-
ilis and carcinoma has recently attracted some attention
from the profession, and it has been claimed in certain
quarters that a transformation of a syphilitic into a can-
cerous process is possible. The first cases of combined
cancer and syphilis were reported by Jonathan Hutchin-
son, and following him Langenbeck directed attention to
this unusual class of cases. Lang, of Vienna, recently
exhibited a case of the kind before the “ Medizinisches
Doctoren Collegium.” The patient was a woman who
had suffered from syphilis for a protracted period. Scars
of former syphilitic processes were present upon the trunk
and face, the palate being perforated, and the upper lip
having suffered considerable loss of substance. At the
time she came under Lang’s observation, most of the ul-
cers were covered with a white scab, the histological ex-
amination of which did not reveal any sign of importance
from a diagnostic standpoint. About a month later, how-
ever, a small, white, indolent ulceration appeared upon
1 Read hefore the Mississippi Valley Medical Association, Septem-
ber 10, 1889.
October 26, 1889]
THE MEDICAL RECORD.
457
the hard palate. A small portion of the involved tissue
was excised, and upon microscopical examination by Pro-
fessor Weichselbaum, was found to be epithelioma. In
the course of the discussion Professor Lang stated that he
had observed three other cases which were very similar, the
development of the carcinoma upon a syphilitic soil being
demonstrated in each instance by microscopical examina-
tion. The first case, which came under his observation in
1883, had suffered from a characteristic course of syphilis,
which included numerous relapses of iritis and gummatous
ulcerations upon the face. Under anti-syphilitic meas-
ures all of the ulcerations cicatrized, with the exception of
one, which became transformed into a cancroid of the skin.
The second case was that of a man, aged forty-six, who
had suffered from various syphilitic ulcerations on differ-
ent parts of the face and body. After anti-syphilitic treat-
ment one ulcer, located beneath the tongue, proved
resistant to treatment, and became transformed into can-
cer. In the third case a syphilitic infiltration, located in
the lower lip, underwent a relapse at the end of a year, and
assumed a carcinomatous character.
It is unfortunate that the profession have not more care-
fully noted the cases in which carcinoma has developed
upon a syphilitic base. There are many cases in which
careful study might demonstrate the casual relation of
syphilis to malignant disease.
The case which I have had the opportunity of observing,
and here recording, was one the progress of which I had
been enabled to study for a protracted period, and there
can be no possibility of doubt as to the primary condition
upon which the malignant disease that eventually destroyed
the patient’s life was engrafted. In recognizing the trans-
formation of syphilitic processes into cancer, I do not
wish to be understood as claiming that the histological
elements of syphilis may be transformed into those char-
acteristic of cancer, but that the elements of syphilis hav-
ing been removed, they leave the tissue so damaged that
continued irritation will result in cancerous degeneration.
On the other hand, a syphilitic process may recur so fre-
quently, and be so obstinate to treatment, that the irrita-
tion thereby produced is capable of causing cancer.
It is as yet too soon for us to discuss the question of
the existence of special bacilli in syphilis and cancer for
the purpose of disproving the possibility of the transfor-
mation of the one into the other. It is conceivable that
both cancerous and syphilitic deposits may act in the same-
manner as other irritating processes in the tissues. It is
to be presumed that if a cancer were present in the mouth
of a syphilitic subject, syphilitic processes would be more
apt to develop in the vicinity of the malignant disease
than elsewhere. A somewhat similar relation exists be-
tween the presence of the syphilitic process and the de-
velopment of carcinoma. Whether actual transformation
can occur or not, it is certain that cancer may develop in
tissues which are indubitably affected by a syphilitic
process, and that said cancer may go on to destruction of
tissue, and finally, of the life of the patient. This may
occur without any preliminary change in the physical ap-
pearance of the tissues affected by syphilis prior to the de-
velopment of the cancer. I feel warranted in speaking
thus positively from my experience with a case which I
am about to relate.
In regard to the bacillus of cancer, it is as yet an un-
known quantity. As far as the bacillus of syphilis is con-
cerned, no one has, so far, been able to positively demon-
strate that the supposed bacillus of syphilis is really the
specific bacillus. In the words of Dr. N. Senn, “that
syphilis is a specific disease cannot be doubted, that it is
due to a microbe cannot be doubted, but to establish this
positively, experimenters must do what Koch did before
he announced the specific origin of tuberculosis.”
To put the matter of the transformation of syphilis into
cancer concisely, I would say that I do not believe that
syphilitic cells can possibly be transformed into cancer
cells; but I infer that the irntation of the tissues pro-
duced by the former may, in the presence of favorable
constitutional and local conditions, develop a new process
of tissue-building or neoplastic formation which will re-
sult in the formation of cancer cells. I have taken the
liberty of relating my own case in detail.
Case.—The patient, a man, aged twenty-nine, contracted
syphilis at the age of eighteen. He stated that at that
time he contracted a hard chancre, which inflamed and
caused paraphimosis, which lasted about a month, and left
the mucous membrane of the penis in an irritable condi-
tion that resulted in the frequent appearance of fissures
and ulcerations, some of which were treated by me from
time to time after he came under my care. Secondary
symptoms appeared about four months after the primary
sore, and according to the description a pronounced papu-
l>pustular eruption appeared and resulted in considerable
scarring of the skin. Mucous patches presented them-
selves in successive groups, and, as the patient expressed
it, “ were very annoying, especially those upon the tongue.”
After the secondary period became manifest the physician
in charge of the patient put him upon mercury, a thorough
course of which was given for about three months, when
he went to the Hot Springs. He remained at the Springs
for three months, was rubbed with an enormous amount
of mercury, and badly salivated twice. He went home,
and at the end of two months eruptions again appeared
upon the body, with also larger mucous patches than be-
fore, his tongue at this time giving him some considerable
trouble by reason of the general soreness of the organ.
At this time an old eczema of the hands, which had
troubled the patient off and on all his life, broke out, and
in combination with the syphilis gave him a great deal of
trouble. He again went to the Springs and remained
there for eleven weeks, during which time he took mer-
cury internally quite freely. He again went home, and
was apparently well for three months, when mucous
patches and eruptions broke out, sores appearing at this
time upon the penis. About five years after the begin-
ning of the syphilis the patient fell under the care of a
physician who again rubbed him freely with mercury, the
treatment being continued for about six months. Heim-
proved for a time and then quit treatment, as such pa-
tients so frequently do ; but again got worse and went back
to the same physician, and for at least eighteen months
took mercury in considerable quantity. He was then
advised to go to Mount Clemens, Mich.; he remained `
there about fifteen months, and while there became en-
tirely well of his eczema, the syphilis, however, never
leaving him entirely.
In 1884 the patient consulted me for the first time. He
had then unequivocal cerebral syphilis, and tuberculo-
squamous syphilides in considerable number were scat-
tered about the forehead, forearms, and thighs, with a few
scattered squamz upon the trunk. Scars of former pus
tular syphilides were visible upon the forehead, forearms,
and legs; the tibiz and sternum were excessively tender,
and considerable pain was experienced at night. Ceph-
alalgia was a constant symptom and gave the patient in-
tense suffering. An apparently gummy ulceration, with
several fissures, existed upon the penis, just back of the
corona. | l
The tongue was rough, and coated with a thick, dirty,
yellowish-gray fur, with marked dryness in the centre and
posterior part of the organ. Several tubercular nodules
were also observable, one in the centre of the tongue, and
the others near its base, those upon the right side being
especially marked. On inquiry I found that the tobacco
and alcohol habits had been persisted in for a greater por-
tion of the time that he had been under treatment, and,
much to my surprise, he informed me that his physicians
had not restricted him in the matter of either indulgence.
‘The treatment at this time was very vigorous; cod-liver
oil and iron were ordered,on account of the patient’s
marked debility. ‘The mixed treatment and the iodide of
potassium in saturated solution were given, the iodide be
ing run rapidly up toa dose of three hundred grains per
diem, and maintained at that point for three weeks, the
458
disease being completely resistant to treatment until the
end of that time. Local applications of the acid nitrate
of mercury were made to the tongue from time to time,
and with apparent benefit. As soon as the symptoms be-
gan to yield to treatment the dose of the iodide of potas-
sium was diminished to about sixty grains per day, the
tonics being meanwhile continued. At the end of three
months the patient was free from trouble, with the excep-
tion that his tongue was more thickly coated than ever
(psoriatic), and the nodules upon its surface were still per-
ceptible. No amount of care and treatment ever caused
this condition of the tongue to disappear entirely, and, as
the history will show, it subsequently became the source of
terrible trouble. The case remained comparatively well
until about five months ago, the tongue creating some
uneasiness from time to time on account of commencing
ulceration of the nodules upon its surface, but yielding
rapidly to treatment. On each occasion, however, the
nodules and furring of the tongue became more promi-
nent, and remained so in spite of treatment, the furring
becoming a sort of membranaceous deposit, like wet cham-
ois leather, which reformed as fast as it was removed.
At this time, while at the Hot Springs under the care
of Dr. Vaughn, the tongue began to swell, and assumed a
threatening appearance ; the nodules began to ulcerate,
and at one time a severe hemorrhage occurred.
I have not received the complete history from Dr.
Vaughn, but suffice it to say, that after all means of treat-
ment had been tried for two months without avail, the
case was pronounced probably cancerous by the attending
physician and several others who saw it in consultation.
At this time Dr. Vaughn referred him to me with a view
to possible excision. Upon examination I found the
tongue filling the mouth and pressing upon the teeth in
such a manner that it had become eroded and ulcerated
by them. Salivation was profuse ; a deep ulcer existed at
the centre and back part of the organ ; the enlargement
seemed to be rather more marked upon the right side.
The submaxillary glands were slightly enlarged ; there
were no other lesions present upon any part of the body.
Microscopical examination at this time failed to demon-
strate the presence of cancer. No further examination
of the tissues was made until after the tongue had been
excised.
As the patient experienced great difficulty in masticating
and swallowing, he was subsisting entirely upon fluid food,
and, not being very robust primarily, had become greatly
emaciated. ‘lhe treatment instituted was chiefly a tonic
one, in conjunction with an alterative mixture containing
iodide of sodium and the chlonde of gold; milk punches
were allowed, and the patient instructed to take as much
sweet cream and milk as he could without creating diges-
tive disturbance. Local applications were made of a
compound of carbolic acid, iodine, and menthol, in mild
strength. Improvement was at first very rapid, and at
the end of a week the tongue was nearly reduced to its
normal size. In a few days, however, it again enlarged
upon the right side, this enlargement being peculiar in
that it was limited by the raphe, the tongue being at least
double the thickness upon the right side that it was upon
the left. ‘The appearance was precisely the same as that
presented by several cases of acute glossitis that I have
seen, and resembled it strongly in the rapidity of its ap-
pearance ; the increased thickening having come on within
twenty-four hours. ‘This condition of the right side of
the tongue soon subsided, but was succeeded by enlarge-
ment of the tubercular nodules previously mentioned, and
by the appearance of several new nodules. These ap-
peared not upon the margin of the tongue, but upon its
upper surface. In a few days the ieft side of the tongue
underwent a diffuse enlargement, precisely similar to that
which had occurred upon the right, and in exactly the
same way subsided, and was succeeded by the develop-
ment of tubercular nodules. ‘lhe whole tongue now
gradually increased in volume, and became so large that it
hung over the edges of the teeth and protruded through
THE MEDICAL RECORD.
[October 26, 1889
spaces left by the extracted teeth. There was little or no
pain, and such as there was was referred by the patient to
the “ holes,” as he expressed it, worn in the tongue by the
teeth. As soon as the case began to get worse the chlo-
ride of gold, or alterative mixture, was stopped, and the
iodide of potassium was again run up to three hundred
grains per diem ; there seemed to be some improvement,
and the drug was stopped for two weeks. At the end of
this time it was again begun, as the case had again as-
sumed a threatening aspect, and was now incre to the
enormous dose of six hundred grains per diem. I soon
became convinced that the iodide had lost its effect, and
was producing no result, unless perhaps increasing the
swelling of the tongue. Mild inunctions of mercury were
tried next, at the suggestion of a professional friend, but
they merely served to make the case worse, as had been my
experience with his previous troubles.
Punctate cauterization with the galvano-cautery was
tried, with some reduction in the size of the tongue. Soon
after this, however, sloughing began, and destroyed the
greater portion of the right side of the organ, the remain-
der of the tongue being undermined and eroded, and the
floor of the mouth extensively invaded by the central ul-
cer, of which mention has already been made. During
this time I exhibited the patient to a number of my pro-
fessional friends, among whom were Drs. Hawley, Hayes,
Zeissler, and Baxter, all of whom pronounced the trouble
syphilitic, agreeing with my own diagnosis.
The case went on from bad to worse, many different
lans of treatment being tried without avail. The slough-
Ing continued until the tongue was in such a condition
that even if healing had been possible the organ would
have been practically useless. ‘The base of the tongue
was a foul mass of hyperplastic ulcerating tissue, the odor
and secretion from which were not only offensive to the
patient but were prominent factors in producing the con-
stitutional disturbance. There seemed to be no hope of
benefit from either internal or local medication, and, in
addition, the malignancy of the process appeared to be now
established As the patient was anxious to have something
done to remove the foul and stinking mass from his mouth,
I proposed excision with the galvano-cautery, an operation
to which he readily consented.
Operation.—The operation was performed on July 30,
1888, with the assistance of Drs. P. S. Hayes and W. S.
‘Walker, and Mr. Knight, medical student. The Fleming
battery was used, with a platinum wire of moderate size.
A preliminary tracheotomy was not performed because of
the objections of the patient. Great difficulty was expe-
rienced in the operation, on account of the necessity of
separating the tongue longitudinally, there being a large
mass of ulcerating hyperplastic tissue at the base of the
organ which required removal. It was found to be im-
possible to transfix the base of the tongue transversely with
a needle, and at the same time it was necessary to have
something as a purchase for the wire. A stout needle
with a long double thread, to prevent its being detached
and swallowed, was passed obliquely from above down-
ward and forward as far back upon the base of the tongue
as was practicable, a long needle-holder being used for
this purpose. ‘The wire was slipped over the needle and
made to include as much of the base of the tongue as
possible. ‘I'he anterior portion of the tongue was readily
included in the loop, as it was separated from the floor of
the mouth in suclr a way that the electrode needle was
readily pushed beneath it. A small amount of chloro.
form was first given, as I had found by previous experi-
ence that the patient was extremely resistant to ether.
As soon as he was under full anzesthesia, however, ether
was substituted for the chloroform and acted satisfactorily.
The current was turned on and the operation begun, when,
to my embarrassment, the patient became so asphyxiated
that respiration ceased and the pulse at the wrist was
hardly perceptible. I immediately detached the wire
from the tongue and inverted the patient, my assistants at
the same time performing artificial respiration. In about
October 26, 1889]
THE MEDICAL RECORD.
459
five minutes the patient breathed as naturally as ever, and
I was enabled to proceed. ‘The current was again turned
on, and the tongue about half burned through when the
patient again became asphyxiated, apparer tly by the smoke
produced by the burning of the tissues in combination
with the accumulation of blood and mucus in the pharynx,
there being quite free bleeding from a couple of teeth
that were loosened in their sockets in the attempt to pry
the jaws open while performing artificial respiration. The
inverted position and artificial respiration were again re-
sorted to, but it was fully fifteen minutes before it was
considered safe to proceed.
pletely excised. About the time the operation was com-
pleted the patient again stopped breathing, and a repetition
of the previous performance of resuscitation became nec-
I would not advise an operation of this kind to be per-
formed without a preliminary tracheotomy; I certainly
should not want to perform it again myself unless the patient
would consent to be tracheotomized. The operation al-
together occupied about two hours. The patient, three
hours after the operation, was able to get aboard a street-
car and ride to the hospital. At the end of a week the
eschar produced by the cauterization became detached
and left a surface of fairly healthy appearance ; the fetor
of the breath was improved and the sloughing of the base
of the tongue ceased. The floor of the mouth healed
nicely, and remained in a tolerably healthy condition for
several weeks ; the submaxillary glands became smaller,
and the general condition of the patient improved consid-
erably. About a month after the operation, however, the
submaxillary glands again enlarged, becoming larger than
ever, and quite tender. ‘There was comparatively little
pain save a moderate amount of cephalalgia and otalgia.
The ulcerative process on the floor of the mouth recurred,
but did not progress rapidly nor ulcerate extensively. A
small ulceration formed upon the right pillar of the fauces.
These symptoms practically settled the question of malig-
nancy. Professor I. N. Danforth, having examined the
specimens excised, informed me at this time that the case
was of a sarcomatous character, but I inferred from his
report that it did not present typical characters. About
two months after the operation an abscess formed in the
submaxillary glands; this, when opened, gave exit to a
thin, sanious fluid. Pain at this time was very severe. At
the end of about three months an occasional slight hem-
orrhage from the mouth occurred. The patient finally
died, about four months after the operation, from a sudden
hemorrhage occurring during the night.
This unfortunate case is, in many respects, unlike any
other that I can find on record. ‘The literature of the
subject is very meagre. During the course of the disease
there were present distinctive features of several forms of
glossal affection. During the four years that the patient
was under my observation the tongue presented gummy
nodules and ulceration, lingual psoriasis, diffuse syphi-
lomatous deposit, and latterly attacks of subacute glossitis.
At various times before coming under my observation—
and once since, as shown by the history—mercurial stom-
atitis occurred, and formed an important feature of the
case, particularly, I think, as regards the etiology of the
process which finally necessitated removal of the tongue.
Prior to extensive destruction of the organ these various
conditions merged into a general hypertrophy, the tongue
becoming extremely indurated. ‘These various features
must be taken into consideration in studying the case.
Macroglossa, or hypertrophy of the tongue, of a simple
character is very rarely seen, and few cases are on record
of congenital ‘ongin. According to the published re-
searches of Fairlie Clark,’ hypertrophy of the tongue oc-
curring later in life may arise “ spontaneously” (?), or from
wounds, mercurial salivation, or as a consequence of dif-
fuse inflammation from scarlet and other forms of fever.
I will also add to these causes constitutional syphilis.
Attrition against the teeth in these cases of macroglossa |
-_ i i me rn e a a aae ee eee
' Diseases of the Tongue.
The tongue was finally com- .
produces from time to time attacks of acute or subacute
glossitis, each of which leaves the tongue more enlarged
than before (KGnig)." This has been a prominent feature
of the case at present under consideration. The best au-
thorities have recommended for the cases of simple mac-
roglossa the use of astringent solutions in combination
with compression. It is obvious that the latter measure is
not applicable to cases like my own, whether malignant
or not, in which necrosis of tissue is such a prominent
feature. Clark reports forty-three cases, nine of which
were cured by compression and astringents. In some
cases excision of portions of the tongue has been per-
formed with a successful result. ‘This measure was not
to be thought of in the case under consideration.
The causes which operated in the production of the
lamentable condition of my case were, in my estimation,
several. In the first place, it will be conceded that the
numerous attacks of glossitis and stomatitis necessarily
left the tongue in a more or less damaged condition, and
caused a chronic condition of irritability which favored a
deposition of syphilomatous material in the organ at any
time when the constitutional disease should become active.
That the prolonged and injudicious use of mercury, inde-
pendently of salivation, is prone to induce inflammatory
and ulcerative processes of the mouth and the structures
contained in its cavity I firmly believe. Authors are
united in the view that the excessive use of mercury is a
frequent cause of glossitis. It is probable that the exces.
sive, although necessary, use of iodide of potassium still
further enhanced the morbid condition of the tongue. It
is reasonable to suppose that such might be the case when
we take into consideration the fact that the salivary glands
are heavily taxed in the elimination of iodide of potassium
as well as of mercury.
The continued use of alcohol and tobacco, in combina-
tion with the irritation produced by diseased teeth, com-
pleted a chain of circumstances which, in combination
with the syphilitic cachexia, favored the development of
the morbid process in the tongue.
The condition known as ichthyosis or psoriasis of the
tongue is due to the same causes as generalized glossitis,
and is really part and parcel of that process in which
the inflammation is localized upon the surface of the mu-
cous membrane.
According to Hulke,” ichthyosis of the tongue consists
essentially in hypertrophy of the epithelial and papillary
elements of the mucous membrane. The relation of
ichthyosis or psoriasis of the tongue to syphilis.and cancer
is very important, and all authorities unite in acknowledg-
ing its relation to syphilis, although it may occur in non-
syphilitics. In appearance it resembles, in some cases, a
deposition of wet chamois leather upon the surface of the
tongue, as described in my case, which rapidly reforms
after removal. In other instances it resembles a thin
layer or film of coagulated albumin, and in these cases
each successive deposit is more dense and adherent than
the preceding. ‘Ihe condition is prone to develop epithe
lioma, as Weir ° has shown most conclusively by the history
of 68 cases, of which number 35 eventually developed
epithelioma.
Hutchinson has also advanced the opinion that cases
of syphilitic disease of the tongue are especially prone to
develop epithelioma later in life.
That a condition similar to that of my case may under-
go a transition into epithelioma or malignant sarcoma
seems plausible, and such a transition I believe to have
occurred in this instance. ‘The presence of epithelioma,
or its subsequent development in such a case, would be
no argument in my estimation against the accuracy of the
previous diagnosis of syphiloma, inasmuch as it 3s con.
ceded by the best authorities that such processes are prone
to undergo a malignant transition. The course of this
case and its history are widely different from the ordinary
1 Lehrbuch der specielen Chirurgie, 1878.
2 Clinical Society Reports, vol. ii., p. I.
2 New York Medical Journal, March 18, 1875.
460 |
THE MEDICAL RECORD.
[October 26, 1889
clinical features of epithelioma of the tongue. Epithe
lioma of the tongue, beginfing four years ago, would not
have lasted as long as this condition. The average dura-
tion in cancer is less than two years. ‘The age of the pa-
tient would warrant a doubt as to the existence of carci-
noma, cases under forty years of age being very rare.
There was at no time in the history of the case a can-
cerous cachexia, and the constitutional condition fluctu-
ated quite markedly, depending upon the amount of nour-
ishment that the patient was able to take. Several weeks
after the operation he was in better flesh than at any time
for two months previous.
The attacks of glossitis which occurred from time to
time necessarily modified the clinical aspects of the case,
and obscured the distinctive points in differential diag-
nosis. ‘There are some features, however, that deserve
mentioning in contradistinction to those of ordinary cases
of cancer. The enlargement of the tongue was general,
and the sloughing began at several points, this being de-
cidedly unlike cancer, which is usually localized at the
beginning, invades successive areas of the tongue, and
does not attack more than one point, from: which it grad-
ually progresses. ‘The induration in cancer extends with
the ulceration, while in this case it became general before
the ulceration had advanced to any extent. The ylcera-
tion, instead of beginning underneath the tongue or at the
border of the organ at some particular point, as is the case
In cancer, first attacked the tubercular nodules previously
described upon the upper surface of the tongue near its
centre and base. One peculiar feature of the process was
a clean dissection of one-half of the organ, the process
being temporarily limited at the raphe ; a line of progres-
sion that is very noticeable in syphilitic conditions, and
which has given rise in my own mind to the belief that
some of the late lesions of syphilis are of a trophic char-
acter and the result of the syphilitic impression upon the
sympathetic nervous system—a point upon which I will
expatiate more fully in a subsequent paper.
There was a marked improvement from time to time in
this case. Indeed, there were times when it seemed as
though the disease was under control and recovery prob-
able. In this respect there was a marked contrast with
the classical course of cancer, in which the disease grows
progressively worse until its close. After the operation
the parts assumed a healthy appearance, the tendency to
bleeding was entirely checked temporarily, the disagreeable
odor disappeared, and the patient assumed a better color
than before.
In ordinary cancer the tongue becomes absolutely im-
movable, while in this case there was some mobility at all
times, and considerable during the periods of temporary
improvement. ‘The tongue was left harder and more in-
durated after each exacerbation of glossitis. The absence
of pain until late in the case was quite remarkable, and
presented a marked contrast to the course of cancer, in
which the pain is usually very severe. The persistent en-
largement of the lymphatic glands at the angle of the jaw
was the most suspicious symptom in the case, as indicative
of possible or probable malignancy, yet I think too much
stress has been laid upon this feature of glossal troubles
as pathognomonic of cancer ; for, although late syphilitic
lesions do not produce enlargement of the glands ger se,
the septic process which results from necrosis of the tis-
sues, and the decomposition of food which may adhere to
the uneven surfaces of ulcerations upon the mucous mem-
brane, may give rise to irritation of the neighboring glands.
Thus it seems that it is by no means necessary that can-
cer should exist in order that lymphatic glandular reaction
may be produced.
In view of the great danger of processes similar to
those which so long existed in my case, resulting in the
development of malignant disease, it would seem that we
would be justified in adopting some radical measure. Had
I to go through with a similar case again, I should profit
by my experience and destroy the tubercular nodules as
well as the thickened mucous membrane upon the sur-
face of the tongue with the actual cautery. There is, of
course, no means of proving the success of this line of
treatment, and I may never have an opportunity to put
it into practice on account of the rarity of such cases; but
I believe that had it been done in this instance the malig-
nant process might never have developed. No remedy short
of actual destruction would seem likely to be beneficial to
such conditions. ‘The only remedy which ever seemed to
effect the ichthyosis of the tongue in this case was a saturat-
ed solution of salicylic acid, which seemed to check the
progress of the disease and improve the condition of the
tongue for some little time, when it finally lost its power.
The precise period at which a malignant was substituted
for a syphilitic process would be hard to determine. I
am by no means convinced that the diagnosis of syphilis,
made several months before the operation of excision of
the tongue, was incorrect. The course of the case was
certainly unique. Whether the tame of the transition into
a malignant process could have been determined by fre-
quent microscopical examinations is questionable. Such
microscopical examinations of the case as were made were
at the hands of competent microscopists ; but I am free
to say that the results were hardly satisfactory, nor do I
think that they themselves considered them to be be so.
The condition present in the case which I have related
might have been mistaken for tuberculosis of the tongue.
The history and course of the case, however, militated
against such a diagnosis. Tuberculosis is rare as a
secondary condition, and still rarer as a primary disease
of the tongue. In twenty-six cases collected by Delavan,’
nine out of twenty-six were primary ; in this series the
ptimary cases were of greater than the average frequency.
Such cases certainly serve to impress upon us the neces-
sity of recognizing and radically treating precancerous
states of the tongue. Mr. Butlin, in a recent essay before
the Harveian Society of London,” stated that in quite a
number of cases which had been under his observation
carcinoma of the tongue had been preceded by a con-
dition which was so definitely associated with the subse-
quent development of cancer as to deserve the designation
“ precancerous.” This condition he observed in over
seventy per cent. of cases of lingual carcinoma. Papil-
lomatous or warty growths were apparently the most
dangerous of the morbid states which actually and im-
mediately preceded the development of cancer. Such
warty growths he showed to be much more frequent than
was generally believed. The question arose as to whether
it would be proper in cases of leucoma (leucoplakia buc
calis?) and chronic glossitis of a superficial character, in
which warts or warty growths develop on the surface of
the tongue, to remove the entire diseased area, or, at least,
the anterior portion of the organ, instead of, as is usually
done, removing the warty growth with a certain area of
the surrounding tissue. ‘Iwo cases were related in which
wart-like growths developed on tongues affected by leu-
coma, and were removed, and in which, later on, carcinoma
developed, but not at the site from which the warts had
been removed. The internal administration of liquor
arsenicalis was advised 1n all cases of chronic disease of the
tongue which were associated with various forms of chronic
disease of the general integument of a non-specific charac-
ter. Several cases were also related to demonstrate the
advantage of early excision of cancerous affections of the
tongue. In view of the fact that in chronic syphliitic, or
other affections of the tongue, protracted irritation is apt
to develop cancer in the already degraded tissues, it is
desirable to avoid applications of an irritant character.
The nitrate of silver particularly ought to be used cau-
tiously as a stimulant or astringent, but never as a caustic.
When it seems desirable to destroy portions of diseased
tissue by means of caustics, the galvano-cautery is the best
method for accomplishing the object. In leu of this,
some active cauterant should be employed, such as
chromic or nitric acid. i
1 New York Medical Journal, 1877. 2 Analectic.
October 26, 1889]
THE MEDICAL RECORD.
46I
Cinical Department.
THE SEQUEL OF THE CASE OF CEREBRAL
ABSCESS TREATED BY TREPHINING.
Dr. J. W. WricHT, of Bridgeport, Conn., writes: “ The
sequel of the operation for cerebral abscess detailed in THE
MepicaL Recorp of September 21, 1889, page 317,
should now follow, since it reveals the cause of both the
abscess and the failure of a permanent cure. In Septem-
ber the patient again commenced to fail, from a recurrence
.of his former symptoms, and a second operation was per-
formed by the surgeon then on duty, Dr. Worden, Sep-
tember 21st. A small quantity of pus was found and a
drainage-tube inserted, but patient died on second day.
_ “The autopsy revealed the fact that a wire nail two
inches long had been driven through the skull into the
brain, the head of which was sunk into the bone. It had
entered the left parietal bone close to the sagittal suture,
two inches in front of the occipito-parietal sutures. ‘The
point was the centre of an abscess in the white substance
of the brain, which involved the parietal lobules and en-
croached upon the post-central convolutions. The ab-
scess had not ruptured into the ventricles.
“From facts since disclosed, it is probable that the nail
was driven into his head on May 17th, by falling on some
boards containing nails of that size and style.”
TWINS WITH ONE PLACENTA.
Dr. J. H. StRauGHn, of Lexington, Mo., writes: “ Janu-
ary 31, 1886, I was called to see Mrs. J. W , In labor.
After the birth of the first child, on making an examina-
tion, I was satisfied that there was another child in the
womb. After tying the cord of the first child, I made
traction on the cord for the purpose of delivering the pla-
centa, but the woman complaining that ‘I was killing
her,’ I desisted. In.a short time labor pains set in again,
and the second child was soon born. I then delivered
the placenta, and found that there was but one for the
two children. The umbilical cord of each child was at-
tached near the periphery, about equidistant in each case.
The children were both girls, one weighing four, and the
other four and a half pounds. They are both alive and
well at this writing, so far as I know.”
LATE PREGNANCY,
Dr. J.-S. Dotson, of Hornellsville, N. Y., writes: “ In
accordance with your request for reports of late pregnan-
cies, I send you the report of one in my practice, many
years since. Mrs. S——, County of Steuben, this State,
was confined in the summer of 1856, she being then fifty-
two years of age. ‘This was her fifth confinement and
the sixth child, having had one pair of twins. The same
week that I attended the mother, fifty-two years of age,
I also attended the daughter, aged twenty-two.”
CHARCOT’S OPINION OF PROFESSIONAL WOMEN.—M.
Charcot, one of the jury of the Faculty of Medicine in
Paris, in complimenting a young lady who had obtained
her doctor’s degree, said that “ women pass their examina-
tions, when they do pass them, even more satisfactorily than
men; but what will be always a bar to their success is
that they have no real love of their proposed profession.
What they aspire to is the first rank, the most prominent
posts, the most lucrative offices ; and what they dislike is
the humble and unpleasant, but necessary, service of hu-
manity, such as is given by the hospital dresser.” Curious,
but precisely the same thing might just as correctly be said
of men.—Chemist and Druggist.
Brogress of Medical Science.
OPERATIVE TREATMENT FOR PROSTATIC HYPERTROPHY.
—Professcr Kümmel, of Hamburg, in a paper lately read
before the Congress of the German Society of Surgery,
stated that he had performed on six patients a partial
extirpation of the hypertrophied prostate gland. His
cases were véry grave, as they had resisted all other
methods of treatment. There was fever, bronchitis, and
considerable vesicular dilatation. In such cases the op-
eration is indicated, while it is the contrary when the
kidneys are seriously involved, or when there is a com.
plete paralysis of the bladder. In this last case the opera-
tion is useless, for even after the suppression of the ob-
Stacle spontaneous micturition cannot be re-established.
To extirpate the prostate gland he performs superior cys-
totomy; the bladder is very carefully washed out, and he
then destroys, by the aid of the thermo-cautery, not only
the median lobe, but also all the parts of the gland which
project into the bladder. He then sutures the bladder,
and allows Nélaton’s sound to remain in it. Out of six
patients, one died from collapse, in another the operative
result was negative, four are cured and can urinate spon-
taneously. In the discussion that followed, Professor Socin,
of Bale, said he believed the enlarged prostrate was not
so often accountable for the evil symptoms observed as
is the cystitis, which is so frequent a concomitant. He
thought that the good results which sometimes follow ex-
tirpation of the prostate gland are due, probably, more to
the washing out of the bladder and to the sound left in
position—that is, to the treatment of the cystitis—than to
the operation itself. The cystitis is the first enemy to
combat in the treatment of prostatic enlargement.—Medi-
cal News.
INSANITY FOLLOWING Mumps.—Dr. R. Percy Smith,
Medical Superintendent of Bethlem Hospital, London,
England, has recently called attention to the occurrence of
insanity as a sequela of mumps, giving two illustrative cases
which came under his own notice (Zhe London Medical
Recorder). A \ad, aged nineteen, had had good health
previously, and there was no neurotic family history. A
fortnight before admission he had suffered from mumps,
which was epidemic at the time in the district. The attack
was complicated with exhausting diarrhoea. Five days be-
fore admission he became excited and passed into a condi-
tion of acute mania, from which he rapidly recovered in
Bethlem. ‘The other case was that of a young medical man,
who, after an attack of mumps complicated with severe
orchitis, became depressed, suspicious, and suicidally in-
clined. He recovered after a time, without its having been
necessary to send him to an asylum. Dr. Smith thinks that
in each of these cases the extreme exhaustion caused by
the complication of diseases had more to do with the in-
duction of insanity than fever or metastasis.
EFFECTS OF PROLONGED CHLOROFORM ANASTHESIA.—
Some observations,; made about two years ago by Dr.
Ungar, pointed to fatty degeneration of the heart and
liver as the cause of death after repeated prolonged ad-
ministration of chloroform. Further experiments on dogs
have recently been made by Dr. Strassman, which appear
to confirm this view. Dr. Strassman found that the first
organ to be affected was the liver, then the heart, and
after that other viscera. The nature of the morbid change
was not a fatty degeneration, but fatty infiltration. ‘The
actual cause of death in fatal cases appeared to be the
cardiac affection, as in all such a very marked degree of
change was found in the heart. In non-fatal cases the
morbid change was found to have disappeared in a few
weeks’ time. When morphine was given previous to the
chloroform, less of the latter was required, and, consequent-
ly, the changes produced were not so considerable as when
the ordinary amount was given. Animals suffering from
hunger, loss of blood, etz., were especially predisposed to
the morbid changes due to chloroform.— The Lancet.
462
THE MEDICAL RECORD:
A Weekly Fournal of Medicine and Surgery.
-
————
GEORGE F. SHRADY, A.M., M.D., EDITOR.
PROPRIETORS AND PUBLISHERS
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
~
New York, October 26, 1889.
THE BRAIN-WEIGHT OF MAN AND WOMAN.
THE subject of the comparative weight of the brain of
man and woman comes up periodically, and almost always
some incorrectness of statement or inadequacy of knowl-
edge is to be observed. Perhaps a certain feeling of gal-
lantry tempts speakers and writers to handle tenderly facts
apparently in conflict with the view that woman is enceph-
alo-morphologically the equal of man.
The average weight of the male brain is 494 ounces—
of the female, 44 ounces ; a difference of over five ounces.
Woman's brain has a higher specific gravity. The man
has a larger brain in proportion to stature (Marshall), but
woman’s brain is larger in proportion to her weight. In
239 Russian brains (Buchstab) the ratio of body-weight
to brain-weight was for the male as 38 to 1; for the fe-
male, 35 to 1. In woman the brain is shorter in the sag-
ittal diameter, being from 6% to 6} inches in man, 6 to 6}
inches in woman (Huschka). The transverse and vertical
diameters are more nearly equal in the two sexes.
The frontal lobe is better developed in man, the dis-
tance from the anterior extremity of this lobe to the
upper end of the fissure of Rolando being in males 152.9
mm. ; in females, 140.6 mm. (Buchstab). On the other
hand, the occipital lobe is more developed proportionately
in woman, the distance from the point of the occipital lobe
to the parieto-occipital fissure being in males 48.7 mm.,; in
females, 51.4 mm. This is for Russian brains, which are
a little smaller than German and English, a little heavier
than Italian and French brains.
The difference between the weight of brain in man
and woman increases with civilization, and is most
marked in the Caucasian races. In Parisians this differ-
ence amounts to 222 grammes, or nearly seven ounces ;
in European nations generally, 163 grammes ; in Hindoos,
120 grammes; in Australians, 103; in negroes, 82; in
Chinese, 15.
The greatest sexual difference as regards brain-weight is
found at birth, when the female brain weighs 347 grammes,
and the male 393, or about 4 more, while the total weight of
the male infant is about y more than that of the female.
The female brain begins to lose weight after the age of
thirty, that of man not till ten or fifteen years later. The
loss in woman is very slight, however, and she keeps up a
high brain-weight much later (till seventy) than man, so
that in old age the difference in brain-weight is reduced to
its minimum, or a little over three ounces.
Definite statements cannot be made regarding the sex-
THE MEDICAL RECORD.
[October 26, 1889
ie eee ee
ual differences in convolutional complexity, or the thick-
ness of the gray matter, two very important points in
estimating the intellectual powers of the organ.
Despite much loose talk regarding the unimportance of
brain-weight as a test of intellectual superiority, ıt is un-
questionably an important factor. What Thurnam calls
medium brains range in weight between 4o and 524
ounces for men, and 35 and 474 ounces for women. All
brains in size above this are called megalocephalous.
Now the tables of brain-weights collected by Bastian and
others show that the proportion of great men who are de- s
cidedly megalocephalous is twenty-five per cent., while the
proportion in average men is four per cent. to five per cent.
Thé proportion of incipient megalocephaly (¢.c., weight
above 524 ounces) among eminent men is nearly sixty per
cent. There can be no doubt that the majority of eminent
men have large brains, just as the majority of ordinary men
have forty-nine-ounce brains. Certain individual cases
furnish exceptions, and distinguished talent can coexist
with a small brain, but it is not the rule.
When a brain falls to a weight of 37$ ounces in a
man, or 324 ounces in a woman, it is called microcephal-
ic, and the rule is that below these limits idiocy exists.
There is just five ounces less amount of brain-matter,
however, needed to keep a woman from idiocy than is
needed fora man. Hence we may reasonably suppose
that this, which is nearly the average difference in brain-
weight of the sexes, represents not tissue necessary for
mentality, but corresponds with the smaller muscular mass
and shorter stature of woman.
THE INVASION OF THE “ MASSEUR.”
WE must beg our readers to keep a close eye upon the
masseur. He is bearing down upon unhinged humanity
with a steady and relentless stride. He develops in the
midst of us, he sails over from Germany and England to
us, while, if there are any graduates of Heilgymnastik still
left in Denmark, Sweden, or Norway, we should like to
know it; for ıt has appeared to us, after some busy morn-
ing, that they have all called. Truly, the masseur is
among us. He is a man of great resources. As his fra-
ternity increases, he does not lose heart, or complain
of competition, or seek protection from the State—he
simply enlarges his field. In olden times the rubbing of
a stiff knee with officinal linimentum saponis was the
centre and circumference of massage ; soon, however, we
learned how soothing was the emollient and theobro-
mated hand upon the hyperesthetic skin and diseased
muscle. The masseur became firmly established as the
resourceful prop of hysteria and unfailing staff of morbid
locomotion. But then the sinewy and insidious hand be-
gan to gather adventitious aids, and seek new worlds to
conquer. Having organized its movements into a com-
pany of Gallic polysyllables, so that its manœuvres of ża-
potiment and petrissage and effieurage should not be mis-
taken for plain, every-day slap-slap, jab-jab, and thump-
thump, it proceeded to attack all the several diseases and
organs of the body. Adipose tissue in excess was made
to disappear, while glandular tissue, if mammary, was
rubbed to make it grow. Massage has now applied it-
sclf to diseases of the eye, and granular lids are, guoad
the granulations, artistically rubbed off; it has invaded
the mouth and throat, reducing hypertrophied tonsils,
October 26, 1889]
THE MEDICAL RECORD.
opening the Eustachian tubes, and curing catarrh and
deafness. The abdominal viscera were the early and
easy subjects for this now illustrious science. ‘Ihe
colon’s lax vermicular waves are tempestuously hastened,
and the modest stream from the smaller bowel has
scarcely babbled through the ileo-czcal valve before it is
rushed madly into the rectum. ‘The pelvic organs have
of late received the devoirs of this new art; and the
uterus has been rubbed and stroked and pommelled, all
in pure French terminology, until this martyr-viscus could
not help but free itself from adhesions and congestions,
and pillow itself gently on its original vesical cushion.
Lastly, we learn that the heart is to have massage. The
heart has been, we are told by poets, torn and bruised,
and bled and broken ; but it remains for modern science
to see that it shall have effeurage and lomi-lomi.
There are still a few things left for the masseur. Can
he not apply ‘apotiment to the brain, or, at least, to the
cerebellum? Has he done justice to the kidneys? Might
not the ovary receive a course of artistic jabbing before
it is removed and bottled. When all fields are con-
quered, and every viscus springs responsive into blooming
juvenescence beneath his learned touch, we recommend
the masseur to Christian science.
FIFTY YEARS OF COUNTRY PRACTICE.
Dr. Alonzo Garcelon, ex-Governor of Maine, is seventy-
six years old and is still in the active practice of his pro-
fession. He this year completes the semicentennial of
his medical career. The Lewiston Journal gives us
some gossip regarding the doctor’s life-work, but particu-
larly about his travels. He estimates that with his horse
and chaise he has driven about three hundred and sixty
thousand miles, or fourteen times around the earth. Such
an estimate is based on the supposition that he has
travelled an average of a little less than twenty miles a
day, or seven thousand two hundred miles a year.
This is, perhaps, a rather high estimate, but it is quite
within the bounds of possibility.
The reflection which occurs to one in contemplating these
figures is that an enormous amount of purely mechanical
and unproductive labor has to be expended by the coun-
try doctor in his daily work. While this time is not by any
means all lost, for there is health and mental rest, or, per-
haps, productive ratiocination, in a moderate amount of
ambulation, yet three hundred thousand miles is too far
for the average man to go with horse and carriage, and
expect to do the highest class of work in life.
It is all the more credit to Dr. Garcelon that he has
succeeded in travelling pretty nearly as far as to the moon
: and back, and yet has acquired both political distinction
and medical prominence. But the country practitioner
most needs a means of lucomotion swifter than the horse.
Dr. Garcelon in riding his three hundred and sixty thou-
sand miles has had to give up nearly seven solid years,
and twenty years of working days out of his total fifty,
simply in riding to his patients and home again.
“INFALLIBLE ANTIDOTE” FOR MALARIOUS FE-
VERS.
Dr. CHARLES G. R. Nay.or, Civil Surgeon, of Burmah,
India, addresses a report to the Deputy Surgeon-General
of British Burmah in which he asserts that carbonic-acid
AN
463
——$=
gas is an infallible antidote to malarious fevers of all types
and durations. Dr. Naylor’s report is republished in
Edinburgh. It was first made eight years ago, but is now
put forth again in an enlarged form and with the empha-
sis and confidence drawn from a fuller experience.
Dr. Naylor does not claim originality for his treatment.
It was devised or discovered by Dr. John Parkin, of Lon-
don, who tested its value while visiting the malarious dis-
tricts of Italy, Spain, and West Africa.
The rationale of the gas treatment is expounded by
Drs. Parkin and Naylor, but it is far from being satisfac-
tory or scientific and it need not occupy our space.
The gas is administered in solution and is got in its
cheapest form by dissolving bicarbonate of soda, gr. xxx.,
in three ounces of cold water, and throwing into the solu-
tion tartaric acid, gr. xx., in a powdered state, the mixture
to be stirred rapidly once, and swallowed as soon as pos-
sible in a state of effervescence. The patient must be
made to lie down immediately after, to prevent eructation
and escape of the gas, so apt to occur in a sitting posture.
The doses of soda and acid must be decreased to suit
the different ages of children, as gr. xxx. of bicarbonate
of soda are not soluble in the small quantity of water
suitable for administration in one dose to very young
children.
Sometimes the soda is given first and followed by the
acid.
The remedy is best administered just before the par-
oxysm is expected, or in the remission if the case be one
of remittent fever. Dr. Naylor cites a long list of cases
cured by the gas.
Bews of the GHeek.
Dr. CARL KOELER, the discoverer of cocaine anzs-
thesia, has been made Instructor in Ophthalmology at the
New York Polyclinic.
THE CHICAGO MEDICAL LIBRARY ASSOCIATION, incor-
porated in September last for the purpose of securing and
maintaining a library for the advancement of the medical
and kindred sciences, held its first regular meeting on Oc-
tober 4th, at the Grand Pacific, at which the following
were elected officers: President, Dr. N. S. Davis; Vice-
President, Dr. Edward A. Lee; Secretary, Dr. Bayard
Holmes ; Zreasurer, Dr. E. Ingals. Dr. William F. Smith
was made a Director in place of Dr. Mary H. Thompson.
— Fournal of American Medical Association.
THE SOUTHERN SURGICAL AND GYNECOLOGICAL AS-
SOCIATION will hold its next meeting in Nashville, Tenn.,
November 12, 13, and 14, 1889.
New York OBSTETRICAL SocieTy.—At the annual
meeting of the Society, held October 15th, the following
officers were elected for 1889—90 : President, Dr. J. E.
Janvrin; rst Vice-President, Dr. H. C. Coe; 2d Vice-
President, Dr. R. A. Murray; Recording Secretary, Dr.
A. M. Jacobus.
THE Beaumont MEDICAL COLLEGE, of St. Louis, was
burned to the ground recently. The Faculty have, how-
ever, secured another building, and the lecture course will
be continued.
464
THE MEDICAL RECORD.
[October 26, 1889
oe
“ GynalA,” A New Disease.—A Dr. Steinerkopf, who
may be some relation to Dr. Holzerkopf, or perhaps Dr-
Dammkopf, has discovered a new disease which he calls
“ gynaia,” and which he defines as “the simulated exist-
ence of feminine moral qualities in the person of a man.”
An acute and learned commentator of Dr..Steinerkopf’s
disease thus describes it editorially in the Vew York Med-
ical Journal: “ The discovery made by Dr. Steinerkopf
is, that what has been yclept effeminacy is in reality a
disease which is curable, and not a concomitant of con-
genital anorchidia, or a resultant of an early training anal-
ogous to the subalar rearing of the offspring of a uniparous
hen, when occurring in a male. ‘This disease, “ gynaia,”
is characterized by the exhibition of timidity, aversion to
tobacco and to dogs of non-personal allegiance, manners
of ratiocination untrammelled by the friction exerted by
logic, and other qualities commonly observed in the typical
human female.” | l
GASTROTOMY FOR A SET OF FALSE ‘TEETH.—It is stated
by Connecticut papers that a young woman of Bridge-
port, a domestic, who swallowed, or thought she swal-
lowed, a plate of false teeth, was subjected to the opera-
tion of gastrotomy without finding the teeth. She still
complained of agonizing pain and was sent to a hospital
in New York, where (the doctors having been put in pos-
session of all the facts) a second gastrotomy was per-
formed, and on her recovery from ether a set of teeth
prepared for the occasion was shown her, and she at once
recovered from all pain and discomfort.
A CASE OF HyDROPHOBIA is reported to have occurred
at Astoria, L. I. ‘The disease attacked a saloon-keeper
who had been bitten by a dog three months before.
Dr. IRA HAWLEY BARTHOLOMEW, aged sixty-one, ex-
member of the Michigan House of Representatives, ex-
President of the State Medical Society, ex-President of
the Michigan Agricultural Society, and who held the office
of Mayor of Lansing, Mich., for three consecutive terms,
died October 18th, of bronchitis. Dr. Bartholomew was
well known in the medical world, and was a contributor to
the prominent medical journals of the country.
MEDICAL SCHOOL DISTURBANCES IN CANADA.—A tele-
gram from Montreal states that the students of Victoria
Medical School are still in opposition to amalgamation
with Laval. The Church has taken the matter in hand.
Archbishop Fabre has sent the following letter to the Rev.
Mothers Superior of the Hotel Dieu and the Catholic
Maternity Hospitals : “ On account of particular circum-
stances, I have ruled that no student in medicine can be
admitted in your wards to follow a clinical course, unless
he is bearer of a card of admission reading as follows :
‘ Laval University, Montreal ; School of Medicine and Sur-
gery of Montreal,’ and signed by Drs. Mignault and Fou-
cher, Joint Secretaries.” It is believed that the students will
now yield to the action of the authorities in uniting the
Laval and Victoria Medical Schools.
MEDICAL Co-EDUCATION.—The announcement is made
that the University of Pennsylvania contemplates throw-
ing open her classes for the admission of women. No
exceptions are mentioned, and the wording of the resolu-
tion, which was passed by the Faculty with but two dis-
senting votes, warrants the inference that the school of
medicine was included.— 7imes and Register.
RoyaL Lepers.—After having made out Francis I. and
Henry VIII. syphilitics, the Russian emperors epileptic,
the English scrofulous, the Bavarian imbecile, and
the Spanish the last in stages of degeneracy, historical
critics are discovering leprosy among kings and princes.
A writer in Votes and Queries says: “ There is, I think, no
doubt that Henry IV. of England and Robert Bruce were
lepers. About Henry III. I am not sure. But I have
tried to discover any authority for what I am quite sure
that I read some years ago—but where I cannot remem-
ber—that Adelicia of Louvaine, second wife to Henry I.,
became a leper, and that that was the real reason why, when
a happy wife and mother, she left her second husband,
William de Albini, to whom she was tenderly attached,
and entered a convent.”
THE DISSEMINATION OF TUBERCULOSIS.—The Berlin
correspondent of the Medical Press says: “ I have already
repeatedly alluded to the labors of Dr. Cornet, in the
Hygienic Institute under the auspices of Professor Robert
Koch, in regard to the dissemination and prevention of
phthisis. Being a Bavarian by birth, he some time back
sent a copy of his publications to the Bavarian Govern-
ment, with the request that they should put the correct-
ness or otherwise of his views to the test. It was npt to
be expected that they should undertake an extended inquiry
at the dictate of a private individual, but they did pass on
the writings to the @ber Medizinal Auschuss. The re-
ferent on the occasion, Professor Bollinger, has decided
to enter on an investigation as regards prisons. It is
notorious that a great number of prisoners, nearly one-
third, die of phthisis. Professor Bollinger has deter-
mined that they shall not die of phthisis contracted
within the prison walls, #.¢., if Koch’s views on its etiology
are correct. For the future, all cells are to be disin-
fected as thoroughly as after cholera or the plague.
Further than this, all prisoners already phthisical, or sus-
pected of being so, are to be removed. All sputa are
to be disposed of in the way recommended by Dr. Cornet.
The proposed experiment has all the appearances of be-
ing a crucial one, and the results will be watched all over
the world with great interest.”
TyPHOID FEVER aT YALE.—Several students at Yale
are down with the typhoid fever, but nothing like an
epidemic prevails or is feared.
A BILL To ESTABLISH A STATE BOARD OF HEALTH has
been introduced into the Legislature of Georgia, but has
met great opposition, and from accounts given is not
likely to pass.
WILKIE COLLINS A MORPHINE TAKER.—Zhe Medical
Press and Circular says: “It will be recollected that
one of his most sensational novels was entitled ‘ Science
and Heart,’ and that it portrayed a demoniacal doctor
who vivisects his own child in his craze for biological
investigation. Those who were familiar with the author's
earlier novels and the spirit of good-nature which per-
vaded them, wondered at the flights of crazy rhodomontade
which this book contained, but it now appears that when
it was written, and afterward, until his death, he was the
victim of morphimania, and that the agony gush which he
wrote was the outward and visible sign of the brain aber-
ration produced by the continual and excessive use of the
drug.”
October 26, 1889]
Dr. Epwarp DEANS, at one time City Physician of Chi-
cago, took a dose of morphine with suicidal intent on
the 14th inst., and died on the 16th, at the County Hos-
pital. He was seventy-one years old.
THE PRINCE OF WALES is reported to have Bright’s dis-
ease. We trust he will not make that unpleasant affection
the vogue.
A FEW SPORADIC CASES OF YELLOW FEVER have been
recently reported at Key West, Fla.
A New MepicaL COLLEGE has been organized at
Wichita, Kan., with a corps of eighteen professors. At-
tendance on three full lecture-courses is required for
graduation.
A DEATH FROM THE ADMINISTRATION OF CHLORO-
FORM is reported in the Cincinnati Lancet-Clinic by Dr.
William L. Muzzey. ‘The patient was an apparently healthy
man, thirty years of age.
CONFERENCE OF INSANE ASYLUM SUPERINTENDENTS
AND MANAGERS.—A conference of the superintendents
and managers of asylums for the insane in the State of
New York was held at Buffalo, October gth. Dr. John
D. Hill, President of the Board of Managers of the Buf-
falo Asylum, presided, and a permanent organization was
effected. It was agreed to hold an annual convention,
and that the next one should be at Binghamton, on
the third Wednesday in September, 1890. Papers were
read by Dr. J. B. Andrews, Superintendent of the Buffalo
Asylum, Dr. P. M. Wise, of the Willard Asylum, and
others.— Boston Medical and Surgical Journal.
A New HosPITAL IN PHILADELPHIA.—Mr. John B.
Stetson, of Philadelphia, who has organized much char-
itable work in that cfty, is building a hospital in connec-
tion with the North Fourth Street Union Mission. The
hospital is nearly completed.— Boston Medical and Surgt-
cal Journal.
AS WE HAVE STATED BEFORE, in the judgment of
those most competent and of those who have carefully
examined Pasteur’s antirabic inoculation methods, they
are believed to be measurably successful in practice and
to be scientifically legitimate. We regret to observe that
our usually acute contemporary the Medical Standara
has allowed itself editorially to commend the silly asser-
tion of a rabid anti-Pasteurite that Pasteur “has never
studied the subject of rabies or hydrophobia, and that he
practises a clap-trap method without analogy in theory or
practice in the whole round of. medical experience, and
which results in an absolute increase of deaths from hy-
drophobia ! ”
WHOOPING-COUGH.—Bromoform in doses of 5 to 20
drops. daily, and phenacetin in 7 to 10 grain doses, are
among the new remedies recently recommended for whoop-
ing-cough.
MENTHOL IN THE VOMITING OF PREGNANCY.—Dr. S.
Gottschalk, of Berlin, reports a case of obstinate vomit-
lng of pregnancy (Berlin. klin. Woch., p. 875) which was
promptly controlled by the internal use of menthol.
The following formula was used :
B. Menthol Pee ee ee ee a o ae ee e a o Sete OL
BICONOL:: astern docu hae AEEA A 20
Wate aaeeea be dot ea ae wel ENT 150
M. Sig.: 3j.q. 1h.
THE MEDICAL RECORD.
465
Obituary.
e PHILIPPE RICORD, M.D.,
PARIS, FRANCE.
Tus most famous of-French physicians died at Paris,
October 23d, in the eighty-ninth year of his age.
probably not generally known that Ricord was an Amer-
ican by birth and education. He was born in Baltimore,
October 10, 1800, and when a mere lad went to Phila-
delphia for the purpose of studying medicine. In 1820
he went to Paris, where, in March, 1826, he received the
degree of M.D., and began to practise at Olivet, near
Orléans. Two years later he returned to Paris, where he
delivered a course of lectures on surgery, which gave him
some renown, and in 1831 he was appointed Surgeon-in-
Chief of the Hôpital des Vénériens du Midi. ‘This post
he filled most ably for nearly thirty years, retiring in 1860
on account of age. He had, in the meantime, acquired
a great reputation as a specialist in venereal diseases.
In 1862 he was appointed Physician in Ordinary to
Prince Napoleon, and in 1869 became Consulting Surgeon
to the Emperor Napoleon III., whom he had previously
attended with great devotion during a severe illness. In
return for his services the Emperor presented him with a
snuff-box and twenty thousand francs. He became
a Commander of the Legion of Honor in 1860, and a
grand officer in 1871 for services as Chief of the Ambu-
lance Corps during the siege of Paris. He was also the
recipient of many foreign decorations. Ricord was not
only a brilliant surgeon but a man of great learning and
wit.
Society Reports.
AMERICAN PUBLIC HEALTH ASSOCIATION.
Seventeenth Annual Meeting, held at Brooklyn, N. Y.,
October 22, 23, 24, and 25, 1889.
First Day, ‘TUESDAY, OCTOBER 22D—MORNING SES-
SION.
THE Association was called to order at ro a.m. by the
President, Dr. HosMER A. JOHNSON, of Chicago.
Dr. J. H. RayMonp, Chairman of the Local Commit-
tee, made a brief address of welcome, and explained what
arrangements had been made for the reception of visiting
delegates and for their entertainment in the city.
A long list of members-elect was then read and ac-
cepted.
PROFESSOR CHARLES A. Linps.ay, ot Yale College,
read a paper by Dr. W. ‘Thornton Parker, of Newport,
R. I., entitled
THE OVERSHADOWING OF OUR HOMES.
Houses overshaded are not healthful, however commo-
dious or well built they may be. Too many trees near
sleeping and living rooms are injurious and induce disease.
A soil loaded with roots and shaded from the sun is unfit
to live upon. Free drainage, abundant sunlight, and pure
air in free circulation must be obtained by thinning out
shade-trees, which are delusive ornaments and a dangerous
menace. The nervous system, as well as general bodily
health, suffers from a lack of sunlight. A National Board
of Health should have authority to discipline summer re-
sorts and other localities where health-seekers jeopardize
their lives through neglect in such matters of hygiene.
In the discussion which followed, opinions quite oppo-
site to those of the writer were expressed. Delegates
from Washington and New Haven said that although
their streets were thickly shaded, the rate of sickness was
no greater than elsewhere. Cutting down trees would do
more harm than good.
It is .
466
THE MEDICAL RECORD.
[October 26, 1889
—_————_ es ss ee _aeee...?..?.?.k _ ——EeEeEeEe—_e—u_0o0eS0u_ee_OO7Va ee
Dr. JAMES F. HiBBERD, of Richmond, Ind., read a
paper on
CLOTHING IN ITS RELATION TO HYGIENE.,
Considerable has been done to procure sanitary cloth-
ing for soldiers, sailors, and other government servants,
but ordinary citizens have little regard for the varying re-
quirements of the climate. Many dress too warmly to
allow proper functions of the skin. The popular estimate
of the hygiene of the skin is below its real importance.
Interference with the physiological action of the skin en-
dangers health, and is the primary cause of many consti-
tutional disturbances. ‘There should be established and
maintained a power of resisting disease by avoiding over-
dress, and the consequent too great generation of heat in
the skin, and also by periodical exposure of the surface
of the body to low temperature.
so arranged as to allow free circulation of air and proper
ventilation of the exhalations of the skin, without too great
loss of caloric in cold weather. Clothing that irritates
the skin produces abnormal perspiration, and predisposes
to peritonitis, rheumatism, and kindred ills.
Dr. WALKER cordially indorsed the views of the paper,
and substantiated them by his own experience. When
children kick the clothing from their beds, it signifies that
too much heat is being generated for their well-being.
The meeting then took a recess to inspect the
SANITARY EXHIBITION,
under the direction of Dr. A. N. BELL, of Brooklyn.
There were presented in great abundance various food-
preparations, medicines, disinfecting apparatus, specimens
of sanitary plumbing, garbage-consumers, ice-machines,
etc.
AFTERNOON SESSION.
Dr. JEROME WALKER, of Brooklyn, read a paper on the
CAUSES AND PREVENTION OF INFANT-MORTALITY.
‘The common belief that infant-mortality in this country
has diminished of late years is not sustained by statistics.
‘The death-rate might be reduced under favoring condi-
tions, but these conditions will not be reached while the
control of health-boards remains in the hands of mere
politicians. A radical change must be made in this re-
spect and in the better education of the masses. A large
proportion of deaths in institutions for children is prevent-
able, and the mortality may be lessened by giving the con-
trol of all medical and sanitary matters into the hands of
reliable and responsible physicians.
Mr. ALFRED F. WHITE, C.E., of Brooklyn, then read a
paper on the
RELATION OF ‘THE DWELLINGS OF THE POOR TO INFANT-
MORTALITY.
Statistics were given showing the need in this country of
such institutions as the Peabody Association of London.
The evils of crowding families in unhygienic apartments,
with every opportunity for the spread of communicable
diseases, are responsible to a great extent for the great
mortality among infants. Scarcely fifty years ago
there was not a tenement-house in New York, but
they are now found not only in large cities but
in rural towns, and growing up in all directions.
‘They affect not only the health but the minds and morals
of their occupants, and are a public danger. In London
large sums of money have been expended in heroic
measures to grapple with this evil, and the death-rate has
been lowered to a point which twenty-five years ago
would have seemed impossible. In 1888 the mortality
in London was 15.99 per 1,000, while in New York it
was 26.18; in Boston, 23.23; in Brooklyn, 22.72; and
in Philadelphia, 20.70 per 1,000. ‘These figures ‘show
The clothing should be,
abundant room for advance in obtaining conditions which
shall assist to maintain health and prolong life. ‘The
study of the problem of housing the poor was begun over
fifty years ago in London. The Improved Industrial
Dwellings Company was one of the first societies to make
a practical test. They invested £1,000,000 in buildings
which accommodated 5,300 families, comprising 22,000
individuals. Abundant light and air are supplied to every
room, and separate sanitary conveniences to each tenant.
Stairways are provided only on the outside of the build-
ings, and there is no common interior shaft or any com-
munication from floor to floor. Somewhat after the plan
of these are the Tower Buildings in Brooklyn. In the
city at large the annual deaths of children under five
years average between 9 and ro to 100, while in these
buildings only 6 or 7 (according to the agent's figures).
In the old-style tenements in New York the Board of
Health figures show a corresponding rate of 11.4 per 100.
In Brooklyn the records show no instance in which a
contagious disease has been communicated to an adjoin-
ing apartment, above or below. Cholera infantum may
be lessened in these buildings, in so far as the summer
heat is alleviated by thorough ventilation from front to
rear in every apartment.
DISCUSSION.
Dr. E. H. BARTLEY, of Brooklyn, spoke on the nec-
essity of milk disinfectants, and attributed much of the
disease of children to impurities in the milk.
Dr. WALKER referred to a series of experiments made
with the milk from cows fed at Prospect Park, on brewers’
grain, from distillery slops, and from reliable dealers.
Feeding cows on brewers’ slops increased the supply of
milk, but such milk putrefied quicker, and apparently with-
out going through a stage of fermentation. Milk given
by cows fed on pure hay was found to be the best.
Dr. MAXWELL, of Florida, inquired why infantile
diarrhoea was so rare in the South and so commonly fatal
in the North. The death-rate from that cause in San
Francisco was five, and in New Orledhs seven, in ten thou-
sand; while in Boston it was twenty-five, and in Chicago
thirty-five, per ten thousand. Why ıs cholera infantum as
common in some small towns and even in farm-houses in
the Middle States, as in large cities?
Dr. McDonaLp, of Missouri, thought that cholera in-
fantum is nearly always caused by the check to the ner-
vous system in a sudden transition from heat to cold.
Dr. J. P. THompson, of Kentucky, took an opposite
view, and argued that the disease is always produced by
indigestible food.
Dr. STAUNTON, of Ohio, and Dr. CLARKE, of Buffalo,
spoke of the necessity for disinfecting milk and seeing that
the cows are judiciously fed.
Dr. GrorGE Homan, Secretary of the State Board of
Health, St. Louis, Mo., then read a paper entitled
A SUGGESTED MINIMUM BASIS OF COMPENSATION TO LOCAL
HEALTH OFFICERS.
‘The meeting then adjourned.
EVENING SESSION—PUBLIC RECEPTION.
Dr. J. H. Raymonp, of Brooklyn, presided and opened
the meeting with a few words of welcome, congratulating
the Association on its large membership—now over six
hundred—and its good work in battling with disease. It
has succeeded in preventing as well as in quelling epi-
demics. Its influence and teaching have subjected to
scientific control nearly every form of pestilential visita-
tion.
Hon. ALFRED C. CHAPIN, Mayor of Brooklyn, in be-
half of the city, welcomed the Association to Brooklyn as
one of the most healthful cities of the country. The
need of such work as this body performs is felt in
healthful as well as diseased communities. As the health
October 26, 1889 |
-—— — ——
THE MEDICAL RECORD.
467
of the city is due in part to the vigor and good constitu-
tion of its founders, so the promotion of the
HEALTH OF THE PRESENT GENERATION
will bear fruit in its descendants, and succeeding genera-
tions will be thankful for our efforts in securing their
health. The medical profession and the State are mut-
ually dependent in advancing the public weal, and should
work together to make good laws and induce correct
habits among the people.
Dr. ALEx. Hutcuins, of Brooklyn, then delivered the
ADDRESS OF WELCOME
in behalf of the medical profession.
lege and laboratones, the hbraries and the homes of the
city. He referred to the comprehensive National Sani-
He reviewed
the growth of measures for the prevention of disease and
tary Exhibition of Sanitary Appliances.
the development of public health legislation.
THE PRESIDENT’S ADDRESS
was then delivered by PROFESSOR HOSMER A. JOHNSON,
M.D., of Chicago. He stated that the purpose of the
Association was not only to interest and secure the serv-
ices of physicians, but all other scientific men and the
public generally. ‘The necessity for such organizations in
behalf of the public health is great, and their importance
should be more recognized. A National Department of
Health is more needed than the Department of Agricul-
ture, and a Department of Vital Statistics more than a
Department of Animal Industry. Within the memory of
many in the audience, there was not an efficient board of
health in the world. ‘To promote hygienic living and
sanitary surroundings, and thus reduce the causes of dis-
ease, it is necessary to disseminate scientific knowledge.
Plague and pestilence have owed their origin and spread
to ignorance and neglect of the laws of health. Com-
parisons show what science has done for public health in
recent years. Legislative enactments and police regula-
tions are required for protection, and have been stimulated
by bitter experience with epidemics, and often framed in
times of danger. ‘They are thus too often provisional and
insufficient. They should be made in times of safety.
There should be a removal or destruction of the evil
agencies which threaten society. It-is the province of
this Association to inform the public in regard to proper
sanitary precautions. A health officer is as much needed
in every community as a justice of the peace or a con-
stable. The collection of vital statistics is also important,
and every town and village should have proper registration
of all births, deaths, and cases of communicable disease.
There should also be a national Board of Health, with
the power and means for attaining its much needed ends.
The matter of proper quarantine should also receive
more public attention and more complete legislation with
regard to zymotic diseases. Typhoid fever was formerly
regarded as a “ visitation of Providence.” ‘The time is com-
ing when such disease will be considered as due to crime.
A death from typhoid fever now means not so much
a dispensation of Providence as it means foul water, foul
food, or foul air. A city is decimated by a pestilence,
and it is found that its foundations are honeycombed with
cesspools, and its drinking-water is diluted sewage. ‘The
judgments of God, in the light of these revelations, be-
come no more mysterious than the pains of the child that
thrusts its finger into the flame only to feel the terrible in-
fliction that follows. ‘There has come to be an enthu-
siasm in the medical profession on this subject, which has
made itself felt in various ways. ‘This zeal has communi-
cated itself to the public. An intelligent foundation has
been laid for sanitary reforms.
The average length of life now is forty years, but an
intelhgent regard for the laws of health in the community
ought to add another forty years. There are more deaths
annually from preventable diseases than from any one
visitation of cholera or any other dreaded epidemic.
He invited the Asso-
ciation to the hospitals and dispensaries, the medical col-
The death-rate of twenty-six of the principal cities of
America, with a population of 9,873,448, is 20 per 1,000.
It is morally certain that this rate could be reduced by
means and methods now known to sanitary science to 16
per 1,000, and probably still less than that. The death-
rate for London for the year 1888 was 18.5 per 1,000.
This can be still further reduced. ‘That of New York and
Brooklyn for the same year, taken together, is 25.5 per
1,000—New York, 25.9; Brooklyn, 23.7. The death-
rate of these two cities, if reduced to that of London,
' would secure a saving of 7 per 1,000, or annually 15,986
hves. These lives are public wealth. But this is not all.
For one death annually two persons are sick during the
entire year, or, in other words, there are two years of dis-
abling sickness to one death; 31,972 years in New York
and Brooklyn of sickness—preventable sickness—annually.
The value of these years of sickness cannot be reached
° with accuracy, but the wages lost on account of sickness,
the cost of care and maintenance during sickness and con-
valescence, and the money value of the lives destroyed,
considering them only as machines, will, in New York and
Brooklyn, reach annually into the millions.
Rev. Dr. RicHarp S. Storrs, President of the Long
Island Historical Society, next made a brief address. He
alluded to the relations of amity and helpfulness which
should exist between the clergyman and physician.
Health and holiness are derived from the same root, which
signifies wholeness. ‘There is no conflict between science
and religion. One throws light on the origin, the other
on the destination of man.
Hon. SETH Low, the president-elect of Columbia Col-
lege, expressed sympathy with the work of the Association.
Brooklyn is approaching a new problem in sanitary mat-
ters. Built at first on high land sloping to the bay, the
city easily secured good drainage. Now the growth of
the city eastward occupies land sloping but slightly toward
the sea; and the drainage, instead of pouring into a
swiftly flowing tide, finds its way to landlocked basins.
The question of proper sewerage and the disposition of
sewage forms one of the most important problems before
this Association. A visit to the sewage-farm in Paris was
very instructive, as showing this waste material converted
into a useful product.
SECOND Day, WEDNESDAY, OCTOBER 23D —- MORNING
SESSION.
Dr. Joun S. Btuines, of the U. S. Army, Washing-
ton, D. C., read a paper entitled
THE UNITED STATES CENSUS IN ITS RELATION TO SANI-
TATION.
He emphasized the importance of the collection of vital
statistics. Many do not regard this as so important as
other work in behalf of public health. In order to con-
vince the press and the community that the work of a
Board of Health is necessary, you must produce constant,
undeniable evidence ; and this evidence must be mainly
death-rates, to which should be added all the sickness-
rates obtainable. ‘To do this there must be a complete
registration of deaths and births, and an enumeration of
the whole population. Before this Association meets again
the Eleventh United States Census will have been taken,
and its methods and results are of great interest to all
sanitarians. One of the most important questions to be
settled before the census is taken is what shall be the
boundaries of the special districts of the city for which a
separate statement of the population is desired. In some
cities the wards form fairly satisfactory districts for the
purpose, and where this is the case it makes the problem
very easy. But in many cities these divisions bear no
proper relation to different sanitary conditions. There-
fore in about a dozen of our large cities it is proposed to
make a systematic division of the area into sanitary dis-
tricts having special relations to altitude, character of
habitations, or of population, etc., and to have special
death-rates calculated for each of these districts. This is
468
being done in conference with the health authorities of
these cities, and it is hoped that in this way some very in-
teresting data will be obtained which will serve as a foun-
dation for sanitary work in the future.
To make the statistics as correct and useful as possible,
all deaths occurring in hospitals should be charged to the
ward or district of the city from which the patient was
taken to hospital], when this can be ascertained. Otherwise
the death-rate in the ward in which the hospital is located
will be too high and in the other districts it will be too
low.
be also reported. Moreover, it is very desirable that in all
cases of deaths of colored persons it should be stated
whether the decedent was black or of mixed blood, such
as mulatto or quadroon. One of the most important
questions in the vital and social statistics of this country
relates to the fertility, longevity, and liability to certain dis-
eases of those partly of negro and partly ot white blood,
and the only way to obtain data on this subject is through
the registration of vital statistics. For all cities of ten
thousand inhabitants and upward it is proposed to collect
as complete information as possible with regard to alti-
tude, climate, water-supply, density of population, sewer-
age, proportion of sewered and non-sewered areas, and
other points bearing on the healthfulness of the place
which will permit of interesting comparisons with the death-
rates. The cordial co-operation of all physicians and
sanitarians is solicited in making the data of these reports
accurate and complete. It is desired to make these vital
statistics an unanswerable argument in favor of systematic
public sanitary work and of the granting of State and mu-
nicipal funds necessary for maintaining such work.
Dr. J. N. McCormack, of Kentucky, offered a resolu-
tion recommending that the sanitary authorities of Mex-
ico and Cuba be invited to send representatives to the
future meetings of the Association. ‘This was referred to
the Executive Committee under the rules.
PROFESSOR LINDSLAY then read the paper prepared by
Dr. Ezra M. Hunt, Secretary of the State Board ‘of
Health, Trenton, N. J., entitled
THE PREVENTION OF PHTHISIS PULMONALIS AND METHODS
FOR ITS LIMITATION.
The paper criticised the writings of those who regard the
infection of phthisis pulmonalis as exclusively due to in-
halation of the dried sputa of this disease. The theory
was advocated that the breath of a consumptive patient
is capable of carrying the contagion.
Discussion of the paper was postponed, and after a
brief intermission, for business notices, Dr. W. M. SMITH,
Quarantine Officer of the Port of New York, reada
paper, illustrated by stereopticon views, on
IMPROVEMENTS AT THE NEW YORK QUARANTINE STATION.
He began with the history of the earliest establishment of
a quarantine station in New York, and went on to de-
scribe how the present grounds were taken up for that
purpose. Illustrations of the ground plans of the build-
ings were thrown on the screen, and the speaker explained
how the drainage and sewerage of the island were con-
structed ; how patients suffering with contagious diseases
were enabled to enjoy an outing without coming in con-
tact with any of the other patients. ‘Then the methods of
disinfecting were explained, and views of the various
chambers used for the purpose were shown.
The Association then adjourned and proceeded to take
an excursion to the Quarantine and East River hospitals,
accompanied by Dr. Smith.
EVENING SESSION.
Dr GEORGE M. STERNBERG, U. S. Army, of Baltimore,
Md., gave an account of |
RECENT RESEARCHES RELATING TO THE ETIOLOGY OF YEL-
LOW FEVER.
‘The investigations were made in Havana, between the
middle of March and the first of September, 1889. Am-
THE MEDICAL RECORD.
The birthplace of the parents of the decedent should »
[October 26, 1889
ple material has been obtained for a thorough research by
modern culture methods. Thirty autopsies have been
made in typical cases of yellow fever. The cultures ob-
tained require further study and extended comparative
research before any definite conclusion can be reached as
to the specific etiological relation of one or other of the
micro-organisms found in yellow-fever cadavers, princi-
pally in the intestine. One method followed in the entire
series of cases was the preservation of a piece of liver or
kidney in an antiseptic wrapping, by which the exterior
was sterilized and the entrance of germs from without
prevented. Such a piece, after forty-eight hours in the
laboratory, appeared fresh and had no odor, but when cut,
was found to contain various micro-organisms. The cut
surface had an acid reaction. The bacilli were of various
species, and corresponding with those found in the con-
tents of the intestine. No satisfactory evidence has been
obtained, up to the present time, that any one of these is
the veritable yellow-fever germ. One of the most con-
stantly found of these micro-organi was a large, mo-
tionless, anaerobic bacillus, resembling that of malignant
cedema. ‘This, and others found in a less number of
cases, were present in small numbers at death, and in a
large proportion of cases the result of an examination
made immediately from fresh liver-tissue was negative.
Material from a piece of liver, kept as above, and con-
taining micro-organisms, is very pathogenic for guinea-pigs
when injected subcutaneously in small quantities, while
the fresh tissue may be injected in considerable amount
without noticeable effect. The micrococcus of Freire has
not been found in any cultures of this series, and the ba-
cilli of Finlay and Gibier have not generally been found in
the tissues of yellow-fever cadavers. |
Dr. ‘THEOBALD SMITH, of Washington, read some
PRELIMINARY OBSERVATIONS ON THE MICRO-ORGANISM OF
TEXAS FEVER.
Cultures have been made from the spleens of animals
who died of Texas fever, and a variety of bacteria found.
A variety of experiments led to the discovery of an or-
ganism within the red blood-corpuscles. ‘The intra-
globular bodies found are round or oval and nearly color-
less. ‘There 1s usually one, but two or more may be
found in one corpuscle. Stereopticon views of the or-
ganisms found were shown upon the screen.
This was followed by a paper by D. E. Satmon, D.V.M.,
Chief of the Bureau of Animal Industry, Washington,
entitled
SOME GENERAL OBSERVATIONS ON TEXAS FEVER.
The resemblance in the characteristics of yellow fever
in man and ‘Texas fever in cattle was noticed. Each dis-
ease has a permanently infected and well-known district
which is its home. The contagion of both diseases is
carried not by the sick, but by the healthy. Natives in the
infected districts have a certain immunity from disease,
while non-residents entering the locality will contract the
fever. Both diseases, when carried north of their home, re-
quire a period of warm weather for development. Neither
contagion survives a winter of snow and frost beyond its
home. Both diseases are accompanied by an inflamma-
tion of the liver which causes yellow discoloration of the
tissues, and in both hzematuria is seen. ‘These points of
similarity may indicate that the germs have a similar na-
ture, but the facts are given as a coincidence.
EDWARD ATKINSON, LL.D., of Boston, Mass., read a
paper on
THE ART OF COOKING.
A form of oven heated by an oil lamp, with great sav-
ing of heat and fuel, was shown, and food prepared before
the audience.
The meeting then adjourned.
CHLORALANIDE is the name of the latest new hypnotic.
It is a combination of chloral and formamide, and is given
in doses of 15 to 60 grains.
October 26, 1889]
AMERICAN DERMATOLOGICAL ASSOCIATION.
Thirteenth Annual Meeting, held at Boston, Mass., Septem-
ber 17, 18, and 19, 1889.
First Day, TUESDAY, SEPTEMBER 17TH — MORNING
SESSION.
THE President, Dr. J. E. GRAHAM, of Toronto, Canada,
called the meeting to order at 10 A.M., and after a short
executive meeting, in which reports were read and com-
mittees appointed, Dr. Graham, as presiding officer,
made
THE OPENING ADDRESS.
_ He referred to Boston as a city which had always been a
centre of activity in dermatological matters. ‘The Har-
vard had been among the first schools to establish a chair
of dermatology. The earliest works on the subject were
published here. “ Brief Notes on Small-pox and Measles”
was the title of a book published here as early as 1677.
Ihe hope was expressed that the present gathering, in this
birthplace of American dermatology, would be a profitable
and pleasant one. The importance of greater attention
being paid to sanitary matters was dwelt upon, and the
possibility of preventing the spread of many infectious
and contagious diseases by the enactment of sanitary laws.
In two diseases, not themselves dangerous, but extremely
disagreeable, viz., scabies and tinea tonsurans, much could
be done in the matter of eradication and prevention
by appropriate measures. Reference was made to Dr.
White’s recent paper, in which an increase of scabies in
Boston was noted, and the inspection of children in pub-
lic institutions advocated by it was’ indorsed.
tonsurans, when once firmly implanted in an asylum
or school, is with the utmost difficulty eradicated. He
referred to a provincial town in Canada in which
Inspection had resulted very favorably. The subjects
of syphilis and leprosy, as great menaces to the public
weal, were then taken up. ‘The evil resulting from the
first was very wide-spread, while the attempts to eradicate
it, or check its progress, were few, spasmodic, or of local
character. In other countries, where laws had been en-
acted relating to syphilis, the results had not been very
encouraging. Denmark and France were especially spo-
ken of, where imperfect registration defeated the objects
of the enactments. One fault in this country lies in the
imperfect knowledge of the disease acquired in our med-
ical schools. Students are too apt to think, if they intend
practising in the country, that they will not be called
upon to treat the disease. ‘This is a great mistake; un-
fortunately, it is to be found in all sections, and affecting
all classes. Absolutely free treatment in all hospitals and
public institutions was advocated. Separate wards and
hospitals should be set apart where these patients could
be treated with consideration, and inducements should be
held out to them to enter. Great danger threatened the
community at large, and public moneys should be freely
spent for this object. Examination of wet-nurses was im-
portant, as they were very frequently found affected.
Periodical examination of soldiers and sailors should also
be made. Care in vaccination, circumcision, and proper
instruction of youth were prophylactic means not to be
neglected.
_ The spread of leprosy has recently excited much atten-
tion. Dr. Morrow’s paper has caused discussion of the
subject. Leprosy is contagious, in the wide acceptation
of the term. Each leper, by direct or indirect transmis-
sion, 1s a focus of danger. Inoculation has become a
well-established fact. ‘The germs may be introduced by
food, or possibly by inhalation. Instances of this are not
proven, but we are not in a position to deny its weight.
Hereditary transmission is not now so much thought of as
hereditary predisposition. ‘There has been no decided
increase here, till of late years. Development of the
germs seems to depend on the condition of the individual
with whom they come in contact. Immunity here de-
THE MEDICAL RECORD.
Tinea’
469
pends. on manner of living rather than on any peculiar
idiosyncrasy. The slow spread here is explained by the
fact that those attacked are of other than Anglo-Saxon
race. It is possible that an Anglo-Saxon leper, living
among Anglo-Saxons, would prove a source of infection.
If once started it will be impossible to control it. The
facts favorable to its extension here are, that it exists in
every quarter; we have it on every side. There is no
danger of a rapid spread, but of an insidious progress un-
til it becomes formidable. The Government should take
measures at once to prevent its spread. The speaker ad-
vocated sending back cases to their own country ; keep-
ing suspected cases under surveillance ; and segregation.
It is difficult to secure separation, as the individual is un-
willing to enter a settlement. Asylums should be made
desirable places of residence. Dr. White advocated, in
1874, at the first meeting of this Association, a considera-
tion of questions of national importance. Up to that time
there had appeared no cause of alarm in regard to lep-
rosy, but at that time he thought it by no means improb-
able that a foothold might be obtained. Certainly in
many States and cities too little attention has been paid
to such sanitary considerations. ‘The rule to hold the
meetings of this Association in large centres of population,
where rare skin diseases could be presented, should be
carried out.
The first paper read after the President had declared
the Association open for business was one by Dr. F. B.
GREENOUGH, of Boston, on
HERPES ZOSTER,
based upon personal observations extending over sixteen
years, in which time two hundred and fifty-five cases of
the disease had been treated out of a total of seventeen
thousand seven hundred and forty-one cases of skin dis-
ease. ‘The average age had fallen between ten and fifteen
years, and the largest number of cases in any cycle of five
years of life were found between these years, the number
being fifty-nine. The youngest patient was three months
of age, and the oldest was aged eighty-eight. The neurotic
origin of herpes zoster has been pretty generally conceded,
but as it is observed with somewhat greater frequency in
the spring-time, we must assume that certain unknown
factors influence the eruption. The situation of the
lesions, as recorded, shows that the costal region is af-
fected in about fifty per cent. of the cases, the facial and
cervical in about eight per cent., and the abdominal in
about six per cent. The older the patient the more likely
was it that pain would be a prominent symptom. In nine-
teen cases the pain was very severe, and the average age
of these patients was forty-four years. In several in-
stances the vesicles appeared to pass beyond the median
line on the back, but in each instance careful examination
showed that there was a slight curve of the spine to ac-
count for the appearances. One patient had a double
zoster of the nose. Two cases showed lesions upon the
fingers at the terminal ends of the brachial nerve. ‘The
reader had observed a herpes progenitalis extending upon
the shaft of the penis which closely resembled a zoster.
As to treatment, the abortive method is not favorably
looked upon. It is advised to leave the vesicles alone as
much as possible, and to prevent their rupture. Diachylon
plaster, permanently applied to the affected region, has
seemed to do as much good as anything. No benefit was
derived from internal antirheumatic remedies.
Dr. Fox, of New York, said that upon close questioning
violence will often be found to have preceded the out-
break. Internal remedies, in his experience, werè without
effect, and most of the methods of treatment in vogue
were extremely unsatisfactory. He had given up collodion
applications. Much benefit could result from galvanism.
Dr. Rosınson, of New York, could not regard the dis-
ease as a neurosis, but looked upon it as an infectious
process.
DR. ZEISLER, of Chicago, spoke of the occurrence of
zoster soon after the internal use of arsenic. In one case
470
recently observed it appeared after Fowler’s solution had
been increased up to thirty-drop doses.
Dr. Bronson, of New York, said there was an unsolved
mystery about zoster. It does not depend upon time, lo-
cality, or age. Its occurrence but once in a lifetime sup-
ports the theory of infection. He has secured good
results from the application of gutta-percha dissolved in
chloroform.
Dr. SHERWELL, of Brooklyn, spoke of three cases he
had observed in which a zona ophthalmica was attended
with an eruption upon the ala nasi of the same side. He
employed occlusive dressings, galvanism, and had also
given internal remedies with seeming good effect.
Dr. Harpaway, of St. Louis, spoke of the possibility
of chronic zoster, and related a case of herpes upon both
sides of the neck which had persisted for months, and
showed the usual signs of zoster. ‘Ten or twelve cells of
an ordinary galvanic battery usually gives relief from the
pain, but in some cases, at least, there is present an element
of imagination. Protective dressings and collodion are
much superior to any form of ointment.
Dr. BuLkLey, of New York, said the proportion of
cases in New York was similar to that given by the reader
of the paper. He has seen a zoster in a patient upon
whose body were the signs of a previous attack. He
would regard it as the result of a simple neuritis, due at
times to cold and at times to injury, and had oftem seen
it develop in patients under arsenical treatment. Great
relief of pain is secured by the galvanic treatment, and at
times it appears to have an abortive effect. He prefers
a tight-fitting bandage, under which the skin and lesions are
thickly dusted with starch powder, to any other dressing.
_ Dr. Howe, of Boston, said the collodia dressings had
given him little satisfaction, excepting in the erythem-
atous form. Galvanism has, on the other hand, given
great relief. As a dressing he applied thin strips of cork
above and below the eruptian, and maintained them in
place by adhesive strips. ‘The lesions themselves are best
dusted with some bland powder.
Dr. Kiorz, of New York, referred to the paper on this
subject read by Kaposi at the Prague Congress, in which
epidemics of the disease were reported. He maintained
that the affection in which recurrence took place differed
from the ordinary zoster. He himself could not accept
the infectious theory. He had seen double zoster of the
face. Two personal cases were related in which deep
scars were left. Both patients were syphilitics, and the
speaker thought this often the cause of scars.
- Dr. Morrow, of New York, had seen the eruption fol-
low a blow after a short interval. He had also observed
the lesions of zoster extending down over the toes. In
one case the pain was localized in the knee. Many things
point to its infectious nature, and the fact that it occurs
after injury does not disprove the theory. A hot-water
bag to the spine often gives relief from the pain.
Dr. RosInson said a zoster-like eruption could follow
an injury, but this did not prevent a subsequent true
zoster from appearing, and making it seem like a recur-
rence.
_ Dr. Grauas, of ‘Toronto, Canada, spoke of a fatal case
in a boy under his care. Febrile symptoms and pain pre-
ceded the eruption by three days. On the fourth there
was severe pain on the opposite side of the face, and on
the fifth the patient died. Autopsy showed intense in-
flammation of the Gasserian ganglia on both sides. A
bacillus of unknown name and nature which was found
in the ganglia was demonstrated before the Association.
Dr. GREENOUGH, in closing, said that in one case he
had mentioned the lesions were limited to the finger and
thumb.
Dr. HEITZMANN, of New York, then read a paper on
MICROSCOPICAL STUDIES OF MALIGNANT TUMORS OF THE
SKIN.
‘The basis-substance of the fibrous connective tissue of
the derma is living, and capable of proliferation. In der-
THE MEDICAL RECORD.
[October 26, 1889
matitis we observe in the earliest stages an augmentation
of the living matter leading to the appearance of inflam-
matory corpuscles. A breaking asunder of the inflamma-
tory corpuscles leads to the formation of pus-corpuscles.
In the production of tumors the tissue of the derma in-
variably falls back into its protoplasmic condition, with new-
formation of medullary or indifferent corpuscles from which
a tissue originates. The newly formed tissue may remain
in an embryonal or medullary condition, as in sarcoma.
He had seen all varieties of ‘sarcoma in the skin, but
thought it necessary to make but two varieties: G/odo-
myeloma, identical with Virchow’s “ round-celled sarco-
ma,” and sfpindle-myeloma, or spindle-celled sarcoma.
Sarcoma of the skin does not often ulcerate ; the tissues
over them become thinner and thinner, and finally break
through, and a superficial ulceration may take place. The
new-formation of myeloma-corpuscles takes place from
the protoplasm between the bundles of connective tissue
and also from the basis-substance of the bundles them-
selves. All epithelial structures will sooner or later dis-
appear when myeloma comes in the skin. When the
growth proceeds very rapidly they will be transformed
into myeloma-corpuscles. Two views are held regard-
ing cancer: 1. That it invariably starts from epithe-
lia. 2. That the connective tissue may furnish material
for it. Primary cancer, according to the reader, may ap-
pear in places where there is no trace of epithelial forma-
tion. Small glistening bodies or corpuscles in groups
were shown under the microscope, which the author re-
garded as the pre-stage of cancer and an almost sure indi-
cation of the extension of the process if found beyond
the tumor ; or, if found after operation, recurrence could
be predicted. i
Dr. Rosinson agreed with the views respecting the
structure of the derma. He made a broad distinction,
however, between tumors proper and sarcomata, which he
regarded as an infective process. At the point of develop-
ment there is, of course, a dermatitis and connective -tissue
new-growth. He did not think epitheliomata could exist
without previous epithelial tissue, and he cannot now ad-
mit that that connective tissue returns to embryonal tissue
and then becomes epitheliomatous. For example, he had
never seen epithelioma primarily develop in a lymphatic
gland.
Dr. HEITZMANN said he could admit that when it starts,
in the early stage, we could not tell sarcoma from inflam-
mation, but the former goes on to the formation of tumor
while the latter stops. His view--that epithelioma could
develop from other than epithelial tissue—was not yet ac-
cepted in this country, but he thought it would be.
Dr. Morrow, of New York, read a paper entitled
THE DIAGNOSIS OF LEPROSY.
The growing interest in this country in the subject of
leprosy ; the sad fate of Father Damien, which had di-
rected the attention of the whole world to the disease ;
and the lack of sufficient clinical descriptions in the ma-
jority of text-books, had led the reader to consider some
points in the differential diagnosis. Most authors of text-
books have not been sufficiently familiar with the charac-
teristic and pathognomonic features of the disease from
their own clinical observations. During the readers so-
journ in the Sandwich Islands he had had an excellent
opportunity to study the diagnosis in many cases, not only
of those well known to be lepers, but also in suspected
cases under government supervision. In the tubercular
form the prodromal signs possess but little value, and show
nothing characteristic. ‘They are, however, of value in a
retrospective sense. In the macular form the lesions
are not pathognomonic, and are liable to be mistaken for
syphilis, erythema multiforme, etc. ‘lubercular lepra and
syphilis also bear the closest resemblance to each other.
Nodules grouped upon an infiltrated base may also be
mistaken for lupus. ‘The bacillus occurring in leprous
tissue, and nowhere else, is of the utmost importance in
diagnosis. Hypereesthesia is first present in the rosy patch
October 26, 1889]
THE MEDICAL RECORD.
471
of the early macular form, but as the patch clears up in
the middle, anæsthesia takes its place. Pigmentation may
be present from the first, causing a marked resemblance
to chromophytosis, but there is no scaliness. In lepra the
depigmented spots are more grayish than in leucoderma.
Pemphigoid blebs are sparser and more superficially situ-
ated than in ordinary pemphigus. The plantar ulcer, fre-
quent in the tropics, bears a close resemblance to mal
perforans. Many neurotic diseases are simulated : Pro-
gressive muscular atrophy, chronic arthritis deformans,
etc. Unilateral development of lepra is not uncommon.
In the Sandwich Islands one-third of the cases were an-
æsthetic, and two-thirds of the mixed type. Many photo-
graphic illustrations were shown. -
Dr. BuLKLEY asked if other lesions were present in the
case resembling perforating ulcer of the foot.
Dr. Morrow said no, but that the patient had since
then shown other well-marked signs, and was now at the
leper settlement at Molokai.
Dr. GRAHAM spoke of a case of perforating ulcer seen
at ‘Tracadie, in a leprous woman seventy-one years of age,
who had never been in the habit of going barefoot.
Dr. Jackson, of New York, then presented
A CONTRIBUTION TO DERMATOLOGICAL BIBLIOGRAPHY,
consisting of a catalogue comprising over three thousand
titles to works on skin diseases, and more than twelve
hundred on syphilitic subjects, which will be published in
pamphlet form.
THE OCCURRENCE OF PRURIGO IN AMERICA
was the next paper, read by Dr. ZEISLER, of Chicago,
who showed that while the existence of the disease in this
country had been often and in many quarters denied, it
still existed in some localities here to almost as great an
extent as in Vienna. Twelve cases have been seen by
the reader during the past year out of a total of one thou-
sand three hundred and seventy cases of skin disease. He
accounts for the fewer cases generally seen in this country
by the fact of improved facilities for bathing and better
sanitary surroundings, to say nothing of difference in
climate.
Dr. Taylor had seen two typical cases here. The
testimony of almost all members who spoke went to
show that prurigo is not often seen in this country,
although, with scarcely an exception, the gentlemen had
observed and studied the disease in Vienna, and were
familiar with it.
A PRURIGO PATIENT
was presented by Dr. Tilden for Dr. WIGGLESWORTH, of
Boston. A boy born near Boston, about fifteen years of
age, had been under his care for some time. Upon ex-
amination, Dr. Zeisler and severàl others pronounced it
a typical case of the disease.
Dr. Fox thought the only essential difference between
such a case and one of eczema was the question of dura-
tion.
Dr. ALLEN spoke of a case quite similar to the one
presented, 'now under treatment, which he had regarded
as a true prurigo.
Dr. BuLKLey thought many such cases had been classed
as eczema in this country.
Dr. ZEISLER made the point that in papular eczema
the face, hands, and scalp were always affected, while in
prurigo they are free. Mild cases do get well, even in
Vienna, and especially since the beta-naphthol treatment
has been employed.
Dr. SHEPPERD, of Montreal, read a paper entitled
TWO CASES OF ECZEMA MERCURIALE,
describing an eczema as the result of the application of
mistura ammoniaci cum hydrargyra, or, as it is known
in Canada, ‘‘Scott’s Dressing.” It had been used as a
local dressing, spread on sheepskin, in treating synovitis.
An erythematous eczema, at first local, soon spread to the
face and genitals, and resembled rhus-poisoning.
Dr. Morrow said it is not unusual to see drug-eruptions
persist long after the drug is removed.
Dr. GRAHAM had seen the same results from bichloride
dressings.
Dr. Kotz read a paper entitled
CLINICAL OBSERVATIONS ON INJECTIONS OF INSOLUBLE
MERCURIAL SALTS IN SYPHILIS.
The reader was aware that in this country the treatment
was considered one for emergency, and was not looked
upon favorably as a method for general use. Little ob-
jection had been found on the part of any of the patients,
and many were much pleased with it.
Two hundred and ten intramuscular injections had
been made upon twenty-three different patients. Calomel,
the yellow oxide, and the salicylate of mercury were all
tried, but the yellow oxide was most used, in the strength
of 1 to 30 suspended in water, olive-oil, or vaseline. An
average of ten injections was made for each patient.
Two abscesses were produced, both following an injection
of calomel suspended in water. None followed when it
was suspended in oil, Affections of the skin were almost
always favorably impressed by the injections, and the re-
sults in general were so encouraging that the reader does
not feel inclined to give up the method.
Dr. TAYLOR thought it would not often be necessary
to resort to intramuscular injection; still, the method
might be good for certain emergency cases. There are too
many dangers to permit of a permanent adoption of the
method.
Dr. Morrow regarded it as a reserve treatment where
others are contraindicated.
Dr. ZEISLER did not think the method applicable to
cases in general, or practicable.
Dr. SHERWELL thought the dosage inexact.
Dr. Bronson thought it a scientific means of treatment
the application of which we had not yet fully mastered.
Dr. HerrzMann had obtained painful nodules when
the greatest antiseptic precautions were employed.
Dr. Kuorz said abscesses were more frequent in be-
ginning the injections, but as experience is acquired the
danger grows less. The good qualities of the method far
outweigh the bad ones.
(To be continued.)
MISSISSIPPI VALLEY MEDICAL ASSOCIATION.
Fifteenth Annual Session, held at Evansville, Ind., Sep-
tember 10, 11, and 12, 1889.
Dr. GeorGE F. Cook, oF INDIANAPOLIS, PRESIDENT, IN
THE CHAIR.
THE Secretary, Dr. R. L. ‘Thompson, of St. Louis, and
the Chairman of the Committee of Arrangements, Dr. A.
M. Owen, of Evansville, were everywhere. ‘The attend-
ance was good, for this “‘side-tracked village in the pocket
of Indiana.”
The President, owing to the immense programme of
about one hundred papers, begged to be excused from a
formal address, and made only a few opening remarks.
The Committee on Nominations, by their Chairman,
Dr. I. N. Love, of St. Louis, Mo., reported as follows:
President—Dr. Joseph M. Matthews, of Louisville;
First Vice-President—Dr. C. R. Earley, of Pennsylvania ;
Second Vice-President—Dr. T. B. Harvey, of Indianapolis ;
Permanent Secretary—Dr. E. S. McKee, of Cincinnati.
Invitations for holding the next annual meeting were
- received from Excelsior Springs, Mo., Chattanooga, Tenn.,
Cincinnati, O., and Louisville, Ky. Louisville was chosen,
and September 9, 1o, and 11, 1890, appointed for the
meeting. l
The newly elected President was escorted to the chair,
and made some appropriate remarks.
ANTIPYRETICS, ANALGESICS, AND HYPNOTICS,
was the title of a paper by DR. I. N. Love, of St. Louis.
He discussed quinine, opium, antipyrine, acetanelid, bro-
472
mides, urethran, and exalgine. We should guard carefully
against the possibility of self-drugging, and with this end
in view he thinks it the physician’s duty to dispense him-
self all analgesics and sedatives. He can thus limit the
amount taken and, if desirable, keep from the patient a
knowledge of the dosage. All the derivatives of the aro-
matic series, being antiseptic, antipyretic, and analgesic,
are of great value to us in our battles with disease. Ace-
tanelid, in his experience, stands at the head of the list,
and exalgine has been so satisfactory as to justify a more
extended use.
Dr. S. BisHop, of Chicago, read a paper entitled
THE ABORTION OF ACUTE NASAL CATARRH.,
If the case was a severe one he administered half a grain
of morphia and one one-hundredth grain of atropia, lessen-
ing the dose if the attack was a light one.
“ A Simple Method of ‘Treating Fistula in Ano” was the
subject of a paper by Dr. Joseph M. Matthews, of Louis-
ville. ‘This paper created an interesting discussion, which
was taken part in by J. M. Murdock, of Pittsburg, H. H.
Grant, of Louisville, Archibald Dixon, of Henderson, and
W. H. Wathen, of Louisville.
“The Myopic Eye” was the brief title of a pointed
paper by Dr. Dudley S. Reynolds, of Louisville. ‘The
doctor related a series of interesting cases. He indicated
the three principal agents for the arrest of the progressive
myopia : Eserine, pilocarpine, and iridectomy. ‘That-the
myopic eye is alwaysan unsound eye should be constantly
borne in mind. ‘That the myopic state of refraction is
always the result of abuse should be universally known,
for it concerns the whole human family.
“The Treatment of Strangulated Hernia” was the title
of a paper by Dr. W. H. Meyers, of Fort Wayne, Ind.
He advised to shun opium, and scolded at delay. If the
patient 1s seen within a few hours of the accident, we may
employ taxis with no other interference for six or eight
hours as the extreme limit. Otherwise this treatment
should be limited to minutes, and the operation performed.
“The Accoucheur and his Forceps” was the subject of
an essay by Dr..A. S. Bemes, of St. Louis.
Dr. J. A. Larabee, of Louisville, read a paper entitled
INFANTILE THERAPEUTICS.
He thought the old therapeutic furniture fitted remarkably
well the new house with its microbian windows. He
thought infantile therapeutics should include an infinite
knowledge of hygiene and of hydrotherapy. Water is en-
tirely too common to command respect. If it could be
sold in small quantities at fabulous prices it would be
better thought of. He often found it necessary to use a
slight amount of deception to induce the use of water.
He discussed endermatic, hypodermatic, and epidermatic
medication, also the treatment of diphtheria.
Dr. H.C. DALTON, of St. Louis, Supermtendent of the
City Hospital, read an interesting paper entitled
IS SENN’S GAS-TEST INFALLIBLE AND ALWAYS DEVOID OF
DANGER ?
He reported a case of gunshot wound of the abdomen,
the ball passing into the thorax in the left axillary line, be-
tween the seventh and eighthribs. ‘here were no symptoms
of abdominal injury, but, from the direction of the ball, he
suspected that the abdominal cavity had been penetrated.
He resected three inches of the seventh rib and found a
hole through the diaphragm, three inches from the tho-
racic wall. He introduced a glass tube and applied the
gas-test, but received negative results. Laparotomy was
not performed. The patient came near dying from inter-
ference with respiration due to the enormously gaseous-
distended intestines pressing upon the diaphragm. At the
autopsy, eighteen hours after death, two holes were found
in the greater curvature of the stomach four inches below
the cardia, the hole of exit being a half-inch below hole of
entrance. ‘The lower third of the stomach was filled with
semisolid food which had securely plugged up the bullet-
holes during the administration of the gas and prevented
THE MEDICAL RECORD.
[October 26, 1889
its escape into the peritoneal cavity, thus accounting for
the failure of the test. |
He concluded, if semisolid food would cause the test
to fail, semisolid fæces would do the same thing. and
hence the claim that the test is infallible is untenable.
He also reported a case in which the test gave affirma
tive results, the gas escaping and igniting freely. Lapa-
rotomy was performed, and twelve holes were closed by
the Lembert suture, two in the czecum, six in the small
intestines, three in the mesentery, and one in the hole of
entrance. Owing to the gaseous extension, difficulty was
experienced in returning the intestines to the cavity and
closing the wound.. In the attempt, the firm pressure used
caused the holes to burst in several places, flooding the
peritoneum and obliging the peritoneal toilet to be done
de novo. He thinks this, together with the excessive
gaseous pressure upon the diaphragm after the closure of
the abdomen, adds to the shock, and hence he argues that
the method is not devoid of danger. ‘The patient died
eighteen hours after the operation.
Dr. ALEXANDER B. SHaw, of St. Louis, read a paper
entitled
RESULTS OF SUSPENSION IN THE TREATMENT OF AFFEC-
TIONS OF THE SPINAL CORD BY THE SHAW APPARATUS
AND TECHNIQUE.
He began a series of experiments, June 16, 1889, with the
apparatus devised by himself, for suspension in affections
of the spinal cord. After personally suspending a number
of patients every two or three days for several weeks, he
turned the cases over to two assistants, who continued the
treatment after the technique of Dr. Shaw. A report from
them at the end of a little more than two months, refers
especially to three cases, though in all ten have been re-
ceiving the treatment. Two of these patients were af-
fected with tabes dorsalis; the other, with cerebro-spinal
sclerosis.
Case I.—German watchmaker, aged thirty-two, pre-
vious health fairly good; dates present illness from a
burn received over left half of body, which confined him
three months to his bed. After this he noticed difficulty
in walking, until when he came under the treatment he
was unable to walk without assistance. He appeared far
advanced in the second stage of the disease. ‘The great-
est change is in his locomotion; he is now able to walk
all about the institution, climb stairs, and a decided men-
tal change is apparent. ‘There seems an extension of at
least five inches in the length of the neck in the suspension
of this patient. ‘There is some atrophy of the posterior
cervical muscles, The backward bending of the knees,
particularly marked in the beginning of treatment, is much
lessened.
Case II.—German tailor, aged sixty-six. No history
of this patient, excepting some rheumatic ailment several
years ago. He was able to walk with the use of a cane
when he first came under notice, but was in frequent
danger of falling. He was troubled by “girdle pains,”
which have lessened since suspension. On account of his
weight he can stand treatment Lut a short time without
great fatigue. From a state of almost utter helplessness
he has so improved that he was able to walk into the city
(six miles), remain several days, and walk back again.
During an attack of acute diarrhoea he was unconscious
for several days. After consciousness was restored there
was such marked hyperzsthesia that scarcely the slightest
touch could be borne on any part of the body. He says
his eyesight has been improved; rheumatic pains less, and
defecation and urination now normal.
Case III.—Cerebro-spinal sclerosis. Englishman, aged
forty seven, first noticed ailment in 1880; been under al-
most constant treatment from different physicians since.
When suspension was begun, patient had difficult urina-
tion. There was a decided tremor when any co-ordinate
movement was attempted, and placing fluids to his mouth
was often impossible. Speech was defective; power of
locomotion somewhat impaired, 7.¢., ataxic. Decided im-
October 26, 1889]
eee ——
provement has been experienced in several respects;
urination is now normal as to frequency, and he is not
disturbed by tenesmus or burning sensations. When first
received there was transverse and vertical nystagmus ; now
he says he can see farther, and there is not so much os-
cillation. He is able to articulate more distinctly, and
can hold a vessel filled with water quite steadily.
Dr. E. S. McKEE, of Cincinnati, read a paper entitled
STERILITY IN WOMAN ,; ITS ETIOLOGY AND TREATMENT.
The author found the subject a difficult one. He thought
the most common cause of sterility was intra-uterine dis-
ease, and chronic endometnitis its general manifestation.
Inflammations of the pelvic peritoneum and of the para-
metria or their consequences are a frequent origin.
Three things must be determined : Are spermatozoa in the
semen? Do they get into the utero-cervical canal? Do the
vaginal secretions poison the spermatozoa? Sterility in
man must be eliminated before seeking the causes of
childless marriages in the wife. Gross claims that one
out of six sterile marriages is the fault of the husband,
and Kehrer claims one-third, and the cause of the barren-
ness as gonorrhoea. The habits of the wealthy diminish
fertility, while those of the poorer classes seem to favor it.
The injurious effect of excessive fat in women, as regards
childbearing, is generally admitted. The prospects of off-
spring will depend more on the menses than the flesh;
amenorrheeic fat women being usually sterile. ‘The prev-
alence of spasmodic dysmenorrhcea among sterile women,
about two out of five cases, leads to a belief that this
condition has some influence upon sterility. Gonorrhoea
is an important factor. ‘The reflux of semen is not so im-
' portant a cause as supposed ; the mucous discharge of the
glands of Cowper and Duvernay are often mistaken for
semen. A Chicago professor has found in that city that
the hair on the mons veneris of sterile women is straight.
He does not advise curling the hair as a cure for sterility,
however. Sexual incompatibility is well known to exist.
Sterility may be occasioned, when necessary, by obliterat-
ing the ends of the Fallopian tubes with the thermo-
cautery. Some authors claim that consanguineous mar-
riages are sterile. Darwin finds these slightly more fertile
than non-consanguineous. He thinks this a fact because
such marriages take place where there are large groups
of cousins, and fertility becomes hereditary.
The cure of stenlity is one of the difficult tasks of
gynecology. Our imperfect knowledge of the cause is
the origin of our trouble when we come to treatment.
Women addicted to alcohol have become pregnant upon
becoming teetotallers. Obesity is treated by a rigid diet,
the menses increase as the obesity decreases, and the pa-
tient frequently conceives. A hyperzesthetic condition of
the vagina sometimes necessitates anzesthetization. ‘Ihe
radical treatment of endometritis by curetting is frequent-
ly followed by conception. The author has had good re-
sults from a solution of perchloride of iron one part,
glycerine three parts, painted in the cervical canal in
chronic endometritis. Constitutional treatment is often
effective. Outerbridge has devised a new instrument for
the cure of sterility. It consists of a steel wire, gold or
silver plated, with a slight eversion at one end, with the
other bent at right angles. This is inserted into the cer-
vix. Catheterization of the Fallopian tubes is sometimes
effective. Sea-bathing, residence at watering-places, and
the use of mineral waters have a very beneficial effect on
many stubborn cases. ‘The crystalline phosphide of zinc,
one-eighth grain, morning and evening, is highly recom-
mended. ‘l'ea-drinking and the ingestion of tannin and sul-
phur are to be avoided. Belladonna has the reputation
of promoting conception. According to Cohnstein, there
are times with every woman which might be called the
period of predilection for fecundation. If reflux of semen
be the trouble, the hips should be elevated during coition,
and the penis allowed to remain as long as possible in the
vagina. The taking of the knee-chest position immedi-
ately after coitus is recommended, and _ perineorrhaphy
THE MEDICAL RECORD.
473
-iS sometimes necessary. As a last resort, artificial im-
pregnation is necessary in otherwise hopeless cases. It is
disagreeable to all concerned, but there are no real moral
reasons against it. An alkaline vaginal injection of phos.
phate of soda should precede the operation, to neutral-
ize the vaginal secretions. Sexual intercourse should take
place promptly; the syringe, new, free from infecting
matter, should be at the exact bodily temperature, the
semen taken up carefully, the nozzle inserted clear to the
fundus, and the fluid injected.
An extensive bibliography accompanied this paper.
Dr. GEorGE W. Ryan, of Cincinnati, read a paper
entitled —
THE ORTHOPEDICS OF INFANTILE PARALYSIS.
The author reached the following conclusions :
1. That orthopedic treatment, in conjunction with
local treatment of muscles, is useful in all children who
have arrived at the walking age. It gives support and
prevents deforinity.
2. That it tends to preserve, in a measure, the proper
balance between antagonistic groups of muscles by aiding
the weakened group and restraining the normal ones.
3. That by this means the paralytic group are given the
benefit of any movement of which they are capable, and
in this way can they get exercise.
4. That it certainly can correct deformity.
5. That a heavy appliance, or one adjusted by lacing
bands to the leg or thigh, does more harm than good.
6. That such measures are a necessity in the after-treat-
ment of divided tendons and muscles.
7. That in most contractions it is better to divide than
to stretch them.
Dr. C. S. Bonn, of Richmond, Ind., read a paper en-
titled
EARLY DIAGNOSIS OF CHRONIC KIDNEY LESIONS.
‘This paper was really the report of a committee of one
appointed at St. Louis last year. In conclusion he gave
the following summary :
Albumin in the urine probably always means disease
somewhere in the body. In so-called physiological quan-
_tities it may be referred to disease removed from the kid-
neys, and the cause as transient. In pathological quanti-
ties it signifies either inflammation external to the kidneys,
or a lesion of these organs. Many patients with evident
kidney lesions do not pass albumin. Albumin is incon-
stant, and bears no relation to the extent of the lesion ;
but when present must be respected as a prominent fac-
tor in diagnosis. It generally makes its appearance a long
time after other well-marked symptoms have existed, and
the disease is grave when it exists in pathological quan-
tities, and the symptom therefore should not be awaited.
Casts bear an intimate relation to albumin, but appear
later. ‘They are strong proof of renal inflammation, as
they carry, usually, a part of its epithelium. Differentia-
tion of the varieties of kidney lesions can often be
made from this fact ; but they, like albumin, are incon-
stant. Many patients do not pass them at all, and they
always appear too late as a factor in early diagnosis.
The specific gravity of the urine is not to be relied
upon, unless the mean specific gravity of many specimens
is taken for known quantities of urine for twenty-four
hours. ‘This would mean a small amount of urea passed
within the time, since it is the dominant salt eliminated ;
therefore why not test for urea at once ? |
Some outward manifestations of ill-health, perhaps
continued for years, always precede the passing of albu-
min and casts. These symptoms are in common with
well-marked kidney lesions, and are not due to other dis-
coverable physical causes. Cases, often without a change
in these symptoms for years, begin passing albumin and
casts. It is fair, therefore, to assume that the symptoms
referred to are the result of some common cause which
precedes the pronounced kidney lesions. ‘This common
cause seems to be something which produces extension,
474
THE MEDICAL RECORD.
[October 26, 1889
and often inflammation, of serous membranes, which at
the same time, or remotely, involves the kidneys. What
this cause is, we can at present only conjecture ; but
many of its pathological effects might be turned to advan-
tage in early diagnosis. Urea is excreted in abnormally
small quantities in cases of well-marked kidney lesions. It
is also so excreted in cases having the prominent physical
symptoms without albumin and casts.. It is interchange-
able as a means of diagnosis with the outward signs of the
disease, f.e., a knowledge of ill-health being also a knowl-
edge of the amount of urea passed, and vce versa. Urea
is excreted in small quantities for months, and often years,
before albumin and casts appear, therefore a knowledge
of this excretion is invaluable as a diagnostic sign of early
lesion.
The diminished quantity of urea eliminated is the re-
sult of constitutional disturbances, which precede the
local lesion for long intervals of time. Active treatment,
which would be harmful in other diseases having some
- Symptoms in-common, will identify this, generally relieves,
and frequently apparently cures.
TREATMENT OF THE INSANE IN RELATION TO SCIENCE
¿was the subject of a paper by Dr. ORPHEUS EVARTS.
* Superintendent of the College Hill (Cincinnati) Sanitarium.
This paper was very laudatory of the modern treatment,
He did not believe insanity was a disease of civilization.
It was a disordered brain. All who have brains are liable
to this disease.
THE FORMATION OF AN ARTIFICIAL URINARY CANAL
was the subject treated by Dr. W. N. WisHARD, of In-
dianapolis.
Dr. WILLIAM C. WILE, of Danbury, Conn., in discuss-
ing this paper, described an operation for this object
which was original with himself. The paper was further
discussed by Dr. G. Frank Lydston, of Chicago.
PURULENT CONJUNCTIVITIS
was the subject of a paper by Dr. D. A. THOMPSON, of
Indianapolis. He insisted on cleanliness, washing the eye,
if necessary, every half hour with a saturated solution of
boracic acid in water. He also used the nitrate of silver,
but had not met with success in the use of bichloride of
mercury. Discussed by Dr. Knapp, of Evansville.
SYMPATHETIC DISEASES OF THE EYES FROM INFLAMMA-
TION OF THE NASAL PASSAGES
was the title of a paper by Dr. Francis Dow ino, of
Cincinnati. He thought the medical attendant was too
prone to treat the eye disease and overlook the disease
in the nose. He should recognize the fact that the origin
of the disease is in the nose and not in the eye, and shape
his treatment accordingly.
“The Cautery v. the Snare” was the subject treated by
Dr. E. R. ‘Thompson, of Iudianapolis.
Dr. FLETCHER INGALLS, of Chicago, Ill., read a paper on
CHRONIC TONSILLITIS.
He insisted on not subjecting children to the torture of
removal of the tonsils without the benefit of an anzesthetic.
‘The paper was discussed by Drs. William Porter, of St.
Louis, and E. R. Lewis, of Indianapolis.
Dr. I. N. Bloom, of Louisville, reported two ca:es of
“ Amputation of the Penis,” and discussed the subject.
Dr. C. F. McGauan, of Chattanooga, Tenn., read a
paper on
THE TREATMENT OF PULMONARY PHTHISIS.
He thought when there were present symptoms of the dis-
ease without inflammation, the majority of the cases are
capable of cure. He reviewed the treatment of phthisis
since the discovery of Koch, and related his personal ex-
perience. He had phthisis in 1882 (but didn’t look as if
he had) and had recovered. In treatment, we have re-
turned to nutrition and pure air. We should always let
the patient have a thread of hope, though it may be a
false one. ‘Ihe care of the stomach was the great thing.
Give as few medicines as possible, so as to keep the
stomach in good order. ‘The hygienic treatment should
take precedence over the medical. As for health- resorts,
he favored Asheville and Aiken.
“ Differential Respiration” was the subject of a paper
by Dr. F. C. Wilson, of Louisville, who showed his bel-
lows for this purpose.
CONTAGIOUSNESS OF PHTHISIS.
The report of the committee appointed last year was
made by Dr. William Porter, of St. Louis, Mo. He
thought the word portageous was more accurate than con-
tagious. He thinks the evidences of transmissibility in
tuberculosis are conclusive. ‘Two hundred and fifty-one
English physicians, in active practice in families, have re-
plied in favor of the theory of the transmissibility of
tuberculosis. ‘The New York Board of Health has passed
resolutions which acknowledge this contagion. ‘The fact
has.been published that there have been no cases of tuber-
culosis among the nurses and house physicians at Bromp-
ton Hospital. ‘This is true, on account of the excellent
hygiene of that institution, and does not prove the non-
contagiousness of the disease. It has been written that
there was no tuberculosis among the North American
Indians, and but little among the early settlers of New
England. One hundred years ago the climate of New
York was thought to be good for tuberculosis by Euro-
peans, who sent their patients there ; then, later, the prairies
of Illinois were lauded for the same purpose; later still,
the mountains of Colorado and the valleys of California.
He emphasized the fact that the care of localities used as
resorts for consumptives was very important, so that they
do not get infected with the disease. He recommended that
consumptive patients use cuspidors in which there was a
1 to 1,000 solution of bichloride, as it has been demon-
strated that a weaker solution has not always the potency
sufficient to destroy the bacilli. He recommended, as a
prophylactic measure to the spread of tuberculosis, the
most careful inspection of meat and milk. He considered
the future of this subject a bright one.
Dr. Epwin Ricketts, of Cincinnati, read a paper on
TUBERCULAR PERITONITIS, WITH REPORT OF A CASE, ,
in which he advocated the operative treatment in this
trouble.
Dr. ‘THEODORE POTTER, of Indianapolis, said that no
one doubted that the tubercular bacillus causes the dis-
ease. We cannot doubt this any more than we doubt
the laws of gravitation. We must remember that tuber-
culosis is a local disease just as much as is an abscess.
It may become general, but it is not so in the beginning,
and only accidentally becomes so. ‘luberculosis is not
generally hereditary. We are now on more positive and
definite ground in regard to this disease than ever before.
The paper was further discussed by Drs. Earley, of
Pennsylvania; Cutter, of New York; Brayton, of India-
napolis ; Chapman, of Toledo ; Meyers, of Fort Wayne ;
Reynolds, of Louisville; McGahan, of Chattanooga ;
Ricketts, of Cincinnati; Porter, of St. Louis.
Dr. BRANSFORD Lewis, of St. Louis, read a paper on
THF PRINCIPLES THAT SHOULD GUIDE US IN THE TREAT-
MENT OF GONORRHCEA.
The question of bacteriology is considered of the first
importance in every subject of medical or surgical science ;
the admission of this leads to an inquiry as to what the
study anıl acquaintance with the life-history of the gono-
coccus has done for our assistance in the treatment of
gonorrhoea. He concluded that our knowledge had only
served to mollify the severity to a certain extent, and
somewhat shorten the duration of the disease. Beautiful
and touching theories had been constructed to explain
how the gonococcus would quail with fear at the pros-
pect of being literally boiled alive by a hot injection, or
October 26, 1889].
__
of being washed out into the cold world by a prolonged
irrigation, or dried into an Egyptian mummy of a coccus
in the arid soil of an astringent, antiseptic, magic-healing,
absorbent powder, etc. But experience with these various
agents has shown that none are infallible ; that all are sub-
ject to the varying influences met with in treating after
the older prevalent methods.
It must be admitted that germicides and antiseptics do
kill gonococci—in culture-fluids ; why not then in the
urethra? For this reason: ‘The gonococci, in preparing
for the conflict, do not foolishly remain where they may
be brought under the influence of medicaments; they
make their landing and start immediately for the woods,
so to speak. They penetrate between the epithelial cells
and reach the basement (connective tissue) layer, which
obstructs their farther progress. ‘Thus medicines are pre-
vented from reaching them by the tissues themselves.
He concluded that the proper treatment of gonorrhoea
- should be based on the idea, not of checking it in the
early but established stages, but of carrying it through its
various stages, with allowing as little suffering from annoy-
ance and pain, etc., as possible; limiting it as much as
present powers will permit, and preventing complications
and sequelz.
In the second stage lanolin, medicated with non-irritat-
ing antiseptics, and in the subacute, or third stage, the
addition of some mildly stimulating astringent is excellent
treatment. ‘The application was made with an instru-
ment, which was shown, an instrument-box having a
catheter stem ; a late modification was a soft vulcanized
rubber stem. Resorcin was recommended as a medicinal
agent; boric acid or thalline is probably best in general.
Bichlonide of mercury and carbolic acid are too irritat-
ing.
Army and Bavy Mews.
Oficial List of Changes in the Stations and Duties of Cfi.
cers serving in the Medical Department, United States
Army, from October 13 to October 19, 1889.
HaAvARD, VALERY, Captain and Assistant Surgeon.
Leave of absence extended one month. Par. 3, S. O.
240, A. G. O., October 15, 1889.
BRECHEMIN, Louis, Captain and Assistant Surgeon.
Granted leave of absence for one month. Par. 1, S. O.
98, Headquarters Department of the Platte, October 12,
1889.
HEGER, ANTHONY, Lieutenant-Colonel and Surgeon.
Relieved from duty in Division of the Atlantic, and ordered
for duty as Attending Surgeon, Washington, D. C. Par.
2, S. O. 241, A. G. O., October 16, 1889.
ADAIR, GEORGE W., Captain and Assistant Surgeon.
Leave of absence extended for fifteen days. Par. 15, S.
O. 238, A. G. O., October 12, 1889.
O’REILLy, RoBeRT M., Major and Surgeon. Granted
leave of absence for six months, with permission to leave
the United States. Par. 3, S. O. 241, A. G. O., October
16, 1889.
Lorine, L. Y., Major and Surgeon. Sick leave ex-
tended two months on Surgeon’s Certificate of Disability.
Par. 16, S. O. 241, A. G. O., October 16, 1889.
BRADLEY, ALFRED E., First Lieutenant and Assistant
Surgeon. Relieved from duty at David’s Island, N. Y.
H., and ordered to Fort Omaha, Neb. Par. 2, S. O. 241,
A. G. O., October 16, 1889.
EVERTS, EDWARD, Captain and Assistant Surgeon. Re-
lieved from duty at Fort Apache, Ariz., and ordered to
David’s Island, N. Y. H. Par. 2, S. O. 241, A. G. O.,
October 16, 1889.
Maus, Louis M., Assistant Surgeon. Relieved from
duty at Fort Porter, N. Y., and ordered to Fort Stanton,
N. M. Par. 10, S. O. 242, A. G. O., October 17, 1889.
THE MEDICAL RECORD.
475
BRECHEMIN, Louis, Captain and Assistant Surgeon.
Relieved from duty at Fort Laramie, Wyo. Terr., and or-
dered to Fort Apache, Ariz. Terr. Par. 2, S. O. 241, A.
G. O., October 16, 1889.
Harris, H. S. T., First Lieutenant and Assistant Sur-
geon. Relieved from duty at San Antonio, Tex., and or-
dered to Fort Keogh, Mon. Par. 2, S. O. 241, A. G. O.,
October 16, 1880.
GIBSON, JOSEPH R., Surgeon. Relieved from duty at
Fort Sheridan, Ill., and ordered to Governor’s Island, N.
Y. H. Par. 10, S. O. 242, A. G. O., October 17, 1889.
GARDNER, Epwin F., Assistant Surgeon. Relieved
from duty at Fort Lewis, Col., and ordered to Fort Por-
ter, N. Y. Par. 10, S. O. 242, A. G. O., October 17,
1889.
EWEN, CLARENCE, Surgeon. Relieved from duty al
Madison Barracks, N. Y., and ordered to Willets Point,
N. Y. Par. 10, S. O. 242, A. G. O., October 17, 1889.
GIRARD, ALFRED C., Surgeon. Relieved from duty at
Boise Barracks, Idaho, and ordered to Fort Niagara, N.
Y. Par. 10, S. O. 242, A. G. O., October 17, 1889.
Hai, Jonn D., Assistant Surgeon. Relieved from
duty at Fort Niagara, N. Y., and ordered to Madison
Barracks, N. Y. Par. 10, S. O. 242, A. G. O., October
17, 1889.
Taylor, Marcus E., Assistant Surgeon. Relieved
from duty at Fort Stanton, N. M., and ordered to Boise
Barracks, Idaho, Par. ro, S. O. 242, A. G. O., October
17, 1889.
Oficial List of Changes in the Medical Corps of the United
States Navy for the week ending October 19, 1889.
BERTOLETTE, D. W., Surgeon. Detached from the
Franklin, and ordered to duty at Naval Hospital, Phila-
delphia. -
Rusu, N. H., Passed Assistant Surgeon. Detached
from Naval Hospital, Philadelphia, and ordered to the
Saratoga.
Hinsett, C. T., Passed Assistant Surgeon.
the Franklin.
Ordered to
Medical Items.
ConTacious DISEASES—WEEKLY STATEMENT. — Re-
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending October 19, 1889:
Cases. | Deaths,
Typhus (EVER ®. sires ier siaeed nea adeniioueees o o
Typhoid fever ois occas ees lsd esas wees 2usee Sa | 55 12
Scarlet fever.........LnL he vias ec tes csecsen os onno 32 3
Cerebro-spinal meningitis.................00cceee I 3
Measles apo ossssseeooccoonresoesercorooossoos anas | 28 I
DIpline tig as ope iiichia wns Med ware-o-'ew able wile wreck cons : 69 24
SORPLRN SON osise resres E aE aE hae o o
Yellow eveben anen G0 sc Sa ne a ra | o (| o
Cholera isois bn ruen arae i e e a o
URINE oF Business MEN.—There is no question that
too little attention is paid to urinalysis by the majority of
practising physicians, especially the microscopic part of
the work. All know how to test for albumin and sugar,
but very few can make a quantitative analysis of urea, and
a still smaller number have no microscope, neither do
they know the most common crystals. An examination
of the urine will reveal the incipiency of many diseases
which can be throttled at the outset, and then the physi-
cian can exercise his prophylactic powers, the most useful
part of his life work, for it is better to prevent than to
cure. Dr. Clifford Mitchell, of Chicago, in the Medica!
Æra, seems to have been especially interested in the urine
476
of business men, and he emphasizes some important points.
The urine of the over-worked and over-fed American
business man usually shows in the beginning, before any
renal disease is actually present, the following characteris-
tics: The total quantity of the urine for the twenty-four
hours is greatly reduced, sometimes to half the normal
quantity. ‘The color is usually, therefore, darker than
normal, and there is an abundant sediment in which urates,
unc acid, and often calcium oxalate may be seen with the
microscope. The urine being diminished in quantity, and
the acidity relatively increased, the urates and uric acid
cannot be held in solution as they ought to be. Estima-
tion of the total quantity of urea will almost invariably
show this substance to be diminished to a figure consider-
ably below normal, Perceptible traces of albumin and
sugar I occasionally find in the urine of hyperactive busi-
ness men, but in many cases both these constituents are as
yet absent. I say “as yet,” for sometimes, if all warnings
are unheeded, one or the other of these unwelcome visit-
ors, in time, may make its appedrance. I regard persist-
ent decrease in both fluids and sulids of the urine of
great significance in those who eat hearty and exercise lit-
tle. Itis not necessary that either albumin or sugar be
present—there is enough trouble without them. When a
man of average weight voids daily no more urea than we find
in the urine of a delicate woman, or a bedridden patient, it is
time to cry “ Halt.” I have found these patients with di-
minished urea and crystalline sediments have all sorts of
aches and pains. Headache is a very common concomi-
tant. Sleeplessness is another. If I could have my own
way I would estimate the urea in the urine of every pa-
tient in the country suffering from insomnia, or restless
unrefreshing sleep. Not all insomnia is due to lithzmia,
but many cases, apparently hopeless, could be helped were
the conditions properly understood. — Saint Joseph Medi-
cal Record.
TESTS FOR MINUTE AMOUNTS OF ALBUMIN.— The im-
portance of a trustworthy and convenient test for minute
proportions of albumin in urine is coming to be more and
more widely recognized. ‘The subject is treated of ex-
haustively and very clearly in a work recently issued in
Paris, entitled “ Traité de l’'Albuminurie et du Mal de
Bright,” by Dr. E. Lecorché, an adjunct professor of the
Faculté de Médecine, and Dr. C. Talamon,a physician to
the hospitals. These authors have devoted much care to a
comparison of the principal compound reagents used for
the detection of minute amounts of albumin. Those that
they have experimented with more particularly are: A
mixture of acetic acid and potassium ferrocyanide ; a mixt-
ure of acetic acid and mercury bichloride ; a mixture of
acetic acid and potassium and mercury iodide (Tanret’s) ;
a mixture of acetic acid, carbolic acid, and potash (Mil-
lard’s) ; a saturated solution of sodium chloride acidulated
with hydrochloric acid (Roberts); and a mixture of so-
dium phosphotungstate and citric acid (Oliver’s). ‘Tanret’s
test has commonly been considered equal, if not superior,
to all other tests for small quantities of albumin, but Le-
corché and Talamon give Millard’s the preference. So far
as the application of the various tests without the aid of
heat is concerned, they say: “We have no hesitation in
giving the preference incontestably to the American au-
thor.” Both ‘Tanret’s and Millard’s tests, they remark,
show albumin ın the proportion of 1 part to 200,000 and
even 300,000 parts; but, while the disk produced with
‘Tanret’s is pale and diffuse, that caused by Millard’s is
much more distinct, although very thin. Méillard’s test,
they repeat, is the surest and most convenient. Besides
the greater distinctness of the albuminous ring produced
by it, the substances that may lead to error in drawing
deductions from its use are only urates, peptones, and
mucin, and they are easily recognized. Urates and pep-
tones are precipitated on gently heating the test-tube at
the level of contact, and mucin, which always causes a
dusty turbidity adove the line of contact, is readily distin-
guished with a little practice. The authors add that, when
THE MEDICAL RECORD.
[October 26, 1889
heat is employed, Oliver’s test shows some advantages
over both Tanret’s and Millard’s. It is satisfactory to
have such definite and authoritative statements of the
merits of a particular test, and it is gratifying that the
preference is so distinctly accorded to a test devised by
one of our own countrymen. It may be well to remind
our readers of some facts connected with his test for albu-
min. The solution is composed of two parts, by weight,
of ninety-five per cent. carbolic acid, seven of glacial acetic
acid, and twenty-two of liquor potassz. When the quan-
tity of albumin to be tested for is very minute, the urine
should be clarified and allowed to trickle down slowly
upon the solution.— Zhe Mew York Medical Journal.
HEREDItTy.—Sir William ‘Turner, Professor of Anatomy
in the University of Edinburgh, delivered an address on
“« Heredity,” in which, while pointing out that in some
cases structural lesions, such ag hare-lip, color-blindness,
and deaf-mutism, are transmitted, he also maintained, 1n ~
opposition to some physiologists, that acquired characfers
can be transmitted from parent to offspring. He said, in
concluding his address, that whatever the origin of man’s
frame, whether by evolution or otherwise, it could scarcely
be expected ever to attain greater perfection than at
present. Man was, however, also endowed with a spint-
ual nature, and the kind of evolution to be hoped and
striven for was the perfecting of this spiritual nature, so
that the standard of the whole human race might be ele-
vated and brought into more harmonious relation with
that which was holy and divine.
AN AMERICAN VIEW OF MEDICINE IN GERMANY.—In
the course of an address on the “ Remedy for Overcrowd-
ing in the Medical Profession,” Dr. Boyd Cornick (Zhe
Fournal of the American Medical Association, May 4,
1889) makes the following statements. ‘ Germany is
probably excelled by no other government in the world in
the stringency of ıts laws regulating admission to the ranks
of the medical profession. Not only is the preliminary
course of study long and arduous ; not only must each as-
pirant have passed through every successive grade of pre-
scribed preparatory instruction; not only must he have se-
cured the endorsement of some noble university, justly
famed for the high standard of learning which its degrees
imply ; not alone must the aspiring youth devote many
years of time and many hundreds of thalers to a comple-
tion of the course marked out for him by the authority of
the State ; but, in addition to all this, even though the
possessor of a university degree, he must finally pass a
rigid and awe-inspiring Staats-examen before a government
licensing board ; and then, if successful in this latest or-
deal, he is permitted to practise medicine within the con-
fines of the German Empire. As a consequence of all
these stringent requirements, the medical profession of
Germany leads the vanguard in the world-wide march of
progress in the medical sciences. Such results certainly
justify the high standard of qualification requisite for en-
trance into the medical profession of Germany. But,
alas! even in that favored land, whose laws regulating the
practice of medicine are exceeded in stringency by those
of probably no other government under the sun, we are
confronted with the same problem of an overcrowded
medical profession, which is harassing the minds of med-
ical men throughout the confines of our civilization.”
WorRDLY Wispom.—Professor Charpentier, of Paris,
gives the following advice to physicians, as to the most
prudent answer to be given when asked what they think
the sex of the child is going to be. “Reply by asking the
mother what she would prefer in the child, and then give
it as your opinion the opposite is the one to be looked
for. In this way, if the sex turns out to be the one you
have prognosticated, you will be thought a wonderful man,
while if it proves to be the one the mother has wished for,
she will be so pleased that she will easily overlook your
error.”
‘The Medical Record
A Weekly Fournal of Medicine and Surgery
ome Ott
—_ —— à
Vol. 36, No. 18
Original Articles,
ELECTRICAL INJURIES.’
By CHARLES L. DANA, A.M., M.D.,
NEW YORK
WITH the development of new industries or inventions
there occur new disorders or new factors in the produc-
tion of disease and of injuries. These are always slight
in comparison with the benefits that come from great and
successful industries, yet they must be taken into account
by the physician and surgeon.
We are now entering upon an era of tremendous activ-
ity in the practical application of electricity. Aside from
the telegraph and telephone, electricity is becoming rap-
idly introduced as a method of lighting, heating, motor
power, and locomotion. There were in this country alone
in March, 1889, over 219,000 arc-lights, 2,500,000 incan-
descent lights, and over 5,000 electrical plants, with $69,-
000,000 of capital invested (Duncan, Electrical Review,
March 2, 1889). There were 53 electrical railways, op-
erating 329 cars. ‘These figures are increasing with the
greatest rapidity.
Along with the introduction of these new industrial
methods we are meeting accidents and injuries of all
grades of severity; and in time there will be associated
with electrical systems, classes of injuries some of which
will be perhaps peculiar to them, some will resemble those
known as railway brain and railway spine, traumatic hys-
teria, and other neuroses or psychoses, while a large num-
ber will be only of the ordinary surgical character.
The means by which the electrical current does harm
varies, naturally, with the form in which it is used.
The telegraph and telephone produce peculiar neuroses,
due not to the electrical current, but to the peculiar de-
mand made upon the nervous system of the operator,
the results being telegraphers’ cramp, aural and men-
tal disorders of telephone transmitters, etc. Electricity
only does direct injury to telegraph operators through
lightning, or connection with wires carrying strong cur-
rents. Of injuries directly connected with electro-motors
and electric railways there is little yet known. In elec-
tric roads run by a bare wire overhead, accidents are pos-
sible, though the current is not so strong as that usually
employed for arc-lights, being about 500 volts. Most of
the observed cases of electrical injury corne from the ap-
paratus carrying electrical currents for lighting and power.
The currents most in use are interrupted and alternat-
ing currents of 1,000 to 2,000 volts electro-motor force.
Such currents, when received by the human system, have
varying effects, in accordance with the mode of contact
and the susceptibility of the individual. In some cases
they merely stun the victim, and burn the parts in contact
with the wire. In others, they have been known to pro-
duce permanent paralytic effects. Of such cases, how-
ever, there are only two on record. In still other instances
almost instantaneous death results ; while, sometimes, a
mental shock is produced, which affects the system just
as other shocks do, causing conditions known as traumatic
hysteria or neurasthenia.
The number of fatal accidents from electrical currents
during the past ten years has been variously estimated at
from 100 to 200. In this city, according to a report kindly
ee ee ee
1 Read at a meeting of the Practitioners’ Society, October 4, 1889,
New York, NOVEMBER 2, 1889
—
Whole No. 99I
furnished me by the Board of Health, it has been: 1886,
o; 1887, 3; 1888, 5; up to October 19, 1889, 5.
There can be no doubt that an alternating electrical
current of 1,200 volts, properly applied, will surely kill a
human being. I do not wish to bring up the question of
death by this means, however, but only to state that the
physiological fact is, I believe, an indisputable one. _
A further physiological fact, that has been in my opinion
established, is that the electrical resistance of the human
body averages less than 2,500 ohms, with strong currents.
The observations regarding resistance made by Mr.
Kenelly under the direction of Mr. Edison were, as I
have good reason to believe, carefully and scientifically
performed, and constitute a contribution of indisputable
value to this subject. We know that human resistance
varies considerably with the individual, these variations
depending chiefly upon the moistness, thickness, and vas-
cularity of the skin, and upon the carefulness of the con-
tact; also, that it decreases rapidly with the continued
passage of the current, and is less with very strong cur-
rents than with weak ones. Experience seems to show
also that the maximum alternating current which it is
safe to come in contact with is one not over 400 ohms,
though I do not believe that even this could kill, except
It were applied directly to the brain. There is still a dis-
pute as to whether the continuous, interrupted, or alter-
nating current is the safer, and into this controversy I do
not propose to enter. A current of either kind stronger
than 600 ohms would not be a pleasant thing to take.
The electrical current burns or not according to the dry-
ness of the skin and clothes, and the consequent degree of
resistance. With a dry skin there is more burning, less pen-
etration, less shock, and less danger of death. With a wet
skin and good connections, there is little burning and more
serious internal effect. Dr. Biggs has noted that most of
the fatal electrical accidents have occurred on or after
rainy days.
The accidents and injuries from electrical currents have
so far shown that they kill, or they burn severely, or they
do no permanent harm. This, at least, is the rule.
When a person by accident receives a current of from
300 to 1,000 ohms, it promptly knocks the recipient down,
and may cause a temporary tetanus even if the current js
at once broken. Consciousness is not usually lost, but
severe, agonizing pain and terror are felt. In a few
moments the muscles relax, the patient is able to move,
he gradually picks himself up, and in a short time is in
fair condition. His arm or leg, or whatever part was in
contact with the wire, feels numb for some hours or even
longer, but I know of no certain cases of local paralysis.
A vivid account of the effects of a strong but non-fatal
continuous current is given in the Occidental Medical
Zimes, 1889, p. 562. The victim, an electrical engineer,
took hold of a wire in each hand and made the connec-
tion through his body. ‘The current as subsequently
measured was over 1,400 volts, and the current strength
must have been about 1 ampére. He described his feel-
ings as follows :
“< My hands were paralyzed, my arms were as stiff as
bars of iron, and the cords stood out in large bunches ;
my head was turned round in the direction of the current ;
my eyes bulged out with burning pressure and glazed
over ; then I lost my senses and fell to the floor.’ The
fall pulled one of the wires, which was attached to the
ceiling, out of his hand and so broke the circuit. He at
once recovered his senses, and attempted to recouple the
478
wires, when some of the employees interfered, but he was
sufficiently collected to give the necessary directions for
opening the circuit. ‘The time of contact was not less
than five nor more than eight seconds. There was no
pain to speak of—not more than would be felt from a
strong galvanic battery. His hands and fingers were
burnt, but owing to the fact that they were moist, and
that he had a firm hold on the wires, the burns were
slight. ‘The shock to the nervous system was very severe,
and two months later the effects were still evident.”
The electricity, even in fatal doses, does not usually
much affect the nervous structure, but tends rather to
cause carbonization of the blood, paralysis, and disten-
tion of vessels, and sometimes hemorrhages, with occasion-
ally disruption of muscular and vascular or other tissue.
A direct disorganizing effect upon nerve-centres seems
possible, however, from two cases of organic paralysis of
which accounts are given.
A good many electric-light employees get minor shocks
which stun them a little, but they do not seem to mind
it. In some of our dispensaries there is, I am told, quite
a contingent of cases of burns and stunning, with numb-
ness ; but it is only the burns that are complained of.
In more sensitive persons it is quite possible, however,
that morbid psychical and neuro-psychical conditions may
be produced.
Dr. William G. Thompson recently reported a curious
case of traumatic hysteria. ‘The details will be published
in full. I saw and examined the patient, however, and
Dr. Thompson kindly consents to my referring to it. A
man, aged fifty, not long ago saw an JItalian killed by
an electric wire.. Two weeks later, while walking along
the street, an electric wire which had just been cut fell
and struck his head. He grasped it in his hand, and fell
down. He says that he knew nothing until a few hours
later, when he found himself in the hospital. He then
had right hemiplegia and hemianeesthesia, including the
senses of smell and taste. There was limitation of the
visual and auditory fields, bone deafness, pharyngeal an-
zesthesia, and all the stigmata of typical hysteria. The
wire which struck him was a “dead” one; and the blow
was slight, and caused no contusion.
A case illustrating the fact that the strongest currents
may be taken without local or general paralysis is the fol-
lowing, which I shall give only in outline :
A young man, aged twenty-three, was accidentally
struck by a live wire. He grasped it with his left hand,
and instantly fell down. ‘The current, which was that of
-the arc-light, passed through the arm and body for several
moments. He remembers only feeling a sudden blow on
the head which knocked him down and made him partially
unconscious. He heard voices about him, saw a glim-
mering light, felt intense pain, and momentarily expected
death ; finally he lost consciousness.
The result of the injury was that his left hand was so
severely burned that it finally had to be amputated, but
the arm was not in the least paralyzed or anesthetic, and
the effect on the general bodily functions was /. It isa
curious fact, indeed, that some patients feel better after
severe electrical shocks. In others, as already intimated,
the condition known as traumatic neurasthenia or hys-
teria may supetvene. Dr. Peterson has had under ob-
servation a case of this kind. I have also met one such
case.
A severe and sometimes fatal accident occasionally be-
falls the linemen. While at work on the poles they receive
a shock which stuns them so that they fall to the ground
and receive their real injury from this fall.
Such an accident came under my observation recently,
the case being taken to the Gouverneur Hospital in the
service of Dr. Ward. ‘The man was knocked off the tele-
graph pole by an electrical shock, and fell, fracturing the
base of his skull. He eventually recovered.
My present article is intended to be brief and introduc-
tory, and I shall not attempt to cite further cases. It has
not been my purpose especially to call attention to the dan-
THE MEDICAL RECORD.
[November 2, 1889
gers of electrical currents or to exaggerate their impor-
tance. ‘The fact is that the practical introduction of elec-
tricity has been attended with much less fatality than that
caused by gas, steam, railroads, and many other of the 1n-
ventions of modern life.’
Summary.—Some of the points which I have wished to
make in the present article may be summarized here :
The extraordinary increase now going on in the practi-
cal application of electricity—there being already nearly
$100,000,000 invested in lights and power alone.
A practically new class of injuries met in connection
with the hew industries. Such injuries have been hereto-
fore produced only by lightning, and they have been con-
sequently rare.
‘These injuries are not numerous or serious as compared
with those met with in connection with other great indus-
tries. There have been in ten years only about 100 deaths
in the whole world from artificial electrical currents.
The railroad kills annually over 2,500 people (2,541 in
1880) and injures about 6,000 in the United States alone.
Electrical currents produce three kinds of severe acci-
dents :
They kill at once; or they burn severely; or by the
mental and physical shock they cause traumatic neurosis.
Usually, if they burn severely they do not kill. Hence,
practically, the rule is, if contact with electrical wires does
not kill, the victim gets only a burn or a harmless shock.
In very rare cases the current seems to affect the nerves
or nerve-centres, causing paralysis.
The minimum current safe to receive is not definitely
known. Probably eight hundred to one thousand volts
of continuous current, and a third less of alternating cur-
rent, would not be fatal.
The wires for lighting and for power carry the more
dangerous currents.
A SUCCESSFUL CASE OF LAPAROTOMY AND
SUPRAVAGINAL AMPUTATION OF THE
UTERUS FOR RUPTURE.’
By HENRY C. COE, M.D., M.R.C.S.,
PROFESSOR OF GYNECOLOGY AT THE NEW YORK POLYCLINIC; SURGEON TO THE
NEW YORK CANCER AND MATERNITY HOSPITALS; ASSISTANT SURGEON TO THE
WOMAN'S HOSPITAL.
On September 8th, at 1 P.M., I was called by Dr. R. H.
Hayes to perform Cesarean section in a desperate case
of labor. Not knowing what I would find, I hastily col-
lected a few instruments, and with my associate, Dr. G.
A. Kletzschi, accompanied the doctor to a tenement-house
a mile distant, in the fourth story of which we found the
patient attended by Dr. W. A. Hawes, who had been
called to see her in consultation. She was a healthy
Irishwoman, twenty-three years of age, with a rapid, fee-
ble pulse, evidently in a state of collapse. The gentle-
men in attendance feared that rupture of the uterus had
taken place two hours before. Examination of the abdo-
men revealed two tumors, a larger one filling the right
side of the abdomen and extending as high as the ensi-
form cartilage, and a smaller occupying the left iliac
fossa, both being firm and unyielding. It was evident
that the former was the body of the uterus, tilted over to
the right and in a state of tetanic contraction, and the
latter the head of the child. Palpation of the abdomen
above the latter gave an ominous gurgling sound, sugges-
tive of free fluid in the peritoneal cavity. I learned that
prolonged attempts had been made to extract the child
by forceps and version. Introducing my hand into the
—
1 For example, in France, among 223,000 railway employees there is
an annual average of 239.5 killed and 1,850.4 wounded. In Germany
there are 1.35 per 1,000 of railway servants killed and 3.09 per 1,000
wounded. In England the annual mortality is 2.43 per cent. In the
United States among 418,957 employees, in 1880, there were 923 killed
and 3,617 injured—a higher rate than anywhere in Europe (U. S.
Census). In coal mining the ratio in France is 1.56 per 1,000 of killed,
8.87 per 1,000 of wounded.—Froceedings of Congress on Accidents to
Workmen, Paris, 1889.
3 Read before the Section on Obstetrics, New York Academy of
Medicine, October 24, 1889.
November 2, 1889]
vagina, I discovered that the anterior lip of the cervix
was deeply lacerated antero-posteriorly, while another
laceration extended through the vaginal junction on the
left side. Passing my finger tnrough the rent, I entered
the abdominal cavity.
The child, which was of unusually large size (fifteen
pounds), and was dead, presented in the left dorso-anterior
position, with the right hand and foot prolapsed, and was
firmly impacted ; the head seemed to be partly outside of
the uterus. Believing that a further attempt at version
would only extend the tear, I at once decided that laparot-
omy offered the only prospect of saving the woman, and
proposed this to the husband, who consented. The patient’s
condition was desperate, and the surroundings were such
that any approach to antisepsis seemed to be impossible,
but I felt that she ought to have the chance. She had lost a
large amount of blood and her pulse was so feeble that hypo-
dermics of brandy and ether were given. Fifteen minutes
after my arrival, assisted by the gentlemen mentioned, and
by Dr. Huntington, who had been sent for, I made a free
incision, eight inches in length, through a very fat abdom-
inal wall and opened the peritoneal cavity, which con-
tained a quantity of fluid blood and clots. A rent was
found extending upward from the cervix through the left
broad ligament and the lower uterine segment. ‘lhe head
of the child lay in the left iliac fossa outside of the
uterus, being grasped by the edges of the tear. I saw at
once that this was not a case for suture of the uterus, as
arterial hemorrhage was going on from the vessels of the
lacerated broad ligament, and the condition of the pa-
tient was such that no time was to be lost. The uterus
was turned out of the cavity, the cervix constricted by a
piece of rubber tubing cut from a fountain-syringe (I had
forgotten my écraseur in my haste), and the child was ex-
tracted through the rent. Without waiting to remove the
placenta, I secured the tub:ng with a pair of artery-for-
ceps, excised the uterus with the ovaries and tubes, and
proceeded to tie the bleeding vessels. This part of the
operation was completed in twelve minutes. ‘The utero-
sacral ligament on the nght side was also badly lacerated.
The vessels having been secured, and the torn peritoneum
sewn with a continuous catgut suture, the peritoneal
cavity was thoroughly irrigated with hot water, and the
stump was trimmed down and secured in the wound with
knitting-needles. No drainage-tube was used.
The bladder was carefully inspected, and was apparently
uninjured. ‘The cervix had been so badly torn that I ex-
pected it to slough out, as subsequently happened. The
wound was hastily closed and the patient was placed in
bed in fair condition in less than an hour after the opera-
tion, the delay having been due to the time spent in sutur-
ing the torn peritoneum. She rallied well, but had a pulse
of 140 to 150, and no hopes were entertained of her re-
covery. From the outset she was free from nausea, and
was able to take stimulants. On the second day her tem-
perature rose to 102°-103° F., and there was general ab-
dominal tenderness and distention, but, by maintaining
free catharsis and using the ice-bag, peritonitis was aborted.
The urine was drawn during the first four or five days,
after which it was usually passed spontaneously. The
stump quickly necrosed; on the fourth day I replaced
the tubing by a Koeberlé’s serre-naeud, and removed the
entire mass at the end of a week, packing the cavity with
iodoform gauze. The patient’s condition at this time was
not entirely satisfactory. She took nourishment and stim-
ulants freely, but her pulse remained at 120 and her tem-
perature rose every evening to ro1°-102° F. At one
time an exhausting diarrhoea threatened her life. She
complained of no pain, but I feared suppuration of the
hzmatocele which had formed in the left broad ligament.
As there was considerable discharge from the vagina, in-
jections of creolin (1 to 400) were given after the first few
days, with iodoform suppositories.
Early in the second week the urine began to escape per
vaginam, although the patient could retain it to some ex-
tent. A careful examination with the finger and speculum
THE MEDICAL RECORD.
479
showed that a cervico-vesico-vaginal fistula had beer es-
tablished, and that there was considerable sloughing of the
upper portion of the vagina. All the necrosed tissue at
the bottom of the abdominal wound was picked away,
until nothing remained of the cervix but the portio vagi-
nalis ; the wound granulated nicely, but there was a free
communication with the vagina through which urine and
the douche-water sometimes welled up. After the second
week the patient’s temperature became normal, with an
occasional evening elevation to 100°—-101° F., and she
complained of nothing but the constant dnbbling of urine.
Her subsequent history was uneventful. She was allowed
to get up at the end of the fourth week, at which time the
wound still communicated with the vagina, and not quite
so much urine dribbled away as at first. At the end of
the fifth week the abdominal wound had entirely closed.
It is hardly necessary to add that the after-treatment of
such a serious case in a dirty tenement-house required
the constant personal supervision of a physician, and I
take pleasure in acknowledging my indebtedness to Dr.
Kletzsch, and especially to the attending physician, Dr.
Hayes, for their assistance in this most thankless task.
Without the exercise of constant vigilance the patient
would certainly have succumbed to the operation or to
the subsequent complications.
Before commenting on this case, it 1s important to
classify it. As my friend Dr. Robert Harris, of Philadel-
phia, has clearly pointed out, it is neither a Porro nora
Ceesarean section proper, but is an operation sui generis.
I was myself misled by a paper of Professor Lusk’s in
which he refers to the two successful cases of “ Porro’s
operation ” for rupture of the uterus, reported by Slavjan-
sky and Fontana. If it receives any name at all, it should
be called “ Prevdt’s operation,” since Prevét, of Moscow,
reported the first case (unsuccessful) in which the ruptured
uterus was amputated after removal of the child through
the rent, without previously incising the organ. The en-
tire difference between this procedure and the Porro-Ce-
sarean operation lies in the fact that in the former hyster-
otomy is not performed. ‘Through the courtesy of Dr.
Harris, who has taken the greatest interest in my case, I
am enabled to present a table prepared by him, which, so
far as I have been able to determine by personal research,
with the addition of two other cases, is complete up to
date.
I at first supposed that mine was the only case in the
United States, as I believe that it is the only successful
one, but Dr. M. Price has kindly sent me the notes of a
similar operation performed last April, which I will quote
in order to emphasize the difference in treatment in the
two instances. Dr. Harris informs me that there have
been ten true Porro-Czesarean sections for rupture of the
uterus in this country, four women having been saved.
The details of Dr. Price’s case are briefly as follows :
He was summoned by a midwife to see a woman who
was in labor with her seventh child, and had lost so
much blood that she was pulseless. On examination the
child was found to be presenting transversely, the left
foot and leg extending into the peritoneal cavity through
a rent in the uterus. The doctor delivered the child
after performing version, and sent for assistance. The
abdomen was opened, the placenta was removed from the
abdominal cavity, and the uterus was lifted out. The
organ had ‘‘ not only a long laceration in its left wall, but
was considerably torn from its vaginal attachment, ‘with
no apparent contractile power left.” The serre-neud
was applied, and the uterus was removed. The patient
succumbed half an hour later.
The reporter explains that his reason for delaying the
operation was the want of counsel and assistance, and the
fact that he could not communicate with, the husband
until an interpreter had been summoned. ‘While appre-
ciating the doctor’s position, which was more difficult
than my own, since I was able to operate without delay,
I cannot help thinking that if he had waited for assist-
ance without performing version, and then had operated
THE MEDICAL RECORD. [November 2, 1889
References.
Duration of
operation.
|
|
Treatment of
cervical stump.
|
|
woman.
Cause of death in
Result
to child.
operation.
Condition of
woman at time of | Result to woman.
operation
and rupture.
Time between
|
Number ot
pregnancy
|
Age.
Hospital or |
private house. ;
a aie cee ac | een Sle ace
Cases of Ruptured Uterus Treated by Supra-vaginal Amputation, as Initiated by Prev6t, of Moscow.
Locality.
Operator,
Date.
{
Dr. Oscar Prevot .........
A g F z Sh g g | as rapidly as he did (fifteen minutes) the result would
4 : E A : J A Ao Š A have been different. My case was even more unfavorable
BRFSS BE g A S than his, since the patient had been under an anæsthetic
O a ae g f Sod Z NS A -A for three hours, during which time the soft parts suffered
sea 8 3 3 s35 „Se GR 3, severe injury from hands and -instruments. There was
i m a č a AAE I 5 ee oa HE E greater laceration of the uterus and surrounding tissues,
HE AE MEPE PETE: aloy Ag O84 ,Ẹ | and, moreover, more than two hours elapsed between the
yaga as 2gzg sess PR i TF E 3 rupture and the operation. I am sure that a further at-
$ Bg hg Bigg" 904 ~S Sai 8: Sv. E | tempt at version on my part would have terminated the
BORGES Se ERE BSE "3 "E a te E+3 g case fatally in a few minutes. Since the child was -o
a ee ee a a oe ces in all the cases reported, there seems to be no reason why
2 ae : $ : i % | we should destroy the small chance which the mother has
i eo ae s -£ 2: i 4 | of being saved by laparotomy, by trying to perform versicn
a : = x : x : : Æ 4 2: iig | with the certain risk of increasing the tear in the uterus,
ea ea cere Jee ay and adding to the existing shock—that is, if we intend to
be es Seg cee eee ihe gece meee a
y F 2933 :3 #8 VS 7? perform laparotomy at all. If no operation is con
$ E i ? 5 l Eo $ E FE EDE plated, the case is different, and does not belong to the
PRE EER EE EE ZEER | present category, ven the same com
£ BepeSée ig g EE Elg In conclusion, I would say t, given the sam
aif 2 did od o a di oao g | ditions, I would adopt precisely the same method of pro-
Be ot boi. : $ i i l ii i a | cedure in another case of rupture of the uterus, because
Sea a eye , 8 | I believe that it would offer the best chance of saving the
gees oi i! ae: = | patient, for the following reasons: __
agbe, i Sg „Z: 9, : _1. The operation can be performed in the shortest pos-
AFFF Z£ : 2S: £ å oe time. ‘Time is the most important element in these
shae5 2 2 & ge: S 3 esperate cases.
E Sega le T £ 2. It is impossible to properly suture such an exten-
O or a : i: ::g | sive rent, with contused edges, as the one described,
333223 23 8 8 2 88 ¥ E_ | which begins at the cervix and extends through the broad
fo aoe eR Ak A Ae | into th f the ut There is im-
AAA AAP A A A A A AAA $ | ligament up into the body of the uterus.
eg: erent g: See 4 ae a a f minent risk of hemorrhage after removal of the tempo-
S2338 3 : 3 > 8 ii :/g | rary constriction. l
å Cr E iF o up g? 3. Where the prolonged use of instruments, without
6 s 6 8 ŠE $ a: 5 £ $8 5 & strict antiseptic precautions, has occurred, the interior of
2222 288 8 2 V 28 8 $ | the uterus is sure to be badly contused, so that the subse-
of A.A 6 6-8 oe A A% X gy d f ee pe run the
Peg ee a a oe eae quent danger oi sepsis 1S great. wo rather t
SRE igo 8 i gg: € fe: “ | risk of the additional shock to the patient from removing
5.2 „ZE: EES 5 Ei py oioi jy | the lacerated uterus than expose her to the certain risk of
waste a a 2 g 43: go g g vi | septiczemia by leaving it.
Mee as 2 € S A g . Ño & 2 p2 p ee y 6 3 i ü
gag 3 3 EE CAR ae 22 4. Though the objection made by Dr. Harris, that “a
Sea aa 3 B ME Sg : BS goazi: “a | cervix split by laceration cannot be very well fitted for con-
BN 49 | striction, as the part below the wire may discharge septic
: i Bea: 7- : ii ::88 | matter into the abdominal cavity through the rent,” is a
og Bea gs Lge ue be a theless, if the tear in the peritoneum is
fon whtns 2 p gio. Bf 7} good one, nevertheless, if the tear in the peritc
22 sse 8 : 2 : 2 252 22 | $4 | carefully closed, and the stump is properly constricted and
ae ee ae $ : 4 x fz i 5% | shut off from the peritoneal cavity, I believe that there is
a ee oe can sS less danger than there is when we trust to the suture mp
RASS BS i: Se eg E = 2 | without constriction. Finally, with all respect for the
efi. 32 2:8 bs $2 | opinion of such a weighty authority as Dr. Harris, who be-
nes See 2 i 4% | leves that it “would hardly be admissible” to subject a
a RH SF RR SH m 8 £5 | woman with a normal pelvis to “ the unsexing operation
tae ie ee, ee =: op: :` Bg | Of removing the lacerated uterus with the ovaries, as was
re oioi : 2 3: + 3% | done by Prévét,” it should be borne in mind that the lap-
235 0 335.2 ..°3. G Ge E $ arotomist is sometimes called upon to do, and to do at
Do DET ae ee >o 3 $3 & 3 | once, what he believes is the best thing for the patient,
IEIET £ = £= = £7 | without regard to established precedent or she ae
ee ee : © ii i 8 | dinary rules of surgery. In the presence of a
Oe ee oe a ee 4 oy calmly and philosophicall
ye. fee Oe. S = < i < $8 | emergency we cannot reason as y and philosophically
ig Gane 2 ee T B ğu & 25 | as we would in the library.
Bey Gh; 2 © B 3 gRS 3 2y
Eas Sav 0a = D L, & See
e 6 ee. Ok ee oe) Be eras
EZ 28 8G ALS BR zE © Ise ee : E
Togn Le a SEO COLORED SPECTACLES.—Dr. Konigstein, while giving
ie : / 2 i i ii : 88 | directions in his class on the uses and prescribing of spec-
= i boi ooa S i i :i i EË | directions )
. a - . : 5 . > . . perd
35 : i 8 3< 2 g ii : gaj tacles, said that green glass as a protection against strong
- 7 € ieee es 2 et 3% | rays was worse than useless, and did more harm to a sen-
pi ES Se Se Se FOB | sit han good, as they allowed the yell to be
eo. § $9425 3S g vy: a7 | sitive eye than good, as ey allowed the yellow rays to
4 8 5 pogr 3 € 2 3 p5 588 | transmitted, and unnecessarily irritated the eye. As a
Ae < ge 4 3 2,2 S 82 3 gz | protection against strong rays the blue or smoked glasses
B Esya eg Be fe g xy oe were the only real protection. The blue should be light,
SS 2 ae =e | as a deep blue color produces a clear violet disk in the
© 9 858 2 ig ig g a:i i Tk | centre of the lens, which apparently corresponds to the
"2283888 :2 @ 8: fovea centralis, and by a protracted use of dark-blue
Ss § ee fae ge swe i gs Faw: spectacles the patient may become annoyed by the mosaic
ec EES eB ig Eg: work of the fundus of the eye appearing before him. The
e OR S ee OR a phenomenon seems to be connected with the pigmenting
- 8 Ae HE RO AG FH ah = changes in the macula lutea.—Mceaica! Press.
November 2, 1889]
THE MEDICAL RECORD.
481
SOME CASES TREATED WITH HYDROGEN
PEROXIDE.
By D. M. CAMMANN, M.D.,
NEW YORK.
HYDROGEN peroxide consists of water plus an atom of
oxygen, thus forming the dioxide of hydrogen. This oxy-
gen is in a somewhat loose form of combination, and
readily separates itself when brought into contact with de-
caying organic matter or any substance for which it has
an affinity, such as fresh roots of plants, ferments, pus,
and other exudations from the animal body. i
erty makes it a powerful antiseptic and oxidizing agent.
The peroxide of hydrogen is now known to be widely dis-
- tributed in nature, it having been formerly mistaken for
ozone, the tests for which are similar. It has been found
in the air, in rain, in snow and hail, and in various kinds
of forests, more especially among pines. ‘The substance
readily passes through animal membranes without under-
going noteworthy decomposition." Whether it gives up
its oxygen by direct addition to the blood is not quite cer-
tain, But from its known properties and from chemical ob-
servation of its effects such is probably the fact. It seems
also to have some sedative effect upon the nervous system
and to stimulate secretion from the liver and kidneys. It
usually increases the appetite, but not markedly. Dr.
Richardson, of London, first drew attention to the value
of the drug, and recommended it in chronic and subacute
rheumatism, chronic bronchitis with dyspneea, in phthisis,
and as a local application to gangrenous ulcers. He also
strangly advocated its use in whooping-cough, asserting
that it cuts short the disease most effectually. Lately it
has been used quite extensively as a local application and
as an inhalation in various cases with decided benefit. In
rola ala and other throat affections reports are in its
avor.
I have prescribed the peroxide of hydrogen in a con-
siderable number of cases, mostly of pulmonary disease,
in the past two years. Many of them have been decidedly
benefited, and occasionally one has done better than with
any other drug ; but although I believe the peroxide to be
of considerable value, the results attained were not such
as had been hoped for from a drug which may be supposed
to readily give up a share of its oxygen when brought
into contact with the blood. Its value as a local appli-
cation is undoubted. One case of whooping-cough in
which it was given certainly recovered with remarkable
rapidity. Little attention has been paid to its diuretic
effect, yet it undoubtedly has considerable power in in-
creasing the amount of urine.
I will give a few histories, and then a brief synopsis of
the cases of which records have been kept. The patients
took from five to twenty minims of the peroxide, most of
them the larger dose, in a mixture of equal parts of hy-
drogen peroxide, glycerine, and water, from three to five
times a day.
Case I.—In one case of diphtheria in which ten minims
were given four times daily, there was apparently little ef-
fect on the membrane from its use, but it seemed to bring
some color into the cheeks. On account of the favorable
reports of its effect in such cases I should be disposed to
think that with larger doses the effect might have been
more marked. A number of other drugs were used, in-
cluding lime-water, lactic acid, tincture of iron, and
chlorate of potassium, but none seemed to have much ef-
fect in clearing off the membrane, although the child
eventually recovered.
Case II.—In a case of whooping-cough the child took
fifteen minims three or four times daily, with extremely
satisfactory results. ‘The paroxysms of coughing became
less severe almost immediately, and in four or five days
the cough almost ceased. In nine the child was so well
that my attendance was no longer needed.
1 Mat. Med., Nothnagel and Rossbach.
2 Hatfield: Archives of Pediatrics, February, 1888; I. N. Loves
Weekly Medical Review, February 25, 1888.
This prop-
Case III.—Bronchitis and subacute articular rheuma-
tism. ‘lhe woman had had several attacks of rheumatism
in the past five or six years. She took peroxide for three
weeks, with the results that the pains decreased rapidly
and almost ceased after a few days.
Case IV.—Mr. P. G , aged forty-two; emphysema,
and bronchitis with pleuritic adhesions ; slight hypertrophy
of the heart ; May 12, 1888. Family history good; he
has had cough for two or three years, which has steadily
grown worse ; has been too weak to work for the past ten
days; has night-sweats ; weight rapidly decreasing ; appe-
tite poor; appearance anzemic. Physical examination :
Sinking in above the clavicles and below at outer third ;
some bulging of the chest below the clavicles at inner
two-thirds ; dulness on percussion under left clavicle ;
over both lungs respiration short, and expiration a little
longer than inspiration ; respiration feeble over nght side
in front; inspiration harsh under left clavicle ; behind,
inspiration harsh at both bases, otherwise respiration feeble
over both lungs behind; apex-beut of the heart diffused,
prolonged, and displaced to the left. B. Hydrogen per-
oxide, 5 minims, t.i.d.
May 15th.—Cough and expectoration less; does not
feel any better ; the weather has been unfavorable, which
probably has something to do with his feelings.
May 24th.—Cough, expectoration, and dyspncea less;
night-sweats less frequent ; urine not increased ; increase
hydrogen peroxide to 10. minims.
June gth.—Cough steadily improving; expectoration
less; passes an increased amount of urine; dyspnoea
about the same; feels much less nervous ; increase the
peroxide to q.i.d.
June 16th.—Improved the same as in last note.
Case V.—Mrs. M. B——, aged thirty-three ; October
25, 1888. Family history : Her mother had lung trouble,
otherwise family history is good. Previous history: Has
been subject to frequent colds; has had cough for six
weeks; expectoration abundant, greenish or yellowish ;
spat blood four days ago; night-sweats occasionally ;
chilly feelings and fever now and then, but not periodi--
cally ; appetite poor ; bowels open usually more than once
a day ; gives specific history. Physical examination : Dul-
ness under left clavicle ; sibilant respiration more or less
over both lungs, most marked on the right side in front,
coarse rales at both bases behind. R. Hydrogen per-
oxide, glycerine, aqua, 443j. M. S.: 3j., td.
November r1st.—Cough and expectoration less ; is ner-
vous; not less so since taking the medicine ; sleeps better ;
appetite much improved; urine increased; has a good
deal of pain in the side, but none since taking the medicine.
November 17th.— Decided improvement.
November 24th.—Cough, expectoration, and dyspnoea
less ; appetite better; feels better; passes more water
than before ; feels less nervous ; no pain now.
December 4th.—Improving.
An analysis of 19 cases shows that 11 were chronic
bronchitis, most of them with more or less extensive
pleuritic adhesions; 5 were cases of emphysema ; 1 was
pleuritic adhesions with valvular disease of the heart, and
1 was of phthisis. The latter did not improve under the
peroxide, nor subsequently under other forms of treat-
ment. All the others showed improvement, except one
case of chronic bronchitis. By improvement I mean
that some of the symptoms improved, but not in all cases
was there improvement in every particular. Some of the
cases might almost be recorded as cured, so great was
the improvement. Most of the cases were so chronic
that permanent cure could not be expected under any
circumstances.
The longest time any case was under treatment was
nearly four and a half months; the shortest time, five
days ; the average time of treatment was thirty-one days.
The cough was improved in all. ‘The expectoration was
decreased in amount in all except 2; and in 1 of these
it remained the same, and in 1 was increased. All the
cases, except 1, that were troubled with dyspnoea were re-
482
lieved, most of them very markedly. ‘The amount of
urine was increased sufficiently in ro cases for the pa-
tients to notice it themselves ; in 8 cases no increase was
noticed. The appetite improved in 14 cases. In 14 the
patients were less nervous—would not start as easily at
slight noises—and slept better.
That the peroxide of hydrogen is a drug of some value
seems probable. Although I have had no brilliant results
in any of my cases, except, perhaps, in the case of whoop-
ing-cough, still, some of the cases have been benefited,
more apparently by the peroxide than by other drugs. The
diuretic effect has not yet received much attention, but
that it is a diuretic of considerable power in increasing
the amount of urine is undoubtedly a fact.
19 FAST THIRTY-THIRD STREET.
THE MECHANICAL TREATMENT OF DROP-
WRIST AND ALLIED PARALYSIS, WITH
PRESENTATION OF A CASE.’
By V. P. GIBNEY, M.D.,
NEW YORK.
A LITTLE over two years ago, while visiting Mr. Hugh
Owen Thomas, of Liverpool, I saw a rather queer device
on a case of lead paralysis. It was simply an apparatus
to keep the hand hyper-extended to the fullest possible
limit. Mr. Thomas showed this with much pride, saying
that it was the best treatment he had ever seen for drop-
wrist. The explanation was that the extensor muscles
were fully rested, while the flexors, which had become
contracted by position, were overstretched. The idea
seemed a very good one, and in January, 1889, I had an
opportunity of putting the hands of a patient up in this
position. '
She was thirty years of age, and was first taken sick in
May, 1888. She thought that her sickness was due to
drinking water after its long standing in pipes. ‘There
was no other explanation of her illness so far as we have
been able to learn. Her symptoms were cramps in the
stomach, followed by diarrhoea and vomiting. This con-
dition of things lasted for about” three weeks. A physi-
cian who was called to attend her this time gave her some
medicine to control the diarrhoea and vomiting. A month
later she began to experience a pricking sensation in both
hands and feet, followed by numbness, with loss of power
in the hands. She tells me that she was unable to holda
pen in the right hand while writing. During this whole
time she had much pain in the stomach, with loss of ap-
petite. All this occurred in the country.
She appeared at the New York Dispensary some time
in the summer of 1888, and was told there by the physi-
cian who saw her case that it would require one year to
get well. She continued there in treatment for four
weeks, and, becoming discouraged, was admitted to
Bellevue Hospital, and for the first time she was told
that she had lead paralysis. She remained in the hospital
six weeks, taking medicine three times a day, a double
dose at night. She had, at the same time, electricity
three times a week. At the end of this time her pains
began to diminish, her general strength increased, but she
does not admit that her wrist-drop was any better.
She was transferred to the Randall’s Island Homceo-
pathic Hospital a little later. She got a leave of absence
one day, and came to see me on the 8th of January, 1880,
when I found her with complete palsy of the extensor
group of muscles, both wrists, but with considerable
power to flex. I did not make any electrical examina-
tion, but proceeded at once to put her up in the appa-
ratus which I show this evening. I secured the appliances
with a solid plaster-of-Paris bandage, hands and fingers
fully hyper-extended. She went back to the Island and
was not received very favorably because of her helpless-
ness. However, some one of the attendants fed her, and
—_— miŘĖÁ
1 A paper read before the Practitioners’ Society, October 4, 1889.
THE MEDICAL RECORD.
[November 2, 1889
—
on the 8th of February, one month later, I removed the
dressing for examination, finding the patient able to ex-
tend both hands to 180 degrees, but not able to hyper-extend
any. I reapplied the bandage, and on the roth of Feb-
ruary it was found that the hand did not drop any except
after a few minutes’ attempt at extension.
After leaving Randall’s Island Hospital, and while she
was wearing the splint, that is, the latter part of Febru-
ary, she was admitted to the Presbyterian Hospital and
remained four weeks, and was discharged because she in-
sisted on keeping her plaster on. ‘This was her own re-
port. At all events, the splints were removed some time
in March or April, and I did not see her again until the
22d of August, when the cure was complete. I saw her
again on the 3d of October, and I do not discover any
defect in her hands. She came then to return the springs,
and to thank me for the relief she had obtained, and it
was quite willingly that she came here this evening for
your inspection.
I have for a long time been very fond of this method
of treating external paralysis about the foot. I aim ‘al-
ways to over-correct the deformity, and retain this osi-
tion as long as I possibly can. I am at present employ-
ing this method in one or two hemiplegics who have
drop-wrist and some spasm of the flexors, but am not
prepared to report results. ‘he plan commends itself,
I think, on account of its simplicity, and the result in this
special case, I think, is unquestionable.
Progress of Medical Science.
——— ee
THE Mosr RECENT ANTISEPTIC TREATMENT OF
Wounps.—This subject has recently been again dis-
cussed in the Ceniralblatt fiir Chirurgie, and the meth-
ods of. Von Bergmann, Mikulicz, and Schmid, descnbed.
From a résumé published in the October number of the
American Fournal of the Medical Sciences, we learn that
Von Bergmann requires the patient to be thoroughly
cleansed with soap in a warm bath, after which he is
brought immediately to the operating-table, shaved,
washed with alcohol, or with ether, if necessary; and,
finally, the field of operation is washed with bichloride
of mercury, 1 : 500, and surrounded with towels wet in
the same solution. The operating-table is covered by a
sterilized cloth. Operators and assistants cleanse their
hands according to the method pursued in regard to the
operative field. Everything which can come in contact
with the patient—clothing, scrubbing - brush, etc.—is
previously sterilized by superheated steam, except the
sponges, which are washed in boiled water and soaked in
bichloride solution. The instruments are sterilized by
carbolic lotion. For ligatures and buried sutures sub-
limate catgut is used. For superficial sutures, sterilized
silk is employed. Since the air of the ordinary clinic-
room is rich in pathogenic organisms, the wound should
be carefully protected during operation by sublimate
compresses. Absolute hzmostasis is insisted upon, even
slight oozing in connective tissue or bone-cavities being
checked. ‘The wound is then irrigated with 1 : 2,000 sub-
limate solution, dried by means of sterile gauze com-
presses, drained, closed, and dressed with sterile gauze
containing no antiseptic, absorbent cotton, and a moss
pillow. ‘These dressings are sterilized by means of heat.
If the wound is already infected, it should be opened
freely, cleansed, drained and counter-drained, packed
loosely with iodoform gauze, and dressed with sterilized
gauze and the moss pillow. The superficial dressing is
changed, but the packing is not disturbed unless it be-
comes wet and dripping. In that case it is removed and
a drainage-tube substituted for it. After operations
which leave the surgeon not quite sure as to the absence
of infective matter in the tissues, or in case the bleeding
has not been thoroughly checked, or where the wound is
in a region difficult to keep germ-free, Von Bergmann com-
November 2, 1889]
THE MEDICAL RECORD.
483
mands primary iodoform gauze tamponade with secondary
suture. Finally, after resections and arthrectomies per-
formed for the cure of tubercular arthritis, the wound
should be treated with ten per cent. iodoform ether, and
tamponed with iodoform gauze ; the latter to be removed
in two days and the wound sutured without providing for
drainage. In contrast to Von Bergmann’s treatment, Mi-
kulicz commands, in many cases, Schede’s method of ob-
taining healing (moist blood-clot). ‘The ordinary chemi-
cal antiseptics are used. Sponges are discarded for wads
of sublimate cotton wrapped in mull, and kept in sub-
limate lotion. During the operation the wound is washed
out with sublimate solution every five minutes. All bleed-
Ing vessels are tied, the wound finally thoroughly irrigated,
first with five per cent. carbolic solution, finally with the
bichloride of mercury lotion, closed by relaxation sutures
of silk or silver and a continuous catgut suture, and
dressed with protective or gutta-percha tissue, ten per
cent. iodoform gauze wrung out in five per cent. carbolic
lotion, and a moss pillow. In two places a little space is
allowed between the sutures so that any excess of blood
can escape. If there is a cavity left at the operation
which cannot be closed by approximation of the wound-
surfaces, the space for the escape of blood must be left
at the highest portion of the superficial incision. The
bandage is usually not changed till the wound is entirely
healed. After operation upon tubercular inflammations,
Mikulicz recommends iodoform gauze, tamponade, and
secondary suture. Of the one hundred and sixty major
cases treated by this method, Mikulicz has lost only one.
This patient died sixteen.days after operation of con-
sumption. In only three cases did pain and high tem-
perature force him prematurely to change the dressing.
Schmid completely closes his wounds immediately and
discards drainage. Should symptoms denoting tension or
suppuration appear, he removes the dressing, takes out a
stitch, and opens the wound somewhat. The site of op-
eration 1s covered for twelve hours with moist sublimate
compresses, and is finally washed with ether and sublimate
solution. In every pause of the operation the wound is
covered by sublimate sponges. There is no irrigation and
the minimum of sponging. Most careful attention is
given to checking the bleeding, after which the wound is
flushed with bichloride solution, dried, dusted lightly with
iodoform, and approximated throughout its whole extent.
A compression sponge is now applied, iodoform, mull,
and a moss pillow. ‘The dressing is completed by a press-
ure bandage very firmly applied, which can be loosened
if painful in twenty-four hours. In wounds where press-
ure ıs not necessary, salicylated collodion painted over
the skin sutures will prove a sufficient dressing. For in-
fected wounds, Schmid advises free opening, drainage by
means of iodoform gauze, and antiseptic poultices.
THE BEHAVIOR OF THE GERMS OF CHOLERA, TYPHOID
FEVER, AND TUBERCULOSIS IN MILK, BUTTER, WHEY,
AND CHEESE.—Among the numerous labors of the Reichs-
gesundheitsamt has been that of determining the behavior
of certain germs of disease in various articles of food.
Milk is one of the most common articles of diet, and one
of the health office collaborators, L. Heim, of Würzburg,
has lately concluded a lengthened inquiry into the rela-
tions of the bacilli of tuberculosis, cholera, and typhoid
fever to it, and its products, whey, butter, and cheese.
That milk is a favorite medium for dissemination of dis-
ease is well known, and Koch, among others, has shown
that it is peculiarly adapted for this purpose. As regards
cholera, the germs of the disease were still viable after
remaining for six days in milk that had undergone no an-
tisepticizing processes ; in milk of the same character that
had been kept in the ice-chest, on the other hand, no liv-
ing bacteria were found at the end of three days. ‘This
part of the inquiry shows that cholera bacteria remain ac-
tive in fresh milk the whole length of time it is customary
to keep it, and that they do not lose their dangerous qual-
ity for some days after the milk has become sour. The
same germs were found active under some circumstances
even at the end of a month. In ordinary strong cheese
they did not retain their viability over a day, neither did
they in unripe cheese. The bacilli of typhoid were alive
and capable of development in milk at the end of thirty-
five days, but no longer so at the end of forty-eight days ;
in butter they remained active between three and four
weeks ; in cheese only three days, and in whey only dur-
ing the first day. Tubercle bacilli remained capable of
development for ten days in fresh milk ; in milk gradually
undergoing decomposition they lost their power in a pe-
riod varying between ten days and four weeks. In butter,
on the other hand, they retained their full power at the
end of four weeks ; in whey and cheese after two weeks,
but not after four weeks. The practical importance of the
investigations is so obvious as scarcely to need pointing
out, and their bearing on the use of milk, the preservation,
carriage, preparation, and sale of it and its products is
equally obvious. Something has been done, much remains
to be done, to stop the ravages of disease, and the labors
of Dr. Heim are another step forward.—Berlin Corres-
pondence, Medical Press.
CEDEMA OF THE Brain.—Professor Huguenin distin-
guishes two varieties of oedema of the brain—the inflam-
matory and the non-inflammatory. Inflammatory cedema,
or diffuse encephalitis, is observed in perforating wounds
of the skull with any kind of injuries to, or crushing of, .
the brain substance ; in brain tumor, as soon as a central
necrotic softening takes place in it and approaches the
periphery ; in abscess; in infectious diseases; and less
often in hemorrhages and hemorrhagic infarct. As re-
gards uninflammatory oedema, opinions have been at vari-
ance whether the peculiar arrangement of the circulation
within the skull would permit of the exudation of suffi-
cient serous fluid to produce a rapid and fatal pressure on
the brain. As the result of his anatomical studies, the
author takes the view that disturbances of the circulation
in intracranial diseases can produce no fatal cedema as
long as the vessels and the conditions within the skull are
normal; but that these disturbances, for whose adjust-
ment there are fully satisfactory arrangements under nor-
mal conditions, can produce fatal cedema, if previously
existing changes are present in the skull or brain. ‘These
changes are, obliteration of the ports of exit for the lymph,
moderate chronic pressure on the brain through contrac-
tion in the size of the skull, or, much more, through arrest
of its development, diseases of the brain which produce a
greater or lesser degree of pressure. Theoretical con-
siderations would explain the so-called congestive oedema
of the brain, #.¢., the effusion of serum under the mem-
branes, into the brain, and into the ventricles, as being due
to a hyperemia of relaxation, as it is termed, of the ves-
sels of the brain, so that more blood streams through
them. At first this occurs with greater rapidity on ac-
count of the diminished resistance in smaller arteries ; so
that instead of the vessels bearing thirty per cent. and the
surrounding parts seventy per cent. of the pressure, as in
the normal condition, the vessel walls do not bear more
than ten per cent., and the surrounding parts receive about
ninety per cent. The pressure exerts itself against all dis-
tensible parts, such as the fontanelles and the vertebral
ligaments, which yield as far as they are able. At the
same time there is an increased efflux of the cerebro-spinal
liquid through its normal channels, and this may serve to
relieve the pressure. If, however, the tension of the blood-
vessel walls diminishes, and the pressure of the cerebro-
spinal liquid exceeds ninety per cent., this efflux is of no
avail. The pressure becomes so great that compression
of the capillaries takes place, and, thereby, a general ob-
struction to the circulation, with consequent stagnation of
blood in the dilated arteries, and fall of pressure in the
veins. The fluid constituents of the blood then leave the
vessels, collect in the sub-pial space, brain, and ventricles,
and the cedema of the brain is established. This suppo-
sition explains the congestive oedema which is said to be
484
THE MEDICAL RECORD.
[November 2, 1889
common in children, and only rarely to occur in adults.
Not in accord with this is the fact that children, unlike
adults, have fwo arrangements for compensation—the fon-
tanelles and the ligaments ; and still less do those experi-
ments accord, which show that even a very considerable
increase of pressure, artificially produced, does not pro-
voke cedema of the brain. As a result of his studies on
his own cases, the author comes to the following conclu-
- sions: 1. Those children which were supposed to have
died of hyperzemia of the brain, oedema, or slight hydro-
cephalus, were always found to have had a beginning
meningitis, usually of an infectious nature, 2.¢., a strepto-
coccus meningitis. What, therefore, the author would
formerly have regarded as a congestive oedema, he would
now designate as streptococcus meningitis, more or less
developed. 2. On the other hand, fatal cedema of the
brain, of a congestive nature, does occur in children, but
only under particular circumstances. ‘The first of these
is chronic meningitis, which produces obliteration of the
channels of exit from the sub-pial space, and obliteration
of the Paccionian granulations. In adults, also, chronic
meningitis may play a similar ré/e. The second factor in
the production of fatal congestive cedema is present when
a pressure on the brain is already in existence, which is,
perhaps, already nearly as great as can be endured by the
organ. If now any irritation produce a hyperemia of re-
laxation, its action will be very rapid, since the brain pos-
sesses scarcely any further power to yield to pressure. To
this class belong: 1. Fatal cases of oedema of the brain
due to lack of power of the organ to expand; this being
the result of a too early ossification of the sutures. 2.
Fatal cases of cedema of the brain occurring after the
intra-cranial space had already been diminished by some
disease of the brain. Here belong three categories of
affections: acute hemorrhage, tumor, and abscess in the
inner parts of the brain, which have not yet produced a
meningitis ; finally, a traumatism of the brain not com-
municating with the atmosphere.— Zhe American Journal
of the Medical Sciences, October, 1889.
CEDEMA AS A DIAGNOSTIC SIGN IN CARCINOMA OF
THE STOMACH.—Dr. Baert, of Brussels, calls attention to
the frequency with which cedema of the ankles is met
with in cancer after it has lasted a few months—a diag-
nostic aid which is by no means new, but is, he thinks, in
danger of being too much overlooked at the present day
(Zhe Lancet). He gives a number of cases recently occur-
ring in the various hospitals in Brussels in which oedema
was present. In one of these cases the cedema came on
as early as three months after the first symptoms of the
affection made their appearance ; in two other cases it
was noticed after four months; but in most of the other
instances it was delayed till the lapse of from six months
to a year after the onset. In one case, where there was
no evident cause to which to attribute the loss of appetite
and the wasting complained cf by the patient, Professor
Carpenter, noticing some cedema of the ankle, diagnosed
carcinoma of the stomach, and found his diagnosis con-
firmed by the appearance a month afterward of all the
usual signs of the affection. Several of the cases pre-
sented a marked increase in the nitrogen excreted in the
urine. With regard to the deficiency or absence of hydro-
chloric acid in the stomach, in cancer of that organ, M.
Baert admits that it is usual, but agrees with Wolff and
Ewald in saying that this sign is by no means peculiar to
cancer, as it is found in other gastric affections.
SYPHILIS OF THE INTESTINES.—Dr. Barié points out that
little or no attention has been devoted to the study of
syphilitic affections of the intestine, and he suggests that
their supposed rarity inay in reality be due to a lack of
knowledge of the subject. He has collected a number of
observations in which the subjects of syphilis, either hered-
itary or acquired, exhibited undoubted syphilitic lesions of
one or other part of the intestines, sometimes simply en-
largement of the Peyer’s patches, more frequently, numer-
ous ulcerated patches. He mentions more particularly
the case of a woman, aged thirty-two, who was admitted
into a hospital in a state of stupor, with a history of severe
headache and general fatigue of a month’s duration. The
abdomen was tympanitic, painful on pressure, especially
in the right iliac fossa. Profuse yellow fetid stools.
Notwithstanding the typhoid symptoms no rash could
be discovered. Coma supervened, followed by death.
Post-mortem a number of ulcerations were found in
the neighborhood of the cæcum, with irregular excavated
borders, the base being a whitish-gray, and covered with
purulent matters. ‘Two other ulcers were discovered in
the transverse colon, the sigmoid flexure, and the descend-
ing colon. The mesenteric glands were not appreciably
enlarged. The diagnosis of the syphilitic origin of these
ulcers was arrived at by a process of elimination. He
points out that intestinal syphilis attacks the terminal por-
tion of the small and the large intestine in preference, its
effects being localized in the collections of lymphoid tissue.
It produces ulcers with thickened borders, filled with a
yellow puriform material, and all the coats of the gut are
involved in the morbid process. Clinically, the affection
gives rise to an obstinate and profuse diarrhoea, the stools
being yellow, fetid, and, from time to time, sanguinolent.
In some cases the diarrhosa brings about emaciation, ca-
chexia, and death from exhaustion, but in others it takes
on an acute form, and then markedly resembles typhoid
fever. In the latter, the differential diagnosis is very diffi-
cult. Perforation, with consequent peritonitis, is a fre-
quent complication.— The London Medical Recorder.
‘TREATMENT OF PHTHIRIASIS Pusis.— In one of the
weekly meetings of the physicians of the St. Louis Hos-
pital, Pans, the question of treatment for pediculi pubis
was discussed. Dr. Besnier remarked that it is an easy
matter to get rid of pediculi vestimenti, and even of lice
in the head, while those which inhabit the pubic region
are relatively difficult to destroy. An excellent method
consists in giving a bath of an hour's duration, the water
containing ten grammes of corrosive sublimate which has
been dissolved in alcohol. The old-time frictions with
mercurial ointment have been almost entirely abandoned,
because of the irritant phenomena to which they may give
rise. When gray ointment is employed it is best not to
leave it upon the skin for more than two hours, for fear of
producing an erythema, pustulation, and salivation. At
the present time it is preferable to apply, morning and
night for two or three days, a lotion containing corrosive
sublimate dissolved in alcohol, in the strength of 1 to 200
or 1 to 300. The hairs are then to be washed with hot
vinegar, and the nits, thus softened, are readily removed
with a fine comb. It is furthermore necessary to exercise
a close scrutiny for several days to prevent a recurrence.
Dr. Hallopeau employs only frictions with camphorated
alcohol for the cure of all forms of pediculi. In three
days he thus secures a complete cure. Professor Fournier
insists in his clinics upon the frequency of pediculi pubis
in the lower classes, where their presence is almost always
ignored, showing how little itching they occasion in the
majority of cases. As soon, however, as we inform the
patients of their condition they are, on the other hand,
much annoyed by the itching. Another topical applica-
tion in phthiriasis and in pruritus is phenic acid.— Journal
of Anatomy and Genito-Urinary Diseases, September,
x 889. ;
SPERMINE.— Sper mine is an alkaloid found in testicular
juice, in the gray matter of the brain, in eggs, oysters, lam-
preys, fish ova and milt, also in the products of all atonic
mucous membranes. It also appears in the sputa of
senile and acute bronchitis, in the expectoration of
phthisis, and of emphysema with catarrh, and the spleen
and circulation of anæmics and leucocythemics. The
hydrochlorate of spermine, in a dose of one-fortieth of a
grain, injected subcutaneously in a dog of thirteen pounds,
produced marked physical and mental actıvity, and pow-
erful and prolonged stimulation of the genital system.—
Medical Age.
November 2, 1889]
THE MEDICAL RECORD.
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., EDITOR.
PROPRIETORS AND PUBLISHERS
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
New York, November 2, 1889.
THE HARD LOT OF THE ACTING ASSIST-
ANT SURGEON.
THE Association of Acting Assistant Surgeons of the
U. S. A., which was formed about a year ago, has as one of
its main objects the bettering of the position of those who
are now serving the Government in that capacity. The
first step, of course, toward righting a wrong is to make
the wrong known, and we think many of our readers will
be astonished to learn what the duties are of the acting
assistant surgeon in our army, and how his services are
requited by the United States Government. It is safe to
say that one would have to look far before finding a more
poorly paid body of professional men than the fifty “ con-
tract surgeons” at present in the employ of the Govern-
ment. Let us see for a moment what is required of the
acting assistant surgeon and we shall then be in a position
to judge whether the pay and honor that he receives
are a sufficient recompense for his labors. We are in-
debted to Dr. W. Thornton Parker, of Newport, Re-
corder of the Association, for much information on this
subject.
The requirements for admission to this branch of the
service, if such it. can be called, are sufficiently stringent
to prevent any but competent physicians from obtaining
an appointment. One must first apply to the Surgeon-
General for an invitation to appear before a medical ex-
amining board. ‘This request must be in the applicant’s
own handwriting, must contain a statement of his age and
birthplace, and must be accompanied by testimonials as
to his moral character. Next the physical qualifications
of the candidate and his fitness to undergo any probable
hardships of field service or exposure in any climate or at
any season of the year must be rigidly tested by the board,
anda favorable report will not be made in any case in
which this is doubtful. The oral examination is in the
branches taught in the common schools and the candi-
date must satisfy the board that he has a good knowledge
of orthography, grammar, and the fundamental rules of
arithmetic, including operations with fractions, and that he
has a fair acquaintance with geography and history of the
United States. His examination will not be continued fur-
ther if he be found deficient in these branches. There is, fur-
ther, an oral examination in anatomy, surgery, practice of
medicine, obstetrics, and diseases of women and children,
therapeutics, including tests and antidotes for poisons
and the writing and compounding of extemporaneous pre-
scriptions. One question each upon anatomy, surgery,
THE MEDICAL RECORD.
485
practice of medicine, and obstetrics will also be given to
the candidate in writing, and his written answers to the
same are preserved as part of his record and transmitted
to the Surgeon-General’s office. r
Appointments are made from among the successful
candidates according to their standing in this examina-
tion.
After their appointment the acting assistant surgeons
have the same duties to perform as those with commis-
sions who enjoy the rank and pay of first-lieutenants, cap-
tains, and majors, but their standing and their position
in the army are very different. Their pay is about one
hundred dollars per month, and their rank is—nothing.
In one respect they are worse off than the humblest em-
ployee of the Government, for they are not subject to the
civil service rules, and are liable to dismissal at any time,
without cause. A clerk in one of the departments at
Washington is allowed a certain vacation every year, but
an acting assistant surgeon in the army is paid only for
actual service rendered. If he is incapacitated for work
by sickness, contracted, it may be, in the discharge of his
duty, his pay stops. Or if he feels the need of a brief
rest, after several years of continuous service, he must
take it at his own expense, and at the sacrifice of his sal-
ary for the entire period. But even this is not all. No
matter how long he may have served his country his pay
remains the same, and finally, when, broken down by age
and long service, he finds himself obliged to give up work,
he is let go without so much as a “thank you,” and must
henceforth shift for himself as best he can. And beyond
and above all this material hardship, these men—culti-
vated professional gentlemen—are forced to submit to
many indignities against which a self-respecting mechanic
would rebel. But on this point we cannot dwell now,
and will briefly consider the means by which it is hoped
to ameliorate the lot of the contract surgeon.
The demands of the Association can certainly not be
regarded as extravagant or unreasonable. As announced
in a recently issued circular, it 1s proposed to present a
“ petition signed by the acting assistant surgeons, and en-
dorsed by assistant surgeons, surgeons, and others who
may favor the same, to the Military Committee of the
next Congress, praying that acting assistant surgeons of the
army (now serving), many of whom have served long and
faithfully, performing all the professional duties of com-
missioned surgeons, and many of whom are past the age ©
permitting them to apply for examination for commissions
as first-lieutenants in the medical corps, be commissioned
assistant surgeons, with the rank of second-lieutenant of
cavalry, not to be in the line of promotion, the pay (that
of second-lieutenant) not to be increased, and to be al-
lowed forage for one horse ; that at the expiration of the
regular fall term of service, or on account of disability,
they be placed on the retired list of the army.”
We have only one criticism to offer in regard to this
proposed petition, and that is, that the Association is far
too modest in its request to Congress. ‘The rank and pay
of a first-lieutenant would be none too much to ask for,
and would probably be not much more difficult to obtain.
The proposed petition is regarded with favor by many
of the older officers of the army, and we hope that the
Surgeon-General, whose endorsement would naturally
carry much weight, will also, at the proper time, unite his
486
influence with that of others who are endeavoring to ob-
tain this measure of justice for a most deserving body of
physicians.
WILL THE TIME EVER COME?
As we have read the remarkable work of Mr. Fdward
Bellamy, “ Looking Backward,” we have felt a certain
pride that the chief spokesman is portrayed as a physician.
We are not to infer that this was the chief idea of the
writer in making this selection, but there is, nevertheless,
conveyed a delicate compliment in the choice. We should
feel a certain degree of disappointment did we believe the
character of Dr. Leete to be purely an ideal one for the
present age, for it is our firm conviction that some of the
most noble men alive to-day are engaged in the practice of
medicine. ‘They may not be taking a prominent part in dis-
cussing social and industrial problems, but they come in
contact with all sorts and conditions of men, and can make
no small contribution to the data which form the basis of
such discussions. It is no wonder, therefore, that Mr.
Bellamy has chosen the medical calling as that one to be
followed by his exponent of the ideas of one hundred
years from to day.
It is very easy to follow out in imagination another
chapter along this line of altruistic development. We can
imagine Dr. Leete telling Mr. Julian West how hospitals,
dispensaries, and medical societies were managed in the
times in which he lived. ‘There will be no code, for all
men will be properly educated, and be gentlemen. With
perfect confidence does the family practitioner refer his
patient to the specialist, well knowing that the latter will
send him back again, with diagnosis stated and a line of
treatment suggested. There will be no rivalry to be ap-
pointed physicians to the new hospital, for each one
chosen will offer to resign in favor of his unsuccessful
competitor, and the only possible embarrassment will come
from the excess of self-abnegation. The occupation of
the consequential and patronizing hospital manager will
be a lost art. Contributors to medical journals will never
write on both sides of the paper, will ever send their
manuscripts rolled up, nor desire reprints and extra copies,
and will wait their turn for publication. Their thoughts
will be condensed, and their great aim will be to say as
much as possible in the fewest number of words. As
all men will be educated, and the private research of
each be made public property, the opinion of the retiring,
common-sense, professional neighbor will be as worthy of
at least as courteous a reception as that of some unknown
Herr Professor, with an unpronounceable name, from the
middle of one of the southern provinces of Austria.
Also, physicians will be represented on the governing
boards of what few medical charities may remain, for the
new industrial system, with its consequent abolition of
poverty, will render them entirely unnecessary. ‘The dis-
pensary “rounder” will rival the mound-builders as an
effete historical curiosity. The ‘“able-to-pay patient”
will have been evoluted out of existence, and while the
supply of clinical material may be disappointingly small
to some of our great men, the comfort of the rank and
file of the profession will be greatly enhanced. State ex-
amining boards will exist everywhere, and the so-called
generous and unselfish rivalry between the few medical
schools that are then needed will cease.
THE MEDICAL RECORD.
[November 2, 1889
We will not enlarge on this theme, nor can we promise
that the elixir vitæ, or, as our Western contemporaries
call it, the Methuselah Cocktail, offers any prospect of
our being enabled to live till the Golden Age.
But, seriously, when one comes to read Mr. Bellamy’s
book, he realizes how sadly the times are out of joint, so
far as social and industrial questions are concerned. His
illustration of the stage-coach in the opening chapter is
grim, but most sorrowfully truthful. His Utopia does
not seem by any means a purely imaginative one, though
the very antipodes of the present age. ‘‘ Looking Back-
ward” should be read by every physician. It shows one’s
general social duty, regardless uf his calling. It contains
a warning for the thoughtless rich, and a promise for the
unfortunate but honest poor. ‘To every reader will it
suggest new thoughts, and in everyone inspire new hopes,
and loftier ambitions. ‘The authors idea of “ national-
ism” may be chimerical, but his motive is praiseworthy.
OUR ILLUSTRATION PLATE OF SMALL-POX.
In this issue we present a fourth of the series of eruptive
diseases from Morrow's “ Atlas of Skin Diseases.” In the
three figures we have presented the leading types of the
variolous eruptions. As small-pox is, fortunately, not a
common disease, but, unfortunately, a very contagious
one, it becomes every practitioner to be on the alert for
a correct diagnosis in the earlier stages, in order more
particularly that the proper preventive measures may be
taken against the spread of the malady. ‘The plates should
be studied in connection with a detailed account of the
symptoms, which latter can be found in any of the text-
books on practical medicine.
The figures in the plates show very truthfully and artis-
tically the different degrees and varieties of efflorescence,
viz., the papular and vesicular over the entire body, the
umbilicated on the foot, and the confluent variety of the
mature pustules on the face.
A careful inspection of these truthful and well-executed
pictures cannot fail, we believe, to interest the large num-
ber of our readers who are apt during the season to meet
with a case.
COMPARATIVE VALUE OF ANTIPYRIN, ANTIFEBRIN,
AND PHENACETIN.
WHILE the regular and systematic use of antipyretic drugs
in continued fevers is no longer to be considered a safe
or wise practice, yet their employment in ephemeral
fevers, in acute febrile attacks, heat-stroke, and very high
temperatures in all conditions, is often stringently indi-
cated. A study of the comparative value of antipyrin,
antifebrin, and phenacetin, recently made by Surgeon-
Major A. Crombie, of Calcutta (Zhe Practitioner), gives
us some facts o° practical interest.
Dr. Crombie’s observations are very clearly summarized
es follows : l
1. As regards efficacy, antipyrin comes first, and there
is little to choose between antifebrin and phenacetin.
2. That as regards safety the advantage lies with phen-
acetin. A subnormal temperature never resulted from
the use of that drug. Dr. Crombie had seen subnormal
temperatures as the result of the use of antifebrin, but
never collapse, which he had once seen from the use of
antipyrin.
November 2, 1889]
THE MEDICAL RECORD.
487
3- As regards rapidity of action, antipyrin, probably
on account of its solubility, comes first, antifebrin sec-
ond, phenacetin third. ‘The fall after the use of phen-
acetin is more gradual, and the minimum is not reached
for three, four, or even fivehours after the administration
of the drug.
4. As regards duration of effect the advantage lies
with phenacetin.
5. As regards certainty of action, Dr. Crombie quotes
them in the same order as that of rapidity—antipyrin,
antifebrin, phenacetin. Phenacetin should be prescribed
either in powder or in lozenges which are soft and friable.
6. As regards inconveniences, in the climate of India
phenacetin is followed by just as profuse sweating as
either antifebrin or antipyrin, and this, to his mind, is
the great drawback in the use of antipyretics, patients
having to change their clothing once or twice in a night
after the use of any of these drugs. Whether or not an
antipyretic will yet be found which will be capable of
safely reducing abnormal temperature without causing
profuse perspiration remains to be seen, but as yet we do
not possess one.
Dr. Crombie adds that there is one peculiarity which
phenacetin does not share with the other antipyretics. He
alludes toa soothing and soporific effect which it un-
doubtedly possesses, so much so that in cases of slight
feverishness accompanied by insomnia and great restless-
ness small doses of three or four grains of phenacetin,
not sufficient, in India at least, to produce perceptible
diaphoresis, insure a quiet, peaceful, and sleepful igt,
with no headache in the morning.
In conclusion, he says that in heat apoplexy, dnas
and hyperpyrexia generally, antipyrin is indicated. In tem-
peratures of 103° to 105° antifebrin or phenacetin, in
temperatures below 103° the preference should be given
to phenacetin.
Hews of the Geek.
AN IMPORTANT PRECEDENT FOR THE ASSOCIATION OF
AMERICAN PHYSICIANS AND SURGEONS.—Dr. C. H. Mastin,
of Mobile, in declining the office of president of this as-
sociation, at the recent meeting of the executive commit-
tee, expressed the opinion that someone not a member of
the committee should be selected for this high office.
For obvious reasons this is a valuable precedent, and is
fittingly set by one who is an illustrious example of South-
ern chivalry and modesty.
Woman’s HOSPITAL OF THE STATE OF NEw YoRK.—
Drs. Horace T. Hanks and Bache Emmet have been
upani.cously appointed as Visiting Surgeons to fill the
vacancies occasioned by the death of Dr. James B. Hunter
and the resignation of Dr. Charles Carroll Lee.
Outro STATE SANITARY ASSOCIATION.—The seventh
annual meeting will be held in the hall of the Young
Men’s Christian Association, Dayton, O , November 21
and 22, 1889.
MEDICAL LEGISLAToRS.—Of the 557 members returned
at the recent general elections to serve in the French
Chamber of Deputies, 48 are doctors ‘of medicine, 4 are
druggists, 1 is a dentist, and 1 a veterinarian.
A New DIsEASE—CONFECTIONERS’ Fincers.—Dr. Ro-
driguez Mendez, Professor of Hygiene in the Medical Fac-
ulty of Barcelona, has just published in a new Spanish
journal, Za Medicina Prdctica, some notes of a case of a
peculiar affection of the fingers and nails which appears
to have been due to the patient's trade, that of a confec-
tioner (Zhe Lancet). Poncet, of Paris, and Albertin, of
Lyons, have also observed the existence of this affection
among those who are engaged in the calling of a confec
tioner. Dr. Mendez’s patient was a man about forty years
of age. His trouble was a combination of onychia and
paronychia, caused by immersing the hand in hot and
cold syrups. .
. Rıcu MEn’s DISPENSARIES.— The Johns Hopkins Hos-
pital is found to be a not unmixed blessing to the medical
profession of Baltimore. The Maryland Medical Journal
says that, in the last six months, five thousand dispensary
patients have been treated there, and that these consist
largely of persons who used to go to a physician. Much the
same kind of story is told by physicians of this city, regard-
ing the Vanderbilt and the Presbyterian Dispensaries.
New York NEUROLOGICAL SocieTy.—The commission
appointed two and a half years ago to investigate the rela-
tion between disturbances of the ocular muscles and func-
tional nervous diseases will make its report at the stated
meeting on Tuesday next at the Academy of Medicine.
Crviu SERVICE REFOoRM.—It is well known that the
state of civil service reform in New York is not what its
friends could wish it to be; and that it would be well if
some clear presentment of the facts were made by those
who have had occasion to know best as to the details
and as to abuses—in the interests of better sanitation.
It looks asif the only answer to the question was, “ What
are you going to da about it?”
AN INTERVIEWER IN THE GUISE OF A PATIENT.—
A young woman, a reporter on a sensational daily pa-
per of this city, paid a visit to a number of physicians
recently in the guise of a patient suffering from headache.
Every detail of her various interviews, the diagnosis made,
prescriptions and advice given, and fees charged, were
subsequently written out and published in a most sensa-
tional way. ‘The differences in diagnosis and advice were
considerable and were made to appear rather ridiculous,
as might easily be done by a person presenting only a
subjective symptom. ‘The performance, we think, was
a great piece of impertinence and one in which repu-
table journals or journalists would not be concerned.
The physician is under bonds to respect the confidence
of his patients and the obligation is almost as great that
the patient should not go and gabble to the public per-
sonal items regarding the physician.
DeaTH OF Dr. Moses D. CARBEE.—At Haverhill, N.
H., October 23d, of diphtheria contracted in practice,
Moses D. Carbee, M.D., aged forty-two years. Dr. Car-
bee was graduated from the University of Vermont in
1873, and for fifteen years had been honored and loved
in Haverhill and the surrounding country as a skilful and
faithful physician, and qn unfailingly kind and sympathetic
friend.
Dr. PIETRO Laura, one of the leading physicians of
Italy, died recéntly at Genoa in the seventieth year of his
age.
488
THE -MEDICAL RECORD.
[November 2, 1889
THE STRING IS PULLED AND THE BAND STOPS ITS PLay.
—The physicians of the Eastern Dispensary, having been
much annoyed during their auscultatory practices by a
neighboring museum band, have made an arrangement with
the latter by means of a connected signal-bell to stop the
music during chest examinations. Statistics show, how-
ever, that the bell is rung but one and a half times daily.
Our good brothers are evidently not quite up to their op-
portunities. How much the latter would be appreciated |
by their fellow-practitioners who could shut off the “ little
German band” by the pull of a string, or by orange the
patellar reflex a free play on the sidewalk.
THE LATE Dr. James B. HuNTER.—At a meeting of
the Practitioners’ Society of New York, October 4, 1889,
it was Aesolved, That the members of this Society express
their deep regret at the sudden and untimely death of
their late colleague, Dr. James B. Hunter. ‘They recall
the fact that he was one of the founders of the Society,
that he was its first President, and always took an especial
interest in the success of its work, to which he made
practical and original contributions. Dr. Hunter was
esteemed for his social qualities as well as for his emi-
nence as a physician ; and in his unfortunate death the
members feel a sense of great personal bereavement.
W. T. BuLt,
R. F. WEIR,
Committee.
CHARLES L. DANA,
PROFESSIONAL SERVICES OBLIGATORY.—A French
court has recently decided that physicians are bound to
give in good faith their professional services when solic-
ited by those who represent the law.
AN EXCELLENT Drawinc by Albrecht Dürer was found
lately in a medical book in a library at Zwickau. It rep-
resents a dying man sitting behind a stove and Death
threatening to extinguish the light of life, while a female
form personifying the Art of Healing approaches to save.
THE GERMAN IMPERIAL MINISTRY OF THE INTERIOR
has made a grant of $20,000 toward the expenses of the In-
ternational Medical Congress to be held in Berlin in 18go.
THE TRANSPORTATION OF Dean RopiEes.—The Asso-
ciation of Baggagemen, which recently met in Detroit,
passed resolutions insisting that all bodies of persons dead
from contagious diseases, held for transportation, must be
properly prepared for shipment by being wrapped in sheets
saturated with mercuric chloride and placed in metallic
caskets, to prevent the spread of disease.
THE Docror’s Earnincs. — According to Dr. Jar-
vis’ tables, the average of the lives of physicians is fifty-
six years. If you begin practice at twenty-four, your ac-
tive-life prospect will be thirty-two years, and from a thou-
sand to fifteen hundred dollars will represent your aver-
age yearly income. Now, were you (through God’s
mercy) to practise these thirty-two years without losing a
single day, and collect (say) eight dollars every day of the
time, you would receive but $93,440. Deduct from that
amount your expenses for yourself and your family, your
horses, carriages, books, periodicals, and instruments ;
your taxes, insurance, and a multitude of other items for
the whole thirty-two years (11,680 days), and then, so far
from being nch you would have but little,
very little, left to support you after you naturally reach
the down-hill of life, or are broken down in health and
faculties deteriorated, and in need of a physician yourself,
through worry, anxiety, and fatigue in the discharge of
your duty.—Dr. CaTHELL, in last Edition of Physician
Himself.
INOCULATING CANCER.—At a meeting of the Gesell-
schaft der Aerzte in Zurich, Dr. Hanau stated that he had
succeeded in inoculating carcinoma from rat to rat. On
November 28, 1888, he excised two pieces of a carcino-
matous lymphatic gland from a female rat with malignant
disease of the vulva, and transplanted these into the nght
half of the scrotum in two old male rats. One of the lat-
ter died on January 14, 1889. ‘The necropsy revealed a
generalized “ carcinosis” of the peritoneum (including the
great and small omentum). In the other, which was
killed on January 25th, there were found two typical can-
croid nodules (one 2.5 millimetres in diameter, the other
the size of a pea) on the gubernaculum testis and the
cauda of the epididymis. ‘The transplanted malignant
growths proved to have precisely the same structure as
those which had spontaneously originated in the first an-
imal. According to Dr. Hanau’s theory, the cancroid
infection should be attributed to the agency of live epi-
thelial cells, and not to any pathogenic microbes. Another
series of the author's experiments on the artificial produc-
tion of cancer in rats by means of a prolonged local use
of such irritant substances as tar, etc., gave negative re-
sults. The application caused an eczematous rash, with
some infiltration of the corium, but no malignant disease.
A SIMPLE REMEDY FOR THRUSH AND SORDES, writes
Dr. W. T. Ord. in Zhe Lancet, is equal parts of lotio
nigra and glycerine mixed. He adds: “I attribute its
action to the germicidal power of the mercury. ‘The
quantity used is so small as to be quite harmless. An-
other condition in which I have found the same lotion in-
valuable is in that of the sordes which collect so abun-
dantly on the teeth, lips, and tongue in many cases of
enteric fever. It cleans these parts as if by magic, and
renders that unpleasant process known as “scraping the
tongue” quite unnecessary. It may also with advantage
be painted over the fauces, etc., in those unhealthy con-
ditions of the throat which are so common in typhoid. I
tried it in one case of catarrhal stomatitis, but it had no
effect, whereas chlorate of potash effected an immediate
cure. Also, in ne sordes of advanced phthisis it seems
to be of no use.”
SoME REMARKS ON Hypnotism.—Dr. Hunter McGuire,
of Richmond, ventured to criticise the subject of hyp-
notism in a letter to Dr. L. G. Pedigo (Virginia Medical
Monthly). Dr. McGuire does not think much of hyp-
notism, and does not believe in it at all. He contributes
the following profound historical comment on the subject :
“It was practised many years ago by the early Greeks,
from whom, probably, Mesmer took the idea. Under
different names, it has over and over again been repro-
duced. It comes now as hypnotism. Ina year or two
it will again disappear, possibly to be revived in twenty or
thirty years.” Dr. McGuire is, we regret to say, much be-
hind the medical knowledge of the day, for while criti-
cisms on the therapeutic application of hypnotism are
much needed, the validity and scientific importance of hyp-
notic phenomena are no longer to be questioned.
November 2, 1889]
THE MEDICAL RECORD.
489
MEDICAL SOCIETY OF THE COUNTY OF NEW YORK.—
At the annual meeting, October 28, 1889, the report of
the Comitia Minora contained the following: Resolved,
That the Comitia. Minora recommend to the Society that
hereafter members two years or more in arrears of dues
shall have their names omitted from the published list of
the Society, and that while thus in arrears such members
shall receive no notice of the Society’s meetings nor its
publications. Resolved, That such members be notified of
these resolutions, at least one month before the publication
of the directory. A motion to adopt the report with its
recommendation was made. Dr. Piffard objected, saying
that if a physician was a member of the Society it was not
legal to drop his name from the published list. Having
offered an amendment to the motion, he withdrew it, and
accepted one offered by Dr. Fry, to the effect that that
portion of the report containing the resolutions be stricken
out. Dr. A. F. Curner, a member of the Comitia Minora,
Stated it was not the intention to leave out the names of
those in arrears of dues from the published directory, but
to place them in a separate list. Dr. Laurence Johnson
and Dr. Daniel Lewis spoke of the trouble and expense
connected with attempts to collect back dues from delin-
quent members, and of the injustice of their sharing
equally in most respects the benefits of membership with
those who had complied fully with the by-laws. Dr.
Lewis said it was impractical to do as Dr. Piffard had
suggested, to collect arrears of dues through action at law.
Dr. Shultz thought it would be an insult to publish a sep-
arate list of members in arrears of dues. He inquired
whether the provision made for publishing the directory
would not permit of including in one list only the names
of members who had fully complied with the by-laws,
while the names of others should appear in the general
. list of registered physicians. The report, including its
recommendations, was adopted. Dr. Piffard wished it to
appear on the minutes that he questioned the legality of
the proposed procedure. Dr. John S. Warren, the treas-
urer, read his report, which showed receipts for the year
of $4,739.95; disbursements, $3,563.90 ; balance in the
treasury, $1,176.05. It had been found correct by the
Auditing Committee, and was accepted. At the election
of officers, Drs. Crampton and Currier were appointed
Tellers. Dr. L. Bolton Bangs having withdrawn as can-
didate for the presidency, there remained but one name
for each of the following offices: For President, Dr. A.
S. Hunter; Vice-President, Dr. J. Leonard Corning ;
Secretary, Dr. C. H. Avery; Assistant Secretary, Dr. W.
E. Bullard ; Treasurer, Dr. John S. Warren. Dr. Piffard
was instructed to cast an affirmative ballot for the gentle-
men named, which he did. The following Censors were
elected: Drs. Daniel Lewis, George H. Fox, Laurence
Johnson, N. G. McMaster, George A. Abbott. Names
of delegates to the Medical Society of the State of New
York are as follows: Drs. D. H. Goodwillie, William
Stevens, Albert S. Newcomb, Frank B. Carpenter, Samuel
Lloyd, Peter A. Callan, Ralph Waldo, Urban G. Hitch.
cock, William A. Dayton, Charles A. Powers,{Willy Meyer,
Henry D. Chapin, George R. Elliott, John Dorning, Sen-
eca D. Powell, Robert T. Morris, Francis Valk, David
D. Jennings, William C. Jarvis, Malcolm McLean, Egbert
H. Grandin, William P. Northrup, R. C. M. Page, Robert
B. Talbot. Dr. Daniel Lewis read the report, on the
“ Medical Directory,” and said the expenses, which had
been $1,145, would be fully covered by the receipts. He
requested that members send any information which they
might have of change of address, etc., especially‘of those not
members of the Society. . The report was accepted, with
thanks to the editor for the faithful and painstaking manner
in which he had brought out the edition. By unanimous
consent the by-laws were suspended, and Dr. Julius Alt-
haus, F.R.C.P., London, and Mr. Henry Mortis, F.R.C.S.,
London, were nominated for honorary membership. Dr.
J. Leonard Corning read the report of the Board of
Censors, which also included that of the counsel, Mr.
Purrington, regarding the prosecution of illegal practi-
tioners. In eleven out of thirteen cases tried, convictions
were obtained. The annual dues for the ensuing year will
be three dollars. Dr. Richard Van Santvoord read the re-
port of the Committee on Hygiene, which dealt chiefly
with the condition of the public, private, and parochial
schools. ‘There was still overcrowding in many districts.
The new buildings, however, were better arranged, from a
sanitary point of view, than the old ones. Improvements
had been made in many of the latter. Superintendents
and teachers in the parochial and some private schools,
and in Sunday-schools, were the most derelict in comply-
ing with sanitary laws. The Secretary read the report of
the Committee on Ethics, which stated that but two com-
plaints had been made ; in one the parties complained of
were not members of the Society ; in the other sufficient
cause for action had not been shown. Dr. E. H. Grandin
read the report of Committee on Prize Essays, which
stated that but one essay had been offered in competition.
It did not fulfil the conditions requisite in regard to
originality. Dr. O. B. Douglas stated that but one essay
deemed worthy of the prize had been offered in twelve
years. He moved that the Comitia Minora be instructed
to consider the advisability of changing the conditions on
which the prize was to be: awarded. Dr. J. L. Corning
thought it might with advantage be awarded the member
who produced the best paper during the year. The
motion was carried.
A HOSPITAL For Liperia.—Liberia, the colored repub-
lic on the west coast of Africa, founded by the American
Colonization Society some forty years ago, is, according to
Mrs. Jane Rose Roberts, wife of the late President Rob-
erts of the young nation, utterly destitute of institutions in
which her poor and sick people can be cared for. Mrs. Rob-
erts has come to the United States for the purpose of pre-
senting the facts in the case to the friends of Liberia. The
hospital which is needed will cost $20,000, and Mrs. Rob-
erts has thus far in hand $1,400, with $300 promised her
by the American Colonization Society. The nearest hos-
pital to Liberia is the one at Cape Palmas, about three
hundred miles from Monrovia.— Boston Medical and Sur-
gical Fournal.
PROPOSED MEDICAL CONGRESS IN SPAIN.—A meeting
was recently held in the rooms of the Spanish Medico-
chirurgical Society, at Madrid, with the view of arranging
an international medical congress, to be held at Madrid
in 1890. ‘Though the proposal received influential sup-
port, the general feeling was that it would not be desirable
to organize a gathering which should in any way clash with
the Congress at Berlin.
490
Obituary.
PROFESSOR ISAAC E. TAYLOR, M.D.,
. NEW YORK.
THE venerable Professor Isaac E. Taylor, M.D., President
of the Bellevue Hospital Medical College, died suddenly at
his residence in this city, October 30th. He was born in
Philadelphia, April 25, 1812, and graduated from Rut-
gers College, N. Y., in 1830, and received his degree of
M.D. from the University of Pennsylvania in 1834. In
1835 he entered into mercantile business, but returned
to his profession in 1839, settling in this city. In 1840
he visited Paris and entered the office of Professor Ca-
zeaux, and returning to this city in 1841 he commenced
practice by attaching himself to several dispensaries. In
1851 he was appointed visiting physician to Bellevue
Hospital, and was connected with this institution in the
capacities of attending and consulting physician until his
death. He originated the idea of establishing a medical
college in connection with Bellevue Hospital, and carned
it out. He was made the President of the college at the
start, and shortly after was named President for life. He
was also Professor of Obstetrics there, and lectured regu-
larly up to about eighteen months ago. He was a very
active man, and looked sharply after the affairs of the
college up to the time of his death. He was consulting
physician for the Bellevue, Charity, Maternity, and
Woman’s Hospitals, and the New York Infirmary. He
was a member of the Medical Society of the County of
New York, the New York Pathological Society, Physi-
cians’ Mutual Aid Association, Society for the Relief of
the Widows and Orphans of Medical Men, and the New
York County Medical Association.
Dr. Taylor was, during his more active career, a con-
stant and valued contributor to medical literature, and de-
vised numerous original operations which bear his name.
His clinical experience was very large, and his counsel
was eagerly sought and greatly valued, more especially in
his chosen field of obstetrical work. He was married in
1835, his wife dying in 1867, leaving one son and three
daughters.
at eae
a a — a ee | iua
Reviews and Botices of Books.
SYNOPSIS OF HuMAN ANATOMY. By JAMES K. YOouNG,
M.D., Lecturer on Orthopedic Surgery, etc., University
of Pennsylvania. 12mo, pp. 393. Philadelphia and
London: F. A. Davis.
THIS is a very carefully prepared compend of anatomy,
and will be useful to students for college or hospital ex-
amination Itis condensed to the uttermost, and is cal-
culated more for a review manual than for the beginner.
There are some excellent tables in the work, particularly
the one showing the origin, course, distribution and func-
tions of the cranial nerves.
INDEX CATALOGUE OF THE LIBRARY OF THE SURGEON-
GENERAL'S OFFICE, U.S.A. Vol. X. 4to, pp. 1,059.
Washington : Government Printing Office. 188g.
Tuis volume, which is the tenth of this remarkable series,
is of the usual large size, and includes 7,658 author-titles,
representing 2,905 volumes and 7,282 pamphlets. It
also includes 14,265 subject-titles of separate books and
pamphlets, and 29,421 titles of articles in periodicals.
The compiler, John S. Billings, U.S.A., has evidently done
his best to keep the present volume up to the high stand-
ard of its predecessors.
TRANSACTIONS OF THE ASSOCIATION OF AMERICAN PHY-
SICIANS. Third Session. Vol. III. 8vo, pp. 404.
Philadelphia : Printed for the Association. 1888.
THE Association of American Physicians, although in its
infancy, has already made an enviable reputation for
THE MEDICAL RECORD.
\
[November 2, 1889
sound and progressive scientific work. No one will fail .
to appreciate this fact who peruses the admirably written
papers which are collected in its three volumes. ‘The
present one contains the papers read at the meeting in
Washington, September, 1888. Leading with the well-
timed address of the president, Dr. W. H. Draper, we
have the important topics of typhoid fever, Bright’s dis-
ease, and cardiac affections treated from different points
of view by the’members, with here and there an interest-
ing and anomalous case. It would be unjust to the dis-
tinguished gentlemen who contribute to this volume to
make any distinction as to the respective merits of pa-
pers presented. Suffice it to say that all of the topics
are discussed in a very satisfactory if not masterly man-
ner. Itis a pity, however, that so much valuable mate-
rial is buried practically in a volume of “ Transactions,”
which must necessarily have a limited field of usefulness.
A TREATISE ON SURGERY, ITS PRINCIPLES AND PRACTICE.
By T. Homes, M.A. Cantab., Consulting Surgeon to
the St. George’s Hospital, etc., London. Fifth Edi-
tion. By T. PICKERING Pick, Surgeon to, and Lecturer
on Surgery’ at St. George’s Hospital, etc. 8vo, pp.
1,008. Philadelphia: Lea Brothers & Co. 1889.
Tuis work, which has now arrived at its fifth edition, still
maintains its position as a standard text-book on the prin-
ciples and practice of surgery. Not many material alter-
ations have been made, save in the direction to add to its
value. The chapter on eye diseases has been wisely
omitted as unnecessary, in view of the fact that special
works on ophthalmology cover this ground more effectu-
ally and satisfactorily. Among the subjects which have
had more especial and extensive emendation are those on
diseases of the bones and joints, abdominal surgery, and
intestinal obstruction, and the operative treatment in
reference to cerebral localization. Mr. Pick has per-
formed his part of the work with rare judgment and
skill. ‘The book contains many original illustrations
which add much to its merits as a whole.
TRANSACTIONS OF THE NEw YorkK STATE MEDICAL Asso-
CIATION FOR THE YEAR 1888. Vol. V. Edited for
the Association by ALFRED LupLow CarroLL, M.D.
8vo, pp. 610. Concord, N. H.: Republican Press
Association. New York: J. H. Vail & Co. 1889.
‘THe “ Transactions” from this society are always interest-
ing, practical, and instructive. For an association now but
five years old it has done an amount of good work un-
equalled by any other in that period, and is now fairly en-
titled to the first rank among State societies. ‘The methods
of carrying on its discussions are novel and admirable.
Certain topics are selected, and certain leading men are
assigned to discuss them from different stand-points. The
results have been exceedingly gratifying in giving a prac-
tical turn to the solution of leading questions which could
be taken in no other way. ‘The notable features of the `
present volume are the “ Address on Medicine ; or, Medi-
cal New York in 1800,” by Dr. John Shrady ; the “ Address
on Surgery,” by Dr. W. H. Carmalt, of Connecticut ; the
“Introductory Remarks on Tumors,” by Dr. J. W. S. Gou-
ley, of New York, with the exhaustive discussion following
the same, and also the comprehensive and practical discus-
sion on puerperal septicemia. In typography the book
is a model of its kind.
RECTAL AND ANAL SURGERY, WITH DESCRIPTION OF THE
SECRET METHODS OF THE ITINERANT SPECIALISTS. By
EpmMuND ANDREWS, M.D., LL.D., Professor of Clinical
Surgery, Chicago Medical College, and EpwarD WYLLYS
ANDREWS, A.M., M.D. Second Edition. 8vo, pp. 137.
Chicago: W. T. Keener. 188g.
‘THE second edition of this practical work has been revised
and somewhat enlarged. It is an excellent work for the
general practitioner, and contains much useful and well-
digested information regarding the treatment of the com-
moner and more troublesome affections of the rectum and
anus.
MEDICAL RECORD
November 2^4 |889 >
VARIOLA - SMALL POX.
From Dr. P A.Morrows Atlas of Venereal and Skin Diseases.
WILLIAM WOOD & COMPANY. Publishers.NEW YORK. u” oar
November 2, 1889]
TRANSACTIONS OF THE AMERICAN SURGICAL ASSOCIATION.
Vol. II. Edited by J. Ewinc Mears. 8vo, pp. 225.
Philadelphia: P. Blakiston, Son & Co. 1889.
THE present volume is much smaller than any of its pre-
decessors, but is not proportionately better. It contains
some excellent papers, however, among which may be
mentioned “ The Early Diagnosis of Malignant Growths,”
by Dr. J. Collins Warren, of Boston; ‘ Hernia,” by Dr.
Claudius H. Mastin, of Mobile; “ The Anti-tubercular
Power of Iodoform,” by Dr. Lewis S. Pilcher ; “ On Gun-
shot Wounds of the Intestines,” by Dr. Theo. A. McGraw,
of Detroit, Mich. ; and “ Distended Gall-bladder simulating
Floating Kidney,” by Dr. J. Ewing Mears, M.D., Phila-
delphia.
A HANDBOOK OF GENERAL PATHOLOGY. By Dr. Eb-
win Ktess. Part Second. General Pathological
Morphology. Pp. 836. Jena: Gustav Fischer. 1889.
(Die Allgemeine Pathologie.) .
IN none of its phases has pathology fairly recovered its
equilibrium, since the powerful impetus was given to eti-
ology by the discoveries of Koch and the formulation of
a new bacteriological technique, less than a decade ago.
It actually seemed for a time as if work in morphological
and physiological pathology along the old lines was to be
largely neglected, and the results of the older work insig-
nificant in comparison with the new achievements which
each day recorded in the fields of bacteriology. But we
have learned a good deal in these few years, not only about
what does, but about what does not, cause disease. We
have learned that a great deal of exact and painstaking
work is required to establish an etiological relationship be-
tween a given bacterium and the disease with which it is
associated. And what is more to the point, we have learned
that even when this etiological relationship is fully estab-
lished, we have only just begun to solve the problems which
a complete knowledge of its pathology demands. We are
now far enough away from the glamor of the new light to
be able to judge of proportion more accurately, and can
now see that both the morphological and the physiologi-
cal phases of pathology are rapidly advancing, although in
a direction which has been considerably changed by the
new bacterial discoveries and by the new technique.
The older accumulations of knowledge in morphology,
which are embodied largely in the works on pathological
anatomy and histology, have undergone some revision in
view of etiological researches, but barring the new addi-
tions, remain substantially the same. _It isin general pathol-
ogy that the results of recent work and discovery are most
conspicuous. But general pathology is a theme which in
this country secures very little special attention, either in
the medical schools or among practising physicians. Fall-
ing in the colleges usually to the lot of the professor of
practice, it cannot or does not, unless he be a competent
pathologist, secure the attention which it intrinsically de-
serves. Glimpses‘here and there of the causes of disease
and of the highly significant degenerative processes the
student may indeed catch. ‘The results of inflammations
and the appearances and general phenomena of tumors
he can become acquainted with in a desultory way. A
knowledge of bacteriology as related to disease usually
comes to him only in the most fragmentary way, and then
frequently from a lecturer who, unfamiliar with its practi-
cal details and incapable therefore of deciding what are
its just proportions, contents himself with an attitude not
always simply of intelligent scepticism, but frequently of
levity or downright hostility, or largely ignores the subject
altogether. Laboratory instruction can do something, but
when its practical work is done there still remains want-
ing, for the most part, that point of view which harmonizes
and correlates the multitudes of facts and which comes
- from the study of general pathology. For students whose
horizon is wide enough to reach beyond the limits of the
final examination and the diploma, for medical men who
are unfamiliar with all the bearings of the new discoveries
on their previous knowledge, and for teachers who need a
THE MEDICAL RECORD.
491
full exposition of our knowledge in a most intricate field,
and references to the rapidly widening literature, the work
of Klebs, on general pathology, will be most welcome.
The first part of the work, which dealt with the causes of
disease—“ General Pathological Etiology, including Bac-
teriology ”—appeared in 1887. ‘The second part, compris-
ing “ General Pathological Morphology,” and dealing at
length with the degenerations, with inflammation, and with
tumors, is now in our hands. This book, containing over
eight hundred pages and numerous colored plates, shows
like the first part, in all its details, that frich and varied
practical experience, that broad and scholarly conception
of his theme, and that enthusiasm for his work which those
who know Professor Klebs as a writer, or personally as a
teacher and investigator, would naturally expect. We
must await the completion of the work by the issue of
Part III., on “ General Pathological Physiology,” before
an attempt is made to estimate its varied features in detail.
CYCLOPÆDIA OF THE DISEASES OF CHILDREN, MEDICAL
AND SURGICAL. The Articles written specially for the
Work by American, British, and Canadian Authors.
Edited by Joun M. Keatinc, M.D. Vol. I. Illus-
trated. Philadelphia : J. B. Lippincott Co. 188ọ.
To those. who have failed to keep note of the wonderful
activity among the students of disease in infancy and
childhood the appearance of a work such as the one be-
fore us will be a revelation. Here are four large octavo vol-
umes, of over eight hundred pages each—the first, indeed,
has very nearly one thousand pages—devoted exclusively
to a study of the peculiarities of disease occurring in the
young. It shows what progress medicine is making in our
times, for, as Dr. Jacobi truly says in his introductory
chapter, such a collection of monographs as are here pre-
sented could not have been written at the time when he
began his professional life.
In a brief notice of this kind we cannot do more than
indicate the contents of this first volume, any extended
review of the individual articles being, of course, impossi-
ble. Even to set down the titles alone of these articles
would take up much of the space allotted to notices of
this sort, since there are forty-one separate monographs
by nearly as many authors. ‘The work opens with an in-
troduction by Dr. A. Jacobi, of this city, in which are set
forth the peculiarities of constitution of children, by rea-
son of which disease occurring in them undergoes certain
modifications of the type seen in the adult, and is there-
fore a sort of apologia for pediatrics. In Part I. are con-
sidered general subjects, such as the anatomy of the child,
nursery hygiene, the diseases of the foetus, general diag-
nosis and therapeutics of infancy (the latter for some rea-
son placed at the end of the volume instead of in its
proper place), the pathology and hygiene of puberty, in-
fant-feeding, etc. ‘The Second Part is devoted to fevers
and miasmatic diseases occurring in children It seems
odd to read here an article on yellow fever, yet it is as justly
entitled to consideration in a work of this kind as is ty-
phoid fever or small-pox. The illustrations are numerous
and of a high order of excellence.
In concluding this short notice we cannot refrain from
congratulating the distinguished editor upon the happy
inception of such a work as this, and we feel a measure
of pride in thinking that the book is an American one.
There are, it is true, several contributors from England,
and their articles add not a little to the value of the book.
But these are comparatively few; the editor is an Ameri-
can, the publishers are American, and the work itself is
one which American medicine may justly claim as its own,
and for which it has no cause to feel ashamed. It is at
once an evidence of the progress made by students of
pediatrics in this country, and a foundation upon which
these and other workers may build in the years to come.
The book is valuable to every family practitioner, whose
work is so largely among children and whose success in
his profession will depend in great measure upon the skill
with which he handles these miniature men and women.
492
THE MEDICAL RECORD).
[November 2, 1889
THE LiFe REGISTER.
1888.
THIS is a small book intended for recording the growth,
health, etc., of children. The use of such registers is
Increasing, and their interest and value cannot be ques-
tioned.
London: West, Newman & Co.
LECTURES ON Nervous DISEASES. From the Stand point
of Cerebral and Spinal Localization, and the Later
Methods Employed in the Diagnosis and Treatment of
these Affections. Pp. 778. By Amsrose L. RANNEY,
A.M., M.D. Philadelphia: F. A. Davis. 1888.
Dr. RanneEy’s book consists of sections upon the anatomy
and physiology of the nerve-centres; upon the clinical
examination of patients ; sections upon nervous diseases,
and upon electricity in medicine, the latter section being
made up chiefly of his already published treatise upon this
subject.
The parts upon nervous diseases proper, and especially
upon functional nervous diseases, will be found of most
interest. The author entertains, as we believe, very ex-
aggerated views as regards the influence of anomalies of
the ocular muscles and of eye-strain, in producing nervous
disorders, ‘Those, however, who wish to know about and
test these methods will find descriptions of the technique
here. The chapter on Electricity is somewhat sanguine,
but is on the whole a good one. We can hardly say as
much regarding the anatomical part. The colored dia-
grams give picturesqueness to the pages, but the author
seems at times to have sacrificed anatomical accuracy to
. chromatic effect. ‘There is, however, much in this section
also which will be found convenient and instructive.
SUGGESTIVE ‘THERAPEUTICS. A Treatise on the Nature and
Uses of Hypnotism. By H. BERNHEM, M.D. Trans-
lated from the second and revised French edition, by
CHRISTIAN A. HERTER, M.D. Pp. 420. New York
and London: G. P. Putnam’s Sons. 1889.
WE have already called attention to the work of Dr.
Liebault and Professor Bernheim in the domain of mental
hypnotism, and have affirmed our belief in the essential
soundness of their views regarding this subject. Hypno-
tism has passed from the domain of empiricism and is now
being made the object of careful scientific study. Its
power in therapeutics is no longer questioned. Its prac-
tical usefulness and its safety as remedial measures re-
main stil] to be determined. The presentation in English
of Bernheim’s book will enable American readers to learn
the views of scientific men who advocate the use of hypno-
tism by the physician, and they can themselves test and
judge regarding it. We trust that no one will fail, in look-
Ing over this work, however, to read carefully the chapter
on the dangers of hypnotism, which are there candidly
stated. It will certainly make everyone feel that he can-
not be too careful in applying it. Dr. Herter has made
an excellent translation.
THE INSANE IN FOREIGN CounTRIES. By WILLIAM P.
LETCHWORTH. New York and London: G. P. Put-
nam’s Sons. 1889.
Mr. LETCHWORTH has written a most interesting book,
not alone to physicians, but to all interested in the care of
the insane. It contains the record of many months’ care-
ful study under most favorable conditions ; and the pages
are illustrated with cuts and photo-lithographs which put
the volume almost on the plane of an edition de luxe.
A HANDBOOK OF ‘THERAPEUTICS. By SIDNEY RINGER,
M.D. ‘Twelfth edition. Pp. 524. New York: Wil-
ham Wood & Co. 1889.
Few therapeutical works are so rich in practical sugges-
tions as this of Dr. Ringer, and no therapeutical author
has been more extensively quoted or followed. Ruinger’s
work is a classic, and its usefulness and popularity are at-
tested by its numerous editions. A valuable feature of
Dr. Ringer’s work is the part devoted to general symp-
toms, regarded from a therapeutic point of view. The
author also gives many practical hints and directions
about other remedial agencies than drugs.
A TEXT-BOOK oF Human PuysioLocy. By AUSTIN
Fut, M.D., LL.D. With three hundred and sixteen
figures in the text and two plates. Fourth edition,
entirely rewritten. Pp.872. New York: D. Appleton
& Co. 1888.
As stated on the title-page the present edition is entirely
rewritten. By leaving out historical references and un-
necessary discussions the work is, however, not increased
in size. One new plate and sixty-one new figures have
been introduced ; and two plates and sixty-three figures
left out.
An examination of the new work produces, on the
whole, a most favorable impression. It is a good students’
text-book, and no doubt will continue to merit its former
well-deserved popularity.
TRAITÉ D’HysT£ROTOMLE ET D’HySTERECTOMIE PAR LA
VOIE VAGINALE. Par le Dr. LAURENT SECHEYRON.
Précédé d’une Préface de M. P£an. Paris: Octave
Doin. 1889.
A TREATISE ON HySTEROTOMY AND HYSTERECTOMY BY
THE VAGINAL METHOD. By Dr. SECHEYRON. With
a Preface by Dr. P£AN. Paris, 1889.
A STUDY of this bulky volume will strengthen an al-
ready widely accepted view, namely, that the vaginal
method of extirpation of the uterus is the proper one
for malignant disease of that organ. Péan does not em-
ploy sutures, using instead his well-known hemostatic
forceps to control all bleeding. The work before us
contains, in the main, French statistics, and is interesting
on that account to all those who wish to remain au fait
of the special work done by the French in this branch of
surgery.
Surcicat BacrerioLocy. By Nicolas Senn, M.D.,
Ph.D., Professor of Principles of Surgery and Surgical
Pathology, Rush Medical College, Chicago. 8vo,
pp. 270. Philadelphia: Lea Brothers & Co. 1889.
Tuis is a well-prepared résumé containing the essentials
of our knowledge regarding the bacteria of surgical dis-
eases. The compiler has selected his data with good
judgment, and presents them in a clear and concise
manner. As an introduction to the study of physical
bacteriology the unpretentious little volume will serve a
good purpose.
LEÇONS DE GYNECOLOGIE OPÉRATOIRE. Par VULLIET
et Lutaup. Paris: I. B. Bailliére et Fils. 1889.
LESSONS IN OPERATIVE GYNECOLOGY. By Drs. VULLIET
and Lutaup. Paris, 1889.
Drs, VuLLIET and Lutaup have here collected a series
of essays on many of the most important questions of
modern gynecology. Several controversial matters are
discussed in a spirit of fair criticism, and while no great
amount of originality is displayed, the authors show that
they have good judgment and a large experience. These
essays will be read with interest by all who are interested
in surgical gynecology.
LECONS DE CLINIQUE CHIRURGICALE PROFESSEES A LA
SALPRTRIBRE. Par O. TERRILLON. Paris: Octave
Doin. 1889.
CLINICAL LECTURES ON SURGERY.
Salpêtrière. By Professor Terrillon.
Dr. TERRILLON is one of the leading surgeons of the
French capital. Those who wish to familiarize them- |
selves with the latest surgical tenets of the French
school will do well to peruse those instructive class-room
lectures. It will be seen from their study that modern
surgery is international.
Delivered at the
Paris.
November 2, 1 889 |
Society Reports,
NEW YORK ACADEMY OF MEDICINE.
Regular Meeting, October 17, 1889.
THE PRESIDENT, A. L. Loomis, M.D., IN THE CHAIR.
GUNSHOT WOUNDS OF THE ABDOMEN, WITH SPECIAL REF-
ERENCE TO WOUNDS OF THE INTESTINES.
Dr. Lewis A. Stimson read the paper. It contained
reference to the statistics of operative interference in
cases of gunshot wounds of the abdomen prior to 1875;
the cases were very few, the operation was very generally
- condemned, and had been performed only where there
was positive evidence of intestinal perforation. Such
cases dated from Boden’s, in 1831. Since 1876 the cases
operated upon in the Chambers Street, New York, and
Roosevelt Hospitals showed a mortality of 81.2 per cent.,
while those not operated upon showed a mortality of
sixty-five per cent. He added to the recent statistics
three cases which had entered his hospital service, one of
which was operated upon during his absence, by the house
surgeon, and died; one of the others died, the other re-
covered. But no general rule could be laid down in favor
of either interference or non-interference. The selection
of cases in which to operate, however, was difficult. After
general peritonitis or septiczemia had set in an operation
would be likely only to hasten death, and reduce the per-
centage of recoveries from interference, and therefore
should not be undertaken further than to establish drain
age. When the ball had entered the abdominal cavity
it was almost sure to have perforated some of the viscera,
particularly if its direction were not oblique.
He offered objections to rectal injection of hydrogen
gas for diagnostic purposes, pronouncing it distinctly in-
ferior to exploratory incision in facility, efficiency, and
security.
Dr. Joun A. WYETH thought the question of whether
to operate or not was in almost as much doubt, notwith-
standing further statistics, as it was nine years ago when
Dr. Sims read a paper on the subject. He quoted the
conclusions contained in that paper, as they appeared in
‘THE Mepicat ReEcorp, October 5, 1881, as expréssing
his views to-day. There could be no fixed rules regard-
ing interference and non-interference ; the surgeon would
have to be guided by the condition of the patient, situa-
tion of the wound, direction and size of the missile. When
the opening was smal], the mucous membrane of the in-
testine might pout and prevent extravasation. After ex-
travasation and the development of peritonitis the estab-
lishment of drainage was all that could be hoped for from
operative interference.
Dr. ROBERT ABBE had seen large perforations made
by bullets of twenty-two calibre. Extravasation was less
likely to take place if the perforation was near the mesen-
teric attachment than if on the other side, as he had ob-
served in one case. If the patient were seen in time, an
exploratory operation should be made. ‘The absence of
blood from the urine was not proof that the bladder or
kidneys had not been injured. Immediate anastomosis
should not be advocated, since to prolong the operation
even some minutes might be the cause of a fatal termina-
tion. He also condemned injections of hydrogen gas for
diagnostic purposes.
Dr. WILLY MEYER had opcrated on a man who had a
bullet-wound of the abdominal walls anteriorly. The
bullet could be felt near the spinal column; he had hæ-
moptysis, and had also once vomited blood from the
stomach. Yet at the operation the outer wall of the stom-
ach near the cardia was found only to have been scratched
. by the bullet, the mucous membrane not being divided.
The patient died after about fourteen hours, but no autopsy
was obtained. In Vienna a patient was shot in the ab-
domen, did not vomit blood, recovered, had hzmateme-
THE MEDICAL RECORD.
493
sis after six months, died, and at the autopsy it was found
that the bullet had passed through the stomach, making
two perforations, which had healed but reopened, causing
the hemorrhage. Dr. Meyer thought the technique of
this form of abdominal surgery would improve, and that
it would be safer for the patient to have the abdomen
opened than left alone.
Dr. B. F. Curtis thought the statistics contained in
the paper were unreliable, as being unfairly prejudicial to
operative interference by able surgeons. ‘They might make
a better showing if the cases of bad operators could be
ruled out. He was glad to see the operation when prac-
tised upon moribund patients condemned. Here drain-
age would effect all that could be hoped for.
Dr. THomMas MANLEY mentioned some points in a case
which he saved by operation, and reported two years ago.
More recently he had seen two other cases in which it was
known that the lower part of the lungs was penetrated,
but it was not positive that the stomach had been touched.
One man recovered without an operation, the other died
shortly from internal hemorrhage. Operative interference
should not be delayed, not even on account of shock.
Dr. Stimson closed the discussion, and said one could
not be guided by the size of the bullet in deciding whether
to operate or not. Replying to Dr. Curtis, he said one
operator could give one hundred as his percentage of re-
coveries, but he had had only one case.
Collective experience in these cases might be of advan-
tage in determining when to operate, but improvement in
technique would have to come from experience in general
surgery.
A PORTRAIT OF DR. HOWARD PINCKNEY
was presented by the family, and was accepted by the
Academy with a vote of thanks to the donors.
SECTION ON SURGERY.
_ Stated Meeting, October 14, 1889.
ROBERT ABBE, M.D., CHAIRMAN.
PRESENTATION OF CASES.
Dr. F. B. Curtis presented a case of
SUTURE OF THE DIVIDED FLEXOR TENDONS OF THE HANDS.
A young man, a year ago last July, sustained a wound of
the left forearm by glass, dividing all the flexor tendons.
The tendons were sutured immediately after the accident,
and all healed by first intention excepting. one, which
sloughed and healed by granulation. A depression was
left at the place of sloughing. ‘The patient afterward
had considerable power in the flexors, which had contin-
ued to increase, yet Dr. Curtis thought his condition might
be improved by freeing the tendons from the cicatricial
tissue which surrounded them.
‘THE CHAIRMAN thought the question of further repair
was one of a great deal of interest. He saw no reason
why the tendons might not be isolated where they were
bound down by cicatricial tissue and allowed to take their
place after separation in new cellular tissue, which would
permit of free use.
Dr. REGINALD SAYRE called attention to the case pre-
sented by Dr. A. M. Phelps last spring, in which a cut
across the forearm had divided all the flexor tendons and
these had united ina mass. Dr. Phelps afterward dis-
sected them out, separated them, and allowed union to
take place under blood-clot. He understood the result
had been good.
Dr. A. M. PHELPs said that motion in the hand in that
case had been somewhat improved, but the result had not
been as good as he had expected, and not as good as It
had been in two other similar cases. He thought the
man had used the hand a little too much; the result
would have been better, he believed, had it been kept in
the splint in the extended position five or six weeks, per-
mitting of a little active motion once perhaps in two or
three days.
494
EXCISION OF TUBERCULAR BODIES IN THE SHEATHS OF
THE FLEXORS OF THE THUMB AND INDEX AND LITTLE
FINGERS.
THE CHAIRMAN presented a woman on whom he had
excised the sheath of the flexors of the thumb and index
and little fingers because of the growth of melon-seed
bodies, now recognized to be the result of tubercular in-
flammation. The case was interesting in connection with
the question of secondary operations to free divided ten-
dons. Notwithstanding complete removal of the sheath of
the tendons in this case, and in other cases, freedom and
power of motion had afterward been complete. The
wound, of course, must be kept antiseptic, and primary
union take place, without any pus. In his case only vol-
untary motion was resorted to; this was begun on the
sixth day.
Dr. Curtis related the case of a girl who, last winter,
had suffered from an attack of cellulitis in the hand.
When he saw her shc had entirely recovered, but the right
forefinger was bound down by adhesions in the tendon at
the metacarpo-phalangal joint. He laid back a flap,
found the tendon and its sheath bound together in a mass
of fibrous tissue, dissected them apart, put the finger in
extension, closed the wound, kept up active motion, and
had a result of normal power and motion.
HEALING UNDER BLOOD-CLOT FOLLOWING PARTIAL EXCIe-
SION OF BONES OF THE ANKLE.
Dr. A. M. PHELPs presented a boy, about seven years
of age, who had been submitted to excision of the astrag-
alus for tubercular disease of the ankle-joint. The disease
rzlapsed, other bones becoming involved, and a surgeon
had condemned the case for amputation. The patient
then came under Dr. Phelps’ care, and he opened the
joint, followed sinuses down to the bones, and scraped
nearly all the bone out of the periosteal covering except
in the cuneiform. After suitable dressing without ligation
of the vessels, the Esmarch bandage was taken off and
the cavities allowed to fill with blood. The dressing was
not changed for three weeks ; union was primary ; at the
end of five weeks the bones had become solid, there hav-
ing been reproduction of the os calcis, cuboid, and
scaphoid. ‘There was very good motion of the ankle-
joint, the child walking as well as he hadeverdone. The
operation was done last May. A plaster-of-Paris dressing
was worn some time after the fifth week.
EXSECTION OF THE ANCHYLOSED KNEE, UNION BY BLOOD-
CLOT.
Dr. Phelps also presented an Italian girl who, when
five years of age, had had extensive osteo-myelitis, involv-
ing apparently the entire tibia, fibula, and femur. The
knee was anchylosed at a right angle. ‘Ihe patient had
Jain in bed five years. The question was debated whether
to amputate or to exsect the knee. The latter method
was adopted in November last, and it was Dr. Phelps’
intention on cutting down upon the knee to perform Fen-
wick’s operation, making the end of one bone concave
and the other convex, but he found tubercular or fatty
degeneration in the interior of the femur and tibia, and
consequently scraped them out, leaving only the shell,
which he coaptated in a straight line by wires, allowing
the cavities to fill with blood. When the first dressing
was changed, at the end of five weeks, the clots had or-
ganized and formed bony union.
Dr. Powers inquired of Dr. Phelps what histological
changes took place in the reproduction of bone through
blood-clot.
Dr. PHELPS replied that the blood-clot itself was not
supposed to organize, but that it acted as a framework
for the growth of the cell-tissue which took place in it,
constituting the normal elements in that particular local-
ity. As the new tissue formed the blood-clot became
absorbed.
THE MEDICAL RECORD.
[November 2, 1889
Dr. B. F. Curtis read a paper (see p. 449) on
KNOTS, LIGATURES, AND SUTURES.
THE CHAIRMAN thought the paper showed in modern
surgery a weeding-out process as regarded numerous
methods formerly employed to accomplish the same ob-
jects. He thought this might be carried a little farther
by dropping the hare-lip pin and excluding from the list of
operations lumbar colotomy, its place being taken by in-
guinal colotomy. He had noticed that some operators, in
tying a ligature around a bit of a bleeding vessel, dropped
the forceps before making the second knot. He thought
this was no more convenient than to leave the clamp on
until the knot had been completed, and was somewhat
unsafe, inasmuch as a bit of tissue dropped by the forceps
might enter between the knots. In certain cases, as in
wounds about the face, it was sometim >s desirable to stuff
the wound with iodoform gauze, take it out after twenty-
four or forty-eight hours, and insert sutures. He had
learned by experience to avoid giving the patient pain, if
an anesthetic was not given, by introducing the sutures at
the time of the operation, and tightening them at the second
dressing. The wound was sticky, and primary union took
place with as narrow a cicatrix as usually took place when
the sutures were tied in the first instance.
Dr. REGINALD Sayre believed the buried shoemaker’s
stitch had not been mentioned. It was very desirable in
certain plastic operations. a
Dr. DawsaRN called attention to a way of obviating
the tendency to a fold at the end of the continued suture,
namely, by threading the needle at both ends and begin-
ning in the middle of the wound. He also said that the
surgical knot was not so likely to loosen before being tied
the second time if the first portion were jammed in the
angle of the wound by a sudden half-twist of the two sut-
ure ends. In gastrotomy it was surprising to observe how
rapidly union took place by scratching the opposing peri.
toneal surfaces. He had recently used Abbe’s catgut
rings in a case of enterotomy, and although the patient
died of shock, yet the rings were readily applied and gave
great satisfaction.
THE CHAIRMAN having spoken of an apparent fracture
at the end of a finger, consisting, probably, in rupture of
the extensor tendon, which in one case he cut down upon
and sutured, Dr. Gibney said he had seen similar cases,
and had had opportunity in one to test hyperextension
kept up long enough to cure the case. ‘The Chairman
thought Dr. Gibney’s method, where it could be carned
out, was preferable to suturing. Dr. Van Arsdale had
cured one such case by a splint.
Dr. A. J. McCosu read a paper giving a
REPORT OF A CASE OF NEPHRO-LITHOTOMY FOLLOWED BY
NEPHRECTOMY.
The symptoms pointing to renal calculus had existed three
years or longer, which various kinds of treatment had
failed to relieve, until in July last he cut down through
the lumbar muscles, and removed through kidney tissue
proper a calculus which was felt in the pelvis of the organ.
‘The stone weighed one hundred and twenty-two grains.
The kidney was apparently little diseased, and no pus
escaped. Two sutures were placed in the capsule, draw-
ing the incision together. Pain ceased; the urine for a
while contained blood ; after a few days some pus escaped
through the dressings, but at the end of three weeks the
patient got out of bed, and was considered well, except
for the granulating sinus in the loin. On the afternoon
of the thirtieth day from the operation the patient com-
plained of pain in the region of the kidney; passed some
blood in the urine; the pulse increased. ‘The symptoms
continued next day; the sinus in the loin was broken up.
The symptoms growing worse, the finger was pushed down,
it was supposed, upon the kidney, reopening it apparently,
for urine and blood discharged. ‘The hemorrhage was
controlled by iodoform gauze. ‘The urine containing pus,
on the fourth day the packing was removed, and it was
November 2, 1889]
thought the hemorrhage from the wound would not recur,
but it proved more profuse than on the previous day. It
continued after the dressing, as indicated by the urine,
and the next day, the thirty-fifth after the primary opera-
tion, it was determined to cut down and freely expose the
kidney. The last rib had to be excised to permit of draw-
ing the kidney well up into the wound. It was removed.
It contained another small calculus. The edges of the
previous wound were sloughing, and the whole organ was
congested. Some hours after this operation there was
complete suppression of urine, and the patient died within
thirty-two hoursin a state of coma. Dr. McCosh thought
it probable that the nephrectomy would not have proven
more successful had it been done on the afternoon of the
thirtieth day.
THE PRACTITIONERS’ SOCIETY OF NEW
YORK. l
Stated Meeting, October 4, 1889.
V. P. Gisney, M.D., PRESIDENT PRO TEM.
Dr. V. P. GIBNEY read a communication (see p. 482) en-
titled,
THE MECHANICAL TREATMENT OF DROP-WRIST AND ALLIED
PARALYSIS.
Dr. Dana said that the apparatus, if really of the value
apparently shown, would be a most valuable addition to
the therapeutics of this disease. In his experience wrist-
drop from lead and pressure was the common form of the
peripheral paralyses, among the working-classes at least,
and it was sometimes very intractable to treatment. The
_ history of Dr. Gibney’s case seemed to show that the ap-
paratus was of positive value.
Dr. G. F. PEasopy, while ready to admit clinical demon-
stration of the value of the treatment, could hardly under-
stand how the splint could secure such results by simple
immobilization.
Dr. Gipney thought that the modus operandi was by the
entire rest it gave to the muscle.
Dr. Bryant thought the interesting question was whether
rest of the wrist would cause recovery more quickly than
if it were allowed to be exercised. ‘The natural view was
that in a case of paralysis of the muscles a certain amount
of exercise promoted their recovery.
Dr. G1BNeEy also reported a case of
. SUPPURATIVE OSTEITIS OF THE KNEE-JOINT.
The patient I present this evening is one who was left
me as a legacy in the Hospital for the Ruptured and
Crippled in November, 1887. The boy had been for many
years an inmate of the hospital, under treatment for hip
disease. ‘The active disease had long since expended it-
self, and there remained a high degree of deformity of the
left hip, which I proceeded to treat by manual force under
ether at different sittings, and finally employed the protec-
tion hip-splint which he now wears. The history of the
right knee dates from September, 1888. ‘The cause of the
invasion of disease here has not been discovered. ‘The
substance of the notes taken from the hospital record is
as follows :
September 8, 1888.—For the past week has com-
plained of pain ‘about the nght knee, and for the past two
days the pain has been very severe. ‘The right knee is
sharply flexed, and there 1s much reflex spasm. The hip
functions are found to be perfect, but the normal contour
of the knee has changed somewhat. ‘There is noevidence
of synovial distention, but there is considerable tenderness
over the inner head of the tibia. A diagnosis of osteitis
is made, and the knee is put up in plaster-of-Paris.
September 13th.—Knee found greatly swollen from
distention of fluid, patella cannot be made to touch the
inner condyloid space ; has some cellulitis on the inner
aspect of the knee. An aspiration into the joint relieves
him of nearly two ounces of thickish serum.
On September 15th an incision made over the head of
THE MEDICAL RECORD.
495
the tibia into an abscess, with evacuation of about an
ounce of pus.
September 2oth.—-Has obtained some relief, but the
sinus is still open.
By October 1st discharge was very profuse, boy suffer-
ing very much, and a bracketed splint 1s applied in order
that the knee can be the better dressed.
October 5th.—His suffering has been very great. The
synovial sac is much distended. ‘The tenderness and
soreness over the head of the tibia is such that no local
applications give any relief. Under ether to-day an in-
cision one and one-fourth inch in length is made over the
inner head of the tibia, right side, and the bone in this
locality is found to be quite extensively softened, the
tissue being broken down so that the finger can be in-
serted well into the head. The parts are thoroughly
scraped with a Volkmann's spoon, and all necrotic tissue
thoroughly removed. The cavity is about one and one-
half inch in depth. ‘There was very little hemorrhage.
Before completing the operation the whole cavity is cau-
terized with the tip of the Paquelin cautery, and after
washing out with sublimate solution, is packed with iodo-
formized gauze, and dressed antiseptically throughout.
The joint-cavity is not invaded by the operation, but a
large needle of an aspirator is introduced, when about
two ounces of serum is withdrawn containing a number of
flocculi. The sac is then washed out with carbolic acid,
I to 40, and the limb put up in a plaster-of-Pans bandage.
October 7th.-—Patient is doing well, gauze is removed
and found to contain very little discharge. Temperature
yesterday evening was 101}° F.
November 7th.—His improvement has been uninter-
rupted, he has gained flesh, his intellect, which, by the
way, was apparently much impaired before the operation,
has become clearer. The special impairment of intellect
was a moroseness, peevishness, with some muttering oc-
casionally, which made us very anxious about the mental
condition.
On December 5, 1888, the plaster-of-Paris is removed.
Knee found in excellent condition, motion over an arc of
from 15 to 20 degrees ; no joint effusion ; wound healed, |
no sinuses. From this time until March 16th there was
nothing of special importance. We kept him ina wheeled
chair for a long time, gradually left off all dressings from
the limb, and on March 2oth he was discharged with
function of knee about perfect, able to walk about, and
had not complained of any pain or inconvenience for two
or three months. He was provided with a canvas knee-
lacing as protection, and has been attending occasionally
the out-patient department to have his hip-splint attended
to.
October 2d.—I saw him in the out-patient department
to-day and found his knee still in excellent condition, and
it is as you see it this evening. His range of motion
seems to be perfect, there is no synovitis present, and the
cure is complete.
Dr. BRYANT said he had only seen three cases where
the knee-joint was implicated indirectly.
Dr. SHRADY stated that, in cases of abscess of the head
of the tibia, it was almost astonishing to know how closely
the cartilage of incrustation could be invaded in an op-
eration without extension of trouble to the knee-joint.
In two cases which he had operated upon recently the
partition was exceedingly thin, but no trouble followed
the operation. In the majority of cases of extension of
inflammatory processes which had come under his obser-
vation the route of involvement of the joint was more or
less indirect, by burrowing underneath the cartilage, and
around and through the ligamentous tissues surrounding
the joint.
Dr. Josera D. BRYANT presented specimens removed
in a case of
STRANGULATED HERNIA.
The specimens presented were the omentum, which had
been removed previously from an old and recently stran-
496
THE MEDICAL RECORD.
[November 2, 1889
gulated entero-epiplocele, together with the sac, which was
ligatured, cut off, and the wound treated by the open
method for radical cure. The specimens were intended
to illustrate the evil effects following persistent, continu-
ous, and forcible taxis for forty minutes or so, with the
patient under the effects of an anesthetic. ‘The omental
contents, together with the sac, were inflamed to a degree
giving rise to a capillary oozing from the newly formed
vascularity of the continuous surfaces of the sac and its
contents. Only the superficial layers (integument and two
layers of superficial fascize) had escaped recent agglutina-
tion with the remaining agglutinated coverings of the her-
nial protrusion. Twenty-four hours after the taxis the
patient’s temperature had risen to 1qQ1$° F.; pulse, 96 ;
the contiguous tissues were swollen, oedematous, tender,
and somewhat painful.
method of treatment was performed. At the end of four
days the condition of the tissues was such, as the re-
sult of the vigorous taxis, that any other than the open
method of treatment was deemed to be inexpedient, if
not unsafe.
Dr. SHRapy said that patients generally had a better
chance when the operation was done at once than to
trust to taxis, as ordinarily done by the general prac-
titioner. He had seen more damage from injudicious re-
sort to taxis than from any other source. He thought it
ought to be the rule that if a well-qualified man cannot
succeed in reducing the hernia under ether, the operation
should be done before the patient was allowed to wake
up. In other words, never attempt taxis, under ether,
unless everything is prepared for an immediate operation.
Dr. ROBINSON inquired with regard to the old method
of applying a rubber bandage in such cases.
Dr. Bryant said that in an irreducible hernia the rub-
ber bandage might answer, but in strangulated hernia it
would not.
Dr. Dana read a paper (see p. 478) entitled
ELECTRICAL INJURIES, WITH REPORTS OF SOME CASES.
_ Dr. Bryant said that he had only seen one case, and
that, he thought, was one which Dr. Dana had already
reported. The man suffered very severe surgical injuries
of the hand, and the hand finally had to be amputated.
Dr. HERMAN M. Biccs said that, through the courtesy
of the coroners’ physicians, he had been invited to view the
bodies of five persons who had been killed by shocks
from the electric-light wires. In four of these autopsies
had been performed.
The first case was that of a boy aged fifteen years who was
killed in April, 1888. While passing along the street he
grasped a broken telegraph wire which hung from an elec-
tric-light wire. He instantly fell to the ground with some
convulsive movements, and when persons who saw him
fall reached him he was dead. In this case there were
no superficial bums. ‘The accident occurred on a wet
morning, just after a severe rain.
In April, 1888, a few days after the accident in the
previous case occurred, a clerk grasped the support of a
low hanging electric light on the Bowery, while he was
standing on some iron doors leading to the cellar. He
fell with some convulsive movement to the ground, dead.
In this case there were some extensive burns of the
thumb and index and middle fingers of the nght hand.
This accident also occurred on a wet day.
In May, 1888, a lineman while repairing wires on the
second floor of a building on Murray street, lost his bal-
ance and grasped a supposed dead wire and was instantly
killed. ‘There were extensive burns of the hand and also
burns over both knees, about two and a half inches in
diameter. He was kneeling at the time of the accident
on an iron window-casing. His trousers and drawers
were burned through at the knees where they rested on
the iron casing.
In the early part òf the present year an engineer was
found lying on the floor, dead, near a dynamo in the
‘The operation for the open -
engine-house of one of the electric-light ‘companies.
There were no external injuries found on the body.
In September, 1889, the superintendent of an electric-
light plant was killed instantly by coming in contact with
an electric-light wire. ‘There were severe burns found
on the hands and on one arm in this case.
Autopsies were performed in the first four cases | de-
tailed above, and with the exception of the fourth case,
in which no lesions of any kind were found, the changes
in the viscera were practically the same and were briefly
as follows: The blood was dark and fluid everywhere,
the viscera were congested, especially the lungs, and there
were petechial hemorrhages in the pleura, pericardium,
and peritoneum. In one or two of the cases there were
also some larger hemorrhages underneath the pleura.
On many of the points of hemorrhage in the serous
membranes there were delicate deposits of fibrin on the
surface of the membrane.
Rigor mortis was well marked in all the cases.
Microscopical examination of the organs was not made,
but examination of the blood did not reveal -any morpho-
logical changes in the corpuscles. |
Dr. FREDERICK PETERSON stated that he did not be-
lieve any new or unknown disease had been introduced by
the employment of dangerous electrical currents in various
industries, for precisely the same disorders have been
known to the profession as occurring from electricity in
its natural form of lightning. Lightning produces shock
of all degrees to the nervous system. As one-third of the
people struck escape death, it is from disorders of the
nervous system that these victims suffer, and these dis-
orders are commonly functional in character. Among
the most frequent neuroses, generally of a transient char- .
acter, produced by lightning, are catalepsy, aphonia, deaf-
ness, blindness, tinnitis aurium, neuralgias, indoplegia,
and various paralyses and anzsthesias. One instance was
that of an intermittent brachial monoplegia recurring at
every storm. He cited the experiments with artificial
lightning—discharges from Leyden jars—made upon lower
animals by Richardson twenty years ago, and by Noth-
nagel nine years ago, in which varying degrees of anzsthe-
sia and paralysis were produced, transitory in nature.
As to the pathology of electrothanasia, he had made
autopsies upon a number of dogs at the Edison laboratory,
after killing them with dynamo currents, and examined
many tissues microscopically immediately after death, and
some later, after hardening in Miiller’s fluid. In all the
blood was dark and thin. Electricity has been shown ex-
perimentally to rob the blood of its oxygen ; a shock sent
through a test-tube of blood will darken it, while shaking
in a jar of oxygen restores the redness. The blood and
all the visceral tissues seemed normal under high magni-
fication. He had examined microscopically lung, muscle,
nerves, spinal-cord, brain, etc., but found no changes. In
two dogs there were capillary ectasies in: the sheaths of
the large leg-nerves through which the current had passed,
and also in the spinal cord, with here and there extrava-
sations of blood. ‘The action of the current is probably
both chemical and mechanical. Its mechanical force is
expansive or explosive in its nature, thus accounting for
the coarse lesions found often after death by hghtning—
perforation, amputation, etc. The following case had
been referred to Dr. Birdsall and himself by Dr. M. D.
Field for examination, and was a good example of the
sort of neurosis produced by a shock from a commercial
current.
August J , aged twenty-five, Elevated Railroad em-
ployee, hitherto a very strong and healthy man, on August
13, 1889, about 11 a.M., while at work picked up a wire
on the Elevated Railroad, which was probably dead, but
enlivened by his moving it and bringing it into circuit with
some other. He had a buzzing in his head, and instant
muscular rigidity followed almost immediately by relaxa-
tion. He had evidently made a circuit by picking up the
wire, and his tetanic spasm had broken it again. He felt
momentarily unhurt, then fell in a heap and was conveyed
November 2, 1889]
THE MEDICAL RECORD.
497
to hospital. In the ambulance he recovered conscious-
ness, but was so drowsy at the hospital that they forcibly
kept him awake. He was burned but very slightly. He
was able to walk home unassisted at 6 P.M. the same day.
For a week he had considerable muscular twitching, like
chorea ; suffered from insomnia, and when asleep would
dream of touching the wire, getting a shock, and would
then suddenly waken. There is no sign now of any or-
ganic disease about him. He is unable to work, however.
He has pain in moving his eyes, but his eyes are normal.
He walks in a stooping position, and says he cannot
straighten up because of pain in his back. His muscles
twitch occasionally, according to his account, and he has
a slight tremor, and the knee jerks and wrist-jerks are ex-
aggerated. He is troubled with headache, and his face
has a somewnat anxious look. He evidently has sus-
tained a profound shock to his nervous system, and his
mind is much absorbed in the contemplation of his morbid
condition and symptoms. His state is more than one of
neurasthenia, and less than hypochondriasis. It evidently
corresponds to the traumatic neuroses due to other kinds
of shock, like railway-brain, railway-spine, etc.
He mentioned another case of a man in whom chorei-
form movements had developed after a severe shock from
an electric-light wire.
Dr. PEaBopy reported a case of
HEMORRHAGE IN THE MIDDLE EAR IN FRACTURE OF THE
BASE OF THE SKULL WITHOUT EXTERNAL SIGNS OF
HEMORRHAGE.
The case which I have to narrate this evening relates
to a fracture of the base of the skull, the line of fracture
having passed through the petrous portion of the right
temporal bone.
The patient presented none of the usual symptoms, such
as hemorrhages and motor paralysis or spasm, and. the
diagnosis was rendered certain only by the use of the ear-
speculum.
The patient, W. H.——, thirty-seven years of age, mar-
ried, a native of the United States, was driver of a sweep-
ing-machine by occupation.
He was admitted to Bellevue Hospital on September
25, 1889. He stated that the previous night, at midnight,
while at work upon his machine, he became suddenly
dizzy and fell to the ground, without, however, sustaining
any severe injury or contusion. When he got up he was
still dizzy and was suffering from a very severe pain in
the head which was especially marked in the right parietal
and occipital regions. It was of such severity as to pre-
vent him from sleeping during the rest of the night. It
had also prevented him from working or even attempting
to work. When he was admitted to the hospital, late in
the afternoon of the day following the injury, he com-
plained of an exceedingly severe pain in his head, located
where I have described it, and he was very deaf. He
could be made to hear only by shouting very loudly in
close proximity to him.
The house physician gave him the usual dose of antipy-
rine, and had him put to bed at once.
I saw him the following afternoon and found him suf-
fering exactly as he had been when he entered the hos-
pital. His tongue was heavily coated, his breath foul,
and his bowels very constipated. He was still sure that
he had sustained no violence in his fall ; even in response
to close questioning it could not be ascertained from him
that his head had come into contact with anything harder
than the brush of his sweeping-machine.
I ordered him a dose of calomel to move his bowels,
and directed that fifteen grains of phenacetine be given
for his headache.
The next day his bowels had moved, but his headache
and deafness were unchanged.
As it had occurred to me several times in the autopsy
room to find, in fractures of the petrous portion of the
temporal which had given no evidence of their presence
by bleeding upon the surface of the body, that there
nevertheless had been hemorrhage into the middle ear
sufficient to surround the ossicles with a clot of blood, I
determined to use the ear-speculum in this case. i
It is, of course, plain that to get bleeding from the ear
in fracture of the skull we must have the fracture, with
hemorrhage into the middle ear, lus a laceration of the
membrana tympani. If the latter factor be not present,
and the blood not sufficiently abundant to escape through
the Eustrachian tube, it will remain shut up in the middle
ear. I had seen this condition in several instances where
the diagnosis had not been made until it was disclosed by
the autopsy.
The use of the ear-speculum in this patient showed a
small hemorrhage in the periphery of the membrana tym-
pani arteriorly, and elsewhere in the periphery there was
visible an abundance of venous blood on the inner aspect
of the membrane. In the left ear the membrane was
found tu be thickened and white, presenting the appear-
ance of pathological alterations of old date. —
I at once had the man removed to the quietest corner
of the ward, and put him upon large doses of sodium
bromide. o
On the same day he was visited by his companion in
the street-sweeping work. This man said that the patient's
tale was very different from the facts : that he had fallen to
the ground with great violence, and had struck his head very
forcibly against some of the iron of his sweeping-machine
in front of the revolving brush, that he was entirely uncon-
scious when he was lifted from the ground and had re-
mained so for a considerable time, less than an hour, and
that he was dazed and stupid and very difficult to arouse
during the following night and day preceding his entrance
to the hospital, and that he complained of nausea, and had
vomited soon after the accident.
His subsequent history is very brief. He remained in
the same condition as to pain in the head and deafness for
nearly a week, although he was kept somewhat dull and
stupid by full doses of the bromide. After this time the
pain began to disappear, and with it his deafness rapidly
improved. ‘Iwo weeks after the accident the pain had
disappeared entirely, but the deafness still continued quite
marked, although much less so than it had been at first.
The blood was still visible through the membrana tympani.
At the date of preparation of this report of his case, one
week after the meeting of the Society, he was so much im-
proved that he insisted upon leaving the hospital and
going to work, in spite of my advice to the contrary.
It seemed to me that the case was of some medico-chi-
rurgical interest in view of the difficulties in the way of a
positive diagnosis in such cases, and also in view of the
very great importance of making the diagnosis as the only
safe basis of prognosis and treatment in a condition which
is always grave.
Dr. Peabody said, in reply to a question as to the de-
gree of deafness, that it was very considerable ; he could
only converse with the patient by shouting.
Dr. SExTon thought that no very great deafness could
arise from hemorrhage in the middle ear. He thought
that the injury must have involved central parts other than
the middle ear in order to cause a great degree of deaf-
ness.
Dr. WALKER said that he had met with a case which
resembled that of Dr. Peabody’s, several years ago. He
was called one day to see a boy, aged six or seven, who had
fallen off from a high stoop, where he was playing with
some other boys. He had struck on the back of his head,
and was somewhat stunned. He had some cerebral symp-
toms, vomiting, and feeble pulse, so that he was led to ex-
amine for injury of the skull. He found the middle ear
filled with blood, as shown by the congestion, and appear-
ance of the tympanic membrane. It remained filled with
blood for a period of fourteen days. Dr. Roosa saw him
afterward. Finally he recovered. He had no external
bleeding, no hemorrhage into the eye, into the orbital or
nasal cavities, and the diagnosis of fracture of the base
was made on the finding of blood in the middle ear.
498
THE MEDICAL RECORD.
[November 2, 1889
Dr. Sexton said that, in rare cases, where there was
thickening of the membrane of the drum, it would be
pretty hard to tell whether there was blood in the middle
ear. He thought it would sometimes be difficult to tell
the presence of extravasations from some tumor that had
existed there.
AMERICAN PUBLIC HEALTH ASSOCIATION.
Seventeenth Annual Meeting, held at Brooklyn, N. Y..
October 22, 23, 24, and 25, 1889.
(Continued from p. 468.)
Turd Day, THURSDAY, OCTOBER 24TH—MORNING SES-
SION.
PRESIDENT JOHNSON, of Chicago, took the chair at 9 A.M.,
and some business matters were attended to.
Dr. Joun S. Bitiincs, U.S.A., discussed the paper on
“ The Prevention of Phthisis Pulmonalis,” read on the
preceding day. He argued in favor of the belief that the
sputa of consumptive patients is the essential factor in
communicating the disease. Not more than one case in
ten thousand receives the infection through the breath.
Greater precautions should be taken in the disposal of the
expectorations of phthisical patients.
Dr. ALBERT M. Gimon, U.S.N., recommended the
adoption of a resolution stating the sense of the Associa-
tion to be that the destruction of the sputa is necessary to
limit the spread of this disease.
Dr. R. MARTIN, Commissioner of Health, Milwaukee,
Wis., read a paper on
THE DISPOSAL OF GARBAGE AT MILWAUKEE.
The subject of the various cremators was discussed, and
those now in the market condemned as unsatisfactory and
useless. Cremation as a system has had its day. Its
claims have been exaggerated, and speculations given as
facts. The cremator used in Milwaukee for twenty
months, doing the entire work of the city, was found to be
objectionable. The system now in use there is the Merz
System, which gives satisfaction. It has been used con-
stantly since June 11th. The quantity of garbage daily
collected and disposed of is now fifty tons. ‘The collect-
ing carts drive up a covered roadway to the second story
of the building, and the garbage is thrown on the floor and
scraped into driers. Eight to eleven hours are spent in
drying and eight hours more in the extractors, where the
oily matter is removed by benzine. When the bones are
separated the process is complete, and a good fertilizer is
the result. There is no odor about the building save in
sie Jai where the garbage is deposited, and there very
t.
Dr. S. S. Kitvincton, Commissioner of Health, Min-
neapolis, Minn., followed with a paper giving
STATISTICS ON RIVER POLLUTION, WITH OBSERVATIONS
RELATING TO THE DESTRUCTION OF GARBAGE AND REF-
USE MATTER.
In the majority of cities the problem of the disposal of
waste matter is practically unsolved. A circular letter
was sent to health-officers in one hundred and seventy-five
cities in the United States, and replies were returned by
only sixty-six. Less than one-third of these showed the
possession of any statistics regarding the quantity of waste
materials disposed of per annum. A surprising indiffer-
ence to the subject is shown in many directions. Health-
officials in cities of one hundred thousand to five hun-
dred thousand inhabitants “ have not thought about it,” or
“have no opinion on the subject,” or “ have had no ex-
perience and entertain no views.” We can no longer
leave to nature the chemistry of our waste products with-
out danger to ourselves. The practice of pollution of
water-courses by the deposit therein of waste material is
undesirable at best, and intolerable where rivers or lakes
are used as sources of water-supply. In the Mississippi
River, during the past year, eight cities alone deposited
152,675 tons of garbage and offal, 108,250 tons of night-
soil, and 3,765 dead animals.
In the Ohio River, five cities in the same period dumped
46,700 tons of garbage, 21,157 tons of night-soil, and
5,100 dead animals. In the Missouri River, four cities
cast 36,100 tons of garbage, 22,400 tons of night-soil, and
31,600 dead animals. No theory of self-purification of
running water will serve to dwarf the magnitude of this
sanitary crime. Earth-burial of waste materials in large
quantities within or near large cities should also be con-
demned. Two methods remain which commend them-
selves to students of this matter.
1. Rapid decomposition of waste products by speedy
withdrawal of the water and gases contained, with a view
to converting them into profitable forms of fertilizer and
machine oil.
2. Rapid and complete combustion, with a view to
their entire destruction.
Rendering works have attempted the production of
fertilizer by the former method. A scientific apparatus,
known as the Merz System, is in operation in three or
four cities. It is not yet proven to be a sanitary or eco-
nomical solution of the problem. Cremation is the better
way of destroying combustible materials, and sewage and
night-soil should be deodorized, diluted, and used as a
fertilizing agent. ‘This method has been proved a practi-
cal success in many large cities. There were twenty-
three, out of thirty-five health-officials written to, who in-
dorsed the cremation systein. Household cremation of
animal and vegetable waste, by kitchen ranges and fur-
naces, is an economic and sanitary possibility.
Dr. G. C. ASHMuN, of Cleveland, O., presented a res-
olution instructing the Executive Committee to secure,
for the next meeting of the Association, 2 presentation of
the causes and means for prevention of diphtheria. An-
. other resolution requested the same committee to prepare
a plan for uniform classification of vital statistics.
Proressor W. O. ATWATER, Director of Office of Ex-
periment Stations, Department of Agriculture, Washing -
ton, made an address on.
FOOD IN ITS RELATION TO HEALTH.
Charts were shown illustrating the nutritive value of dif-
ferent dietaries, and comparing the quantities of food
consumed by various classes of people in the United
States and Europe. Great injury results in this country
from overeating, particularly of meats and sweetmeats.
The standard of German physiologists is exceeded by
nearly all classes here. Sedentary persons consume as
much food as would be required for active muscular work.
The system is taxed in excretion of the excess of food,
and thus undermined and predisposed to disease.
DISCUSSION.
Dr. JEROME WALKER thought that we all eat more than
necessary, and gave some facts from the experience in his
own family. He claimed that meat once a day was
enough for any ordinary person. The practice of children
consuming large amounts of crackers was condemned.
EDWARD ATKINSON, of Boston, had gathered facts to
show the size of the American man, by inquiries of dealers
in ready-made clothing. From measurements of about
two hundred million garments he learned that the average
man is 5 feet g inches in height, measures 34 inches
around the waist, and 36 inches, chest, and weighs between
one hundred and fifty-five and one hundred and sixty
pounds. In a similar way he learned that the Southerner
had gained one and a half inch in waist-measurement
since the war.
With regard to the disposal of refuse, Dr. EDWARD
CLARK, Health Officer of Buffalo, N. Y., spoke in favor
of the extractive method, and said the Merz System had
given great satisfaction in his city, where the method was
first tried. Health-officers from numerous cities had in-
spected the works and approved them. A heat of 350°
F. is obtained in the driers, and all disease-producing
November 2, 1889]
germs are destroyed. Night-soil and sewage are not treated
by the works in Buffalo.
Mr. Henry A. FLEISCHMAN, of Milwaukee, spoke of
the economic side of the question. The larger the amount
of garbage the greater the saving to the city by the Merz
System. It has been adopted in eight cities, in some of
which cremation had been tried and abandoned. ‘The
latter method may be sanitary but is wasteful. It is found
by extraction that fifty-five per cent. of garbage is moist-
ure and ten per cent. grease ; the remaining thirty-five per
cent is a useful fertilizer.
Drs. McDonald, of Missouri, Conn, of New Hamp-
shire, Van Derbergh, of Buffalo, N. Y., Clough, of Den-
ver, Col., and Gihon, of U.S. Navy, also discussed the
subject.
Dr. H. W. WELLs, Medical Inspector of the U. S.
Army, called the attention of the Association to the Wash-
ington
MUSEUM OF HYGIENE.
He made bnef mention of its history and work and in-
vited inspection by the members willing to visit it.
The meeting adjourned, to meet at the Hoagland Lab-
oratory of the Long Island Medical College in the after-
noon.
AFTERNOON SESSION.
: Dr. E. PLAYTER, of Ottawa, Canada, read a paper on
the
PREVENTION OF TUBERCULOSIS IN MAN.
Among the predisposing and preventable causes of pul-
monary tuberculosis, the most marked are: First, malfor-
mation of the body in gross configuration or minute
structures ; second, rebreathing of expired air, from lack
of ventilation; third, defective and innutritious diet.
Imperfectly developed chest and lungs are commonly
noticed in civilized countries, but too little attention is
paid to correction of these defects. In two hundred and
fifty phthisical subjects, averaging 5 feet 54 inches in
height, the chest-measurement was only 314 inches, in-
stead of 37 inches, the proper circumference for that
height. Suggestions were offered for exercising the lungs
and chest-muscles as a prophylactic measure.
Dr. P. H. KRETZSCHMAR, of Brooklyn, read a paper
entitled
NOTES ON THE PREVENTION OF PULMONARY CONSUMPTION.
Efforts to prevent the development of this disease should
be concentrated in two directions: First, to destroy, or
lessen the number of tubercular bacilli floating in the air ;
and, second, to prevent the human organism from develop-
ing a disposition to acquire consumption.
I. Since total destruction of the deadly bacilli is hope-
less, we must diminish their number. Isolation of patients
has been tried a hundred years in Naples and Portugal
without any marked diminution in the prevalence of the
disease. Isolation of all consumptives, unless by interna-
tional law, is infeasible as well as cruel. The teachings
of Dr. Comet, of Berlin, should be our guide. His ex-
periments demonstrate that (1) the consumptive per se is
not, but (2) the sputa are, the source of danger. It is of
vital importance to destroy the bacilli in the expectora-
tions as soon as possible. The spittoon should find more
universal use. Carpets should be banished from homes
of consumptives. A pocket-flask should be carried for .
use in place of the handkerchief, when spittoons cannot
be found. Expectorations should never be swallowed,
ro only to avoid self-infection, but contamination of the
geces.
_ II. Rokitansky gives the characteristics of the “ phthis-
ical habitus ” as a small heart in a chest of small antero-
posterior diameter and long perpendicular dimensions,
large lungs, and proportionately small abdominal cavity.
THE MEDICAL RECORD.
499
The disposition to acquire the disease is oftenest found in
the offspring of consumptive parents. The views of Dr.
Brehmer, of Goerbersdorf, are indorsed ; viz., 1. If there
are many children in a family, those born after the sixth
are apt to develop consumption. 2. If several children
in a family are born at short intervals, the younger are
liable to develop the disease. 3. If the offspring of
healthy parents, born under the above conditions, escape
the disease, their children are apt to develop it. Patient
and prolonged investigation leads to the belief that “ only
a small proportion of phthisical patients can be found who
do not possess a family history which either demonstrates
a directly inherited tendency, or a directly or indirectly
acquired disposition toward the development of the dis-
ease.” Of 506 cases at Dr. Brehmer’s sanitarium, 184
(36 per cent.) were offspring of consumptive parents or
grandparents; 147 (29 per cent.) had an acquired dispo-
sition, being from families where there were many chil-
dren, or where the mother had children rapidly ; 153 were
children of parents who were born under the above con-
ditions but had themselves escaped the disease. Dr.
Brehmer’s statistics have been verified in the experience
of the writer. Certain functional or structural changes in
young subjects indicate danger of future tubercular infec
tion. They are: 1. Anatomical defects in the chest,
which are a part of the “ phthisical habitus.” 2. The fact
that the subject is a small feeder. 3. The fact that dur-
ing the age of puberty the subject has suffered from pal-
pitation of the heart. 4. The fact that at the same time,
and frequently for years afterward, there has been epistaxis.
Transfer of threatened subjects to a proper climate ina
high altitude will save many lives. Out-of-door life is
also advisable.
In the discussion which followed Dr. HIBBERD, of In-
diana, advocated the importance of proper clothing and
the cultivation of a vigorous condition of general health to
enable the system to withstand disease.
Dr. PLAYTER opposed the theory of heredity of tubercular
disease, and defended his belief in small lungs as predis-
posing to consumption.
Dr. Cyrus Epson, Chief Inspector oi the New York
City Health Department, read a paper on
DISINFECTION OF DWELLINGS BY SULPHUR DIOXIDE.
An extended experience in the use of this fumigant has
led to the belief that it is a thorough and almost perfect
destroyer of the infection of the acute exanthemata and
diphtheria. The evidence, however, is mainly circum-
stantial. Statistics were quoted from the records of the
department to show the non-recurrence of disease where
premises had been fumigated by this agent.
Dr. G. M. STERNBERG, of U. S. Army, sustained the
position of the paper, and said that points of vaccine
virus exposed to the fumes of sulphur dioxide had proved
incapable of producing vaccinia, while some of the same
virus not thus exposed had been efficient in the opposite
arms of the same patients.
Dr. Raymonp, of Brooklyn, spoke of the importance
of having the sulphur burned “in the presence of moist-
ure,” as recommended by the Committee of the Associa-
tion on Disinfectants. Health-boards are not explicit in
directing this. The purpose is not to prevent fire, and
should not be used to wet walls or articles in the room, as
that causes bleaching and corrosion by the acid formed.
There are some reasons to doubt that all immunity from
recurrence of the diseases is due to the fumigation ; vac-
cination and other measures usually accompany the disin-
fection, and the same families arẹ not so susceptible to a
second infection, if they escape the first, as fresh subjects
would be.
The subject was further discussed at some length by
Drs. Bryce, Maxwell, Chapin, Van Derbergh, and Durgin.
A paper by Dr. Joun H. Raucn, Secretary of the State
Board of Health, Chicago, Ill., entitled “ The Utilization
and Purification of Sewage,” was read by title only, as the
author was absent, and the meeting adjourned.
500
THE MEDICAL RECORD.
[November 2, 1889
EVENING SESSION.
Rev. CHARLES R. TREAT, of New York, made an ad-
dress (illustrated by numerous stereopticon views) on the
subject of
SANITARY ENTOMBMENT.
After reviewing the practice of earth-burial in churchyards
and cemetenes, and showing the injury to the health of
residents adjoining such places, he spoke of the effect
of the atmosphere upon corpses exposed in cold or dry
climates, and compared the result obtained by embalm-
ing. A method of entombment on a large scale within a
small area, by a sort of co-operative building plan, was
then suggested. The bodies, enclosed in the apartments
thus provided, would be subject to a constant current of
desiccated air, to secure the same effect as that of the at-
mosphere in Arizona, Palermo, or Western Peru.
Dr. BENJAMIN LEE, Secretary of the Pennsylvania State
aie of Health, Philadelphia, read a paper on the ques-
on,
DO THE SANITARY INTERESTS OF THE UNITED STATES DE-
MAND THE ANNEXATION OF CUBA?
Among the reasons for an affirmative answer were the
following: The constant communication between this
country and Havana, which is a notorious breeding-place
of yellow fever; the only means of eradicating the dis-
ease 1s a proper system of sewerage and drainage, which
the Spanish Government is not likely ever to undertake ; a
single wide-spread epidemic of this disease in the United
States would cost more than the purchase-money of Cuba;
leprosy prevails to a serious and constantly increasing ex-
tent in Cuba, is absolutely unrestricted, and already has
obtained a foothold in the ports of this country in closest
communication with Cuba.
Following this paper, Dr. Prince A. Morrow, of New
York, gave a series of stereopticon views showing the dif-
ferent stages and varieties of leprosy.
Dr. MAxwELL, of Florida, differed with the paper read
on the expediency of annexing Cuba, on the ground that
it 1s useless to attempt to prevent the entrance of a dis-
ease—yellow fever—which already exists in this country.
A paper on “ Railway Sanitation,” by Dr. S. W. LATTA,
of Trenton, N. J., was read by title, and will appear in the
“ Transactions ” of the Association.
FourtH Day, FRIDAY, OCTOBER 25TH—MOoRNING SES-
SION.
_The closing session of the Association began at 9 A.M.,
with announcements by the Executive Committee, through
the Secretary, Dr. I. A. Watson. ‘The resolutions al-
ready recorded were favorably reported and adopted.
A report from the Advisory Council was then received,
and by its adoption the Association decide? to hoid
the next meeting at Charleston, S. C., not earlier than
November 1, 1890.
The following officers were elected, on one ballot, for
the ensuing year: Presideni—Dr. H. B. Baker, of Lan-
sing, Mich. First Vice-President—Dr. Frederic Monti-
zambert, of Quebec. Second Vice-President—Dr. Joseph
H. Raymond, of Brooklyn. Secretary—Dr. Irving A. Wat-
son, of Concord, N. H. Zreasurer—Dr. J. B. Lindsley,
of Nashville, Tenn. Zxecutive Committee—Drs. L. F.
Salomor, of New Orleans, La.; William Bailey, of Louis-
ville, Ky.; H. B. Horlbeck, of Charleston, S. C.; Walter
Wyman, of Washington, D. C.; J. F. Kennedy, of Des
Moines, Ia.; P. H. Bryce, of Toronto, and the twelve ex-
Presidents of the Association.
A new Advisory Council, composed of a member from
each State and Province, was announced, and a resolution
of thanks to the city officials, the New York Quarantine
officer, the Local Committee, and others, was adopted.|
D. E. Sarmon, D.V.M., Chief of the Bureau of Ani-
mal Industry, Washington, read a paper on “ The Neces-
sity for a More Rigorous Inspection of Meat producing
Animals at the Time of Slaughter.”
Dr. A. M. Gimon, U. S. Navy, read a paper prepared
by Dr. R. O. Bearp, of Minneapolis, Minn., entitled
THE CAUSES OF INFANT MORTALITY.
They were classified as arising from the bacillus tuber-
culosis and from nutritional and nervous disorders. The
prevention of infantile disorders would be greatly pro-
moted by the education of the people in sanitary matters.
One of the great mistakes of the present day was to re-
gard infants’ stomachs as of a different character from
those of adults. The too frequent feeding of infants is a
vice almost universally prevalent and quite generally
countenanced, or actually encouraged by the profession»
It is grounded in custom, as absurd as the incasement of
Chinese infants’ feet in permanent baby-shoes. It is in-
trenched behind that most dangerous of all arguments,
among the ignorant, the argument from experience ; while
it is condemned by every careful observation of the lower
orders of animal life, and by every physiological principle
bearing upon infancy.
Dr. JEROME WALKER, of Brooklyn, in discussing this
paper, called attention to the agreement in the recom-
mendations of the three papers on this subject read be-
fore the meeting, and thought the subject of infant-mor-
tality might well be referred to a committee to collate
statistics and report to the Association.
Dr. J. H. Raymonp concurred, and moved the ap-
pointment of such a committee with Dr. Walker as chair-
man. The matter was referred to the Executive Commit-
tee with power.
Dr. G. C. ASHMUN, of Cleveland, O., said that no class
of the community needed instruction more in regard to
this matter than the medical profession.
Dr. W. M. SMITH, of New York, said a more intelli-
gent observation of death certificates by Boards of Health
is needed. When practitioners attribute mortality to
“ debility,” “ marasmus,” or “heart-failure” the certifi-
cates should be returned for correction.
Drs. Rohe, McDonald, Hibberd, and Jaynes also spoke
on this subject.
Two papers by Edgar Richards, microscopist of the
United States Treasury Department, upon “ American
Methods of Manufacturing Oleomargarine,” and “ The
Oleomargarine Law of the United States,” were read by
title and ordered included in the proceedings of the Asso-
ciation.
AMERICAN DERMATOLOGICAL ASSOCIATION.
Thirteenth Annua Meeting, hela at Boston, Mass., Septem-
ber 17, 18, ana 19, 1889.
(Continued from p. 471.)
SECOND Day, WEDNESDAY, SEPTEMBER 18TH—MORN-
ING SESSION.
Dr. Harpaway, of St. Louis, read the first paper, en-
titled
LUPUS ERYTHEMATOSUS, ENDING IN DEATH.
The patient was a man, twenty-three years of age, whose
lupus erythematosus of the face followed an eczema which
had itself appeared subsequent to rhus-poisoning.
Improvement took place for a time under Klotz’s
plaster and a salicylic and sulphur ointment, but the lym-
phatic glands became implicated; the neck aumessd a
board like hardness. The temperature reached 104.5 F.,
due, the reader thinks, to the adenitis. Suppuration took
place in some of the glands, while gland after gland be-
came involved in a tuberculous process. The patient
died suddenly of pneumonia.
Dr. TAYLOR was inclined to regard such a case as one
of a subacute infective process.
Dr. GREENOUGH said lupus erythematosus was un-
doubtedly present, but part of the dermatitis might be due
to local irritants.
November 2, 1889]
Dr. TAYLOR, of New York, read a paper entitled
A HITHERTO UNDESCRIBED FORM OF NEW-GROWTH OF
THE VULVA.
‘The paper was based upon a long and careful observation
of two cases in Charity Hospital. In one case the growth
was subsequent to chancroids, and its nature was benign
and purely inflammatory, as shown by microscopical exam-
ination made by several careful pathologists. ‘The author
does not accept at all the views of those observers who
regard these hypertrophic and ulcerative vulvar lesions as
identical with lupus or the result of syphilis, or due to tu-
berculous infection, and thinks the term “ esthiomene”
should be discarded. He considers most of these non-
malignant growths as simple hyperplasias of the tissues
induced by irritations, inflammations, and traumatisms.
Many cases are due to essential and specific syphilitic in-
filtrations, Others are caused by hard cedema, and still
others by simple hyperplasia in old syphilitic subjects who
suffer from chronic ulcerations of the vulva long after all
specific lesions have departed. In healthy persons the
same irritating causes might only result in vulvitis. Some
rare cases are those of simple inflammation resulting from
antecedent ulcerative and inflammatory conditions.
The surface of the new-growth which involved the per-
ineum in these cases was of a maroon or chocolate color,
and was either dry or gave rise to a scanty reddish serum.
Both patients had died.
Dr. Bronson had seen one of the cases, which to him
resembled an epithelioma. He could not regard it as
simply inflammatory.
Dr. HEITZMANN said the process was surely a malig-
nant neoplasm, and he had decided after examination of
the specimen that it was sarcomatous. Lack of ulcer-
ation, temporary cicatrization, flatness of tumor, and death,
all pointed to sarcoma.
Dr. ROBINSON agreed with the last speaker.
Dr. TAYLOR ia closing said he could vouch for the
clinical features. The histological part of the examina-
tion had been conducted by men whose opinions he re-
spected, still he shuuld be glad to have anyone present
examine all of his specimens, and to consider the diag-
nosis still sub judice. No evidences of metastatic growth
had been observed.
SOME SUGGESTIONS IN DERMATOLOGICAL THERAPY
was the title of a paper by Dr. SHERWELL, of Brooklyn,
in which he first considered
‘A SIMPLE METHOD OF TREATING SCABIES,
which consisted in the application of dry powdered
sulphur to the body as well as to the bedclothes. A
mild oil may be rubbed over the skin beforehand, Eight
cases were thus treated with good success,
ECZEMA ANI
was often found due not only to a slight fissure at the
margin of the anus, but to one just within the sphincter.
Hard-rubber bougies should be introduced each night and
left for ten minutes.
ECZEMA AND SYCOSIS OF THE UPPER LIP
are very rebellious, and because of their great annoyance
require careful treatment of the nose, upon the acrid
secretions of which they usually depend.
It is probable, too, that the gases from an ozena may
also prove irritant.
Dr. BULKLEY said these cases were very rebellious. He
had not thought of the gases being sources of irritation,
still they might be. In some cases we must go back of the
local nasal affection to the systemic trouble on which
that depends.
Dr. ZEISLER said these cases were so chronic because
complicated by a distinct disease of the roots of the hair.
He looked upon the nasal catarrh as of myotic origin,
and upon the affection of the lip and hairs as of direct
infection.
THE MEDICAL RECORD.
this affection.
501
Dr. BuLKLEy, of New York, read a paper entitled
WHAT REAL VALUE HAVE MINERAL WATERS IN THE TREAT-
MENT OF THE SKIN?
which will appear in a future issue of ‘THE RECORD.
Dr. Harpaway had always been able to explain the
benefit obtained at springs by other facts than the mineral
ingredients.
Dr. SHERWELL was glad to hear a voice raised against
the harm done by springs in general, as now carried on.
He had often seen their ill effects.
Dr. Grauam spoke of the Preston Springs, in Canada,
at which resort some of his patients with eczema had re-
ceived marked benefit.
Dr. BuLKLeY said he had thought the Missisquot
Spring of Vermont of some benefit in cancer cases. The
water contains a small amount of silica.
Dr. HEITZMANN read a paper entitled
DERMATITIS PAPILLARIS.
As is well known, a slight irritation may cause a pseudo-
keloid. After trauma exuberant outgrowths at times take
place, and Kaposi has named such a condition of the
scalp dermatitis papillaris. It is similar to myxo-fibroma.
The Hebrew race appears to show a predisposition to
The reader has recently had two cases —
under observation, both of this race. In one the lesions
were the size of a pea and situated upon the chin, and in
the second case the occiput and neck were affected.
They are hard to the touch, raspberry-like, cicatricial tissue
is present, and here and there bunches or tufts of hair
difficult to extract. Hebra warned inst operation.
Kaposi advises the use of scissors or knife if the tumors
growup. Heroic treatment, the reader thought, should be
avoided, and caustics only be applied in a gentle way, such
as the solid stick of silver nitrate every two weeks. He
had found a three per cent. alcoholic solution of salicylic
asid most efficacious. Such cases are rare.
Dr. Fox said he had seen one of the cases reported.
The size of the growths was decreased by electrolysis.
‘They were subsequently removed by operation in Vienna,
but returned with increased vigor. He had also treated
a case on the occiput of a negro. He regarded it as the
same affection as keloid, modified by location. All who
spoke had observed cases of the affection, some preceded
by sycosis, and some resembling keloidal growths. `
Dr. ZEISLER read some
CLINICAL NOTES ON SYCOSIS.
He had found little in literature regarding sycosis capil-
litii, in which here and there were little tufts of hair at-
tended with itching, burning, and pain in the scalp. ‘Two
personal cases were reported in which epilation, sublimate
lotion, and ammoniated mercury ointment at night had
given good results. He had seen keloid in sycosis.
Dr. Rosinson believed in a sycosis of the scalp, the
lesions of which are isolated and the secretion serous.
He thought the ground should be made unfavorable for
the development of cocci by internal treatment.
Dr. BuULKLEY spoke of a follicular inflammation of the
scalp in which a small scar resulted and caused a localized
baldness. He regarded it as constitutional.
Dr. DENSLOw reported a case, seen during the year, in
which deep-seated abscesses had existed for several years
upon the scalp, and had regarded it as an acne. Large
doses of ergot had good effect. l
Dr. Korz agreed with Dr. Robinson that pustules
were secondary and not essential features.
Dr. GRAHAM had seen the lesions of a sycosis disap-
pear during a typhoid, and recur as soon as the patient
was well, so he did not regard it wholly as a local disease.
Dr. ZEISLER answered that we know in febrile disturb-
ances scabies, eczema, and other skin eruptions disappear.
We know that acne, eczema, and sycosis are distinct af-
fections, but his two cases were so similiar to sycosis of
the beard that he had named them as he did.
502
THE MEDICAL RECORD.
[November 2, 1889
Dr. SHERWELL read a paper entitled
RELAPSE OF PEMPHIGUS FOLIACEUS AFTER ELEVEN YEARS’
QUIESCENCE.
The first attack was in 1877, the second in 1878, and the
third during the present year. Bullz gradually appeared,
until nearly the whole body was covered. Subsequent
dry scales formed, and made the case resemble a pityriasis
rubra. The same author read a second paper on
IMPETIGO HERPETIFORMIS.
The patient had borne several children, and never had an
eruption until three years ago, when vesicles formed upon
the arms and legs, and soon became pustular. In the
present attack nearly the whole body was implicated, and
several relapses took place. When seen by the reader
the lesions were impetiginous, and a grave prognosis was
made. Improvement, however, took place, and furfura-
ceous desquamation followed. He believed it a similar
process to Duhring’s dermatitis herpetiformis. Hospital-
ism may have had something to do with the fatal result
in the Vienna cases.
Dr. HEITZMANN asked how this could be the same
affection as Kaposi’s impetigo herpetiformis, in which
pustules from the first were necessary for a diagnosis if
vesicles were observed early.
Dr. ZEISLER referred to TE published case, which was
typical, and proved that the disease could occur here.
He believed impetigo herpetiformis a disease sui generis.
Dr. BuLKLEY thought herpes gestationis distinct from
this affection.
Dr. Rosinson had seen the subject of the first paper,
and it was surely pemphigus foliaceus.
Dr. SHERWELL said that while all the lesions in his
case of impetigo were not pustular from the first, some
were.
ACNE CACHECTICORUM.
Dr. Bronson read a description of a case of rare erp-
tion in a young boy. ‘The lesions were papular, tuber-
cular, and pustular, and occurred as grouped lesions,
coming in successive crops on various parts of the body,
the face, back, and nates being the regions most affected.
The face about the eyes was very cedematous, and the
patient’s general condition was anzmic and below par.
‘There were many deep-seated dermic abscesses, and pits
like those of small-pox. Arsenical poisoning had been
thought of, but excluded.
Dr. Morrow thought the case which he had seen re-
called the features of arsenical poisoning
Dr. ALLEN had also examined the patient, and, while
agreeing in the diagnosis, had thought there might still be
poisoning by arsenic as a basis.
The Secretary read a paper by Dr. STELWAGON on
THE ALLEGED TOLERANCE OF THE IODIDES IN LATE SYPH-
ILIS.
The author is of the opinion that the tolerance is not
more marked in syphilitic than in non-syphilitic patients.
A number of cases were reported to illustrate how fre-
quently the iodide is not well borne. His own experience
corresponds to that of Haslund, that large doses could be
given in psoriasis with an equal freedom from iodism to
that seen in syphilis.
Dr. TAYLOR said that Wood’s conclusions drawn from
nervous cases were faulty. We are apt to give up the use
of iodide too early because of a beginning coryza, while, if
pushed, it would often be found well supported.
Dr. GREENOUGH said that some patients will bear large
doses when small ones will cause bad symptoms.
Dr. DensLow added his experience in one case of un-
doubted syphilis. The patient could not stand even the
smallest dose.
Dr. SHEPHERD had found the iodide of ammonium bet-
ter tolerated than the potassium salt.
. Dr. BULKLEy had found the conjoint administration of
arsenic to increase the tolerance.
‘The next meeting will be held at Richfield Springs,
September 2, 1890.
The officers elected for the ensuing year are : President
—Dr. P. A. Morrow, of New York; Vice Presitdent—Dr.
G. H. Tilden, of Boston ; Secretary—Dr. G. T. Jackson,
of New York. ‘Two new members were elected: Dr. J.
T. Bowen, of Boston, and Dr. C. W. Allen, of New
York.
Correspondence.
OUR LONDON LETTER.
(From our Special Correspondent.)
THE FIRST OF OCTOBER—OPENING OF THE MEDICAL
SCHOOLS—THE INTRODUCTORY LECTURES—THE SANI-
TARY CONGRESS AT WORCESTER— ADDRESSES BY THE
PRESIDENT AND DR. G. WILSON— PAPERS BY DR. TRIPE,
MR. CASSAL, AND MR. WILLIS BUND.
Lonpon, October 2, 1889.
‘THE first of October is a date noteworthy alike to the pro-
fession and the public. To the latter it marks the com-
mencement of pheasant-shooting, while to members of
our profession it signalizes the opening of the medical
schools in London and the provinces (not in Scotland,
where the winter session commences later). Few there
are to whom the first of October is not a specially signifi-
cant date. Even among those quite unconnected with
any of the medical schools, it recalls the memory of early
studies and struggles. Although much abused, the “ in-
troductory lecture ” still survives at many schools, though
what useful purpose it serves, or can serve, it would be
difficult to say. At University College the introductory
lecturer for the present year (Mr. Rickman J. Godlee)
went so far as to say in his lecture that the custom of
giving introductory addresses was laborious to the giver
and useless to the student. At King’s College the
lecturer was Sir Albert Rollit, M.P. He referred to the
progress made by the medical profession in recent years
as regards their relationship to the State, but considered
there was room for further improvement as to this. He
thought the establishment of a local university for Lon-
don, in addition to the existing university, would be of
benefit. He also urged the importance of keeping logic
in the foreground of their studies unless they went in for
theology, when, happily, faith naturally supplanted logic.
At St. Thomas’s Hospital the address was given by Mr.
William Anderson, Assistant-Surgeon to the hospital. It
was chiefly devoted to an historical review of the progress
of medicine and surgery in Europe, from the beginning of
the sixteenth century to the present time. At St. Mary’s
Hospital Dr. Robert Maguire was the lecturer, and his
lecture was devoted mainly to an account of the history
of preventive inoculation. When once germs had been
introduced into the body we could, he said, rarely con-
trol their action. ‘To obtain full protection from their
action the body must be rendered incapable of being
attacked by the germs. In many cases protection was
given by a former attack of the disease from which the
animal had recovered, and the object of protective in-
oculations was to produce a similar result. M. Pasteur’s
work was discussed and criticised at some length. At the
Middlesex Hospital Mr. Bland Sutton discoursed on
“intellectual blindness.” ‘To illustrate blindness in ob-
servation, he mentioned a number of simple defects com-
monly overlooked by students. He also gave a brief
account of cretinism and pointed out that, though oc-
curring mainly in Alpine districts, it was now clear that
cretins were born in this country, and that the disease was
not confined to human beings but occurred also in calves
and dogs. Dr. P. S. Abraham gave the lecture at the
Westminster Hospital and dwelt upon the advantages of
a careful tr He was of opinion that the medical
curriculum should be extended to not less than five years
-
November 2, 1889]
THE MEDICAL RECORD.
593
to give a man a chance of applying himself. At St.
George’s Hospital the address was given by Dr. Clifford
Allbutt. At the remaining hospitals—Guy’s, St. Barthol-
omew’s, Charing Cross, and the London—there was no
lecture.
The Sanitary Congress took place last week at Worces-
ter, under the presidency of,Mr. G. W. Hastings, M.P.
In the presidential address various influences bearing upon
public health were referred to. In speaking of the sani-
tary condition of houses and habitations, the necessity of
proper appliances for the disposal of sewage was especially
pointed out. Mr. Hastings said he was himself strongly
in favor of placing the liquid sewage on the land directly.
Associated with this subject was the necessity of looking
after the construction of drains and sewers, and all the
requisite appliances. Excellent work was being done by
the Plumbers’ Company, in London, by training and regis-
tering skilled workmen for the purpose. Another leading
influence on health was that of occupation. Too many
trades in this country tended to produce disease. The
beautiful porcelain manufacture in Worcester still occa-
sioned, in some instances, danger to the health of those
engaged in it; but he was glad to say that a great deal
had been done to lessen.the danger. Inventors were con-
tinually at work in various occupations, not only to im-
prove productions, but to improve health. One of the
most remarkable of these was the new machine for bottle-
making. Under the old plan of making bottles by blow-
ing, the lungs of the workmen had been so much affected
that their lives extended to not much more than thirty
years in duration. With the new machine all blowing
was done away with, and, as he had pointed out at New-
castle (in a discussion in the Mechanical Section of the
British Association), there was no reason why the longev-
ity of bottle-workers should not equal that of other ar-
tisans. The importance of preventing river pollution
and of exercising sufficient control over dairies was
dwelt on, and recent sanitary enactments referred to,
among them being the bill rendering compulsory the noti-
fication of infectious diseases, which Mr. Hastings spoke
of with approval.
An interesting address was given by Dr. G. Wilson on
“ The Policy of Prevention in Some of its Social Aspects,”
in which it was pointed out that an immense amount of
disease was due to heredity, errors in diet, abuse of lux-
urles, overwork and worry, and other preventable causes.
Dr. Wilson pointed out that, as to the first of these causes
—heredity—in addition to the diseased offspring result-
ing from unhealthy parentage, multitudes of maimed and
doomed children resulted from unsuitable or imprudent
marriages, apart from diseased parentage. Unthriftiness
In marriage too often led to intentional neglect of the
children amounting to culpable homicide. It largely ac-
counted for false thrift, under the name of infant life as-
surance, spreading its baneful influence even into innocent
village communities. He doubted whether public opinion
was advanced enough to enforce a certificate of health on
the part of persons about to marry, but he thought some
check should be put upon the appalling waste of infant
life by prohibiting marriages unless the man could pro-
duce reasonable proof that he was in a position to main-
tain a wife.
Among the papers read at the Congress was one by
Dr. Tripe, Medical Officer of Health for Hackney, on
“ Winds and their Sanitary Effect.” A northeasterly wind,
so much dreaded in this country in winter, passed over
the northern portion of Russia, including Siberia, before
reaching us, and was consequently cold and dry. It was
frequently treacherous in summer, and caused colds.
Easterly winds, which passed over part of Russia and
Germany, were dry and biting, having the character of a
land wind a little tempered by the German Ocean.
Mr. C. E. Cassal read a paper on “ The Extension of
Public Analysis,” which led to some discussion. ‘Ihe
view was expressed that the original adulterators of foods
being the great offenders, should be proceeded against
and not the humble shopkeepers, who were, in most cases,
ignorant of the adulterated character of the goods which
they sold. Mr. J. W. Willis Bund read a paper suggesting
the establishment of a standard for effluents from sewage
works. It was followed by a discussion in which attention
was directed to the great extent to which fish are poisoned
in our streams by sewage.
OUR PARIS LETTER.
(From our Own Correspondent.)
CHLORALAMIDE—OBTAINING ATROPHY OF THE EYE BY
OPERATION—THE RELATIVE ACTION OF THE IODIDES
OF POTASH AND SODA—SACCHARIN A DISTURBER OF
DIGESTION.
Paris, October 11, 1889.
CHLORALAMIDE is the name of a substance recently intro-
duced into therapeutics as a useful hypnotic. It consists
of a combination of chloral and of formanide. It is ob-
tained under the form of colorless crystals, soluble in
about nine parts of water, or in one and a half of spirit.
Numerous researches on animals and on man have been
made, and it has been found that this new product pro-
duces sleep at a dose of from one to four grammes. The
sleep is produced less rapidly than with chloral, but more
quickly than with sulphonal, generally in half an hour,
whereas it is induced in a quarter of an hour with chloral.
No injurious action has been observed on the digestive tube,
nor any consecutive and persistent troubles which are
manifested after the employment of sulphonal. It is
easily administered in powder, either in wafers or in wine
or tea, three grammes of chloralamide corresponding with
two grammes of the hydrate of chloral. When once sleep
is induced, the effects last from six to eight hours. But
no effect can be obtained in delirious patients or those
which are very much excited. It succeeds, on the con-
trary, in subjects affected with insomnia after alcoholic ex-
cesses, and in neuropathic and hysterical subjects. Chlo-
ralamide presents, besides its little influence on the san-
guineous pressure, that which permits it to be prescribed
without danger to patients who are the subjects of organic
affections of the heart, the advantage of not being dis-
agreeable to take, nor does it give rise to any disagreeable
sensation after waking from the sleep induced by it.
In the Journal d'Oculistigue Dr. Fano proposes an
operative expedient with the view of obtaining the atrophy
of the eye, and substituting it for the extirpation of that or-
. The operation consists in puncturing the vitreous
body, which is followed by an abundant escape of the vitreous
humor. ‘This idea was suggested to him by the observation
of what takes place after certain operations for cataract by
extraction, in the course of which the hyaloid membrane
is accidentally wounded. The rule, in the cases of this
kind, even when the extraction ends favorably, is consec-
utive atrophy of the eye. ‘The author submits the follow-
ing case as an illustration: A young girl of seventeen,
affected with a congenital buphthalmos of both eyes ; one
of these, the right, was injured by an instrument which
pushed it outside the orbit, and produced at the same
time a rupture of the blood-vessels of the superior eyelid
and of the sub-conjunctiva] cellular tissue. Instead of
proceeding immediately to the extirpation of the globe,
he practised a large puncture of the cornea and of the
part attached to the sclerotic. A certain quantity of the
aqueous humor, followed by vitreous humor mixed with
blood, escaped. At the end of three weeks the eye was
atrophied, without the development of any inflammatory
accidents. He subsequently had two occasions to put
this mode of treatment into execution, and with equal suc-
cess.
Professor Germain Sée has made a very important come
munication at the Academy of Medicine this week, on the
relative action of the iodide of potassium and the iodide
of sodium. ‘The learned professor asserts that the action
of these two salts is very different, the one from the other ;
the sodium acts neither on the heart nor on the blood-
504
THE MEDICAL RECORD.
[November 2, 1889
vessels, whereas the potassium has a well-marked action
on these organs.’ If one injects into the veins of a dog
one gramme of the iodide of potassium, it is seen that
this animal well supports this dose, and even three grammes
may be injected without any bad effects. Far from being
a poison, the iodide of potassium has a tonic action on
the heart, which places it second only to digitalis and
renders it useful in the treatment of the greater number
of the affections of the heart; but in the nervous affections
of that organ it is more injurious than useful. As regards
the iodide of sodium, it has no action whatever on the
heart, and cannot in consequence replace the iodide of
potassium.
Dr. Fourrier, of Compiégne, writes that since it has
been known that saccharin impedes the action of the di- -
gestive fermentations, and that clinical observation has
shown that its ingestion was susceptible of troubling more
or less profoundly the acts of digestion, it has been pro-
hibited as a substance which may be employed for ali-
mentary purposes. It has, however, remained a medica-
ment, and according to the researches of Dr. Constantin
Paul, it may be placed in the class of antiseptics. As
such, Dr. Fourrier remarks that it was rational to try it
in the treatment of aphthz, and this has been fully con-
firmed by clinical experience. Dr. Fournier treated ten
cases of aphthz consecutive to measles by painting the
inside of the mouth with a solution of saccharin. Eight
times the milky patches had disappeared in from twenty-
four to thirty-six hours; twice only they resisted the treat-
ment for three days, but this was attributed to the paint-
ings not having been properly practised. ‘The following
is the solution employed by Dr. Fournier : Saccharin, one
gramme ; alcohol, fifty grammes. A teaspoonful to be
put into half a tumbler of water, with which the mouth
should be painted five times a day. A more concentrated
solution would be dangerous, as it would irritate the
mouth, as shown by several cases which came under Dr.
Fourrier’s observation.
Official List of Changes in the Stations and Duties of Ci-
cers serving in the Medical Department, United States
Army, from October 20 to October 26, 1889.
WaKEMAN, WILLIAM J., Captain and Assistant Surgeon.
Relieved from duty at Fort Walla Walla, Wash.Terr.,
and will report in person to the commanding officer,
Fort Bidwell, Cal., for duty at that station. Par. 7, S. O.
248, A. G. O., October 24, 1889.
Davis, WiLLiaAM B., Captain and Assistant Surgeon.
Relieved from further duty at Fort Porter, N. Y., and
will report in person, upon expiration of his present sick
leave of absence, to the commanding officer, Fort Preble,
Me., for duty. Par. 6, S. O. 248, A. G. O., October 24,
1889.
RAYMOND, Henry I., First Lieutenant and Assistant
Surgeon. Upon being relieved from duty at Fort Bid-
well, Cal., will report in person to the commanding
officer, Newport Barracks, Ky., for duty at that station.
Par. 7, S. O. 248, A. G. O., October 24, 1889.
SHANNON, WILLIAM C., Captain and Assistant Surgeon.
Relieved from duty at Fort Yates, Dak., and will re-
port. in person to the commanding officer, Fort Apache,
Ariz. Terr., for duty at that station. Par. 7, S. O. 248,
A. G. O., October 24, 1889.
CHAPIN, ALonzo R., Captain and Assistant Surgeon.
Relieved from duty at Newport Barracks, Ky., and will
report in person to the commanding officer, Fort Yates,
Dak., for duty at that station. Par. 7, S. O. 248,
A. G. O., October 24, 1889.
‘Mearns, EDGAR A., Captain and Assistant Surgeon.
Granted leave of absence for two months. Par, 5, S. O.
244, A. G. O., October 19, 1889.
KENDALL, WILLIAM P., First Lieutenant and Assistant
Surgeon. Leave of absence extended one month. Par. 6,
S. O. 244, A. G. O., October 19, 1889.
CLENDENIN, Paul, Firs@Lieutenant and Assistant Sur-
geop. Relfeved from duty at Fort McIntosh, Tex., and
will report in person to the commanding officer, Camp
Eagle Pass, Tex., for duty at that station. Par. 7, S. O.
248, A. G. O., October 24, 1889.
Ecan, PETER R., Captain and Assistant S On
being relieved from duty at Camp Eagle Pass, Tex., will
report in person to the commanding officer, Fort McIn-
tosh, Tex., for duty at that station. Par. 7, S. O. 248,
A. G. O., October 24, 1889.
BRECHEMIN, Louis, Captain and Assistant Surgeon.
So much of paragraph 2, S. O. 241, October 16, 1889,
as directs him to report for duty at Fort Apache, Ariz.
Terr., is revoked. He will report in person to the com-
manding officer, Presidio of San Francisco, Cal., for duty
at that station. Par. 7, S. O. 248, A. G. O., October 24,
1889.
Medical Items.
ConTaGious DIsEASES—WEEKLY STATEMENT.— Re-
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending October 26, 1889:
Cases. | Deaths.
Typhus fever oon 30 hs shows tka Sasha Nek o o
Typhoid fevers csccsiecsicascvee teres. oin 50 14
Scarlet fever..........n ou Suid eh Shaewewe os eere aja 40 5
Cerebro-spinal meningitis.................0.2.008 o I
Measles o iicuanoen esie e a eA Ea E Eaa tae tees 41 2
Diphtherid..sscsesorsi eesriie Se core arden ord 78 16
Small-pox ...escssssesoosesososoeserreseseeso seo o o
Yellow levero sss ccs we iena E EEE o o
CHO OR Asis sie aane gri RRE EEE E o o
ABSURDITIES AND CRUELTIES OF WOMAN’S DRESS.—
At the recent meeting of the British Association for the
Advancement of Science Mrs. C. Stopes read an interest-
ing paper on “ Psychological, Physiological, and Physical
Aspects of Dress.” Mrs. Stopes confined herself to con-
sidering the attire of her own sex, many of the absurdities
of which she denounced. The aim of dressmakers, she
said, seemed to be to make women incapable of free mo-
tion or prompt action. Prompt physical action, in case
of an emergency, was almost impossible to a woman, and
by disuse her powers became injured. Long dresses gave
rise to uncleanliness and the risk of receiving infection of
various kinds from street dust swept up. The inequalities
and disproportions of clothing were then dwelt upon, after
which Mrs. Stopes pointed out the injury to health caused
by using high heels. High heels were valuable only when
walking up hill; a patent might be taken out for movable
heels to be screwed on when ascending mountains. But
the woman who wore high heels was perpetually walking
down hill. ‘The habit of wearing tight stays was an evil
of national importance. If we heard of a government
punishing malefactors by tight lacing we should cry shame
on it for cruelty and demand the cessation of so horrible
a punishment. Nature revenged herself, for none of the
compressed organs could act healthily and freely.
COMPARATIVE OssTETRICS.—A giraffe has been born
in the Cincinnati Zoo, it being the first delivery of this kind
that ever took place in this country. It is said to have
been a head presentation and to have been a long labor,
the baby being nearly six feet from tip to toe when
dropped.
ê
e Ů— _— a a
Vol. 36, No. 19
Original Articles,
a a e e e o
THE TREATMENT OF HERNIA.’
By JOSEPH: D. BRYANT, M.D. `
NEW YORK.
CUSTOM, in this Association, declares in favor of a formal
discussion of some special subject of general interest.
Fate decreed that it fall to the lot of the reader to outline
and open the discussion, also to indicate those who have
so kindly consented to honor and to enlighten the occa-
sion with their presence, and with the results of their
labors. The treatment of hernia is the special subject
that was submitted by “ the powers that be,” for our con-
sideration, and now we—the writers—will submit the con-
clusions to your consideration, hoping that these conclu-
er
_ sions will justify the previous action of the “ powers,” at
least in some degree.
The subject, hernia, is an ancient one, and has associ-
ated with it the dust and traditions of the earliest times
of medical and surgical matters, It can be safely as-
sumed, I think, that the consideration of means of relief
from this affliction was but a step behind the first occur-
rence of the affliction itself ; and the age of the affliction
is best measured by the length of the time of the establish-
ment of the present relations of the abdominal contents
and their walls with each other.
The first person who had the first hernia was the first
one to contemplate means of relief from it, and no doubt
soon learned to seek the same relief in the recumbent
posture, and from manual pressure, that these measures
afford to-day. ‘The mechanical treatment of this affliction
had its inception, no doubt, at about the time that the first
unfortunate sufferer had succeeded, after much labor and
pain, in reducing a strangulated viscus. He appreciated
at once that the abdominal contents must be kept in their
proper places; and he had, without doubt, noticed the
fact that the recumbent posture met this requirement ;
but to remain lying was then, as now, neither wise,
pleasant, nor remunerative. ‘To retain the viscus in the
proper place by manual pressure while in the erect post-
ure, was recognized to lead to improvidence, to encourage
impertinence, and to end in despair. It contemplated a
too practical application of that good biblical maxim that’
teaches “ Let not thy left hand know what thy right hand
doeth.” The use of bandages and soft compresses for
the retention of hernial protrusions was recommended by
Celsus, near the first century, and, too, cures were claimed
by him to follow their use, especially in young children.
Galen confirmed the treatment of Celsus, and, about five
centuries later, Theodorus Ztius emphasized the method
and the results. Pads of wood and of iron, held in posi-
tion by a non-elastic soft girdle, were employed in Italy
in the thirteenth century. In the fourteenth and fifteenth
centuries, Bernard de Gordon and Gatanaria advised the
use of an iron girdle, which, however, was soon exchanged
for the hard-pad and soft-girdle appliance previously in
use. In the sixteenth century, Fabricius Hildanus de-
vised a truss of flexible soft iron, which could be moulded
to fit the form of the patient. It is said that to Matthias
Major belongs the credit of having first employed, in
1665, a truss with an elastic steel spring. ‘The time at
1 Read at the meeting of the Medical Association of the State of
New York.
New York, NOVEMBER 9g, 1889
“Whole No. 992
my disposal will not permit me to dwell at length on the
further development made in hernial appliances. In
fact, it is hardly necessary, since it is now only requisite to
attach the hard pad of the thirteenth century to the elas-
tic steel spring of the seventeenth, to form the substan-
tial construction of the majonty of the serviceable trusses
of the nineteenth century. ‘The greater number of medi-
cal men of the present day are blissfully ignorant of the
truss armamentarium now in the market, also of the meas-
urements, means, and method of fitting them properly to
patients. ‘The patients thus afflicted are relegated to the
‘instrument makers,” or to other mechanical agents, for
the proper truss and appliance, and the application of it.
In a large number of cases, no doubt, this course on the
part of the medical man is actuated by the sense of his
own inability to meet the demands of the case; when
this is the true cause, while we may commend him for his
sincerity, still we must respectfully submit that he is a
much too willing exponent of the sentiment that teaches
“ Where ignorance is bliss, ’tis folly to be wise.” I will
not say more on this point, but will avail myself of the
privilege extended by law to those who are not required
to testify as to matters that may criminate themselves.
The consideration of the worth of trusses should contem-
plate the elements of the instrument that contribute to
cure, to comfort, to convenience, to cheapness, and to
durability. e ,
That ruptures are cured by the proper use of trusses,
there can be no doubt; but the number of substantial
cures resulting is, unfortunately, small. It is impossible
to estimate, with any degree of practical precision, the
percentage of cures resulting from hernial appliances,
since these appliances are commonly worn for the comfort
and convenience they afford, rather than for the purpose
of a cure. Although it is proper to say that there are
many trusses extolled for the certainty of cure, these, how-
ever, soon become associated with other things of a worldly
character, that contribute to heart-sickness by reason of
“ hope deferred.” I have at this time under observation
several patients who have worn trusses for two to five years
by my direction, and they stil] continue to wear them by
the same advice, although anxious in a few instances to
lay them aside, because, as they express it, “ It has not
been down in months.” It is, in my judgment, unwise to
dispense entirely with the use of the truss, no matter how
sure the patient, or even the doctor, may be of cure. In
fact, the greater security lies in the judicious continuance
of the use for patients who are certain of having recovered.
Persons under twenty years, especially children, who wear
the appliance faithfully, may expect to be markedly bene-
fited, if not cured, when suffering from either form of in-
guinal or femoral hernia of a reducible nature. ‘I'he cure
contemplated, however, is one that does not provide for all
physical contingencies of human life. It is a cure in the
sense that the structures may be then as able to withstand
the effects of force as before the primary appearance of
the hernia. It is a cure in the sense that the ordi-
nary vocations of life may be safely met ; while all others
should be feared to the extent of seeking a safe retreat
behind the friendly support of the ubiquitous truss again.
It is my practice, when the means of the patient will
permit, to advise the procurement and use of three dis-
tinctive trusses : one, intended for comfort, strength, and
durability, for day use; another, equally serviceable in
other respects and impervious to water, for bathing-use ;
the last, for comfort and security during the hours of rest.
506
THE MEDICAL RECORD.
[November 9, 1889
The advantages arising from this course are obvious, and
too, it is equally obvious that if due care be not exercised
in changing these trusses, the anticipated benefits from
their use cannot occur. The establishment of the habit
of assuming the recumbent position while making the in-
terchange, is the only simple and safe method of proce-
dure.
The manner in which cure is accomplished by a truss is-
not as yet thoroughly agreed upon. It is, however, a most
important matter to be decided, as bearing on the proper
mechanism of the truss itself. Do trusses cure hernia by
establishing adhesive inflammation between the serous
surfaces of the sac? or by retaining the viscera in the
normal position, thereby permitting the displaced and
stretched tissues to resume, as far as possible, the normal
relations with each other? or, are both of these influences
active in the cure? In my judgment the cures are rare
where each of these influences plays an equal part in the
cure. It is not my belief that adhesive processes are
often excited within the sac by a hernial appliance. While
it is no doubt true that in exceptional instances, by reason
of the vigor of the appliance or peculiarities of the patient,
adhesion may be effected, still a method or means Jirectly
intended to accomplish this indication would “make the
treatment worse than the disease.”
The occlusion of the sac appears to me to be due to
contracticn of that structure—a contraction dependent on
the normal resiliency of it, aided by the friendly pressure
of the contiguous surrounding tissues, caused by their re-
turn to the previously normal position. This contraction
is of a uniform character at all aspects of the sac, as is in-
dicated by the cord-like appearance of its remnant. If
the obliteration of the sac were due to inflammatory ad-
hesion incited by a peculiar variety of truss, then, indeed,
would the local symptoms incident to such a process and
the outlines of the occluded sac point to this change as
the means of cure. I believe it is not tooemuch to say
that the tissue composing thé sac, and also the tissues
around the entire sac, will return to substantially their
normal dimensions and relations when the distending and
disturbing influences that have caused the change in them
are long removed. If this be true, then the theoretical
construction of a truss becomes quite a simple matter.
The implement holding the pad in position should be
elastic, and should exercise a degree of pressure sufficient
to hold the truss in proper position, and at the same time
exert enough additional force on the pad to prevent
escape of the viscus. ‘The pad should be of such a size
and shape that, while the force from it does not tend to
separate the point of exit of the viscus, still it will prevent
the insidious entry into it of the intestines or omentum for
even a short distance. In other words, the pad should be
slightly convex, and large enough to exert pressure to
some little distance beyond the border of the rupture. It
should be hard, because a hard substance only will main-
tain the necessary relations just described. If it were
soft, then the inequality of the resistance at the face of
the pad, due to the existence of the separated and
stretched tissues of the abdominal wall, would permit an
Inequality of the surface of the pad that would interfere
with the return of the abdominal wall fibres to the normal
relations. Furthermore, soft pads are less cleanly and
less durable than the hard, consequently more matatag
and expensive.
It seems to me to be entirely proper to consider the d
fect on the contents of a hernial protrusion exercised by
their continuous retention within the normal cavity. It is
a fact that cannot be gainsaid, that the long-continued ex-
istence of omentum, mesentery, and intestine, even in a
gradually enlarging hernial sac, causes stretching and a
more or less elongation of the omentum and the mesen-
tery, and possibly of the intestine itself. The elongation
of the omentum, and of a limited portion of the mesentery,
is surely familiar to surgeons who have had the opportun-
ity to study the characteristic appearance of the contents
of hernial sacs, in connection especially with the at-
tempted attainment of cure through radical means. It
follows, naturally, if these tissues be retained within the
abdominal cavity, that they, too, will again resume the
normal proportions to a degree, at least, that entitles the
hernial appliance to some favorable consideration in con-
nection with the change
The mechanical treatment of irreducible hernia intro-
duces two additional aims, viz., support and protection
of the protrusion. The protrusion should be so supported
as to prevent further increase in the size of the protrusion
itself, and also further increase in the area of the aper-
ture of escape through the abdominal wall. A moderate
upward traction on the protrusion is sufficient to neutral-
ize the influences of gravity and other natural forces on
it, and, in addition, to hold it gently against the abdominal
wall in the course of the line of displacement. This con-
dition of hernia ought always to be so protected as to ob-
viate the dangers that ensue from the bad effects of trau-
matism. Neither time nor propriety will permit me to
speak of the forms of trusses in the market. The medical
man himself must judge between them, or from his inner
consciousness evolve still another mechanism that equals
or surpasses those already known. I will, however, sub-
mit the following conclusions to your consideration :
1. No form of truss yet constructed can be relied upon
to cure any variety of simply reducible hernia.
2. The manner of the production of hernia, and that
of its so-called cure by mechanical appliances, are such
that cure by mechanical appliances, alone, need not be .
expected now, or hereafter.
3. Practical relief from the annoyance of a hernial pro-
trusion may be had by the use of hernial appliances,
which, however, ought always to be worn during all un-
usual physical efforts.
4. The so-called cures from hernial appliances are de- ,
pendent on the restoration of displaced tissues to the nor-
mal positron, and to obliteration due to natural resiliency
of tissues ; not, as is often claimed, to the inflammatory
adhesion of serous surfaces, caused by special mechanical
effects.
5. ‘The hard, shghtly convex pad, with the elastic steel
spring attached, constitute the principal parts of the most .
philosophical, comfortable, cleanly, and durable of hemial
appliances.
6. Suspension, elevation, and protection of irreducible
hernial protrusions, are the main indications for this me-
chanical treatment.
Not long since, Mr. Heaton, of Boston, employed and
recommended a method of treatment for the cure of re-
ducible herniz, which seemed, at that time, to offer tu the
afflicted of this condition the same ecstatic hope of im-
munity from it that the “ Elixir” of Brown-Séquard in-
cited in the credulous minds of frisky, though worthy, per-
sons who had passed the “ Rubicon ” of life. Unhappily,
however, for the latter class, the percentage of cure bids
fair to be far less than that claimed for the former. I,
myself, have had no experience with the “ injection me-
thod,” and do not now contemplate circumstances that
will cause me to adopt this method of treatment, except
perhaps in the young, and in cases of incipient hernia,
when other methods are not deemed advisable. However,
there are with us to-day those who have tried the method
effectually, and from them it is more befitting that state-
ments should be received as to the efficiency of this me-
thod, than from one who can counsel only with theory
and the lack of experience. It is, at all events, certain
that a more effective method of radical cure is to be
found in connection with the various operative proced-
ures of the present day, than from the method by | injec-
tion.
This leads to the inquiry, “ Which is the best method
of treatment for the radical cure, the ‘open’ or ‘ unopen'
method?” I know of no better way of determining as to
the relative merits of any special method of cure of any
special condition, than that of inquiring at once as to the
indications to be met, and as to whether or not this or
<
November g, 1889]
ural demands for a cure. ` Let us take, as an illustration,
a complete, simple, reducible, indirect inguinal hernia, and
inquire as to the physical status of the affliction. 1. We
find the internal ring dilated to admit the escape of the
viscus ; 2, the peritoneum is elongated by stretching and
growth to form the sac; 3, the omentum, the mesentery,
and perhaps the intestine, are elongated hy the continued
traction incident to their escape. The internal ring of
fascia, and the corresponding peritoneum, are the first
obstacles to the escape. When the viscus once enters the
inguinal canal, the descent is not opposed by other than
the tense elongating and enlarging peritoneal sac, the con-
nective tissue in the inguinal canal, and the passive and
- varying pressure of the aponeurosis of the external oblique
muscle, aided, perhaps, by the retentive influence of the
elongating omental and mesenteric tissues. When once
well in the inguinal canal, but little else obstructs the de-
scent except the peritoneum composing the sac, and the
lax fascize and integument of the abdomen. It therefore
appears that the most substantial obstacle to the escape
of hernia exists at the internal ring, and that when this is
overcome, the formation of a complete hernia is merely a
matter of time, facts which are confirmed by the clinical
histories of cases of this form of hernia. From these
statements it appears that the chief aim for the accomplish-
ment of a radical cure must consist in.so strengthening
the internal ring and contiguous parts, that escape of in-
testine 1s both opposed and defeated. Now, which of
the two methods just cited, the “ open” or the “ non-open ”
method, better strengthens the internal ring? The method
of Macewen is, it seems to me, as good an example of the
“ non-open ” method of treatment as can be selected. At
least it is employed most frequently, is most strenuously
defended, and best understood of the “ non-open” me-
thods. The method of Macewen occludes the peritoneal
opening and strengthens the peritoneum at the internal
ring, first by somewhat passive, afterward adhesive closure
of the neck of the sac; also by elevating the serous mem-
brane at this point, or “ bossing ” it, as it is often called,
and by diminishing the capacity of the inguinal canal at
the lower portion by the approximation of the conjoined
tendon and the external pillar. The “ bossing” is oc-
casioned by confining the “ ruffled” sac between the peri-
toneum and the fasciz at this point. ‘The occlusion of
the peritoneal opening presumptively converts the peri-
toneum at this point into a nearly continuously smooth
surface, when taken in connection with the contiguous
peritoneum ; while the “ bossing ” is supposed to elevate
the peritoneum at the internal ring somewhat, to which
elevation is assigned the functions of fortifying against
and turning aside the internal visceral pressure at this, the
weakened point. Assuming that all takes place that has
just been described, we can add still further support by
including the strength of the recently divided abdominal
tissues, united as they are by the sought-for primary union.
That it is reasonable to assert that closure of the neck of
the sac does do it, as has just been stated, there can be no
consistent doubt; but that the ruffling and placing of the
sac itself, as is practised in this method, secures the
“ bossing ” in many cases, is open to grave doubts. I am
not aware that the occurrence of “ bossing” has been
actually demonstrated, but I am rehably informed that
the reverse of the proposition has been noticed, under
circumstances calculated to demonstrate it. It is difficult,
indeed, to understand how the “ bossing ” can be main-
tained, even if it had occurred at the outset, when the
“external support to the internal pressure at this point is
much lessened from the normal by the absence of, and
by the weakened and elongated state of, the usual support-
Ing tissues.
So much for the physical state of the “non-open”
method. Let us now conduct a similar comparison in
connection with the “open” method. In this method
the neck ‘of the sac 15 closed by a ligature. ‘The sac is
then cut off, aponeurosis of the external oblique slit up
to opposite the internal ring, and the entire wound is
caused to heal by granulation, care being taken to so
treat the wound as to cause the cicatrix to reach up to
and support the peritoneum at and about the point of lig-
aturing, which is the weakest place. Other stitches are
taken to modify the shape and size of the scar, but the
grand finale is this; with honors easy between the meth-
ods, so far as peritoneal surfaces are concerned, the peri-
toneal structure of the latter is supported and fortified by
a cicatrix, which occupies the inguinal canal, and which
it is thought will prevent the further escape of hernia, so
long as the cicatricial tissue continues to exercise the pecul-
tarities characteristic of its nature. ‘The integument and
fasciæ, too, are involved in this scar. In the “non-open”
method the degree of the resisting influence exercised by
the reunited tissues is also somewhat problematical, for
the tissues, when healed by primary union, are capable of
withstanding but little, if any, greater force than when in
the normal state. The comparative resistance of normal
tissue with that of cicatricial tissue, is easily understood
when the latter is noticed so frequently to draw the for-
mer toward itself, with the same grim certainty that the
unsuspecting mariner is said to have approached the tra-
ditional maelstrom. My experience with the “ non-open ”
method is limited to nineteen cases, but I regret to be un-
able to state the results after a period of sufficient length
(three years) to enable me to form more than an approxi-
mate estimate of the worth of the method from my own
experience. ‘The majority of these (eleven) were hospital
cases, all of which passed from my observation in from
four to six months. Of the remainder, I have no reliable
knowledge, except in one instance of two years’ standing
which is s#// cured. Suffice it to say, however, that so
long as they were kept under my observation, no return
was noticed except in one—a hospital case—and this was
within four months after operation. As to the “ open”
method, my experience is limited to five cases,’ all but
one of which have been performed during the last year.
In the winter of 1887, in a clinic given at Bellevue Hos-
pital, I treated a case of hernia for radical cure by the
open method, in all practical respects. ‘The wound was
packed with gauze, but not with the special care and pre-
cision advised by Dr. McBurney. ‘The healing occupied
about six weeks, and when the patient was last heard
from, one year after, he was still in a sound condition.
I cannot close this portion of the subject without call-
ing to your attention a somewhat newer method of op-
erating that.I have practised on three distinct occasions.
It certainly has some features that commend it, and, be-
lieve me, neither of these has to do with the fact that the
method was devised, so far as I know, by myself. It is
performed by weaving the sac, after separation, and lig-
aturing its neck with catgut into the pillars of the ring in
the following manner: Fig. 1 shows the isolated sac,
with the neck A tied (see foot-note on page 508), also the
pillars of the ring slit for the purpose of weaving. Fig. 2
shows the sac carried upward beneath the inner pillar, and
through the upper slit. Fig. 3 shows the sac carried
downward through the slit nearest the border of the inner
pillar, thence downward beneath the outer pillar of the
ring to and forward through the lower slit of this pillar.
Fig. 4 shows the sac passing upward through the slit near-
est to the margin of the external pillar, and finally, if long
enough, upward beneath the free margin of the inner pil-
lar again. ‘The borders of the pillars are then approxı-
mated by making tension of the sac, and the whole mass
is finally quilted together with deep stitches of catgut,
leaving sufficient room, however, for the passage of the
cord (Fig. 5). The external wound was closed in each
‘Instance, and primary union followed without an unfavor-
able symptom. One of these cases was a female with a
large, direct, painful inguinal hernia, which could not be
retained in place by mechanical means, and the patient
2 — ee ee a
1 Since the writin
four months before,
return.
of this paper, one of this number, operated on
as been reported to me as showing evidences of
508
THE MEDICAL RECORD.
[November 9, 1889
could secure comfort only by continuously assuming the
recumbent posture. At the end of four weeks she was
allowed to go about, and six months from this time, when
last seen, was still in sound condition. In the second
case the hernia returned six months after operation, dur-
ing a severe attack of whooping-cough. ‘The third case
di
A
y
H
Eh.
"A
Mi
mi ii
Pad
‘j 1
AHR.
Fic. 1.—The [Isolated Sac.
disappeared from observation entirely, as soon as allowed
to leave the hospital. This method closes the neck of the
sac, the same as the others; but, unlike the others, fills
the inguinal canal with normal serous tissue, which is so
placed as to support the peritoneum and fasciz exten-
sively at the weakest part. It is possible that still greater
firmness can be secured if the wound be treated openly
after the weaving and quilting processes are completed.
In one of these cases the fasciz in contact with the peri-
toneal sac were not disturbed, but were woven in as if
peritoneum alone were present.
duces a larger amount of tissue into the canal, and corre-
‘spondingly increases the strength of the region, and like-
wise obviates any impairment of the nutrition of the sac
that might arise from the removal of the fasciz from it.
It has been assumed that the ligaturing of the neck of the
sac will cause the sac to slough, especially in old persons.
In one of the cases operated on by myself, the patient
was about sixty years of age, and, as already reported, a
rapid and uncomplicated recovery supervened. How-
ever, if the danger of sloughing of the sac dependent on
the ligaturing be the main objection to this method, then
passive means of primary closure of the neck of the sac
1 Since the presentation of this paper, I have had an experience
which has caused me to advise against one step of the operation—lig-
aturing the neck ofthe sac. In a clinic given at Bellevue Hospital
but a few days since, this method of treatment for radical cure was
practised on a patient aged fifty-two. Four days after the operation
a temperature of 102° caused an examination of the wound to be made.
The superficial tissues had healed perfectly, but a limited separation
of them, made for the purpose of examining the condition of the inter-
woven sac, disclosed the fact that limited portions of the sac were un-
dergoing inoffensive disintegration. It has frequently been my prac-
tice to ligature the neck of the sac, before ruffling and depositing it,
after the method of Macewen, and never before have symptoms
arisen that were suggestive even of the idea of a similar untavorable
result. However, it is proper to say in this connection, that since the
uvowal of the unfavorable course in this case, others of a similar nat-
_ure, in connection with a different method of operation in the practice
This modification intro.
opinion that this method cannot be employed indiscrim-
inately as can the open method, since it frequently hap-
pens that the sac is illy developed, or so much damaged
by isolation that it will be unwise to hope for particular
benefit from the weaving process, even if it be possible to
employ it ; and, too, not infrequently the external pillar
of the ring may be found to be so narrow and attenuated
as to render its slitting impracticable. The following
conclusions are submitted in connection with this phase
of the subject.
1. ‘That the open method of treatment is the most ra-
tional and the simplest method for the radical cure of
hernia, provided the resulting cicatrix meets the expected
requirements ; consequently, the additional time required
for treatment by the open method will be time well em-
ployed, if the cure resulting from this method should offer
greater immunity from return of hernja than does that of
any other method of treatment. 2. That the best sources
from which to judge of the absolute and comparative re-
sults of the methods of radical cure are afforded by in-
firmaries for the ruptured, where the unfortunate persons
go finally for relief, as a last resort. 3. That failure of
the open method to cure, leaves the patient less amenable
to the beneficial effects of a truss, and to subsequent
radical treatment, than a failure from the non-open
| ‘method, by the substitution of cicatricial for normal tis-
sue ; therefore, the percentage of primary cures from the
open method should much exceed those of other methods,
to insure the final benefit of the patient. 4. That the in-
terweaving of the sac with the pillars of the ring, followed
by open or closed treatment of the wound, will afford in
many cases equal, and even greater, security than by any
other method of treatment.
Fic. 2.—Sac going through Upper Slit of Inner Pillar.
The “ medicinal and manipulative measurés” of “ pal-
liative character” employed for “ strangulated hernia,”
and the “reliance” placed in them, will be governed
of the Hospital, have been announced. It is now my intentigced-
omit ligaturing the neck of the sac, and to employ instead- . .
passive means of closure. Dy injec-
A the Ae SPPON I shall scrape the inner surface
of the sac slightly witha knife, and then pass a catgut li
and around both walls of the sac at the middle or they Dest method
the abdominal peritoneum, so as to include in the gra OF ‘ unopen
ture a portion—say one-fourth of an inch in width. :rmining as to
The ligaturing of this portion will prevent the entran; f
into the neck, without impairing the nutrition of the sa¢ CUTE ol any
closure of the neck has taken place under the pressuynce as to the
mer fr not this or
Ra.
t . ;
Wi patient, to attempt the reduction.
by tity
Method,
ineco rmb,”
doin sful, each will cry “ What a brave boy am I.”
0,
November 9g, 1889]
THE MEDICAL RECORD.
599
largely by the experience of the medical attendant ; by
the surgical atmosphere in which he moves ; by the means
of carrying into effect the measures which he deems best
for the patient ; and, too, they will be modified not a lit-
tle by the predilections of the patient and of the friends.
‘The medical measures that quiet pain the easiest and
quickest, and cause complete relaxation of the tissues,
represent the palliative remedies to be employed. The
measures that favor most the influence of the force of grav-
ity on the protrusion, with or without the use of taxis, are .
together the palliative manipulative measures of standard
reliability. Morphia injections, hot-water baths, with
elevation of the part bearing the hernial protrusion, are
Fic. 3.—Sac going through Slits of Inner and Outer Pillars.
the best and most available means at the command of the
medical attendant. If these be combined at once with
well-directed and moderate taxis, a successful return of
the viscus may be prognosticated under ordinary circum-
stances. If these means fail, and the local or constitu-
tional symptoms of strangulation continue, then taxis
` should be tried again briefly, under complete anesthesia,
and, if not successful, herniotomy should follow at once.
Too long, too frequent, and too forcible taxis are the rul-
ing tendencies outside the hospital influences. ‘Taxis
ought not to be employed continuously for longer than a
quarter of an hour. If it be properly directed, this is
sufficient time in which to safely effect a reduction of the
Fic. 4.—Sac passing through Outer Pillar and Beneath Inner Pillars.
gut ; if improperly directed, then even ¢/zs is much too
long a time. ‘The frequent employment of taxis in a
single case arises from the unwise practice, that often in-
spires each medical man whocomes in contact with the
The majority make
the attempt from proper motives; a few from vain and
elfish ones that too often prompt the effort only because
hers have failed. ‘The latter are the “ John Horners”
the case, who, although they may not “stick in a
try to “stick in” the viscus; and if suc-
Too
forcible taxis comes of inexperience, haste, and unwar-
ranted energy. Inexperience as a cause will always ex
ist, but haste and unwonted vigor need never be practised.
In view of the general knowledge of antiseptics in sur-
gery, and of the results of their use, and also of the im-
mense advantage to the patient from a radical cure, there
is little ultimate benefit that can come to a patient now
from even the wise and successful employment of taxis.
However, it is not my intention to advocate the abolition
of taxis; there is nothing so practical that can take its
place. ‘The ablest surgeon, the humblest physician, and
the suffering patient, each employ taxis at the onset of
the case, and not infrequently the self-experienced and
self-educated patient employs it even more successfully
than either of the others. It is the aduse, not the use, of '
taxis that demands condemnation. The medical attend-
ants of hernial unfortunates should employ taxis when re-
quired, and should know how to do it properly in all re-
spects. There are far greater numbers of medical men who
can perform taxis successfully, than who can operate prop-
erly on strangulated hernia. Improperly performed taxis,
when employed as cases arise, is not as fatal a procedure
as inexperienced, bungling herniotomy under like circum-
stances. It is well to remember that, however confident
the surgeon may þe of the proper course to be pursued
in a special case, that the patient and the friends may dif-
fer from him in some important respects. They will
Fic. 5.—Quilted Tissues.
often oppose operative measures, because patients of
whom they have known have died after the performance
of them, and also because persons have recovered without
them, and, too, in the face of the positive assertion of the
surgeon that life can be saved only by operation. In such
instances as these, one has but to state firmly, yet respect-
fully, his convictions of the case, and if unheeded, then
decline to assume a responsibility which he himself
can have no voice in creating. Your attention is invited
to the following conclusions regarding this part of the
discussion :
1. The abuse, not the use, of taxis constitutes an evil
against which all surgeons should protest.
2. That a quarter of an hour of well-directed and con-
tinuously applied taxis is a rational procedure ; longer
than this is unnecessary, therefore unwise and harmful.
3. ‘That repeated attempts at reduction on the part of
different persons is pernicious, therefore dangerous and
destructive.
4. That the present status of modern operative surgery
has reduced the successful employment of taxis to the po-
sition of rendering but little practical benefit to the pa-
tient, except ın special cases.
The rigid enforcement of antiseptic principles should
be adhered to in all cases of hernial surgery. ‘The anti-
septic technique is as essential in successful radical cure
operations, as in herniotomy itself. Hours can now be
consumed in writing numberless pages on the “ best tech-
nique applicable to an operation for strangulation hernia,”
and, at the end of the time little more will be said than
ought now to be well understood by all such as may be
510
r T
©
lled on to operate for relief from this physical calamity.
I will not, therefore, take the time of the Association by
dwelling on the details of the line of incision, division of
layers, identification of the sac, location and division of
the construction, etc. It is my belief, however, that the
surgeon who now neglects to perform an operation for a
radical cure, as an addendum of herniotomy, falls short of
his duty of consulting the best future welfare of the pa-
tient, provided, of course, that the immediate condition
of the patient and of the tissues will permit. ‘The ques-
tion as between the selection of the open or non-open
method in these cases, is largely a matter of expediency,
in which the patient and friends should be consulted at
the onset. If the time at the patient’s command be short,
and the condition of the tissues be favorable for it, then
the non-open method should be selected. If, however,
the final benefit to the patient alone be the only matter
for consideration, then it is hoped that the open method
may prove more highly commendable. The following
conclusion is submitted :
That, all things being equal, radical cure should be
practised as an addendum to herniotomy.
It happens occasionally that gangrene of the contents,
or even of the sac itself, complicates strangulation. This
is a complication of vital importance to the patient in a
literal, and to the surgeon in a professional, sense. The
proper treatment of such cases calls for as great display
of skill and judgment on the part of the surgeon as is re-
quired for the treatment of almost any other surgical con-
dition. The treatment of this complication should be
divided into two classes, the preventive and the remedial
treatment. ‘The preventive treatment consists in an early
reduction by taxis or by other means; or, failing in re-
duction, a prompt operation. The extremes of time after
strangulation, befofe gangrene occurs, can never be ac-
curately known, nor is it wise that these periods should
even be approximately known, since it is unwise and dan-
gerous to allow the question of the length of time of the
existence of strangulation, as bearing on the occurrence
of gangrene, to exercise any special influence on the oper-
ative judgment of the surgeon, since the existence of gan-
grene cannot be usually determined until after exposure
of the contents of the sac by operation. The waste of
important time in either nursing or considering hair-split-
ting theories, or in idle and useless prognostication, is evi-
dence of the fact that much learning may become more
dangerous even than a little.
The remedial treatment applies to the question, “ What
shall be done if gangrene have occurred?” If the sac
alone be gangrenous—which is improbable—the gan-
grenous portions should be removed, the contents of the
sac returned, the neck of the sac closed, superfluous por-
tions of the sac cut off, and then radical cure should be
sought for under the open method of treatment. If the
intestine be gangrenous, the surgeon will then be obliged
to entertain the propriety of practising one of the three
following plans: 1, Of leaving the gangrenous intestine
alone and relying on nature to form an artificial anus ; 2,
of the removal of the gangrenous portion and the stitch-
ing of the gut to the wound (if the constriction have al-
ready been divided), thus forming an artificial anus ; 3,
of excision of the gangrenous portion, immediate union
of the extremities by sewing, and the return of the intes-
tine to the abdominal cavity.
Which one of these plans should be adopted will de-
pend largely on the following considerations: 1, The
physical condition of the patient; 2, the physical condi-
tion of the wall of the intestine ; 3, the portion of the
THE MEDICAL RECORD.
[November 9, 1889
not difficult to understand that the additional time re-
quired to bring relief through nature’s efforts alone might
be the determining cause of the death of the patient ; and,
too, the early relief of the intestine from the effects of in-
terna] pressure and extreme vascular plethora, will reduce
the extent of the sloughing toaminimum. ‘There appears
to me to be no doubt of the fact that, after carefully pro-
tecting the wound from contact with the intestinal con-
tents, the gangrenous intestine ought to be incised
sufficiently to relieve its fecal and vascular plethora. I
deem it unwise to divide the constriction before incision
and depletion of the intestine, except the constriction be
thought to be too narrow to permit the escape of the ‘con-
tents without division—a degree of closure that must be
rare indeed. ‘The reasons for this opinion are: 1, Such
a course may permit the intestine to elude the grasp of
the surgeon and escape into the abdominal cavity, with ob-
viously fatal results; 2, after depletion of the intestine,
the division of the constriction may be found to be un-
necessary, and even unwise, if the establishment of a
temporary artificial anus be contemplated. However, if,
after depletion, the extent of the gangrenous portion of
the intestine appears to be limited in part or entirely by
the seat of the constriction, or the amount of non-gan-
grenous intestine outside of the seat of stricture be too
small to meet the requirements of a properly formed arti-
ficial anus, then the constriction should be carefully di-
vided, and the intestine drawn down sufficiently, at least,
to bring to view a healthy, complete, intestinal circum-
ference, which should then be stitched to the border of
the wound with silk, or otherwise retained if immediate
or remote enterorrhaphy be contemplated. If, after the
depletion of the intestine, a sufficient amount of non-gan-
grenous gut remain external to the constriction to meet
the further demands of the case, then the constriction
need not be divided, provided, of course, that the internal
pressure from intestinal contents has been entirely re-
lieved. The means to be adopted by the surgeon to de-
termine the existence of gangrene of the gut are standard
matters in almost innumerable publications. I can add `
nothing to the list of stereotyped measures so long em-
ployed for this purpose. After exposure of the gut, if the
question arise as to whether or not gangrene may super-
vene, care should be taken to completely relieve all con-
striction of the gut, and also to retain it i# síu until this
element of the prognosis is determined ; then the degree
and extent of the gangrene will control the subsequent
action of the surgeon. If it be of so small an area that
the removal and the repair do not reduce the calibre of
the intestine to less than two-thirds the normal diameter,
the gangrenous area should be removed, the opening closed
by sewing, and the intestine returned to the abdominal
cavity. It is important to remember, however, that an
impairment of the mesenteric border of the intestine
should not be thus treated ; this condition calls for ex-
cision of intestine to the extent of the mesenteric impair-
ment, otherwise gangrene of the intestine may ensue to a
similar extent. If gangrene of the gut be too extensive
to admit of a simple method of repair, what then should
be done ? , Shall an artificial anus be established to be
cured by a subsequent operation, or shall the gangrenous
intestine be excised at once, the extremities united, and
the bowels returned to the normal cavity? If the condi-
tion of the patient be such as to warrant the belief that
an operation of an hour and a half or two hours’ duration
may be performed with reasonable safety, the intestine
should receive a radical and permanent treatment at
once, and be returned into the abdominal cavity.
If the character of the intestinal discharges, the no =
tion of the protrusion, and the anatomical char; p
of the bowel, warrant the belief that the jejyy est
volved, then radical operation should be s meck. dose to..
once, even at great risk to the patient, otherv tmini? * liga *
anition will ensue, which, if it do not destro seas
in a few days, will so quickly enfeeble him $ tace ag. w" m
the possibility of a favorable result from a i pot tt" da ces
oF
5
intestinal tract involved by the gangrene; 4, the sur-
geon’s available knowledge of the technique of the require-
ments of the case.
It is not, in my judgment, ever advisable to allow nat-
ure an unaided course in the matter. The sooner the
tension within the intestine is relieved by causing a free
escape of the obstructed contents, the sooner relief will be
had from the distressing symptoms of strangulation. It is
. of the neck a
aure through ai?
~
Tay
ah
ctu
Others jy, NEction with each army corps, in order that a strict inves-
Of thy
thon
November 9, 1889]
tion. As an illustration of this, Riedel reports a case
where the opening into the intestine was located about
half-way between the pyloric extremity of the stomach
and the czecum (eleven feet), in which rapid inanition en-
sued, and at the end of twelve days radical operation was
performed as a last resort, and without success. It is
wise in this connection to remember that the jejunum is
commonly located in the umbilical and left iliac regions
of the body.
‘The condition of the walls of the gut, adjacent to the
Opening in it, does not exercise so very important influ-
ence on the chance of the immediate radical, or the tem-
porary anal, operation for gangrene, because in either in-
Stance sufficient intestine can be readily withdrawn to
_ Secure sound and non-congested tissues for sewing.
However, other things being equal, it is better to restrict
the extent ot the excision of the intestine to the narrow-
est practical limits, for, the longer the piece removed, the
longer will be the time employed in the operation. ‘The
congested state of the intestine should not cause delay in
the operation if the intestine be involved in the upper
two-thirds, since the danger of inanition due to delay will
be greater to the patient than the sacrifice of all the con-
gested intestine contiguous to the opening. At all events,
the sewing should be done in the perfectly normal intes-
tinal tissues, if the best results are to be expected. It is
proper to say at this time that the removal by excision of
four or five feet of small intestine need not cause undue
apprehension as to the possibility of inanition of the pa-
tient. Koeberlé is reported to have excised nearly seven
feet without causing a resulting appreciable change in the
nutrition of the patient.
In the operative treatment of gangrene of the intestine
by the radical method, rapidity, thorough antisepsis, and
complete familiarity with the technique of the steps of en-
terorrhaphy are of most vital importance ; so important in
fact, that the operation should not be attempted except by
the best skill at command. It is far better for a patient
that an artificial anus be made, even with unfavorable
- prospects, than that immediate radical measures be at-
tempted by those not familiar with their surgical technique,
Since ıt may soon be possible to secure the necessary skill.
It will be noticed that I have not employed statistics, not
described the minute details of measures on the knowledge
of which strong insistance has been made. ‘The reasons
for this course are twofold: 1, Because time would not
permit it; 2, because these facts could be more appro-
priately considered in connection with the special parts of
the discussion allotted to others. ‘The following conclu-
sions appear to me to be properly deduced from the pre-
ceding statements :
1. When gangrene of the intestine has taken place and
the condition of the patient will permit, intestinal repair
should be practised at once, and the gut returned to the
abdominal cavity.
_ 2. When gangrene has occurred, presumptively invulv-
ing a portion of the upper two-thirds of the intestine, in-
testinal repair should be practised at once, and the gut
returned to the abdominal cavity, even if the immediate
result of the operation be somewhat doubtful.
3- When gangrene has occurred and the condition of the
patient will not permit immediate operation, a temporary
artificial anus should be formed.
4. It is better to form an artificial anus, under all cir-
cumstances, when the medical attendants are not familiar
with the details of intestinal surgery.
5. Division of the constriction is not always necessary,
and is often unwise when the formation of an artificial
anus 1s centemplated.
AN INSPECTION OF FOOD IN THE RUSSIAN ARMY.—
The medical authorities of the Russian Ministry of War
have decided to establish ambulatory laboratories in con-
tigation may be made into the quality of the food supplied
by the commissariat.
THE MEDICAL RECORD.
II
ON THE PAT#OLOGY AND TREATMENT OF
INTRA-PELVIC INFLAMMATIONS.'
By L. S. MCMURTRY, M.D.,
DANVILLE, KY.,
FELLOW OF ‘SHER AMERICAN ASSOCIATION OF OBSTETRICIANS AND GYNE( OLO-
GISIS : FALLOW OF THE OBSTETRICAL SOCIETY OF EDINBURGH, ETC.
INTRA-PELVIC inflammations, with their sequelæ, compose
the most common conditions with which the gynecologist
has to deal. In the entire compass of medical science
and practice no subject has been more misunderstood,
and none more erroneously interpreted.
Thirty years ago Bernutz and Goupil, after careful
clinical and post-mortem investigations, clearly described
the true pathology of pelvic inflammations, but it has only
been since operative surgery has opened up the peritoneal
cavity to daily exploration that their researches have been
appreciated and accepted. Even at this advanced period,
many of our prominent teachers and authors classify in-
tra-pelvic inflammations under two heads—fara-metritis,
and peri-metritis—with treatment adapted accordingly.
Modern investigation has swept this classification aside.
confirmed the truth and accuracy of Bernutz’s researches,
and demonstrated the relation of diseased states of the
ovaries and Fallopian tubes, together with puerperal, spe-
cific, and other infections, to pelvic inflammations.
It is not my purpose to review before this audience the
anatomical relations and histology of the pelvic organs, a
task altogether superfluous; nor will I, except in the
most casual way, touch upon the vast literature of pelvic
infammations. It seems to me most profitable at this
time to treat the subject from the pathological and clini-
cal standpoint.
M. Bernutz made a most happy comparison between
inflammation within the pelvis and the same process with-
in the chest. Skene and other modern writers have uti-
lized the same analogy to describe and illustrate the
pathology of intra-pelvic inflammation. In both thora-
cic and pelvic inflammation we have the croupous and
catarrhal processes. We have peritonitis and parenchyma-
tous inflammation on the one hand, while we find pleuritis
and parenchymatous inflammation on the other. In pelvic
inflammations we have recovery by resolution just as in
pleuro-pneumonia, leaving adhesions and bands in the one
cavity as in the other. When the inflammatory process so
interferes with nutrition as to destroy vitality, we have pel-
vic abscess in the one site and pyothorax in the other. We
find the bacilli of tubercle invading the pelvic serous
membrane and contained organs, just as in the pleura and
lungs. A mucous surface furnishes access for infection
in both cavities. M. Bernutz further states that uterine
pathology is as certainly subordinate to a thorough ac-
quaintance with pelvic peritonitis, as pulmonary diseases
have been to a complete knowledge of pleuritis made pos-
sible by the discovery of auscultation. In the light of
knowledge recently established, this last statement shows
how thorough and profound were the researches of these
eminent clinicians and pathologists, MM. Bernutz and
Goupil.
Permit me to.continue in the lines indicated by Bernutz
once again. After discussing the theory of pelvic inflamma-
tion promulgated by M. Nonat—essentally that of pelvic
cellulitis, which until recently held full sway in the practice
of modern gynecology—he says: “ For some time I had
no idea that the view propounded by M. Nonat was a
mere hypothesis which rested on no post-mortem evidence.
And it was not till after the unfortunately fatal termina-
tion of two cases that I was able to prove incontestably,
that the peri-uterine tumor which, during life, presented
all the symptoms of the so-called peri-uterine phlegmons,
was not situated in the cellular tissue at all. In the
autopsies in questior, the tumor, which even after death
presented all the usual signs, was seen to be formed by
the pelvic viscera being matted together by peritoneal ad-
1 Read before the American Association of Obstetricians and Gyne-
cologists, September 18, 1889.
512
THE MEDICAL RECORD.
[November 9, 1889
hesion. «These researches, thn, have led to the
conclusion that inflammation of the pelvic peritoneum,
which is the cause of the visceral adhesions, is a disease
which is very commonly met with. Lastly, I con-
clude that inflammation of the pelvic serous membrane is
symptomatic, and that it is generally symptomatic of inflam-
mation of the ovaries or Fallopian tubes. Thus great in-
terest attaches to the study of this affection, and it is very
important to thoroughly understand the symptoms, in order
to describe satisfactorily the uterine, and more especially
the tubo-ovarian, diseases which occasion it. . . . It
follows from all this that, unless we get fatal cases to en-
able us to determine anatomically where the pelvic in-
flammation began, we cannot state positively whether it
came from inflammation of the ovary or of the Fallopian
tube ; nor whether it was caused by the puerperal state,
by blenorrhagia, scrofula, or any other malady. ‘Thus
we can only lay hold, as it were, of the two ends of the
pathological problem, the primary disease and the serous
inflammation—the intermediate gap we can only fill up
after death.”' Herein may be found the very essence of
the most advanced pathological knowledge of the day
concerning intra-pelvic inflammations, and it is surpassing
strange that the researches of MM. Bernutz and Goupil
lay before the profession for so many years like good seed
= upon sterile ground. It was only when the science and
art of surgery made great strides forward, as illustrated in
the perfected aseptic surgery of the day, that “ the inter-
mediate gap” which Bernutz’ could “only fill up after
death ” was filled up during the life of the patient. The
researches of Bernutz and Goupil in this important field
of pathology are complete, and constitute the basis of the
pelvic surgery of the present time ; their work is the first
and greatest, a monument to the genius and patient in-
dustry of these faithful followers of science.
The points relating to the pathology of pelvic inflamma-
tions which have been established, the correctness of
winch I am fully convinced by my own clinical observa-
tion and experience, may be grouped in this manner:
1. Intra-pelvic inflammations cannot be. properly clas-
sified as para-metritis and peri-metritis, inasmuch as in-
flammations of serous and cellular tissues cannot be sepa-
rated clinically or histologically.
2. Peri-uterine phlegmon of Nonat (pelvic cellulitis of
Emmet) is as rare as inflammation of the cellular tissue.
in other parts of the body.
3. Intra-pelvic inflammation is, as a rule, peritonitis, re-
sulting from disease of the ovaries and Fallopian tubes,
arising in puerperal or gonorrhceal infection, or the mis-
cellaneous infections carried to the endometrium by un-
clean instruments, tents, or medicinal agents, or from
traumatism.
4. Pelvic peritonitis is symptomatic, never idiopathic.
Pelvic peritonitis presents every grade of severity. In
some instances there is a mere inflammatory spot, giving
rise to but little discomfort at the time and passing away
without treatment, leaving a bare trace behind, often
found post mortem.
those instances whereia the peritoneum exhibits subserous
congestion, transudation of serum, and exudation of
plastic material. In a more severe grade there is im-
mense transudation of serum, which accumulates in the
pouch of Douglas, corresponding to pleurisy with effusion.
In a very high grade the entire pelvic peritoneum is in-
volved, the several stages of the process—congestion and
exudation—are followed by suppuration, an affection of
fearful proportions, and unless treated surgically, going
often to a fatal issue. ‘The sequel of pelvic peritonitis
depend upon the vitality of the individual, the grade of
the inflammatory process, and the area involved. Where
the surface is limited, or maybe quite extensive, recovery
may take place by resolution and leave only slight ad-
hesions behind. When the inflammation is higher and
_} Clinical Memoirs on the Diseases of Women, New Sydenham So
ciety, London, 1867, vol. ii., p. 5.
A higher grade is illustrated by .
the exudate more extensive, layers and bands of false
membrane remain, forming organized adhesions. ‘The
products of inflammation may be deposited over the
uterus, ovaries, and broad ligaments, leaving these organs
imbedded or entangled in a mass of adhesions. As time
goes on the exudate passes through repeated stages of
congestion into organized tissue, with constant tendency
to contraction. Pressure upon the ovaries is followed
by inflammation, degeneration, and atrophy of these or-
gans. The fimbriated extremities of the Fallopian tubes
are imprisoned and destroyed. At each recurring men-
strual flux these bands are made tense by congestion, in-
creased in thickness, and more thoroughly organized. In
addition to the lesions entailed by pressure, the secretions
are retained, and ovarian abscess and pyo-salpinx are com-
mon results. When the inflammation is very intense, in-
volving subserous structures, the vitality of tissues is de
stroyed and one form of pelvic abscess is the result.
Although it is not contemplated to discuss the diagno-
sis and symptomatology of intra-pelvic inflammation in
this paper, I must be permitted to dwell for a moment
upon the clinical picture which corresponds to the lesious
I have just described. A woman suffers an attack of
gonorrheea, often contracted innocently, and has a severe
attack of pelvic peritonitis. Or she has an abortion, or
labor at full term, and has the misfortune to become in-
fected and peritonitis results. After a severe and pro-
tracted illness the acute symptoms pass away ; in time she
gets up and is congratulated by her fnends upon her con-
valescence and recovery from so severe an illness. Time
wears on with improvement in her general condition, but
she maintains that she is not well. The menstrual peri-
ods are seasons of intense pain and distress, ard usually
opium is administered. By and by the family physician
makes an examination, and my observation has been that
he usually decidés a malposition of the uterus to be the
principal trouble, and inserts a pessary. The trouble per-
sists, and pain is intensified by the pessary, which after a
varying period has to be abandoned. The woman is an
mvalid. If well-to-do she spends the greater portion of
her time in bed, drives out occasionally, and craves mor-
phia, chloral, and other anodynes. She walks with a pe-
culiar halting gait, has a pinched expression, and suffers
from reflex nervous disturbances. She is treated with
the hot vaginal douche, local applications to the cervix
and vaginal vault, and is improved by none of them.
About this time massage, rest in bed, milk diet, with
varying and unsatisfactory results, will be invoked in her
behalf, but nothing in the way of permanent relief results.
She is a helpless invalid, and a great sufferer. The ulti-
mate issue of the case may be one of three alternatives :
either to hold out until the menopause, when physiologi-
cal repose and atrophy may bring relief; to remain an
invalid for years with opium and all the accompanying
misery, ending probably in abscess ; or to have the dis-
eased and imprisoned organs, with their consequent histo-
logical changes, removed. I submit that the picture 1s a
familiar one to those who see much of pelvic disorders.
In connection with such a pathological state, we must not
overlook the persistent influence of the menstrual con-
gestion upon the growth and density of the organized
exudate to which I have previously referred.
The treatment of intra-pelvic inflammations must de-
pend upon the structures involved. ‘The cardinal fact
that pelvic peritonitis is always symptomatic, always the
sequel and result of infection, must never be lost sight of
in formulatirig any plan of treatment. Catarrhal inflam-
mation of the endometrium may, by the ordinary process
of continuity of surface, extend to the tubes and ovaries.
Prolonged congestion and thickening of the mucous lining,
with retained secretions, results in localized peritonitis.
Treatment by depletion, cleanliness, antisepsis, and
drainage may arrest and limit the inflammatory process
and induce a cure by resolution. The peritoneum is an
immense lymph-sac, quick to open the avenues of micro-
bic invasion. An untidy exploration with the uterine
November g, 1889]
THE MEDICAL RECORD.
513
sound often conveys the infectious spark which spreads | diseased tubes and ovaries from a mass of organized
from the endometrium like fire on the prairie. Gonor-
rhoea is a disease leaving in women the formidable
sequelz of salpingitis, peritonitis, pyo-salpinx, ovarian
abscess, and often general suppurative peritonitis. Labor
and abortion are processes especially prone to admit in-
fection, and unless rigid cleanliness is observed, are usually
followed by varying grades of pelvic inflammation. Rest,
the clean hot douche facilitating drainage, saline cath-
artics favoring revulsive drainage and depletion, are
means of treatment which often arrest and limit the in-
flammatory process and lead to cure by resolution. To
recount the various pathological states of the uterus,
ovaries, and Fallopian tubes, with which general or local-
- ized pelvic peritonitis is associated, would of course greatly
exceed the limits of this paper.
In consequence of the matting together of the pelvic
organs by adhesive inflammation, the exact seat and
starting-point of the inflammatory process cannot be de-
cided by the ordinary means of pelvic exploration.
Fortunately, the indications for operative interference are
so unmistakable that such exactitude in diagnosis is not
essential for proper treatment. ‘The localized pain, the
fixation of movable organs, the exudation, and, when pus
has formed, the rigors, fever, and emaciation, are signs
too positive to be overlooked by the experienced atten-
dant. When the means that I have indicated fail to
secure resolution, and septic symptoms present them-
selves, we may know that the only treatment is to open
the abdomen, evacuate the pus, remove the inflamma-
tory mass (usually Fallopian tube and ovary), cleanse the
peritoneum, and establish drainage. Where the disease
has gone on to suppuration, the surgeon has no option.
The only course worthy of consideration is thorough
removal of inflamed, suppurating, and degenerated
ovaries and tubes, of which pelvic peritonitis is the result.
Equally is it the surgeon’s duty to operate in those cases
in which the diseased tubes and ovaries, one or both, can
be made out by the touch upon the side of the uterus,
accompanied with pain and the familiar functional de-
rangements incident to diseased states of the tubes and
ovaries. I am presuming, of course, upon discriminating
> knowledge on the part of the physician. ‘To operate
early, before adhesions become organized and the inflam-
matory area extends, and before pus forms and the system
is infected, simplifies the operation, enhances the patient’s
chances of recovery, and abbreviates suffering.’ In il-
lustration I may mention hydro-salpinx and hzemato-sal-
pinx as prone to purulent change.
When bands of false membrane have imprisoned the
Fallopian tubes and ovaries, with the consequent altera-
tions of structure already described ; when the tubes are
in a state of constantly recurring inflammation, with func-
tions destroyed and secretions retained ; when the ovary
has become cirrhotic or undergone caseous degeneration ;
when the patient is a miserable invalid and opium habitué ;
then these organs should be removed and the patient re-
stored to health, home, and society. In cases of limited
pelvic inflammation, careful discrimination is necessary in
` deciding upon operative treatment.
For accurate diagnosis an experienced tactile sense and
repeated examination are required. Many cases of intra-
pelvic inflammation of lesser grade are improved, and
some few cases cured, by the hot douche, the application
of iodine and glycerine, the supporting tampon, and rest ;
but the larger class of cases, in which the inflammatory
process has been more active and extensive, are incurable
without operative interference. Moreover, women de-
pendent upon their own labor for a livelihood, and those
of meagre pecuniary resources, are unable to indulge in
months of palliative treatment for temporary relief. To
those of us who have dealt with cases of long-standing
pelvic inflammation at the operating-table, and shelled out
1 Operation by abdominal section should invariably be adopted in
preference to puncture of Douglas’ space through the vagina.
exudate, the cures claimed for electricity in such cases.
are difficult to accept. When treated upon sound surgi-
cal principles, by abdominal section, the results are good,
the cures permanent, and restoration complete.
BRIEF MEMORANDA IN PRACTICAL OTOL-
OGY.
By ALBERT H. BUCK, M.D.,
CLINICAL PROFESSOR OF THE DISEASES OF THE EAR, COLLEGE OF PHYSICIANS
AND SURGEONS, NEW YORK; CONSULTING AURAL SURGEON, NEW YORK BYE
AND EAR INFIRMARY. a :
AMONG the cases which I have seen in private practice
during the past few weeks there have been two which
seem to me to present features sufficiently interesting to
warrant their publication in a medical journal.
A lady, about fifty years of age, and almost entirely
-deaf in her left ear, reported that she had suffered for a
long series of years from an almost constant discharge
from the right ear. At times this discharge had been so
„slight as to lead her to believe that it had ceased; in
point of fact, however, it had simply at these periods be-
come too scanty to actually flow out of the ear. The
hearing had been variable ; sometimes she could hear so
well that nobody would suspect the existence of any de-
ficiency in this respect, while at other times her deafness
would be very marked, lasting sometimes for days together.
Latterly there had been more discharge than usual, and
the duration of the period of marked deafness had been
unusually long. On one or two occasions, during this
period, she had experienced a sensation as if some ob-
stacle had been suddenly removed from the right ear—
practically the only ear with which she can hear—and
then, for a few minutes, she had been able to hear, as she
thought, perfectly well. An examination with speculum
and reflected light revealed the presence of a small quan-
tity of muco-pus covering the apparently unbroken sur-
face of a red and thickened membrana tympani. On
closer scrutiny a barely recognizable irregularity of the
surface was noted in the posterior superior quadrant. At
this spot the tissues appeared to be more succulent than
elsewhere on the surface of the membrane. In no other
respect did this part of the membrane seem to differ from
the surrounding parts. By manipulating the tissues at
this suspicious spot with the end of the slender middle-
ear probe it was readily ascertained that the membrana
tympani was perforated at this point and that granulation-
tissue filled the recess beyond, #.¢., the entrance to the
‘mastoid antrum and the depression corresponding to the
fenestra ovalis. By forcing a small pledget of cotton
into this opening I was able to press back the granulation-
tissue to such an extent that a visible recess or opening
appeared where a moment before there was simply an ir-
regular granulating surface. The moment I had with-
drawn my probe, armed with a pledget of cotton, the
patient exclaimed, “ Now I hear your voice and the
sounds in the street perfectly well !”
The therapeutic problem involved was simply this: The
removal of the cushion-like mass of tissue which prevented
outside sounds from making a sufficiently powerful im-
pression upon the stirrup. As the granulation-tissue
could not be isolated, and consequently could not advan-
tageously be removed by means of Blake’s fine wire snare,
I was compelled to resort to the use of a caustic, viz., sil-
ver nitrate, in the form of a small bead of the pure salt fused
upon the end of a slender middle-ear probe. ‘Three such
cauterizations were made, at intervals of about forty-eight
hours, and then injections of a weak silver-nitrate solution
(five grains to the ounce of water) were made on alternate
days, through the opening in the membrana tympani,
into the mastoid antrum; the glass middle-ear pipette
being used for this purpose. By way of supplementary
treatment the patient cleaned the canal thoroughly, three
times a day, with tepid water introduced into the ear by
means of an Angelo’s ear-douche.
514
In the course of two weeks the inflamed mucous mem-
brane of this part ofthe middle ear had so far recovered
its natural healthy tone that all discharge had practically
ceased, and the patient was once more able to hear well
continuously.
The second case, of which I desire to give a brief ac-
count, occurred in the person of a physician residing in
this city. He consulted me on account of a. un-
pleasant sense of fulness and pressure in the region of the
right ear, associated with an increase of his more or less
habitual naso-pharyngeal catarrh, and with very slight im-
pairment of the hearing. ‘These symptoms had troubled
him for about two weeks. Examination with the spec-
ulum and reflected light revealed the existence of a
noticeably sunken and shghtly congested drum-membrane.
The use of a Politzer’s inflation apparatus afforded only
momentary relief, The diagnosis was, clearly : Obstruc-
tion of the nght Eustachian tube, due to catarrhal swell-
ing of the mucous membrane of that region. ‘The treat-
ment consisted in painting the vault of the pharynx, and
especially the vicinage of the right tubal orifice, three
times a week, with a twenty-grain solution of silver ni-
trate; and at the same time the patient was advised to
abstain from smoking tobacco during the course of the
treatment. At the end of two weeks he reported that his
right ear felt exactly as uncomfortable as it did before
treatment was begun, and that, too, despite the fact that a
very noticeable diminution had taken place in both the
redness and the degree of swelling of the visible fauces.
He called my attention, however, to one or two pheno-
mena which ke had observed, and which led him to think
that a neurotic element played a part in his troublesome
‘symptoms. For instance, he had observed that the press-
ure of the steel arm of his spectacles upon the skin of
the right mastoid process greatly intensified the sense of
fulness in the affected ear. There were other things still
which, as he had discovered, would produce the same
temporary aggravation of this sense of fulness, but I can-
not just now recall them. The patient’s own idea was
that malarial poisoning—from which he had suffered to
some extent during recent times—was at the bottom of
these nervous phenomena, and in accordance with this
idea he began taking ten grains of quinine daily, and con-
tinued to take the remedy in these doses until he ex-
perienced a slight ringing in the right ear. By this time
he had taken ninety grains in all. The effect of the
quinine was very marked. The sense of fulness and
pressure rapidly grew less, and disappeared entirely on the
fourth or fifth day. ‘The sinking in of the membrana
tympani became so slight that it could be barely recog-
nized. Furthermore, the patient had lost al] traces of
the depressed state of mind which constituted one of the
features of the disease in its earlier stage.
A few comments may not be out of place in connec-
tior with these brief histories.
In the first place, I may be permitted to remark, in
connection with the case of otitis media purulenta, that
simple inspection of the drum-membrane, no matter how
brilliant the illumination of this region may be, cannot al-
ways suffice to furnish us with a true and complete patho-
logical picture. Inspection conjoined with careful ma-
nipulation of the parts is absolutely essential, in certain
cases, to the correct determination of the nature, loca-
tion, and extent of the disease. In this particular instance,
the undisturbed picture presented to the eye of the ob-
server was thoroughly misleading.
The second thought suggested by the case under con-
sideration is the fact that sudden and very marked changes
in the power of hearing (in one ear) imply alterations in
the mechanical relations of the stirrup. I am confident
that alterations at the round window (:.¢., in or around
the secondary tympanic membrane) influence the hearing
power far less potently than do those at the oval window.
A pad of granulation-tissue or of greatly hypertrophied
mucous membrane is competent, in the absence of the
anvil, to so greatly diminish the intensity of the sound-im-
THE MEDICAL RECORD.
[November 9, 1889
pulses which reach the stirrup that the corresponding ear
can hear only the loudest tones. But if the anvil and the
‘stirrup still retain their connections, the same mass of
tissue will probably diminish the hearing-power only
slightly. In the present case no trace of the long process
of the anvil could be found, and the stirrup was therefore
entirely shut off by the surrounding mass of soft tissue
from the direct impact of waves of sound entering by way
of the external auditory canal. There is another class of
cases which in all essential features closely resemble the
one described above, but in which the removal of the ab-
structions existing around the stirrup fails to establish
that acuteness of hearing which from time to time so
startles and delights the patient. How are we to inter-
pret the marked spontaneous improvement which takes
place in the hearing power in these cases? In my efforts
to explain it I have assumed the momentary pressure of
some moderately hard substance (like a flake of epidermis
or a mass of hardened secretions) upon the head of the
stirrup—in a word, the establishment, for a few moments,
of a sort of artificial drum-membrane. Acting on this
theory, I have applied all sorts of wooden, metal, and dried
elder-pith contrivances in contact with the head of the
stirrup, but I have never once succeeded in reproducing
artificially one of these brief intervals of acute hearing.
In regard to the -second case, I may remark that the
part played by malaria in weakening the inhibitory power
of the vaso-motor nerves supplying the mucous mem-
brane of the nose, throat, and ear is something new to
me. ‘The discovery of this peculiar relationship, it has
probably been remarked already by the reader, was made
not by myself but by my patient. I have no doubt that
many of my fellow-specialists have experienced the same
difficulty in their own practice, viz., the tendency to give
undue weight to the purely local causes of disease.
WHY PHYSICIANS SHOULD CULTIVATE PHO-
TOGRAPHY. °
By BOARDMAN REED, M.D.,
ATLANTIC CITY, N. J.
AMATEUR photography is just now much in vogue, and it
is cultivated more by physicians than others. There are
good reasons for this. The education of the medical
man, if thorough as it should be, fits him well for the
“ black art.” He is, of course, familiar with chemistry,
and ought also to be conversant enough with physics
and mathematics to master the intricacies of lenses and
the calculation of their equivalent foci.
But even without going at all into the science of it, the
busy doctor may find photography a useful help in his
everyday work, as well as one of the best of all possible
out-door recreations for his vacation season. Like gun-
ning, it lures its votary out into the fields, along the hill-
sides, and by the running brooks. Unlike that rougher
and more ancient sport, however, it does not: lead him
through thorny thickets, or, at unchristian hours, through
tall, dew-laden grass and miasmatic swamps, thus risking
an exchange of his dyspepsia for rheumatism and malaria ;
but rather tempts him to select for his outings the pleas-
antest parts of sunny days, and permits him to: pick his
way by unobjectionable paths to the most picturesque and
romantic bits of scenery in his neighborhood. ‘The exer-
cise and zest are much the same ; but, apart from the ef-
fects upon the health, the amateur photographer has usual-
ly something better to show for his day’s tramp. Suppos-
ing that he has acquired a fair amount of skill, he will be
sure of at least one or more pictures which may sometimes
be really things of beauty, and will then be joys forever.
The gunner, on the other hand, however experienced, may
not find any game, or, finding it, may fail to hit it; and
even when he is most successful the net results of his
day’s sport are promptly eaten, and thereafter exist in
memory only.
Then there is the ethical side of the question—the im-
November 9, 1889]
THE MEDICAL RECORD.
515
memorial tendency of hunters and anglers to stretch the
truth, while photography conduces to literal exactitude in
all respects—but the contrast need not be pursued further.
Turning now to the practical value of photography to
the physician, there are good reasons why every one of us
should own a camera and know how to use it. By means
of the magnesium flash-powder and the extremely sensitive
dry-plates now in use it is not difficult for any person,
after a few hours’ instruction, to make a passably good
negative in an office either by day or night. In this way
cases of facial paralysis, spinal curvature, hip-joint disease,
and marked skin disease, or any form of bodily deformity
can be easily photographed by an instantaneous process,
and thus the best of all records be kept of them for future
reference.
And for those who devote themselves largely to micros-
copy, photography opens up an almost boundless field,
enabling them to fix in enduring forms the magnified rep-
resentations of the specimens studied by them.
Moreover, lessons of value are to be learned from even
the technique of photography. For example, plates that
are exposed too long, as well as those exposed for too
short a time, make weak, unsatisfactory negatives. In
like manner we find that overfeeding as well as under-
feeding may debilitate a patient, rendering him ultimately
weak and unfit for severe exertion.
The writer feels himself deeply indebted to photography
for one highly important lesson in hygiene, that is, the
relative value of out-door sunshine as compared with the
diffused light of an ordinary room. Most persons would
say that the outside light is two or three times as strong
as that within our houses. But the ratio of difference is
vastly greater. Carefully prepared tables show that for a
view at the sea-shore, comprising sea and sky mainly (with
a lens and plate of a certain speed), an exposure of one-
tenth of a second is sufficient. An open landscape away
from the sea would, with the same lens, the same aper-
ture, and the same plate, require one-third of a second.
A fairly lighted interior would require two and one-half
minutes, while a badly lighted interior—such as the rooms
which most ladies prefer to occupy— would require half
an hour to obtain an equally good picture. In other
words, patients strolling on the sea-shore in sunny weather
are in a light not two or three times, but eighteen thou-
sand times, stronger than that in the ordinary shaded and
curtained rooms of a city house ; and the same patients
walking along the sunny side of a street are receiving more
than five-thousand times as much of the health-giving in-
fluence of light as they would receive in-doors in the
usually heavily curtained rooms. |
No wonder such miracles are wrought by sending our
sickly human house-plants to the country or mountains,
or to the sea-shore, where the stronger sunlight, the purer
air, and the invigorating salt-water all combine to revivify
the vital forces !
CocaINE HALLUCINATIONS.—MM. Magnan and Saury
report three cases of hallucination due to the cocaine
habit. One patient was always scraping his tongue, and
thought he was extracting from it little black worms; an-
other made his skin raw in the endeavor to draw out
cholera microbes ; and a third, a physician, is perpetually
looking for cocaine crystals under his skin. Two patients
suffered from epileptic attacks, and a third from cramps.
It is important to notice that two of these patients were
persons who had resorted to cocaine in the hope of be-
ing able to cure themselves thereby of the morphine
habit, an expectation which had been disappointed. For
more than a year they had daily injected from one to
two grammes of cocaine under the skin, without, how-
ever, giving up the morphine injections, which were only
reduced in quantity. The possibility of substituting
cocainism in the endeavor to cure morphinomania is a
danger, therefore, which must be carefully held in view.
British Medical Journal. ;
Clinical Department.
LARGE (EDEMATOUS MYOMA—HYSTEREC-
‘TOMY—RECOVERY.
By NEIL MACPHATTER, M.D.,
DENVER, COL.
‘THE recording of the ordinary cases now met in ab-
dominal surgery has long since ceased to be of more
than passing interest to the gynecologist. What, however,
appears to me to be an interesting case, on account of
the difficulties of making a positive diagnosis and at the
same time illustrating the fact, not too urgently insisted
upon, that it is absolutely impossible to tell beforehand
what complications may be encountered in the removal
of abdominal tumors. ‘The point advocated by those
surgeons, that tumors having adhesions can be distin-
guished from uncomplicated ones has not received suffi-
cient proof. Upon the other hand I maintain, from what
I have seen in this branch of the profession, that absolute
accuracy in the diagnosis of complications cannot be at-
tained before opening the abdomen. Without compunc-
tion I can even go further and say that accuracy in the
diagnosis of tumors is far from being perfect, let alone
the complications which may or may not be present.
Only the novice or the ignorant assert otherwise. A case
illustrating in a remarkable manner the points I have
advocated came under my observation some time ago.
Believing it to be of sufficient interest to the profession, I
bring a résum? of it befcre your readers.
On June 15th last, while in the East, I received
from Dr. William Gunn, of Clinton, Canada, a letter
stating that a patient of his had a tumor that had been
growing for several years, and as she was gradually losing
strength, wished to know if I would go over and operate.
I replied in the affirmative, and a few days subsequently
received a telegram to come on. On account of the de-
lay of trains I arriyed too late to operate on the day I
had appointed. I received the following history of her
case: Mrs, C——, aged forty-two years, married twenty-
one years, the mother of five children, having her last ten
years ago, had never been well since the birth of her last
child. She experienced a dragging sensation and periodi-
cal attacks of pain in the lower part of the abdomen.
These symptoms continued, and five years ago she noticed
a lump in the region of the womb. ‘There were added
now feelings of pressure upon the rectum and bladder.
The attacks of pain became much more severe, and were
occasionally attended by febrile symptoms. I attach
particular importance to this latter symptom, as account-
ing for some of the complications which were encountered
at the operation. The tumor had gradually increased in
size until it now filled the whole abdominal cavity. She
was thin and worn-out looking, and had a drawn, pinched
expression of suffering on her face. Dr. Gunn had re-
mained in doubt as to what kind of a tumor it was, and
upon examination I soon found he had good reason for
his uncertainty. ‘The tumor filled the whole abdominal
cavity and was uniformly round and smooth, presenting.
every feature of an ovarian cystoma. ‘The fluctuation
was quite distinct in every direction. From the fact that
the uterus appeared to be intimately associated and ap-
parently implicated in the enlargement, and the knowl-
edge that the sound could be passed full length into the
uterus, I concluded and was inclined to believe the tumor
to be a myoma of the soft cedematous variety, and that
hysterectomy would be necessary. The almost constant
feature of hemorrhage that accompanies myoma was ab-
sent, and the doctor had passed a hypodermic needle
and drawn fluid from the tumor, so there were many rea-
sons for hesitancy in pronouncing upon an absolute diag-
nosis. I had, however, seen a number of such cases.so
that I inclined to the belief of oedematous myoma, al-
though I was in no way positive.
I have now come across a sufficient number of the
516
THE- MEDICAL RECORD.
[November 9, 1889
soft cedematous variety of myoma to make me believe
they are much more common than is generally acknow]-
edged. Space will not allow me here to go into the full
details of this interesting subject, further than to say that
there are two varieties of myoma, the’ hard multinodular
kind, and the rapidly growing soft cedematous variety.
They are both quite distinct in their history, symptoms,
appearance, pathology, and treatment.
tous kind simulates ovarian cystoma and pregnancy so
closely that it is often difficult and impossible to distin-
guish between them. Indeed, I have upon two occasions
seen one of our most brilliant English surgeons in a quan-
dary, even after the abdomen was open and the tumor
exposed to view. ‘The uterine tissues frequently envelop
and surround the tumor exactly as in pregnancy. This
variety appears at any period of life from puberty to old
age, and does not arrest its growth at the menopause as does
the other variety. This proves that the soft oedematous
myoma is a condition that is not in any way affected or
influenced by menstruation, and therefore we cannot ex-
pect it to gradually diminish and disappear after the
climacteric, nor is the removal of the appendages of any
avail. Hysterectomy is the only remedy for these cases.
The hard multinodular variety, on the other hand, should
never be mistaken for ovarian cystoma or pregnancy, and
is a disease entirely of menstrual life, coming on usually
between the ages of twenty and forty years. It has no
fluctuation, and does not grow so rapidly nor to such a
size as the other. It is influenced wholly by menstru-
ation, and begins to diminish, and gradually disappears
after the advent of the menopause. When the hemor-
rhages that accompany this variety are so frequent and
profuse as to threaten life before the climacteric comes
on the removal of the appendages is clearly indicated, al-
though it is sometimes very difficult to find them on ac-
count of the size of the tumor.
The next morning at ọ A.M. I proceeded to operate.
There were present Dr. Gunn, who assisted, Drs. Wor-
thington and Williams, of Clinton, and Dr. Elliott, of
Brucefield, who administered the anesthetic. On the in-
cision being made through the parietes I discovered that it
was an edematous myoma, and I proceeded to do hysterec-
tomy. The incision was extended upward when I discov-
ered the tumor was intimately adherent everywhere, I
passed my hand and forearm in and broke up as many as
I could. With a corkscrew inserted into the tumor I drew
it out as far as adhesions would allow. ‘These were
broken down and making another effort to draw the tu-
mor out, I found the transverse colon, small intestines,
and omentum tightly adherent at the top. After a good
deal of tearing I succeeded in getting them liberated, al-
though there was considerable bleeding. Parts of the
omentum that appeared gangrenous I tied and cut away
altogether, When I had the adhesions all liberated and
the tumor drawn out of the incision the whole of the
peritoneum on the back part of the abdominal cavity
came away with it. The right ureter was attached about
six inches along the tumor and was drawn completely up
out of the cavity. After careful dissection it was set free
but found to be about twice its normal length from the
zig-zag way it was incorporated in the tumor. When
dropped back it lay like a coil of small rubber tubing. I
examined the corresponding kidney for enlargement but
as far as I could judge from feeling there was no patho-
logical condition. I have seen several hundred abdom-
inal sections, but never before met with this complication.
The muscles along the back and pelvis, the left ureter and
vessels were quite bare. The arteries could be seen pul-
sating quite distinctly. There was a great deal of general
oozing everywhere. Many of the points were tied, others
were controlled by forceps and hot sponges. To make
it complete the bladder was adherent in front. I was
obliged to cut the peritoneal covering above the fundus in
a honzontal manner and then peel the bladder down. The
bleeding from this was scarcely worth mentioning. A tem-
porary clamp was passed around the tumor near its base,
The soft cedema-
and tightened. This controlled all hemorrhage from the
broad ligaments and rendered the subsequent steps of
‘the operation more easy. ‘The tumor, including uterus,
‘ovaries, and tubes, was now cut away close to the tem-
porary clamp. ‘The permanent serre-nceud was now sub-
stituted for the temporary one and screwed as tightly as
advisable. ‘The staple was passed through close to the
cervix, and all redundant tissue above this trimmed off.
The general bleeding was still very considerable and took
some time to properly check, as many clots as possible
were swabbed out with sponges and the whole abdominal
cavity most completely washed out. ‘The abdominal in-
cision was next stitched up and brought to fit as closely
as possible around the pedicle. ‘There were so many rag-
ged edges from torn adhesions that I deemed it advisable
to put in a drainage-tube. It is fortunate I did so, as
there was considerable discharge sucked up by the syringe
for nearly three days. The stump was thoroughly cleaned
and ordinary dressing applied over a saturated solution of
perchloride of iron and glycerine. The patient was
placed back in bed and rallied remarkably well from the
shock. Hot bottles were packed about her and enemas
of beef-tea and brandy given at intervals. This had a
beneficial effect, the pulse gradually becoming slower and
of better volume. During the first night she was very
restless and complained of pain and a sinking, smothering
sensation in her chest, this was probably owing to the ef.
fects of the anesthetic and the balance of circulation
being upset. The following morning she expressed her-
self as feeling more comfortable but very nauseous. This
tendency to vomit continued for some time and was a
very troublesome feature in the after-treatment. I am in-
debted to Dr. Gunn for a full report of the after-treat-
ment and I desire here to write of the excellent -
ments he had made for the operation and my apprecia-
tion of the skilful manner in which he continued the case
afterward.
Notwithstanding the numerous adhesions that were
broken up, and the large area of raw surface that was
left, the temperature remained normal for eight days,
when, owing, no doubt, to stitch abscesses, and the sup
puration accompanying the sloughing process about the
pedicle, it went up slightly and ranged from normal to
1014° F. This good result I attnbute largely to the
manner adopted in washing out the abdominal cavity, and
drainage. Thanks to the genius of Lawson Tait, the ab-
domen can now be cleaned of all clots and débris.
The urine was drawn off for four days, and the bowels
moved by an enema upon the fifth. The stitches were
removed on the sixth and ninth days. On the fourth day
Dr. Gunn cut the wire of the serre-nceud and withdrew
the handle, leaving the wire to come away with the ped-
icle, which sloughed off on the twelfth day. On the
thirteenth day a well-defined lump could be felt on the
right side of the pedicle. Suspecting pus or blood, Dr.
Gunn made an opening into it, and evacuated a consider-
able quantity of both blood and matter. The history
from this out was not marked by anything of importance.
The wound gradually healed up, and the patient recovered
completely. I have just received a letter from Dr. Gunn,
wherein he says: “ The patient feels perfectly well in every
respect. It was an interesting case, showing the difficul-
ties of making a diagnosis, the size of the tumor, and es-
pecially the fact that she recovered.”
What would have been a disastrous accident was nar-
rowly escaped during the operation. ‘There were so many
adhesions of all sizes attached to the growth as I drew it
out, that I at first did not recognize the ureter as such,
and was almost in the act of breaking it down with other
stringy bands of adhesions, when I noticed the peculiarly
rounded and uniform size to be the organ. It was mar-
vellous how it escaped being torn when drawn out with
the tumor, as it was on extreme tension. After liberating
it, I felt not a little uneasiness lest its lumen be occluded,
and disease of the corresponding kidney would result,
necessitating, at a subsequent date, an operation for its
November 9, 1889]
THE MEDICAL RECORD.
517
removal. From the fact that I could detect no enlarge-
ment of the kidney at the time, and that no symptoms
relative to it have since appeared, I have reason to believe
the ureter to be fulfilling its functions properly.
Here I would like to say that I cannot imagine intestines, .
be they ever so intimately attached to a tumor, providing, of
course, they are not gangrenous from pressure or want of
blood-supply from the mesentery, but what they can be,
with a little patience and care, liberated. I say this to
particularly mark my disapproval of a method that was
recently pursued in a similar case in one of the London
hospitals. In that instance the operator found intestine
that was not gangrenous adherent to the tumor, and in-
stead of liberating it in the usual manner, and because,
as he said, of the numerous experiments he had recently
n making in intestinal surgery on dogs, he cut the in-
testine through in two places and sewed the ends together,
only to find, as might be expected, a few days subsequently,
that the bowel ruptured at the seat of union, or rather
non-union, and set up fatal peritonitis. Here is the state-
ment as reported by. the operator himself : “ I then found
that a portion of the intestine was so intimately incorpo-
rated with the growth that it was found impossible to de-
tach it without tearing the bowel or detaching some of the
growth. Under these circumstances, guided by experi-
ence of numerous experiments I had lately made in in-
testinal surgery, I determined to cut away all the intes-
tine implicated, and join the two ends together.” At the
post-mortem it was discovered that the rubber ring used did
not pass down but remained as an obstruction ; “ then
_ the rubber ring had acted more or less as a valve, and
prevented the fæces from passing. This caused distention
of the gut above the seat of operation ; ulceration along
one of the ligatures, perforation, peritonitis, and death.”
Such work as this will surely not enhance the welfare’
of the profession, but is absolutely damaging and discred-
itable. No operator should forget his duties in such an
emergency when the results are weighed against the slim
chances hinging upon the knowledge gained from experi-
. menting upon the intestines of dogs. The results of ex-
periments, especially upon the intestines of dogs, are
fraught with danger when applied to abdominal surgery.
STRELE BLOCK, SIXTEENTH STREET.
Progress of Medical Science.
DEATH FROM SUBLIMATE IRRIGATION AFTER ABOR-
TION.—Seven years since, Tarnier introduced the practice
of washing out the vagina with weak corrosive sublimate
injections. The results proved satisfactory, and the in-
Jections came into e in German and English, as well
as in French, lying-in hospitals, extending freely into
private practice. Like every thorough method of count-
eracting deadly agencies in the human organism, subli-
mate irrigation is not free from danger, and although it
greatly reduces the death-rate and proportion of puerperal
fever cases in long series of labors, some cases of mercu-
rial poisoning will occur in those series, notwithstanding
the most careful administration of the remedy. In Eng-
land, Drs. Dakin and Boxall have published very minute
observations on mercurialism under the above-noted con-
ditions. ‘They appeared in the Zransactions of the Ob-
stetrical Society for 1886 and 1888. Dr. Legrand read
before the Anatomical Society of Paris, in April, a case
of twin abortion, retained placenta, and death from acute
mercurialism. Between the birth of the first and second
child, ten quarts of a1 to 2,000 solution of sublimate
were employed to wash out the uterine cavity, twice, at an
interval of three hours only. Immediately after each in-
jection of sublimate a two per cent. solution of boracic
acid was thrown up into the uterine cavity ; but sublimate
had been several times employed for vaginal injection.
After the extraction of the second child the boracic sol-
ution was injected into the uterine cavity. The intra-
uterine injections were discontinued, and boracic and car-
bolic solutions were used for the vagina. A day later gin-
givitis, salivation, colic, and dysentery set in, and carned
off the patient in five days. The kidneys were large, pale,
and very cedematous; they contained mercurial salts in
solution. The palate was ulcerated; the oesophagus,
stomach, and small intestine healthy. The mucous mem-
brane of the entire large intestine was covered with eschars
and ulcers, most marked on the summits of ruge. The
ulcers began in the czcum, were least abundant in the
transverse colon, and most marked toward the anus. The
above conditions have been noted in many other cases of
death after sublimate irrigations in childbed. The kid-
neys were diseased. Keller, of Berne, has already pointed
out the danger of mercurial irrigation when these organs
are not healthy. The English authorities just quoted both
dwell on this danger. Dr. Legrand relates that the ulcer-
ated intestinal mucosa swarmed with bacteria. This fact,
he adds, must make us despair of insuring intestinal anti-
sepsis by means of corrosive sublimate.—Zhe British
Medical Fournal.
THE OPERATIVE TREATMENT OF TUBERCULAR PERITON-
ir1s.—Dr. F. Spaeth has reported four cases of tubercular
peritonitis, treated by laparotomy, in Dr. Prochownick’s
clinic in Hamburg. The patients were all females between
the ages of thirty-two and forty-three (Zhe Annals of Sur-
gery). The symptoms differed greatly in the four cases,
but in all the inguinal glands on both sides were consider-
ably enlarged. In every case tubercle bacilli were found.
The author thinks this very important, for many cases of
chronic disease of the peritoneum, which at first sight ap-
pear to be tubercular, are found on microscopic exami-
nation to be nothing more than a peritonitis with a nodular
formation, a simple. lymphoma of the peritoneum. To
these errors of diagnosis may be attributed in some cases
the unsuccessful results of laparotomy. So far little at-
tention has been paid to the demonstration of tubercle
bacilli in the excised pieces. Thus in forty-one of Küm-
mel’s cases the results of the microscopical examination
are only mentioned in eleven cases, and in only five of
these were bacilli reported present. ` Of the writer's cases,
one died of collapse five days after operation, to which
condition a marked atrophy of the kidney contributed in
a large degree. The second case died of acute phthisis
three months after operation. ‘The third case died of in-
testinal tuberculosis, and the fourth is now dying of the
same disease. The unfavorable results cannot be attribu-
ted to the operation. ‘The author terminates his paper
with the following conclusions: 1. In primary tubercu-
losis of the peritoneum without implication of other organs,
laparotomy may act as a curative agent and is to be rec-
ommended. 2. In tuberculosis of the peritoneum, where
the female genitals are involved in the process, the oper-
ative treatment has not given any satisfactory results. 3.
In tuberculosis of the peritoneum due to a tubercular en-
teritis, the operative treatment is only palliative. 4. In
genital tuberculosis, unaccompanied by peritoneal tuber-
culosis, early radical operation is to be urged. The indi
cations for operation are not readily determined, owing
to the almost impossibility of making a bacteriological
diagnosis before laparotomy. 5. Primary tubercular
peritonitis is a much rarer form of disease than has here-
tofore been thought. Hence care should be exercised in
making a diagnosis, and a bacteriological examination of
every case should be made.
Actinomycosis Hominis.—Dr. L. Ammentorp re-
ports in the Nordiskt Medicinskt Arkiv, No. XXIV., four
cases of actinomycosis in men—two of the upper jaw, one
of the lower jaw, and one of the lung. In this last case
the patient had worn a tracheal cannula for several years.
The author regarded the case as one due to infection
through the inspired air, a mode of transmission of the
disease not hitherto recognized.
A
518
THE MEDICAL RECORD:
A Weekly Fournal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., EDITOR.
PROPRIETORS AND PUBLISHERS
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
New York, November ọ9, 1889.
PLASTIC BRONCHITIS.
THE literature of this rare disease was reviewed in 1869
by Lebert in the Deutsches Archiv. fiir Klin. Medicin. In
the twenty years which have since elapsed somewhat
more than fifty cases have been reported. In the Prac
iitoner, August, 1889, Dr. West of London gives the re-
sults of a careful collation of these fifty odd cases, includ-
ing one which occurred in his own practice.
In this latter case the patient, a woman, forty years of
age, had enjoyed perfect health until she was suddenly at-
tacked, two years before she came under observation, by
what seemed to be asthma, the paroxysms becoming more
- and more frequent until they occurred every twenty-four
hours. They were asthmatic in type but without cyanosis,
the patient being awakened by the onset of dyspnoea every
night at about two o'clock. After the paroxysm had
lasted two or three hours free expectoration occurred, and
relief was obtained by the patient. The diagnosis of
asthma was at length questioned, because of the sudden
onset of the paroxysms only two years before and be-
cause of the remarkable periodicity of the attacks, and
plastic bronchitis was suspected. Upon examination of
the sputum, this suspicion was confirmed by the discovery
of small but numerous bronchial casts, grayish-white, mu-
coid in appearance, much ramified, the largest being as
thick as a goose-quill and two and one-half inches long.
There had been no hemoptysis, there were no abnormal
signs upon examination of the chest, the general health
was fair, there was no fever or night-sweating, but some
depression from loss of sleep. Various drugs were used
without effect, and after six weeks’ treatment the patient
was discharged as ill as ever.
In the review given by Dr. West of the whole subject
many important facts concerning this strange disease are
develuped. It occurs at all periods of life, but is more
frequent in middle-aged males. It is characterized by
the occurrence of paroxysms of dyspnoea and cough,
which cease at once upon expectoration of the casts. The
paroxysms are usually preceded and followed by a sort of
catarrh. Hzemoptysis may be absent, or it may be very
serious. It generally ceases at once with the ejection of
the casts. There is usually but little pain, except that
which is caused by coughing. In acute cases the temper-
ature may rise to 104° F., in chronic cases it is not often
above normal. Sometimes the onset of an attack is
marked by one or more rigors, which may be so severe as
to suggest pneumonia. As a rule each attack consists of a
THE MEDICAL RECORD.
[November 9, 1889
number of short paroxysms. It may subside after a few
days, never to recur, or it may last continuously for as long
as ten years, or it may be repeated at regular intervals (as
at each menstrual period). Cases have been reported in
which more than ten years have intervened between the
attacks. The disease is seldom fatal, but death may occur
from other antecedent or intercurrent diseases.
Plastic bronchitis is associated in a few cases with
phthisis. Sometimes it appears a few weeks after re-
covery from pneumonia. Pleurisy may be coincident
with it. Syphilis is sometimes present. Occasionally it
follows scarlatina or typhoid-fever. In four cases it was
accompanied by severe diseases of the skin—pemphigus,
impetigo, and herpes zoster. Pregnancy may cause ces-
sation of the attacks. l
The diagnosis of plastic bronchitis is possible only upon
the expectoration of the characteristic casts ; but besides
this it is necessary to exclude pneumonia on the one
hand, and croup or diphtheria on the other. Those
cases only are to be classed as plastic bronchitis where
the paroxysms with this peculiar expectoration occur in
the absence of pneumonia, or where they follow pneu-
monia after several weeks’ interval, or where they exist
for some time before pneumonia (which in this case is
probably caused by them) sets in. Cases must also be
excluded in which the casts are formed in the course of
‘croup or diphtheria. The physical signs in uncomplicated
plastic bronchitis are very indefinite. There are usually
evidences of chronic catarrh; but the rhonchus and
sibilus may be limited to the region about the cast, and
sometimes an evident obstruction to the tubes in some
part of the lung may disappear when the cast is expecto-
rated. Dulness at the base behind may be due to col-
lapse or pneumonia.
The expectoration is muco-purulent and varies in
quantity. The casts are formed of fibrin deposited in
concentric laminz. Amid the fibrin are enclosed small
cells, a few epithelial cells, and sometimes. ciliated epi-
thelium. The casts are branched ; the smallest branches
solid, the larger perhaps with a central lumen. Some-
times only one cast is expectorated in two or three days,
at other times, or by other patients, very many may be
coughed up each day. Often the casts are very much
more abundant at night. There is no specific treatment
for the disease. Inhalations, especially of lime-water, are
much praised, but it is doubtful whether they really do
good. Iodide of potassium is the only internal remedy
generally recommended by those who have treated these
cases. Sometimes complete cure has followed its use,
and often partial relief has been reported.
GALACTOCELE TESTIS.
COLLECTIONS of milky fluid in cysts, or in the natural
cavities of the body, are now and then reported in our
medical journals. In some cases the fluid is found, upon
microscopic examination, to contain the Filaria sangui-
nis hominis, a parasite which causes also chyluria. Of
this nature, probably, are the cases of hydrocele observed
in tropical regions, in which the fluid drawn off by the
surgeon is white like milk. The diagnosis in such cases
is readily made when the fluid is placed under the micro-
scope, the microscopic field being crowded with the char-
acteristic parasites.
November 9, 1889]
In other cases collections of whitish fluid in the scro-
. tum are found, upon examination, to contain semen.
This semen is sometimes normal, being full of vigorous,
quickly-moving spermatozoa ; sometimes it contains tail-
less spermatozoa, the true nature-of which may be deter-
mined by staining with hzmatoxylon, etc.
The cysts which contain this seminal fluid are developed
in connection with the epididymis, and may be of great
capacity, containing as much as twelve ounces of the
milky fluid. This seminal fluid is not found in the cavity
of the tunica vaginalis, although it is possible that the
cysts formed about the epididymis may burst into that
cavity. |
In the New Orleans Medical and Surgical Journal,
September, 1889, Drs. Cocram and Miles report a case
of milky fluid in the cavity of the tunica vaginalis which
seems to belong to a hitherto undescribed class.
The patient applied at the hospital, suffering apparently
from some serious nervous trouble. He was hypersen-
sitive, and very much excited, losing control of speech
when questioned, and unable to fix his attention upon any
subject. He stated that, three months before, he had ob-
served a swelling of the scrotum, and that this swelling
had steadily increased. Examination showed a tense
scrotal tumor, containing at least a pint of fluid. Desir-
ing to confirm his diagnosis, the surgeon introduced the
needle of a hypodermic syringe. Much to his astonish-
ment, an opaque liquid of about the color and consistency
of milk was withdrawn. Upon microscopic examination
by a pathologist the liquid was found to contain a great
multitude of light, almost transparent, granules, which
were all in very active motion. These could not be fat-
granules, because they did not refract light strongly and
because they had the Brownian movement. Three cover-
slips smeared with the fluid and dried (according to the
method used in searching for bacillus tuberculosis) were
stained, one with magenta (Ziel’s solution), one with me-
thyl blue (Loefler’s solution), and one with hzmatoxylon.
Instead of becoming fixed and stained, and appearing as
distinct points, as bacteria would have done, the gran-
ules were now replaced by large films of coagulated or
hardened albuminous matter, like the streaks of mucus
seen in staining sputum. Furthermore, the fluid was
odorless, whereas if it had been thronged with bacteria:
it would have been fetid. The pathologist was of the
opinion that the granules were particles of albuminous
-matter (non-reproductive), having the Brownian move-
ment.
A second examination of the tumor was made five
hours after the first, when it was found that it had dimin-
ished during this time, by two-thirds its original capacity.
It was now loose and flabby, conveying to the touch a
gelatinous sensation of redundant tissue. The fluid was
evidently contained in the cavity of the tunica vaginalis.
Next morning the scrotum was nearly normal in size.
The patient was dismissed cured twenty-four hours after
admission, no treatment except the single hypodermic
puncture before mentioned having been used. Five days
later the fluid was still diminishing. There was the same
gelatinous feeling, but somewhat firmer.
The tumor had developed like a hydrocele. Through-
out its course there was no constitutional disturbance. It
was not due to chylous ascites, for there was no com-
THE MEDICAL RECORD.
5&9
munication between the cavity of the tunica vaginalis and
that of the peritoneum. As far as the writers knew, it
was a unique case.
THE ‘‘BELLY-DISORDER" OF CHILDREN.
THE announcement of a new disease, and especially a
new disease of children, will, in this day, be received
with some incredulity. Dr. R. A. Gibbons, of London,
states (Edinburgh Medical Fournal, October, 1889), that
“the coeliac affection of children” is a disorder which
has not been described in text-books, but is one of great
importance, for the disease, though not very common,
ought always to be recognized. The name “ cceliac affec-
tion” is bad enough, for it means only an affection of
xotXia, the belly. As the pathology of the disorder, how-
ever, is unknown, a name indicating nothing specific may
serve the purpose for the present. `
The cæœliac affection (anglice, belly-trouble) of Dr.
Gibbons, is the name for a disease which in hospitals is
sometimes spoken of as consumption of the bowels.
It occurs in children between the ages of one and
five years, and its striking peculiarity is that, despite its
severe and often fatal course, no lesions are found post-
mortem.
The onset of the disease is usually gradual. The
child becomes pale and anæmic. Perhaps the first thing
especially noticed is the changed color and fetid odor of
the fæces. s
This malodor, says Dr. Gibbons, is sometimes over-
powering, and those who have not encountered it can hardly
realize it. The motions themselves are very large, soft,
whitish in color, and frothy. They resemble very much
ordinary oatmeal porridge. 'The actions may be two or
three in a day, but usually there is only one large one,
and that may take place at a time to which the child is
accustomed. Now and then there are attacks of so-called
diarrhoea, that is to say, the child may have frequent
evacuations of the bowels ; that they may be very loose,
and that they may be occasionally watery if the attack is
severe ; but these attacks of diarrhoea are not an essential
part of the disease, except in the cases of some children
who have these constant attacks of diarrhoea throughout
the whole of the illness. The appetite is poor, usually
capricious, sometimes large. The tongue is frequently
coated with a whitish fur, at other times perfectly clean.
In some cases there are attacks of crampy abdominal
pain, possibly due to ordinary colic.
The most remarkable symptom, according to our writer,
is that of loss of muscular power, with apparently no
great loss of flesh.
The progress of the disease is slow, and its termination
often fatal. i
The diagnosis, according to Dr. Gibbons, presents no
trouble. Great stress is laid upon the examination of the
evacuations, their fetor, and the absence, ordinarily, of
sufficient diarrhoea to cause the severe symptoms.
It is insisted that examination of the bowel and other
organs, after death, reveals absolutely no lesion.
The treatment consists in very careful nursing and at-
tention to dist ; cream, whey, pounded rare meat, mashed
floury potato, are among the articles recommended by
Dr. Gibbons.
520
THE MEDICAL RECORD.
[November 9, 1889
Rews of the Weck.
THE AMERICAN ACADEMY OF MEDICINE.—The Ameri-
can Academy of Medicine will hold its Thirteenth An-
nual Session at Leland’s Hotel, Chicago, Ill, on Wed-
nesday and Thursday, November 13 and 14, 1889.—
RICHARD J. DuNGLISON, M.D., Secretary.
THE ANNUAL MEETING of the New York Physicians’
Mutual Aid Association will be held at the Academy
of Medicine on Thursday, November 14th, at 4 P.M.
THe Late Dr. Isaac E.. Taytor.—The following
resolutions were offered by the Board of Obstetric Sur-
geons of the Maternity Hospital on the death of Dr. Isaac
E. Taylor. Resolved, ‘That in the death of their late
President, Dr. Isaac E. Taylor, the members of this Board
have met with an irreparable loss—the loss not only of a
faithful and efficient colleague, but of a warm personal
friend. Resolved, That in his beautiful and serene old age
they recognized the noblest type of. the good physician,
who retired from the active practice of his profession in
the fulness of his fame and with the universal love and
respect of his associates. Resolved, That they extend to
the family of the deceased their heart-felt sympathy, and
that they. will unite with them in cherishing his memory.
Resolved, That copies of these resolutions be sent to the
family and to the medical journals—Henry C. Cor,
M.D., Secretary. ` |
A New’ MepicaL CoLLeceE BuILpiInc.—Work has
been commenced on the new building for the Medical
College of the New York Infirmary for Women and
Children, at the corner of Livingston Place and Fifteenth
Street.
New York City Boarp oF HEALTH.—The Board of
Estimate and Apportionment has cut down the appropri-
ation for the expenses of the Health Department for the
year 1890 from $417,096, the sum asked for, to $391,-
500. Among the items in which the allowance is re-
duced are hospital supplies, $4,800, and disinfectants,
$3,700. For the present year the total allowance for the
department was $413,600.
THE Hupson River State Hospirat.—The New
York State Hospital at Poughkeepsie has received an
appropriation of $40,000 with which to build additional
acccmmodations for the resident staff and one ward for
the isolation of infectious or suspicious cases.
THE MEDICAL AND CHIRURGICAL FACULTY OF MaRy-
LAND is a venerable and highly respected organization with
a flavor of antiquity in its name and a suggestion of de-
cadence in its membership-list. The State of Maryland
supports over two thousand physicians, but the State So-
ciety numbers only two hundred and eight of these. An
appeal has been made for larger membership.
EXPERT TESTIMONY AT THE CRONIN ‘TRIAL.—Expert
testimony, so called, has received a well-deserved rebuke
at the hands of the lay press, in connection with the Cro-
nin trial. The medical evidence produced by the State
to prove the identity, injuries, and cause of death in the
case of Dr. Cronin was inexcusably stupid. The results
of the autopsy are absolutely of no value because of the
ignorance or carelessness of the persons conducting the
post-mortem. What should have been an exceedingly
thorough and scientific examination of the body found in
the Lake View catch-basin appears from the evidence
produced in court to have been a sort of hit or miss af-
fair, in which various irfdividuals, who, unfortunately for
the cause of science, have medical diplomas, took a more
or less prominent part. It is just such “free for all”
medical examinations with the resulting “expert” testi-
mony that brings well-merited disgrace upon the medical
profession before our courts of justice. The necessity of
some legal ruling as to who shall be considered an expert
is absolutely necessary. * The criminality of allowing igno-
rant and stupid politicians to fill medical offices as a re-
ward for past political defeats is painfully manifest in the
present notorious case on trial.— Medical Standard.
THE PRESIDENT OF THE NEXT INTERNATIONAL MED-
ICAL CONGRESS is Rudolph Virchow; the Secretary is
Dr. Lazar. :
THE CARTWRIGHT LECTURES this year will be delivered
by Dr. J. S. Billings, of Washington, D. C.; the subject
will be “ Vital and Medical Statistics.”
Tue Late M. Ricorp.—Among the last acts of Ri-
cord’s life, says the British Medical Journal, was the ascent
of the Eiffel Tower, and his death was hastened by his com-
ing from Versailles to Paris to vote for the Republic in
very inclement weather. Having to wait on the platform,
he contracted a severe cold, and was attacked with double
pneumonia, Only a few days before his death, one of
his friends, on seeing him, said to him: “ Mais, mon maitre,
vous aves bonne mine.” His characteristic answer was :
“ Mon ami, je ne vous conseille pas de prendre des actions
dans cette mine-la." A charming calembour, which showed
that to the last he retained all the brightness of his in-
imitable wit and gayety of spirit. His kindness to young
men, his generosity to the poor, his hearty welcome and
unbounded liberality to foreigners, and his cordial hos-*>:
pitality to all English visitors did much during all his life
to render him and his profession popular with all visitors.
BriTIsH Hypnotic Sociery.—It is stated that a num-
ber of eminent London physicians have organized a
“ Hypnotic Society,” for the purpose of studying hypnotic
phenomena, and securing a law prohibiting public séances
of hypnotism, mesmerism, etc.
A Discussion ON HysTeERIa recently took place at the
Gratiot County Medical Society, in which a highly interest-
ing profundity and yet diversity of medical opinion was
shown. After the reading of a paper on hysteria by Dr.
Brainerd, and various comments thereupon, a series of
questions was submitted with the following brilliant re-
sults—results calculated to send the Gratiot County So-
ciety thundering down the ages as the great source of true
illumination upon this obscure subject : 1. “ Are most of
your hysterical patients fat?” Kennedy, “ Yes.” Car-
penter, “ No.” Scott, “No.” Brainerd, “ Yes.” 2.
“ Are not the trance cases reported in the papers hysteri-
cal?” Kennedy, “ Yes.” 3. “Is it best to inform the
patient that she has hysterics?” Scott, “ Yes.” Kennedy,
“ No.” Carpenter?“ No.” Barber, “ Yes.” Hatt, “ Yes.”
Kennedy: “ You'll only offend the patient and freeze
yourself out of the case.” And yet some people deny the
utility of medical societies.
é
November g, 1889]
REGULATIONS AND PROGRAMME OF THE TENTH INTER-
NATIONAL CONGRESS.—The general rules and regulations of
_ this Congress have been sent out by the General Secretary,
Dr. Lassar, of Berlin. These relate to the organization of
the Congress, and resemble the regulations that have always
been issued regarding the meetings. I. The Congress is to
open on Monday, August 4, 1890, at Berlin, and to close
on Sunday, August roth. II. The Congress is to consist
of regular, licensed (approbirten) physicians, who have en-
rolled themselves as members and obtained members’
cards. Other learned men interested in the work of the
Congress can become associate members. ‘The cost
of membership will be twenty marks (about $4). III.
The objects of the Congress are exclusively scientific.
IV. The work of the Congress will be done in eighteen
sections. VII. The general sessions will be devoted to
(a) the measures regarding the general regulation of the
Congress, and (4) addresses and communications of gen-
eral interest. VIII. Notices of papers to be read and
abstracts of them must be sent to the Organization Com-
mittee before July, 1890. IX. Written copies of the ar-
ticles to be read must be sent to the Secretary of the Sec-
tion before the conclusion of the session. XI. The
Official languages will be German, French, and English.
XII. Communications must be limited to twenty minutes,
and discussions to ten minutes. XIII. The sessions will
be regulated by generally received parliamentary rules.
XIV. Students of medicine and others interested in the
work of the sessions can be admitted by securing invita-
tions. XV. Communications or questions regarding the
work of the special sections should be addressed to the
President of the Section. Other communications should
be addressed to the General Secretary, Dr. Lassar, Ber-
lin, N. W., Karlstrasse 19.
MEDICAL Paris has been interested during the week
by the marriage of Dr. Bertillon, the distinguished head
of the Department of Medical Statistics for the Depart-
ment of the Seine, with Mademoiselle Schultz, a lady
who passed recently a brilliant examination for the diplo-
ma of Doctor of the Paris Faculty of Medicine.
THE TRADE OF MEDICINE IN GERMANY.—A corre-
spondent of Zhe Occidental Medical Times writes some-
what gloomily regarding the condition of medical affairs
in Germany. He says: “Another serious grievance
under which we labor is the definition of the legal code,
by which the medical profession is*classed, pro pudorem
` hominum, as a trade (ein Gewerbe). In Germany, a duly
qualified practitioner has, beyond his superior knowledge,
positively no advantage whatever from his diploma in the
contest with quacks and charlatans. Of course, if a pa-
tient treated by a quack takes an unfavorable turn, the
case is sometimes inquired into by the authorities, and
occasionally the pseudo-practitioner is duly punished. But,
on the other hand, if a qualified doctor commits any
serious mistake, he undergoes just as severe penalties here
as anywhere else. It is only a little while ago since a
physician of Lübeck, Dr. Binder, was sentenced to several
weeks’ imprisonment for an error artis, and would un-
doubtedly have been put in jail, but for a petition to the
Senate, signed by some thousands of his friends and pa
tients, craving his pardon. As, furthermore, the irregular
practitioner has the advantage of being able to advertise
THE MEDICAL RECORD.
521
and to use other means of attracting patients which are
naturally denied to the profession, it very frequently hap-
pens that a deluded public lay both gold and glory at the
feet of the astute charlatan. And as if this were not
enough, there are even clubs which acknowledge a cer-
tificate from such autodidacts as equivalent to that of a
qualified man. In the new code of civil laws, with which
the nation is to be shortly beneñted, this state of affairs
appears destined to be rendered permanent by the sanction
of the highest authorities, for in the paragraphs dealing
with the question of remuneration for medical services,
the profession is simply classed with artisans, midwives,
and all other persons who do work or perform medical
services for which they receive payment, #.¢., quacks.
This degrading paragraph, I am happy to say, has already
raised so much righteous indignation that we may hope to
see it removed or altered before the final passage of the
law. Prince Bismarck, however, in spite of his having ex-
perienced so much benefit from Professor Schweninger’s
application of Oertel’s method to his case, was ungrateful
enough not to accede to the request of the Physicians’
Association, asking for an official inquiry into the legisla-
tion on medical affairs, so the profession may look out
and shift for itself. The organization of a central body
of representatives for the material interests of the faculty,
with branch sections throughout the empire, as has recently
been instituted under the auspices of the Minister for Sci-
ence, von Gossler, is therefore all the more welcome and
valuable. Although still too young to have effected any
material change, it is to be hoped that this arrangement
will, in future, be productive of much good.”
THE ETIOLOGY OF PNEUMONIA.—Apparently some atten-
tion is due to Dr. Henry B. Baker’s ingenious theory of the
etiology of pneumonia. ‘This theory has been set forth in
Science, but it has been fortified by statistics elsewhere.
Dr. Baker asserts, as a demonstrated fact, that in any
given place, wherever studied, pneumonia is quantitatively
proportional to the coldness and dryness of the atmosphere ;
and as this is true for every month of the year, it follows
that, if there is any pneumonia which is infectious, it is
absolutely dependent upon those meteorological conditions
for its action upon the human organism. He further ase
serts that the expired air in cold, dry weather contains a
relative excess of water; hence the lung-tissue is dehy-
drated, and chloride of sodium accumulates in it. This
condition seems to favor the development of the pneu-
monic infection.
CHRYSAROBIN IN HA&MORRHOIDS.—Dr. Kossobudskii
speaks of this drug in high terms, but he differs from
Unna in the quantity. Dr. Kossobudskii uses a two and
a half per cent. instead of a five per cent. as Unna pre-
scribes. After washing the swelling with a two per cent.
lotion of carbolic, or a one per cent. of creolin, he rec-
ommends the following ointment to be applied twice or
three times a day :
B. Chrysarobini....... otis eases te E ees 0.8
LOU OLOGUN is cise e re en Eea Aae sen sx See 0.3
Ext. belladonna.......... 0... cece cc ccc eee 0.6
£ D EIT PPE AE AEN T E ones 15.0
Or a suppository may be made with cocoa butter. If
bleeding be present tannin may be combined. Dr. Kos-
sobudskii affirms that pain, smarting, and bleeding wi!l
disappear in three or four days.— Medical Press.
522
THE MEDICAL RECORD.
[November 9, 1889
Society Reports,
NEW YORK ACADEMY OF MEDICINE.
SECTION ON THEORY AND PRACTICE OF MEDICINE.
Stated Meeting, October 15, 1889.
R. C. M. Pace, M.D., CHAIRMAN.
Dr. A. Jacosi read a paper on
CHRONIC PERITONITIS, WITH SPECIAL REFERENCE TO THE.
DIFFERENTIAL DIAGNOSIS OF SOME OF ITS VARIETIES.
Primary peritonitis of any kind, he said, was very rare.
When it occurred it was mostly the result of wounds, in-
cluding paracentesis for ascites. Other cases resulted
from exposure and cold. Most of the cases, however,
were of a secondary nature, with very numerous causes.
Thus it might arise under the influence of general diseases,
such as rheumatism, alcoholism, scarlatina, measles, ma-
laria, scurvy, tuberculosis, and carcinosis. The inflam-
mation of the neighboring thoracic cavity might be trans-
mitted through the patent stomata of the lymph-ducts on
the upper and lower surface of the diaphragm, and dis-
orders of circulation depending on pulmonary and car-
diac diseases would result in congestion of the peritoneum,
both visceral and parietal, with its possible consequences,
inflammation or effusion.
The presence of new-formations in the abdominal cav-
ity acted like that of a foreign body ; and in this connection
Ovarian tumors, sarcoma of the kidney, and swelled pelvic
glands associated with irritated and tumefied inguinal and
mesenteric glands were referred to. A young woman that
- he saw dying of acute peritonitis had been affected with
purpura for some weeks, and at the autopsy the peritonitis
was found to have resulted from hemorrhages from some
ruptured vessels of the diaphragm. Floating kidney, by
its changing position and irritating contact with the peri-
toneum, was quite liable to light up a chronic inflam-
matory process. Other causes of peritonitis mentioned
were, affections of the vertebral column and adjoining
parts, such as spondylitis, and abscesses of, the psoas and
iliac muscles and of the acetabulum, and catarrhal and in-
flammatory diseases of the female sexual organs. The
irritation or inflammation of any of the organs contained
in the abdominal cavity was liable to produce peritonitis,
and intussusception in infants was especially referred to.
Perhaps the most frequent cause of peritonitis was a
preceding peritonitis. Indeed, in most cases examined
after death the positive proofs were found of one or more
attacks previous to the fatal one. Dr. Jacobi said he did
not remember a case of perityphlitis that did not exhibit
the adhesions, discolorations, and contractions due to
former peritonitis ; and he thought it probable that there
were but few, if any, cases of foreign bodies entering the
vermiform process unless the latter had previously lost its
elasticity and contractility by an inflammatory change.
Alterations of the mucous membrane of the intestine
constituted the initial stages of local peritonitis in many
instances, and of general peritonitis in some. It was not
only the ‘#¢ima and the submucous tissue which suffered, but
the muscular layer was also implicated in the morbid pro-
cess. ‘The vascular connection between the three princi-
pal layers of the walls of the intestine was such as to
facilitate the transmission of an inflammatory process
from one to another, with the result of giving rise to
cedematous infiltration, paralysis, and constipation. Thus
it was also that a mere diarrhoea was able to develop, in a
shorter or longer time, a local peritonitis. No morbid
process could remain isolated in a locality supplied with
an active blood and lymph circulation, and hence an in-
testinal catarrh grew to be an enteritis, the enteritis a
peritonitis.
This condition of things was still more frequently ob-
served in cases of intestinal ulceration, both acute and
chronic. Even without perforation an ulceration would
lead to peritonitis which is mostly local, but liable to
change into an acute attack under favorable circumstances.
Where there was an open ulcer, or even one that had cic-
atrized months or years before, im the stomach or in the
intestine (no matter of what nature), we frequently found
opposite it a local peritonitis. In the peritoneal covering
there was a thickening, circumscribed and distinct, which
in recent cases was rather soft and accompanied by vas-
cular injection. In old cases the original cell proliferation
had undergone organization and hardening, and the
thickened spot was gray or whitish, and hard. It had lost
its elasticity, and was very apt to burst under a moderate
amount of pressure, thus leading to perforation. In the
midst of apparent health intestinal perforation would often
set in, and death ensue within a day ; and at the autopsy
the physician would learn that the patient had been the vic-
tim of the perforation of the cicatrix of a typhoid ulcera-
tion, perhaps contracted a dozen years previously.
The diagnosis of chronic peritonitis was frequently
missed. Unsuspected adhesions often existed around
tumors, movable kidneys became fixed, intestines became
glued together, all without recognizable symptoms. In
chronic peritonitis respiration was not necessarily ac-
celerated, and particularly was this the case in pelvic per-
itonitis, perimetritis, and pericystitis. ‘There might be
occasional vomiting, especially where there happened to
be an intervening acute catarrh ; but there were other con-
ditions, as, for instance, renal and biliary colic, which were
more liable to exhibit this symptom, and to an excessive
degree. It was often entirely absent, and even in many
acute cases of peritonitis it was not met with. Constipa-
tion was frequent, but diarrhoea was not unusual. The
horizontal position was often quite uncomfortable ; but a
common colic, depending on gas not absorbed or expelled,
also caused drawing up of the knees. It was, however,
when the horizontal posture was shunned in chronic per-
itonitis that the patient was more apt to remain quiet with
raised knees than one who was suffering from flatulency,
where the limbs were generally tossed about continually.
While the abdomen was apt to be tumid, it was to be re-
membered that general adiposity is most fully developed
in this region ; that women who have borne children are
liable to have a large and prominent abdomen ; that the
abdomen of a healthy infant is so large as to measure one-
third of its whole length; that a simple hysterical dilata-
tion and inflation may simulate the tumefaction resulting
from peritonitis ; and that there may occur a local dilata-
tion of the intestine from habitual constipation only.
Moreover, in hysteria there was sometimes met with an
cedematous swelling of both hypogastric regions, which
would complicate the diagnosis still more seriously.
The surface of the abdomen exhibited nets of dilated
veins more frequently in peritonitis and hepatic diseases
than in any other conditions. Inspection might also re-
veal solitary convolutions rising above the level, and palpa-
tion and percussion might lead to the discovery of exuda-
dations of various sizes and shapes, nodules, loops, and
cakes, which may be either hard or soft, and which are
either organized material, thickened omentum, or in-
testines glued together. Fluctuation would show the
presence of fluid more readily than percussion, which
might fail in this, that there might be adhesions between
the parietal peritoneum and intestine in the flanks. The
gas contained in the adherent bowel would yield the tym-
panitic percussion - note although the region might be
filled with fluid. A change of position from one side to
the other, or from the horizontal to the vertical posture,
or vice versa, might contribute to dispel the doubt. —
A chronic peritonitis was sometimes diagnosticated in
the following manner: The patient is on his back, with
the extremities now extended, and now flexed. Pressure
is tried, soft or hard, sudden or gradual, superficial or
deep, in the usual way. According to the seat of the
pain experienced, inflammation or adhesion is made mani-
fest. In many cases, however, the following manipula-
November 9, 1889]
tion answers best : With the palm or finger deep pressure
is first made. Perhaps there is no pain. Relieve the
pressure suddenly, and a local, very distinct and circum-
scribed pain may be felt. Repetition of the experiment
will always give the same result; the symptom being
elicited by the sudden change in the relative position of
the bowels. Not only pain, but the presence of hard,
floating exudations can be distinguished by this and simi-
lar manceuvres.
Every change in the relative position of the bowels
might give rise to pain. A sharp pain after a full meal
might point to adhesions of the stomach ; three or four
hours after eating, to chronic colitis ; a quickened inspi-
ration or a cough, to perihepatitis; pain toward the end
of micturition, to pericystitis. Pain, of varying degree
and persistency, was a very frequent symptom in chronic
peritonitis. Its variability depended often on the degree
of irritation or congestion present, and acute attacks were
frequent when there was a cause for exacerbations. The
seat of the pain varied with the location and the extent
of the lesion. Extensive peritonitis in the pelvis might
not give rise to pain, except such as resulted from defeca-
tion, sexual intercourse, or micturition. The pain attend-
ing pericystitis was quite characteristic ; appearing when
the urine had been about one-half voided. In this, how-
ever, it resembled the spasmodic pain of vesical catarrh,
with the exception that it was more localized above the
pubes, and manifested itself more readily by pressure.
In some cases the pain of chronic peritonitis could not
be diagnosticated from the ente1algia produced by other
causes, such as abnormal contents, fermentation, and
flatulency. Indeed, the anatomical causes of chronic
peritonitis gave rise to these very conditions, for by it the
intestinal movements were retarded, and from it there
might result stenosis, and also twisting and adhesions ;
i through them any function was seriously interfered
wi
The results of chronic peritonitis were very varioug@A
simple attack of acute exudation might shape the whole
future of the patient, and the histories of previous acute
attacks were often not remembered. A few years ago an
eminent physician and surgeon in New York died of peri-
tonitis occurring during convalescence from typhoid fever.
He had often complained of enteralgia and occasional
attacks of diarrhcea during the twenty years that Dr.
Jacobi had known him, but it was only just before his
death that he recalled having suffered from peritonitis
thirty years previously. At the autopsy there were found
discolorations of the serous membrane in many places,
and degeneration, dilatation, and atrophy of the colon to
such an extent as to result in a number of perforations.
From such a case it became evident that the most exten-
sive adhesions and other changes might occur without any
known history whatever. l
The concluding portion of the paper was devoted to an
exhaustive consideration of the important form of chronic
peritonitis known as tabes mesenterica. ‘The main symp-
toms common to every form and case of this were atrophy
and tumidity of the abdomen, and the emaciation reached
a degree scarcely met with in any other morbid condition.
The variety of symptoms belonging to tabes pointed
distinctly to different morbid processes. The gradual
beginning, slow and feverless course, with but little dis-
turbance of the bowels and other organs; the connection
with a severe form of enteritis, continuation of diarrhceal
discharges during the beginning and growth of tumidity,
and moderate or high temperatures during the course of
the morbid process; and the tumidity of the abdomen,
with emaciation following chronic cough and repeated at-
tacks of pulmonary catarrh, ard terminating either in fatal
exhaustion ‘or acute peritonitis, appeared to prove that
there are several distinct forms of tabes, depending on
different causes, and attended with varying anatomical al-
terations. Thus it was evident that the former belief,
that patients die of tabes through starvation, because the
lacteals are no longer able to take up from the food a
THE MEDICAL RECORD.
523
sufficient supply of nutrient matter, was no longer ten-
able.
Besides the simple secondary hyperplasia of the mesen-
teric glands resulting in obstruction, and the tubercular in-
filtration terminating in the same disturbance of function,
there was a third condition which led to the symptoms
recognized as belonging to tabes mesenterica, viz., chronic
tubercular peritonitis. While the child was emaciated,
sometimes to a fearful extent, the abdomen was tumid and
elliptic, its surface shining, the superficial veins dilated,
and the umbilicus expanded and flattened. ‘There was
sometimes ascitis, and sometimes hard and circumscribed
tumors or intestinal convolutions might be distinctly felt
or-seen. ‘There might be colic and diarrhoea, or these
might be absent. The temperature might be normal.
This condition might last for many mionths, even a year.
It was capable of vast improvement, and might yield to
practical recovery, though with a low standard of vitality.
This capability of recovery, with which the experienced
practitioner and pathologist had long been acquainted,
had now and then surprised the surgeons who opened the
abdomen on a mistaken diagnosis, found tubercular peri-
tonitis, sewed it up again, and concluded when the patient
recovered that this was because, and not in spite of, their -
uncalled-for operation. At the present time, however,
we were justified in the belief that only those cases of
chronic peritoneal tuberculosis will have a chance of re-
covery which are local, and not the result of general tu-
bercular infection.
The diagnosis of tubercular peritonitis, or peritoneal
tuberculosis, was apt to be quite difficult, and there were
many chronic cases which could not be differentiated from
non-infectious peritonitis and simple inflammatory pro-
cesses. ‘There were, however, cases of tumid abdomen,
with atrophy of both an acute and chronic character, in
which the nature of the affection could be made out with
some degree of certainty. When the distention of the
stomach appeared after an intestinal catarrh, when it con-
tinued after the diarrhoea had ceased in frequency, when
the temperature remained high, and the symptoms (oc-
casionally) exhibited a “typhoid” character, the exist-
ence of an acute attack of tubercular peritonitis was
probable. This diagnosis was rendered the more prob-
able by the presence of some other symptoms, although
mistakes were possible even then. Among them were
cough, pulmonary symptoms or dulness over the manu-
brium sterni, or below one or both clavicles (pointing to
swelling of the tracheal or bronchial glands), a concomi-
tant history of tuberculosis in the family, and a more in-
tense degree of emaciation than the short duration of an
intestinal catarrh would account for.,
The prognosis of so-called tabes mesenterica was always
uncertain except in the very worst cases. It was abso-
lutely fatal when there was peritoneal and glandular tu-
berculosis complicated with or depending on generalized
tuberculosis. In cases where the diagnosis of a non-in-
fectious hyperplasia of the mesenteric glands could be
made out it was decidedly more favorable. When the
diagnosis of chronic peritoneal tuberculosis had been
made the case was less promising ; still, the possibility of
recovery, or partial recovery, was not excluded.
DISCUSSION.
Dr. Francis DELAFIELD said that the paper was a
most timely one, and that there were few morbid con-
ditions of greater clinical interest than chronic peri-
tonitis. It was an affection constantly coming up for
diagnosis, and as many mistakes were made regarding it
as about any other with which he was acquainted. He
had been accustomed to look at the disease with refer-
ence to the anatomical conditions present, and hence
divided the cases into three classes: first, those in which
there were simply adhesions of connective tissue ; second,
those in which ‘there were present both adhesions and
fluid, either serous or purulent ; and ¢Aird, those in which
wv
1
524
there was diffuse thickening with fluid, but without ad-
hesions.
In the first class of cases the condition was often not
recognized until it was revealed by an autopsy. The
symptoms often corresponded very nearly with those met
with in what is known as “irntable colon,” and it was
very difficult to distinguish between the two. In many
cases it was also difficult to distinguish it from tubercular
peritonitis, when, in addition to connective-tissue ad-
hesions, there was present a large waxy liver. Still an-
other condition with which it was likely to be confounded
was dilated pylorus, in which the stomach felt to the
touch almost precisely like a mass of intestines matted
together. Pain in different parts of the abdominal cavity
gave the physician as much trouble as anything else in the
way of making a diagnosis, and there was, in fact, very lit-
tle to distinguish the pains due to different causes from
each other.
In the second class of cases, where there was fluid in
addition to connective-tissue adhesions, it was often diffi-
cult to distinguish the affection from tubercular peritonitis, :
and the diagnosis between it and carcinoma was also diffi-
cult. Again, we were likely to be puzzled by the shape
' which the peritonitis took. Thus, in certain instances,
fluid was met with in different parts separated by parti-
tions, and there were the physical signs of a solid tumor
with fluid. What seemed like a tumor, however, was
simply the intestines matted together.
In the third class, where there was diffuse thickening
with fluid, but no adhesions, it was difficult to distinguish
the condition from tubercular peritonitis, from multiple
cancer, and from cirrhosis of the liver. Especially was it
hard to diagnosticate it from the latter when the capsule
of the liver was involved, since we were apt to have the
gastric symptoms and the vomiting of blood, which were
so often met with in that affection.
Dr. WitL1AM H. THomson also spoke of the extreme
difficulty of diagnosis in chronic peritonitis, and stated
that personally he had scarcely ever made the diagnosis of
this disease without the mental reservation that the con-
dition present might be something else. He recalled,
however, two cases of cancerous peritonitis which had
one feature in common, which he thought might ‘be of
service in other cases in making the differential diagnosis
between this variety and tubercular peritonitis. The first
was a lady, past forty-five years of age, who presented the
symptoms of ascites. She complained of severe abdominal
pain at times, but had no elevation of temperature. The
special feature of the case to which he wished to call at-
tention was the remarkably low percentage of urea pres-
ent. The urine wag also of low specific gravity. In this
patient the autopsy showed the presence of carcinoma of
the peritoneum. Much of the pain of which she had
complained was referred to the left side, and this was ex-
plained by the fact that two of the false ribs were involved
in the disease. ‘There was also granular contraction of
the kidneys, but this condition was not at all marked.
In the second case there was the same low percentage
of urea in the urine; but here there was no trouble with
the kidneys. As strengthening the diagnosis, there was a
family history of: cancer. In this case there was present
one condition which occurred not infrequently in carci-
noma of the peritoneum, viz., a distinct mdge extending
across the abdomen, due to cancerous infiltration of the
omentum. In cancer of the stomach Germain Sée had
pointed out one diagnostic sign of some value—tenderness
and enlargement of the post-clavicular glands—and Dr.
‘Thomson said he had found this condition also present
in cancerous peritonitis. The diagnosis of tubercular
peritonitis might possibly be made out by the fact that in
this affection the urea did not become diminished, as in
cancer. Again, in cancerous peritonitis there were not
the same fluctuations in temperature that were noted in
the tuberculous form.
As to tubercular peritonitis he had seen one case, in a
young man, in which there was distinct redness about the
THE MEDICAL RECORD.
[November 9, 1889
umbilicus, a sign of this affection to which Wilks had
called attention. When ascites was present in chronic
peritonitis it rendered it very difficult to distinguish be-
tween this condition and cirrhosis of the liver, and this
was notably the case when the history pointed to peri-
hepatitis. The previous history of the patient, as to habits,
etc., however, would generally throw some light on the
question whether cirrhosis of the liver was present or not.
It was a difficult thing to account for many of the cases
of chronic peritonitis, and some of them, he thought, ap-
peared to justify the use of the term idiopathic as nearly
as any affections we had to deal with.
Dr. L. WEBER said that in an obstetrical case which he
had attended many years ago he had had great difficulty
in extracting the child, and after delivery he found
that it was the subject of subacute peritonitis, and that it
had been dead for a considerable time before birth. In
this case the cause of the peritonitis was unquestionably
syphilis. Another child, three months old, which he was
called to attend, had almost from birth presented from
time to time all the symptoms of peritonitis, and at the
end of the third month it died of this disease. Here also
the cause of the trouble was syphilis, and the child had, in
addition, other well-marked signs of hereditary syphilis.
. Five years ago he attended a girl, seven years of age, whose
family history was not good, the members of the family
showing a tendency to tubercular meningitis. She had
developed chronic peritonitis, and in the course of a year
the abdomen had become considerably enlarged. There
was ascites as well as thickening, and the patient was much
wasted. By the prolonged use of the hypophosphites and
cod-liver oil, and removal to the Catskill Mountains, the
fluid and tenderness were got rid of, and the chronic
diarrhoea from which she was suffering was cured, and the
last time that Dr. Weber saw her she was entirely well.
In abdominal cancer, he went on to say, we had all
seen chronic peritonitis, and it was also met with in con-
nion with parasitic troubles, such as hydatids of the
liver. He had never seen a case of chronic peritonitis,
however, which was not of an infectious nature. The
cases described in the earlier part of the paper he would
look upon simply as cases where there had previously
been acute peritonitis, with its consequent results. Of
these, adhesions were the most frequent, and they often
had the effect of impeding the functions of the abdominal
viscera. He had no objection to calling such cases
chronic peritonitis, although personally he did not con-
sider them as true instances of this affection, like the
cases to which he had referred. They were not cases of
general chronic peritonitis, but exhibited simply the re-
sults of adhesions caused by the acute disease, and when
in such cases a fatal result occurred, the patient really
died of acute peritonitis due to perforation.
As to tabes mesenterica, he believed that this was
always a tuberculous affection, and he had been much in-
terested in the reports of the favorable results which cer-
tain surgeons had obtained in this disease by opening the
abdomen and dusting the affected parts with iodoform.
He had not personally had any experience with this
method of treatment, but from what he had read of it he
thought it would probably prove a valuable addition to
our resources in suitable cases of the disease.
PARTIAL OBESITY.—This pathological symptom has
lately. been dealt with by Dr. Bollinger, of Munich. In
his memoir on the subject he describes the case of a
man, forty-five years of age, who had served all through
the Franco-German War (1870-71), and who for the last
six years had suffered from parsielle Fettsucht (partial
obesity). The cheeks, the chin, the throat, the thorax, and
the upper arms exhibited accretions of adipose tissue quite
morbid in their excess. The patient could not account for
it, as he had lived sparingly, had inherited no tendency too
obesity, and had transmitted the same to none of his chil-
dren, twelve in number. Dr. Bollinger finds the disease
to be more common among men than women.— Lancet.
November g, 1889]
THE MEDICAL RECORD.
525
Correspondence.
OUR LONDON LETTER.
(From our Special Correspondent.)
THE HARVEIAN ORATION AT THE COLLEGE OF PHYSI-
CIANS— THE SOCIETIES——DR. HUGHLINGS JACKSON ON
THE RELATIONS OF OPHTHALMOLOGY TO GENERAL
MEDICINE—SIR ANDREW CLARK ON THE NON-TUBER-
CULAR AND NON-CARDIAC HÆMOPTYSIS OF ELDERLY
PERSONS—-THE MEDICAL AND CHIRURGICAL SOCIETY—
. ACUTE LEAD-POISONING— ALPINE CLIMATES FOR PHTHI-
SIS—FORMATION OF A FUND TO ASSIST SUITABLE CASES
—THE ANNUAL MEETING OF THE BRITISH MEDICAL
ASSOCIATION IN 18g90—THE LIBRARY OF THE COL-
LEGE OF SURGEONS.
Lonvon, October 26, 1889.
THE Annual Harveian Oration at the College of Physi-
cians was delivered last week by Dr. James Pollock. A
series of successive annual addresses on the same subject
must necessanly present strong points of resemblance.
To strike out in any originai vein of thought becomes, in
fact, more difficult with every succeeding orator. On the
present occasion the usual account of Harvey’s work was
given, together with the inevitable remark that, although
Italian investigators did much, yet it was by Harvey
that the actual mode of working of the heart was experi-
mentally demonstrated. Harvey’s task would have been
impossible without vivisection, and there were few ani-
mals which he did not thus examine. He was the great-
est exemplar of vivisection, if he were not its originator.
But if great observers had not arisen after him, both medi-
cine and surgery must have remained stationary. Dr.
Pollock then skilfully pointed out how later discoveries
had added to and completed the knowledge obtained by
Harvey, without which, however, they would have beëñ
impossible. ‘Ihe researches and discoveries of Lavoisier,
Priestley, Laennec, Stokes, Corrigan, Latham, and Williams
were briefly referred to. The elucidation of the mechan-
ism of the circulation enabled us to understand the action
of the heart in disease.
Referring to modern advances in pathology, Dr. Pol-
lock said it had been asked, what effect had all our im-
provements in medical science had on the general health
of the country? He answered this question by showing
from statistics that a marked decline had taken place in
the death-rate in recent years, and that by far the largest
proportions of the years added to human life in England
were lived at those ages (between twenty and sixty) at
which the value of life to the community was greatest.
Since the passing of the Health Acts the mortality from
phthisis had greatly lessened, and his own experience was
that the duration of life in those suffering from phthisis
had become distinctly prolonged. ‘There was a slight in-
crease of mortality (from all causes) at the more mature
periods of life (among males of thirty-five and upward),
but this was small and was becoming less ; it was coun-
teracted by the increasing number ot the younger who
now arrived at adult life. ‘This slight increase in adult
mortality might be brought about by the cares and wor-
ries of our higher civilization. Dr. Pollock remarked
that his audience knew well what part of the organism it
was which generally failed under pressure. The public
said it was “ brain,” but they knew that it was “ heart ”—
the motor power which Harvey studied, though perhaps
he did not foresee to what pressure a modern civilization
and struggle would subject it.
The medical societies have now commenced work for
the winter session. The first meeting of the Ophthalmo.
logical Society was held last week, when a presidential ad-
dress on “Ophthalmology and General Medicine” was
delivered by Dr. Hughlings Jackson. Dr. Jackson re-
marked that no department of medicine had greater at-
tractions for him than ophthalmology, and he still thought
what he said in his address to the Medical Society in
1377, viz., that it was the luckiest thing in his medical
life that he began the scientific study of his profession at
an ophthalmic hospital. At an ophthalmic hospital one
had the opportunity of being well disciplined in exact ob-
servation. When a physician saw how carefully and pre-
cisely ophthalmic surgeons investigated the simplest case
of ocular paralysis, he was getting a lesson in exactness,
and would be less likely in his own department of prac-
tice to deal in such generalities as that a patient’s seizure
“had all the characters of an ordinary epileptic fit,” and
more likely to take pains to describe the convulsion, the
place of onset, the march, and the range of the spasm.
Since six crania! nerves and the sympathetic nerve sup-
plied the eye and its apparatus, it was evident that with-
out a good knowledge of eye diseases the thorough in-
vestigation of many morbid affections of the nervous
system could not be carried out. It was not many years
since the ophthalmoscope was rarely used except by
ophthalmic surgeons. Dr. John W. Ogle was the first
‘physician in this country who used the instrument in the
Investigation of medical cases. It was very unlikely that
there was to-day a single patient in the National Hos-
pital for the Paralyzed and Epileptic whose eyes had
not been examined by this instrument. Dr. Jackson
then gave numerous illustrations of the relation of oph-
thalmology to neurology. He remarked that of course
it had much wider relations, and concluded by quoting
the following words from a paper by Dr. James Ander-
son: “ It seems to me the best and most hopeful feat-
ure of ophthalmology that it has relations, closer or
more remote, with every branch of medicine and surgery
—indeed, with almost every branch of science.”
‘The Medical Society of London and the Medical and
Chirurgical Society have held their first meetings during,
the present week. At the former, after the delivery of an
inaugural address by the President (Dr. ‘Theodore Will-
iams) Sir Andrew Clark read a paper on the “ Non-
tubercular and Non-cardiac Hzmoptysis of Elderly Per-
sons.” He related in detail two fatal cases of hæ-
moptysis occurring in elderly arthritic patients. In both
cases the absence of tubercular, malignant, or cardiac
disease was proved by post-mortem examination—which,
however, showed that the hemorrhages were in the im-
mediate neighborhood of patches of emphysema—and
that the minute vessels, the terminal arteries for the most
part, were in those locahties always diseased. Sir An-
drew said that plainly enough the source of the hema
rhage lay in the diseased hlood-vessels, and probably the
disease was of an arthritic nature. Since 1875 he had
seen in persons over fifty years of age some twenty cases of
this form of heamoptysis—a variety of which he had been —
unable to find any clear account in the annals of medical
literature and which he ventured to call “arthritic hæ-
moptysis.” ‘The cases he had related had led him to dis-
continue the ordinary method of treatment of hzemoptysis
by astringents, and to try another method which seemed
more rational and which he had hitherto found success-
ful, viz., rest and warmth, a light and rather dry diet,
counter-irritation to the chest, a succession of small doses
of calomel at bedtime, supplemented by saline aperients
in the morning, and the taking between meals, twice or
thrice in the day, of a mixture containing iodide of potas-
sium, bicarbonate of potassium, and ammonia. Sir An-
drew Clark then related two illustrative cases thus suc-
cessfully treated. In one, the bleeding recurred but was
quickly cured by calomel and salines.
- At the Medical and Chirurgical Society an inaugural
address was delivered by the President, Sir Edward
Sieveking, in which he traced the history of the Society
from its foundation in 1805 to the present time. Dr.
Thomas Oliver, of Newcastle, then read a paper on
“ Acute Lead-poisoning,” which was followed by an ani
mated discussion.
The value of Alpine climates in certain cases of phth-
sis has long been before the profession. Unfortunately,
526
many of the patients most likely to benefit by the climates
in question are precluded from trying them owing to
want of means. It is, therefore, gratifying to find that a
fund has been formed for the pecuniary assistance of such
cases. Drs. Symes Thompson, Theodore Williams, and
William Ewart, have undertaken to examine cases and de-
cide as to their suitability on medical grounds.
Birmingham has been selected as the meeting-place of
the British Medical Association in 1890. Birmi
may justly be descnbed as a stronghold of the Associa-
tion, or, rather, of those who support the present policy
of its Council. ‘The latter could not have shown their
weakness more conspicuously in the present crisis than by
determining to hold the next annual meeting in that town.
- The library of the College of Surgeons is to be kept
open till 9 P.M. on five evenings a week until the end of
the year. Should the experiment be appreciated by a
large number of readers, the extension of hours will no
doubt be made permanent.
BOTH RIGHT AND BOTH WRONG.
To tue EDITOR or Tne Mepica. Recor.
Sir: Paradoxical as the above caption may appear, it
will, nevertheless, be found correct when applied to the
facts and arguments adduced pro and con in reference to
artificial anzsthesia during sleep, as published from time
to time in THe MeEpicaL Record and other journals of
late years. Many cases have been published, where the
effort to produce chloroform anesthesia during sleep was
most successful ; while on the other hand, perhaps a still
larger number resulted in failure.
Any amount of negative evidence, however, cannot break
the force of one well-attested, positive case, much less
that of many. So, it remains to be explained why some
succeed, and why others fail; which, no doubt, is easy
enough when all the factors are considered, and to each
its intrinsic importance is allowed. The proper under-
standing of this difference in the results of the investi-
gation of medical men of equal attainments, is not only of
much interest to therapeutic medicine, but it is of the
greatest importance viewed from a medico-legal stand-
point, since cases will continually arise wherein medical
evidence is liable to be very conflicting, much to the dam-
age of justice, and quite humiliating to professional pride.
It is a well-recognized fact that some persons are of a
matic temperament, and consequently are not im-
pressible in a high degree, through the special senses, to
the various external agencies surrounding them. Their
feeble respondence to external agents during all their
wakeful moments, proves this to be true, and it holds
equally good when they are overtaken by sleep. Hence,
a person so constitutionally disposed would be more
likely to come under anesthesia by inhaling medical
agents during sleep, than others of a different or opposite
predisposition. ‘The experiment tried on such persons,
and under the most favorable circumstances, would not
be likely to be disappointing.
On the contrary, the very opposite would naturally be
expected from a person in whom the nervous system is
wrought up to a high degree of tension. In wakeful and
sleeping moments, alike, a respondence to impressions from
every source is so acute as to be next akin to the morbid
element. The repose of such persons is more of a slum-
ber than deep, sound sleep. A state absolutely of hyper-
gesthesia, both as to touch and sound, exists in persons
thus constituted. Some of them are so sensitive to ex-
ternal agents as to be awakened by another person, espe-
cially if a stranger, on approaching close to the bedside,
although ever so stealthily. Now, in a case like this, un-
der the ordinary state of being, doctors alive to such in-
fluences would hardly expect, beforehand, to succeed in
producing anesthesia during sleep; if so, the subject
would surely wake them to a realizing sense of their mis-
take. ‘hese two opposite states of the constitutional
THE MEDICAL RECORD.
[November 9, z889
make-up, found existing in every community, offer a good
explanation of many successes and failures in an effort at
anzesthesia, thus harmonizing to a certain extent experi-
mentation in this direction.
Again, while the majority of persons are free, perhaps,
- from such pronounced tendencies, they are inclined more
or less to the one or the other, besides being influenced
by many other considerations, either favorable or unfav-
orable in such an experiment.
One who had undergone great fatigue during the day
would be less hkely to wake on the administration of
chloroform, especially if the supper had been light, and it
was in the midst of the first sound nap; the opposite state
of things existing, would of course favor wakefulness.
Owing to habit formed, many persons are easily awakened,
the slightest noise being quite sufficient ; and, as a matter of
fact, it would be next to impossible to bring them under
anzsthetic influence. Most people, especially if fatigued,
sleep soundly about midnight, and at that time would be
less likely to wake on receiving an anesthetic.
Whatever tends to make one restless—such as over-
heating, mental anxiety, pain, or hyperzesthesia from rheu
matism, and insect annoyance—would naturally render a
subject unfit for experiment, because sleep is not sound
enough. Persons who, but just before receiving the
anesthetic, have, from any cause, been deprived of a
large amount of sleep, would be more difficult to wake,
because of that fact; and therefore, much easier to anzs-
thetize while thus thoroughly lost to all sense of their sur-
roundings. Sleeping with one eye open would not apply
in their case. ‘The experiment would be less likely to
succeed in persons laboring under acute or chronic ail-
ments, for usually all such have their slumbers to rest on
them lightly. With children, as might be supposed, the
chances of success appear to be much better. This is
accounted for from the fact that children are more
susceptible to medical impressions than adults; and.
furthermore, they sleep sounder and with more perfect
abandon when there is no disturbing cause. More sleep
is required by them than older persons, unless the very
old; so that when they round up the day’s exercise and
excitement, tired nature is quite ready to fall into the
welcome embrace of soothing Morpheus.
As an illustration of how it acts with children, the case
reported in THE MepicaL RECORD of September 7th, by
Dr. Theodore Potter, is fairly representative. ‘This child
had been on the go all day, when he received the injury ;
and nature was then still further exhausted and undone,
by ceaseless efforts to find relief from pain, for two hours,
at which time, 9 P.M., the limb was placed in com-
fortable position; after this, all things favoring, the pa-
tient soon found relief from suffering and exhaustion ın
deep sleep, from which chloroform inhalation to anzs-
thesia, even, did not arouse him. Doubtless, had this oc-
curred in the forenoon, anzesthesia would then have been
far more difficult, if not impossible, to effect, for the rea-
son that sleep would not have been needed, and it would
be out of the regular order of physiological rest. In most
cases, an injury of like character, no doubt, would inter-
fere with success; but in this instance, the injury occur-
ring when the day was fairly on the wane, and the limb
having been made comfortable, it seems not to have
militated against a favorable issue. Because of greater
pleasantness, and more concentration, it can hardly be
questionec| that chloroform will be found to succeed better
in such attempts than other articles possessed of like prop-
erties. Doubts seem to exist in the minds of many, both
lay and professional, as to whether it is possible for bur-
glars and others criminally inclined, to effect successfully
artificial anesthesia on their intended victims during sleep.
When it is taken into consideration that they ply their vo
cation usually about midnight, just the time the subject
upon whom the experiment is to be tried, as well as all
nature, is wrapt in the deepest slumber, it is not to be
wondered at if they should succeed. Doctors try the ex-
periment, as a rule, on patients afflicted with disease ;
November 9g, 1889]
who are restless, generally, and would be liable to wake ;
but burglars have the very best subjects upon whom to
operate, and this of itself would seem to warrant success,
other things being favorable. In addition, while they may
not be skilled in the administration of an anesthetic, they
have cultivated sleight-of-hand performances, and cat-like
stealthiness, until advantages would perhaps be in their
favor. This is a point upon which there ought to be a
more unanimous conviction and expression by medical
men, in order that justice may be done, and proper pro-
tection given, to the helpless while enjoying “tired nature’s
sweet restorer—balmy sleep.” ‘Ihe medico-legal phase of
this question, is, indeed, a most important one, and the
interest therein centred will doubtless become still greater
as time elapses, for all kinds of wickedness and crime seem
to be fearfully on the increase. In the administration of
an anesthetic during sleep, very much depends on the
manner of giving it in order that the proper effect shall
be produced. That it should be given very gradually, and
much diluted with air, stands to reason; and herein lies
an advantage in burglarious cases, since, from their known
habits of procedure, burglars would be most certain to
give it in that way.
Admitting foregoing elucidations, surely a better corre-
spondence of opinion on this question ought to be reached
by the medical profession.
As to whether artificial anzesthesia applied to different
people can or cannot be effected during sleep, depends on
so many conditions, and such a variety of circumstances,
no one can form a correct conclusion until the question
has been viewed in all its bearings ; and when that shall
have been done by individual inquiry, doubtless profes-
sional opinion will be tolerably unanimous.
B. F. Hart, M.D.
Sweet SPRINGS, Mo.
THE PREVENTION OF SEA-SICKNESS.
To tue EDITOR or Tuu Mepica, Recorp.
SIR: In THE MeEpicaL ReEcorp of September 28th ap-
pears an item, in which it is stated that “ Dr. Ivan A. Mi-
tropolsky, of Moscow, warmly recommends as a simple
method for preventing or aborting all symptoms of sea-
sickness,” the closing of the eyes and making deep and
slow inspirations and expirations. The item also states
that a writer in the London Medical Recorder intimates
that this means is not original with Dr. Mitropolsky,
and cites an article in the British Medical Fournal,
March 24, 1888, by Dr. Leiser, in which the writer says
that sea sickness is caused by irregular and imperfect res-
piration, and that a system of regular free breathing pre-
vents or rapidly relieves it. He also gives the result of
various experiments, which he says were entirely suc-
cessful.
In this connection, I trust that I may be pardoned for
calling attention to an article entitled “ A Study of Sea-
sickness,” contributed by myself to the Century Magazine,
July, 1883.
It was the purpose of that article to show that *“ sea-
sickness is the result of reflex irritations arising from little
surprises to the muscles, and shocks to the nerves engaged
in certain important functions.” Among these important
functions was included that of respiration, which was dis-
cussed at some length. I quote a few sentences :
“ Another source of nervous perplexity, then, of no
small consequence, will be found in the inclination to
breathe synchronously with the swing of the vessel. . . .
If the ship’s motions were only in one direction, and
if they were uniform in time, they would produce, in one
sitting on the deck or reclining in a berth, the same agree.
able effect as swinging on a hammock on shore; but, un-
fortunately, there are too many elements of disturbance in
the rhythm of the ship’s movements to react in such an
agreeable manner. When the ship rolls regularly,
_once in so many seconds, the people breathe regularly, but
when the ship’s motions lose uniformity, the irregularity of
THE MEDICAL RECORD.
527
performing the function (of respiration) would be a sufh-
cient cause for general nervous disturbance.”
In speaking of the means of preventing or mitigating
the evil, the article continues : |
“ Strict attention should be directed to the state of the
respiration. Many a threatened sickness may be averted
by drawing a few deep, full inspirations at regular and
rapid intervals. One who is overtaken by sea-sickness
while lying quietly in the berth in the darkness of the
night, may be quite sure that he or she is breathing in the
same unsteady manner in which the ship is moved upon
the water. If the sufferer, at the first premonition of sick-
ness, would rouse sufficiently to attend properly and ear-
nestly to the breathing process, it is probable that the
nausea would pass away as suddenly as it came. Under
all circumstances, then, the breathing should be strictly
dissociated from the motions of the ship.”
It has not been my purpose to quote at any length from
the article referred to, which treats the subject upon
broader principles than either of the articles quoted by
THE MEDICAL RECORD, nor to refer to any other of the
disturbances arising in the performance of several func-
tions which were recognized as causative in this malady.
My purpose has been only to call attention to the simi-
larity of the views of these writers, so far as this function
is concerned, to those published in a widely circulated
periodical more than six years since.
GEORGE T. STEVENS.
33 West THIRTY-THIRD Street, September 30, 1889.
A MEDICAL EXAMINING BOARD FOR NEW
YORK STATE.
To THe Epitor or THE MapicaL Recorp.
Sir: To those who are close observers of the drift of
opinion among medical men, there can be no doubt that
the question of a Medical Examining Board for the State
of New York—no matter how strenuously it may be op-
posed by an influential minority—must soon force itself
upon us for settlement.
That the Empire State and the metropolis of this con-
tinent, from which all that is progressive and wise should
emanate, should remain passive, with folded hands, seem-
ingly oblivious to the progress which other and younger
States are making, is a confession as shameful as true.
Illinois, Virginia, Alabama, North Carolina, and Minne-
sota have done, and are to-day doing, a hundred-fold more
to elevate the standard of medical education, close the
door to quackery, and increase the respect on the part of
the laity for our profession, than New York State with all
its boasted wealth and culture, and its great didactic and
clinical resources.
It was my privilege to attend recently, at Roanoke, Va.,
the annual meeting of the Medical Association of that
State. The Board of Medical Examiners were then in
session. ‘Twenty-six applicants came before the Board
for license to practise. Twenty-three held diplomas from
well-known medical schools, and three were non-graduates
who had attended one or more courses of lectures. Only
eight of this number received the Board’s permit. These
gentlemen are shutting the door on what heretofore has
been called medical education. Their action was unan-
imously approved by the State Association. This Associa-
tion, by their earnest and united action, have about closed
the door on quackery. If every other State in the Union
would secure such a law and organize such a courageous
and honorable Board of Examiners, can one doubt that
within five years’ time the annual number of graduates
would be very greatly diminished? ‘Those who elect the
calling of medicine would be compelled to undergo
thorough preliminary preparation ; the standard would
be raised equal to that of the best schools of Great Brit-
ain and the Continent.
To brinz about this “consummation devoutly to be
wished,” I respectfully suggest the following :
528
THE MEDICAL RECORD.
[November 9, 1889
1. Let the New York Academy of Medicine issue a call
for a convention of representatives of all unsectarian
County Medical Societies of New York State.
2. At such convention the representation and voting
power of each society to be proportionate to its actual
paid up membership, as attested in writing by the Presi-
dent and Secretary of each society—say, one vote to
every twenty-five members or less. ‘Ihe votes to be by
person or written proxy, and no proxy to be cast except
by a repr2sentative of the society from which it is sent.
3. This convention to draft a set of rules for the better
regulation of the practice of medicine in the State of New
York, and elect a State Board of Medical Examiners.
Such a movement, endorsed and supported by a fair
majority of the profession in this State, would become a
law by act of the legislative body and the Governor. It
could not be successfully resisted or thwarted in its ob-
ject.
This Board to be composed of members of the medical
profession qualified by special experience in the depart-
ments assigned to them as examiners.
_ The proposition to exclude from the Board of Exam-
iners, professors in colleges authorized to confer a degree
in medicine, is not fair; nor would it be just to permit
one-half of this Board to be composed of college profess-
ors, as recently advanced in an article in the North Am-
crican Review. There can be found enough perfectly
competent material outside of the colleges to organize a
dozen examining boards. It would be a fair division, in
my opinion, if one-fourth of the entire Board selected by
the profession in the State were college teachers.
The Board of Examiners should consist of two mem-
bers for each of the following departments: Anatomy,
physiology, chemistry, materia medica, therapeutics, medi-
cine, surgery, obstetrics and gynecology, and pathology,
sixteen in all. The examinations should be written, oral,
and practical. A candidate should be satisfactory in
seventy-five per centum of the grading in each branch.
Failing to secure this minimum in one-half of all subjects,
he should be rejected. Failing in less, that he be allowed
within six weeks a second examination in the branches in
which he was found deficient. Failing a second time, he
should be given one year for a final examination. A fee
equal to the ordmary “ graduation fee” of the colleges to
be charged each applicant. The amount received to go
to defray the expenses of the Board.
_ The question of qualification to be the chief considera-
tion in determining the issue of a permit. All applicants
to be given an equal showing, without question as to the
college from which they hail or the school in which they
propose to practise.
In voting upon the subjects of surgery, medicine, and
obstetrics and gynecology, the affirmative vote of both
examiners in each branch should be required. In the
five other departments one affirmative vote in each may
secure a permit, giving eleven out of sixteen votes as the
lowest possible vote. ‘I'he above to go into effect when
the “ Rules for the Better Regulation of the Practice of
Medicine in the State of New York” should become a law.
There are many minor points of interest which might
be added, but I do not wish to impose further upon your
valuable space. It does seem to me that the Academy of
Medicine, were its vast influence concentrated in the
movement, could not only bring about the organization of
the State Board, but go farther and secure the endowment
and support of a medical college on a grand scale, in
which the requirements for a license to practise should
be three full years of didactic and one year of strictly
clinical work. Jonn A. WYETH, M.D.
DETERMINATION OF SEX.
To THe Epiror or THe Mapicat RECORD,
Sik: Few things are to me more interesting than a mud-
dle, however “deplorable” it may appear to a man in
Siam. In your issue of September 21st, Dr. ‘'hompson
writes from Siam like a man deeply impressed with the
importance of his theme, and thereby enlists my deep
sympathy, and draws me away for the time from the com-
pany of those serene but simpler souls who are content to
view the subject as one of the hidden mysteries of nature.
Dr. Thompson is willing to part with the old supersti-
tion that the right testicle begets boys and the left one
girls, and leaves the impression that with a little persuasion
he would dump into the same waste the theories that boys
are begotten before, and girls after midnight; that it de-
pends upon the relative ages of the parents; that it
depends upon their relative vigor ; upon whether begotten
before or after menstruation ; upon the preponderance of
amatory desire. With regard to the last, however, he
would evidently hear argument, for he asks, with touch-
ing pathos, “ Why the silence of medical men in regard to
it?” Why, indeed ?
I will speak of things about which I have no doubt, re-
marking, by the way, that doctors pick up a good many
things which do not concern them personally. A. had
amativeness well developed. B. had no sexual feeling
whatever. ‘Their ages differed by one year. After long
resistance B., being left alone by the death of her parents,
yielded to A.’s suit and married him. She accepted with
Christian resignation all the burdens of wifehood, but the
sexual act never produced in her any other feeling than
aversion and disgust. Yet she bore children somewhat
rapidly, in this order : Girl—boy—girl—boy—girl. After
the last birth, incensed at her husband for whipping one
of the children, she withdrew from her husband’s bed till
the day of her death, but discharged all the other duties
of wife and mother with dignity and fidelity.
It is not germain, but may be of interest to speak of the
children of this union. The eldest daughter, after much
importunity and repeated refusals, finally consented to
marry an eligible gentleman. She made a gentle and
agreeable companion, yielding all that her husband de-
manded, experiencing neither pleasure nor disgust from
his embraces. But she would sometimes laugh immod-
erately at the most critical periods of his career, recalling
to his memory our old friend Shandy and his clock at
most inopportune moments. His intense interest in pass-
ing events was wholly inexplicable to her. She early con-
ceived, but, unfortunately for this tale, died of uræmic
convulsions a month before term, and the sex of the foetus
was not made manifest. ‘The youngest daughter was an
enigma. Without apparent effort on her part to please,
men “ fell at her feet,” almost as a matter of course. But
she would have none of them, and, after rejecting suitor
after suitor, was gathered unto the angels, where she be-
longed. ‘The boys, like their father, possessed normal
amativeness.
C. was thrice married, to girls three, five, and fifteen
years, respectively, younger than himself. Two of the
ladies may be ranked as normal, with regard to sexual
feeling, the other at zero. The result was male children
only in each case. But “it is well known,” continues
Dr. ‘Thompson, “that an intimate relationship exists be-
tween the physical and psychical condition of the parents,
and conditions or characteristics of the offspring. Is it
too much for us to believe that on the line of this rela-
tionship may be found the determining factors of sex ? ”
I fear itis. An old German farmer and his wife had no
psychical conditions that were visible on the surface. ‘They
needed boys for the farm and ought to have had them ;
. but the result of their love was nine healthy girls. A
neighbor said to the old lady in my presence: ‘ Why
didn’t you turn the bed around? I have heard that that
would change the luck.” Her innocent reply was : “ I did
durned it, and durned it, and durned it, until, bless God,
the gude man could git neider gal nor poy!” But there are
compensations in nature. A neighboring couple had a
similar family, all boys, and no amount of praying and bed-
changing would change the luck.
But I am not accustomed to discuss a subject without
settling it. On one occasion in my student days the Pro-
November g, 1889]
THE MEDICAL RECORD.
529
{essor of Obstetrics devoted a whole hour to the question,
“ Why does labor occur?” He reviewed the speculations
of authorities from the time of Hippocrates down, and left
the question precisely where he found it. After the lect-
ure, in a spirit of flattery no doubt (I had paid for all my
tickets in advance), he asked if I had formed an opinion
on tne question. ‘ Why, Professor,” said I, “ there is no
room for any question about it. God made woman and
subjected her to the operation of certain natural laws.
She conceives, gestation proceeds until the time of Nature
is accomplished ; then labor begins because the woman
can’t help it!”
Why not apply the same rule to the question of sex?
Where is the objection to the hypothesis that sex is in-
herent either in the ovum or in the spermatozoon which
finally impregnates it? We may, then, reasonably irfer
that in the ova of cne female, or the sperm of one male,
one sex predominates and the other in another ; and that
the result of copulation in a given case is purely a matter
of chance, if we exclude Omniscient decree in matters of
such detail. ‘This, it seems to me, would be a satisfactory
solution of the “ depiorable muddle.”
S. 5. ‘TURNER, M.D.,
Acting Assistant Surgeon U. S.A.
PROTECTION FOR RAILWAY ‘TRAVELLERS.
To tHe Epitor or Tue MenicaL Recorp.
Sır : “ Missouri,” in your issue of September 28th, does
well in calling attention to the exposed condition of
the “closet” department of sleeping, parlor, and other
styles of railroad cars. But aside from the danger spe-
cified—direct exposure to the inrushing cold air—there
are other dangers ; those caused by the hornbly cold sur-
roundings in the box, where one must be penned for the
time being ; the lump of ice in the urinal opposite, for one
to stare at while perched on the seat does not add materi-
ally to the comforts, unless as a “peristaltic persuader ”
of the unfortunate occupant of the pen. All this needs
to be, and must be remedied; and “ Missouri” has acted
wisely in taking advantage of the columns of your valuable
and widely circulated journal, as it does not “ advertise”
“ the few new cars for special exhibition.”
Since the subject of railroad car closets has been
broached, it will not be amiss to call attention to other
dangers, aside from those mentioned. ‘These “ conven-
iences ” (?)—inconveniences and death-traps more properly
—-play, I believe, a considerable part in the cause of local
outbreaks throughout the country of typhoid fever.
There are in this Jand of advancement but few water-sup-
plies providing drinking water for our large towns and
cities that are not in constant danger of being polluted
by typhoid or other forms of specific germs—cholera if it
were prevalent. ‘These germs are dumped along the road-
beds of the many railroads that are constantly winding
about the streams of our water-supplies, or, it may be, cross-
ing them at some or many points along thejr course.
This is especially liable to occur where roads are largely
engaged in the transportation of emigrants. It is to be
hoped that these abuses, of railroad travel may be done
away with. Perhaps in no surer way could they be reme-
died than by calling to them the attention of the newly
formed Association of Railway Surgeons, from which so
much good is bound to come in the hope that many other
dangers to which human life is now subjected may be re-
moved.
For my own part, I feel that the house-trap and closet
of most recent design should be placed in all railway
cars ; these to be connected with pipes that would conduct
the flushing water, with the excrementitious materials,
along to the fire of the engine, where they can be run
through a convoluted system of pipes exposed to the in-
tense heat of the fires before being discharged to the earth,
when they will have been rendered innocuous.
RICHARD H. GıBBonNs, M.D.
433 WYOMING AVENUE, SCRANTON, PA.,
October 1, 1889.
EATING BEFORE SLEEPING.
To tHe Epirorg or THe Mepicat Raecorp,
Sır : In a recent issue of THE RECORD I notice an article
on “ The Food Treatment of Insomnia,” by Dr. Eggleston.
There is much truth in what he says.
Very often when at the Asylum I have seen patients
who had long refused food and been sleepless before ad-
mission (notwithstanding that large doses of powerful
hypnotics had been given) going quickly to sleep after
having been fed with the stomach-pump.
Dr. Eggleston seems to think that there is some excuse
for the old saw of “not eating before sleeping,” for he
says, “it may be true that digestion goes on more slowly.
during sleep.”
Now there is really no excuse for the old prejudice, and
we are only able to sleep well without first eating (espe-
cially if hungry) by long training in rebellion against nature.
For is it not a fact that the stomach requires more blood
during the period of digestion, and what more natural,
then, than that the blood be drawn from the brain, as it is
the most vascular organ of the body, and during sleep less
blood is required in the brain? Hence digestion should
aid sleep, and sleep aid digestion.
Common observation of the lower animals all goes to
show the same that the doctor points out with babies;
that to eat first and sleep afterward, is nature’s rule and
their practice.
As the exception proves the rule in many cases, so here.
If one eats uneasily digested food before retiring he will
very likely be disturbed in his sleep, or perhaps may not
sleep. But the same things eaten prior to a season of
waking hours would also have given distress.
The more busy and occupied the man, the less attention
he would likely give to the distress of indigestion. So, on
the other hand, at night, when he has nothing else to do
but think of his pains, they naturally make more lasting
impressions on him ; and, of course, sleep lost is another
penalty, not of having eaten before retiring, but of having
eaten substances that would cause distress under any
circumstances. W. WASHBURN, M.D.
42 Irvine PLACE.
Tew Lustruments.
A NEW NEEDLE-HOLDER FOR REMOVING
HAIRS BY ELECTROLYSIS.
By FREDERICK J. LEVISEUR, M.D.,
PHYSICIAN TO ST. BARTHOLOMEW’S HOSIITAL AND DISPENSARY,
THE removal of superfluous hair is accomplished, as is
well known, by introducing a very fine needle, connected
with the negative pole of a galvanic battery, down to the
bottom of the hair-follicle. ‘The patient completes the
D
E EISNER. N.Y.
circuit by tightly grasping a sponge-electrode—the positive
pole. After a short time, say ten to thirty seconds, the
circuit is interrupted, the needle withdrawn, and the hair
removed by forceps, if found sufficiently loose.
The mechanical difficulty of this simple process con-
sists in probing the little cul-de-sac down to its deepest
part without injuring much the surrounding tissue. A
little instrument which I have devised materially facili.
tates, I think, this operation. It isa needle-holder mod-
ified after the following manner : The small metal point
530 THE MEDICAL RECORD. [November 9, 1889
is ball-shaped and perforated from top to bottom, as well | second short steel tube, making a tight joint; and to this
as from behind above, to in front below. The needle can | is attached sufficient rubber tubing to make a convenient
be inserted and fastened by screw arrangement in three | siphon. We have now an ordinary lavage tube, with a
different positions, so as to form, with the handle, a right, | metal coupling. After emptying the stomach, uncoupling
or an acute, or an obtuse angle. ‘The operator, who is | the joint, and thus removing the rubber tubing, the elec-
standing or sitting behind his patient, holds the instrument | trode, which consists of a spiral steel wire with an en-
like a writing-pen. His forearm is at rest, and a slight | largement at the end, is introduced through the stomach-
movement of the wrist suffices to make the needle enter | tube without removing it. ‘Ihe electrode makes a tight
deeply into the hair-follicle with an easy and elastic plug for the first steel tube, thus preventing the regurgita-
motion. ‘There is no place in and around the patients | tion of fluid from the stomach, and at the same time
face that could not easily be reached with the instrument. | holding the instrument together. The whole makes an
The accompanying wood-cut, showing very well the | uncomplicated affair, very easily managed, and conveys a
principle of my new needle-holder, was kindly furnished | current strong enough for any purpose. It is best to have
to me by Messrs. F. Eissner & Co., of No. 18 Bible . a little weak solution of sodium bicarbonate in the stom-
House, ‘Third Avenue, New York, who manufacture and | ach before introducing the electrode.
sell the instrument. The illustration is froma pen sketch by Dr. H. G.
687 LEXINGTON AVENUE. Matzinger of the Buffalo State Asylum for the Insane.
There remains much to be said about the practical re-
sults of the electrical treatment of gastric disorders. ‘This
is hardly the place to detail clinical experience, but I may
be allowed to express the opinian that this method en-
ables one to effect, beneficially, disturbances of motion.
sensation, and secretion, which, in some instances, baffle
other plans of treatment.
278 FRANKLIN STREET.
A NEW GASTRIC ELECTRODE.
By CHARLES G. STOCKTON, M.D.,
PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE, AND CLINICAL MEDICINE,
MEDICAL DUPARTMENT OF THE UNIVERSITY OF BUFFALO, N. Y.
For the past two years I have been studying the results
of the electrical currents applied by means of a gastric
electrode for the relief of certain disorders of the stomach.
Numerous experiments taught me the importance of
preventing the metal electrode from coming in direct con-
tact with the gastric mucous membrane. To overcome
this objection efforts were made to utilize the column of
water in an ordinary stomach-tube as the conductor of. the
current; and it was found that, by using a saline solu-
tion in the tube, a weak current could be carried, but the
method was troublesome and the results unsatisfactory.
An instrument was then made, by carrying through a
emg ‘and Aavy Hews.
Official List of Changes in the Stations and Duties of Offi-
cers serving in the Medical Department, United States
Army, from October 27 to November 2, 1889.
HEGER, ANTHONY, Lieutenant Colonel and Surgeon.
By direction of the Secretary of War, so much of par. 2,
S. O. 24, October 16, 1889, from this
office, as relates to him, i is amended
to read as follows: Lieutenant-Col-
onel Anthony Heger, Surgeon, is re-
>. lieved from further duty in the Divi-
H sion of the Atlantic, and will at once
report to the Major-General com-
manding the army for duty in this
city. Par. 3, S. O. 252, Headquarters
of the Army, A. G. O., October 29,
1889.
Forwoop, WILLIAM H., Major and
Surgeon. By direction of the Presi-
dent, is detailed as a member of the
Army Retiring Board at St. Paul,
Minn., convened by War Depart-
ment Order dated January 12, 1889,
published in S. O. No. 10, January
12th, from Headquarters of the
Army, vice Captain Edgar A. Mearns,
Assistant Surgeon, who is hereby re-
lieved. Par. 12, S. O. 254, A. G.O.,
D, stomach-tube ; A, rubber tubing; C, first steel tube ; B, second steel tube, coupled ; z clectrode fn situ, October 315, 1889.
forming a plug to first steel tube. Manufactured by George ‘Tiemann & Co.
aS cp rrr ee et nO e ~
O’REILLY, ROBERT M., Major and
stomach-tube an uninsulated wire, which at the distal end ee By direction of the Secretary of War, par. 3,
of the tube terminated in a button so arranged that it lS, O. 24, October 16, 1889, from this office, is so amended
came near the fenestrum of the tube, and yet so that the | as to grant him leave of absence for six months, with per-
mucous membrane could not reach the metal point. This ; mission to leave the United States, to take effect Novem-
contrivance overcame the internal resistance and proved | ber 1, 1889. Par.6,S.O. 252, A. G. O., Washington,
effectual, but it was inconvenient to the patient, inasmuch | D. C., October 29, 1889.
as it was necessary to introduce an ordinary tube for
washing out the stomach before the tube containing the
electrode could be employed.
Finally, I contrived an apparatus which for some months
has been used with satisfaction both by myself and others, |
and which seems to meet every requirement. It is ad-
mirably constructed by Messrs. George Tiemann & Co. It
consists of an elastic stomach-tube twenty-four inches long,
which at the proxima! extremity is slipped over one end of
a short steel tube. Over the other end of this tube fits a
GiBSON, JOSEPH R., Major and Surgeon. Granted
leave of absence for seven days, to take effect from date
of being relieved from duty at Fort Sheridan, Ill. Par.
9, S. O. 249, A. G. O., October 25, 1889.
TayLor, Morse K., Major and Surgeon, retired. Died
October 20, 1889, at San Antonio, Tex.
WILLCOX, CHARLES, First Lieutenant and Assistant
Surgeon. Appointment to rank from October 29, 1889.
Be
November 9, 1889]
Maus, Louis M., Captain and Assistant Surgeon.
Granted leave of absence for two months, on Surgeon’s
certificate of disability. Par. 11, S. O. 249, A. G. O.,
October 25, 1889.
Gorcas, WILLIAM C., Captain and Assistant Surgeon.
By direction of the Secretary of War, is relieved from tem-
porary field duty in the Department of the Missoun, and
will join his proper station (Fort Barrancas, Fla.). Par. 2,
S. O. 251, A. G. O., October 28, 1889.
Maus, Louis M., Captain and Assistant Surgeon. By
direction of the Secretary of War, so much of par. ro, S.
O. 242, October 17, 1889, A. G. O., as directs him to re-
port in person for duty at Fort Stanton, N. M., to relieve
Captain Marcus E. Taylor, Assistant Surgeon, is revoked,
and Captain Taylor will proceed to Boise Barracks, Idaho
Terr., as directed in said order, as soon as medical attend-
ance shall be provided for Fort Stanton. Par. 10, S. O.
249, A. G. O., October 25, 1889.
CABELL, JULIAN M., First Lieutenant and Assistant
Surgeon. Granted leave of absence for two months, to
take effect about November 10, 1889. Par. 7, S. O. 249,
A. G. O., October 25, 1889.
McVay, Haran E., First Lieutenant and Assistant
Surgeon. Appointment to rank from October 29, 1889.
Frick, E. B., First Lieutenant and Assistant Surgeon.
Appointment to rank from October 29, 1889.
By direction of the President, the Army Retiring Board
convoked at Vancouver Barracks, Washn. Terr., by War
Department order dated December 15, 1888, published
in S. O. 292, December 15, 1888, from Headquarters of
the Army, is dissolved. Par. 1, S. O. 250, A. G. O.,
Washington, October 26, 1880.
Official List of Changes in the Medical Corps of the United
States Navy for the week ending November 2, 1889.
NasH, F. S., Passed Assistant Surgeon. Detached from
duty in Bureau of Medicine and Surgery and ordered to
the Petrel, November 14, 1889.
BocerT, E. S., Medical Inspector. Ordered to ex-
amination, preliminary to promotion to Medical Director.
Norton, O. D., Assistant Surgeon. Ordered to ex-
amination, preliminary to promotion to Passed Assistant
Surgeon.
Kite, J. W., Assistant Surgeon. Ordered to examina-
tion, preliminary to promotion to Passed Assistant Sur-
geon. $
STONE, E. P., Assistant Surgeon. Ordered to examina-
tion, preliminary to promotion to Passed Assistant Sur--
geon.
Medical Atems,
Contacious Diszases—WEEKLY STATEMENT. — Re-
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending November 2, 1889:
Cases | Deaths.
Typhus fever occ oc seston Sis Fok thc ceens | o | o
Typhoid fever ausos yora adana enhi 83 | 16
Starlet (ever 35 cg es ace eas eeeniewes ere Se | 38 4
Cerebro-spinal meningitis................. 0000008 | 4 2
Measles: sce ycscanvateaes ENERE ES NEINN soa ' 2I o
Diphtheria susreo erdee codes EEEE LETIS . 80 18
SMaAlLPOX riie nea RAE r ERINE AANEEN Cees | I | o
Yellow fever, oreesa ran iaa nasa dees | o '! o
o | o
Cholera 5s heen. Ssh beran aAA |
THE Lessons oF WortTuy Lives.—Several well-known
figures have recently been taken from the London medi-
cal profession by death. Among them may be specially
mentioned Dr. Habershon, Dr. King Chambers, Mr.
Walter Coulson, and Dr. Lawrence Cumberbatch. Dr.
Habershon was for twenty-six years a member of the med-
THE MEDICAL RECORD.
531
ical staff of Guy’s Hospital. In 1880, being then senior
physician, he r ed his appointment, as a protest
against the way in which the nursing arrangements at the
hospital were carried out by the treasurer in opposition to
the expressed views of the staff. By thus resigning Dr.
Habershon sustained a considerable pecuniary loss, as,
although the hospital appointment was not a paid office, —
the fees from students for clinical teaching amounted to
several hundred pounds a year. Mr. Cooper Forster,
the then senior surgeon, resigned at the same time. In
consequence of their action, neither he nor Dr. Haber-
shon were elected members of the consulting staff. Dr.
Habershon’s published writings were chiefly on diseases
of the stomach and abdomen, and it is remarkable that he
himself died from repeated attacks of hzmatemesis,
which was, on post-mortem examination, found to be due
to simple ulcer of the stomach. Any mention of him
would be incomplete without stating that from early life
he took an active interest in religious and philanthropic
work of various kinds. Dr. King Chambers was at the
time of his death the senior consulting physician to St.
Mary’s Hospital. Dr. Chambers’ career was a remark-
able example of the triumph of will over bodily weakness
and pain. He suffered for many years from aneurism, for
which one of his legs was amputated. He continued to
practice, however, and even remained on the teaching -
staff of St. Mary’s Hospital Medical School (as joint lec-
turer on medicine) after he had ceased to be on the active
staff of the hospital. His lectures were always interest-
ing, and delivered in an effective manner, although he de-
pended largely on his copious notes and lectured sitting
in a chair. Itis by his writmgs he will chiefly be re-
membered, combining as they..did. sound. instruction with
a polish of style rarely met with in medical works. His
‘‘ Manual of Diet” was perhaps his most popular work.
The return of the disease in the opposite limb compelled
Dr. Chambers to retire from active work eleven years
ago. Pressure was successful in effecting a cure, but he
never resumed practice. At the end of last year aneu
risms developed in connection with both carotid arteries,
and, in conjunction with cardiac disease, led to his death.
Mr. Walter Coulson, who died recently, at the age of fifty-
five, had the advantages of both health and fortune to assist
him. His uncle was one of the original members of the
surgical staff of St. Mary’s Hospital, and Mr. Walter
Coulson became assistant surgeon at that institution.
This appointment, however, he soon vacated in conse-
quence of differences with his colleagues respecting his
connection with St. Peters Hospital, which he was in-
strumental in founding. At that date there was great
opposition to special hospitals, and, piqued by the cold
shoulder shown him, Mr. Coulson resigned and appealed
to the governors for re-election. He was defeated by a
small majority. But he continued his work at St. Peter’s
Hospital, and acquired no inconsiderable reputation as
an authority on diseases of the urinary organs, to which
he devoted himself during the past quarter of a century.
His association with his uncle, Mr. W. Coulson, doubtless
contributed to this result, and not only did his uncle assist
him in practice, but at his death left his fortune between
Mr. Walter Coulson and another nephew. As this was
estimated to be between two and three hundred thousand
pounds, Mr. Walter Coulson was thereby rendered inde-
pendent of practice; but he preferred work, and con-
tinued in active practice, although not needing the fees it
brought in. Dr. Cumberbatch was an excellent illustra-
tion of the fact that a man may attain not only success in
practice and pecuniary rewards for his labor, but also no
inconsiderable degree of professional reputation while
toiling in the humbler walks of the profession. Dr. (then
Mr.) Cumberbatch commenced practice in London about
forty years ago as a general practitioner. His success
was marked, and he became known to a wide circle at
the West End. His opinion was especially sought in mid-
wifery cases ; so much so that in time he acquired almost
a consulting practice in that department. He did, in fact,
532
THE MEDICAL RECORD.
[November 9, 1889
become a physician in 1866 by becoming a member of the
- Royal College of Physicians, but he h€ld no hospital or
dispensary appointment.
A REAL ELIXIR oF YouTH.—A physician writes to Zhe
Lancet as follows: “ When the season began in May last,
a veteran aged sixty, I thought that my tennis days were
nearly numbered. A walk of four or five miles tired me.
Aching and burning in my great-toe joints made walking
somewhat painful. I had had rheumatism in my right
shoulder for months, so that I was kept awake at night ;
acute pain at the insertion of the right deltoid accom-
panied elevation of the arm, and the left shoulder was
also uncomfortable. My first day’s practice at tennis
was disheartening. I could scarcely serve over the net
(underhand). My strokes were extremely feeble, and an
overhead stroke caused agony at the insertion of the del-
toid. Nevertheless I persevered, and by the end of May,
after several good warmings at tennis, I lost all my pains,
my joints were freer, I could run about with less aching
of the feet, my strokes were more severe, and I could
elevate my arm for an overhead stroke without pain.
After another month’s practice, playing two or three
times only in the week, so as not to tiré the arm too
much, I was fit for tournament play, and I ended the
. season with winning, early in September, an open veter-
ans’ singles event. The pleasant exercise and exertion
of tennis, taken in moderation, not only drove away my
stiffness, my threatened rheumatism, and improved my
muscular system so that I could walk fifteen miles a day,
or play six or eight sets of tennis in an afternoon without
undue fatigue; but it cleared my mental faculties,
strengthened my perceptions, gave me a better “ grasp
of the situation,” and rendered me more alert in my ordi-
nary work. I still look forward to the enjoyment of fut-
ure seasons and coming tournaments. A game that will
thus renovate a veteran is invaluable from a medical
point of view. If used with discretion, it is to the busy
man more available and of greater advantage to keep him
in condition than cricket, football, or any other game I
know, and the accidents that happen to players of lawn
tennis are very few, and not of a serious character.”
A SIMPLE INHALER.—Dr. E. E. Maddox wnites to the
Practitioner as follows: “ It may be useful to others to
mention the following very simple mode of inhaling vola-
tile remedies, such as pumiline, menthol, eucalyptus, etc.,
for the relief of some affections of the throat and lungs.
Coil a piece of paper into the shape of a cigarette, and
fix it with gum. Then insert into one end a small un-
compressed piece of absorbent cotton-wool, upon which
a drop or two of the desired medicament has been poured.
Air is now drawn through the tube by the patient, who
holds the other end between his lips. This plan is by
many patients, especially by men, preferred to the use of
any form of respirator, or to inhalations mingled with
steam. ‘These last, moreover, have a relaxing effect in
some atonic conditions of the throat. Of a number of
remedies, including menthol, inhaled in this way by a
patient suffering from pulmonary phthisis, I found that
oil of peppermint gave most satisfaction. A small tube
of vulcanite flattened like a cigarette-holder at one end,
with a raised flange or border to be held within the lips,
would doubtless answer still better ; but an inhaler, which
when needed can be made on the spot, has advantages
of its own.”
READING IN Bep.—Some credit is doubtless due to
those who, in despair of a cure for sleeplessness, have
sought to palliate the mischief done to health by reading
in bed in order to procure sleep. ‘Their position is at
best that of mere necessitarians. ‘The advice they offer
may, however, have some value for those who from some
cause are physically unable to fali asleep within a reason-
able time, and who will insist on reading till they do. It
includes various measures intended to prevent or dimin-
ish thegocular strain thus incurred. Bathing the eyes with
weak salt solution, the adoption of a sitting posture, and
the use of sufficiently bright light are among the means
advised. ‘They ought certainly to check the bad effects
of an unhealthy practice. We should have more sympathy,
however, with any attempt to deal with the true source of
mischief—the habit itself. This is in a large majority of
cases unjustified by any real necessity. Whatever the
cause of sleeplessness, whether an idle preceding day, a
midday or evening nap, an empty stomach or an over-full
one, fatigue or worry, the truest wisdom consists in re-
moving this hy the needful change of custom. All rules
of treatment, such as those above statel, maintain the read-
ing habit while they moderate its consequences. This is
our one objection tothem. If sleep requires to be wooed,
it should be remembered that there are available, besides
the treatment of causal conditions, various direct methods
of diverting the mind from the outer world, and thus of in-
ducing sleep. The use of one or other of these is, from
their nature, more rational than the practice of reading in
bed.— Zhe Lancet.
THE CONSTRUCTION OF A NEW BLADDER AFTER EXCI-
SION.—At the Surgical Congress recently held at Bologna,
Professor G. Tizzoni, of the University of that city, and
A. Poggi, gave an account of some experiments they had
made on dogs, with the view of ascertaining whether the
bladder could be removed and an efficient substitute con-
structed by operation. First of all laparotomy was per-
formed, and a loop of small intestine about 7 centimetres
in length, with its mesentery attached, was isolated by two
transverse cuts, washed out with a carbolized solution,
and tied at both ends, one extremity being fixed in front
of the neck of the bladder. ‘The two ends of the divided
gut were then stitched accurately together by circular
suture. The dog soon recovered from the ‘operation, and
a month later the second stage of the experiment was pcr-
formed. ‘The ureters were separated from the bladder,
and the latter was completely removed. The loop of in-
testine destined to be the new bladder was then cut across
at the lower end and stitched to the neck of the bladder.
The ureters were then turned into the artificial bladder.
A slender elastic drainage-tube was placed in the urethra
to carry off the urine during the first few days. The ani-
mal recovered perfectly, and gradually acquired control
over its new bladder, and when shown to the Congress,
two months later, showed no sign of incontinence. ‘The
operation has been repeated with success on several other
animals, and Drs. Tizzoni and Poggi are hopeful that it
may be applicable to the human subject.—Medrcal Re-
corder.
THE DANGER OF “ ‘l'1p-caT.”—The following remarks
of Zhe Lancet are as appropnate for New York as for
London, as many of our readers can doubtless aver from
personal experience: It may be thought that a game
which is one of the most familiar amusements of child-
hood hardly merits the formality of police regulation.
“Tip-cat,” however, is by no means unworthy of this
distinction. Its value as a pastime is utterly insignifi-
cant, but its mischievous effects on the persons of passers-
by have become too common to be overlooked. The
game as played by children in the street 1s dangerous in
its very nature. No one who has come upon a knot of
youngsters thus engaged can have any doubt on this point.
It is enough to see the pointed “cat” lightly tipped up
from the ground, and the mere attempt to strike it away
at random, in order to realize very vividly the fact that
one’s eyesight in the presence of “ tip-cat” is a very pre-
carious possession. ‘The experience of ophthalmic sur-
geons goes to show that injuries to the eye from this
cause are far from uncommon. When, moreover, it 1S
recognized that the results of injuries thus inflicted are
likely to be of the most serious character, it will be evi-
dent that the public are fully entitled to call for the re-
striction, and even the prohibition, of this objectionable
form of street amusement.
‘The Medical Record —
A Weekly Fournal of Medicine and Surgery
ee ee.
— —
Vol. 36, No. 20
Original Articles,
DISINFECTION OF DWELLINGS BY MEANS OF
SULPHUR DIOXIDE.’
By CYRUS EDSON, M.D.,
CHIEF (INSPECTOR, HEALTH DEPARTMENT, CITY OF NEW YORK.
WITHIN the past few years numerous experiments have
been made by biologists with sulphur dioxide. They
have failed in numerous instances to disinfect artificially
infected rags and other material subjected to its influence.
These experiments have led biologists to pronounce sul-
phur dioxide unreliable in its action upon the contagion
of disease.
I have had, in my official position, a wide experience
with sulphur dioxide as a disinfectant, and I have been
led to the conclusion that it is a thorough and an almost
perfect destroyer of the infective matter of the acute
exanthemata and diphtheria.
The facts that I will place before you in this short
paper do not, I am aware, prove perfectly and beyond
doubt that SO, is an absolutely reliable disinfectant.
They seem to me to be strong circumstantial evidence in
its favor, and I present them as such.
The Disinfecting Corps of the Health Department of
the City of New York, during the years 1887 to October
1, 1889, fumigated, by means of SO, generated from burn-
ing sulphur, nearly every room in tenement-houses in our
city that had contained cases of small-pox, scarlet fever,
diphtheria, or measles. I say nearly every case. The
aim of the Department was to have the rooms in every
case fumigated ; but the Corps was a large one, and oc-
casionally a man was found derelict in his duty and had
to be discharged, so that wilful neglect in a few instances
caused some cases to be neglected. The method of
using the sulphur was substantially in accordance with the
rules laid down by the Committee on Disinfection of this
Association. The sulphur was placed in a shallow iron
basin, which was supported in a suitable tub containing
water. Ignition was effected by means of about four
ounces of alcohol poured over it.
I will take each disease separately, and by comparing
the total number of cases with the number of cases that
recurred, the recurrence of which could be attributed to
infection left after fumigation, show the efficiency of the
agent in question.
In the year from October 1, 1887, to October 1, 1888,
we had in our city 321 cases of small-pox. These cases oc-
curred in 227 houses. Eighty-two of these cases were con-
tracted from exposure to some of the 239 original cases,
nearly all of which were in their turn traced to direct ex-
posure to other cases, either out of the city or in it.
Nine cases could not be traced to their cause. They were
probably due to contagion from some mild, unrecognized
case, that travelled about spreading the disease. Not
one single case of the disease was developed from the
clothing or from the rooms in which these cases were, and
from which they were removed to the hospital for small-
pox. No other precaution was taken in the -ase of the
rooms and clothing than that of fumigation ‘xy SO, in
proportion of three pounds of sulphur to each one thou-
sand cubic feet of air-space for at least two hours. ‘This,
ee ee ooo
1 Read before the American Public Health Association, October
24, 1889.
New YORK, NOVEMBER 16, 1889
Whole No. 993
—_—_——_—_—
however, was done in a most conscientious and care-
ful manner, immediately after the removal of each case.
Again, in the year from October 1, 1888, to October 1,
1889, 7 cases of small-pox occurred in 5 houses. # All
were traced to their cause, which was found to be direct
exposure to a previous case. Not a single case occurred
from infection left in the room or clothing by any of
these cases.
We always permit occupancy of rooms that have con-
tained small-pox patients, as soon as they have been fu-
seal
In this connection the effect of fumigation by SO,
upon vaccine virus is interesting. On October 2, 1889,
ten quill slips, charged with vaccine virus taken from a lot
charged equally from the same animal, were exposed in a
room 76 x 15 x 8, to the fumes of one pound of sulphur for
two hours. Each slip was then used to vaccinate a child
that had never before developed vaccinia. All failed to
effect any result. Ten other points from the same lot
were effective upon all but one child of ten other primary
cases. ‘This child evidently had considerable resistance
against vaccinia, as it only took after the third trial.
For the purposes of this paper, the same comparison of
primary cases with secondary cases, as I have stated was
done in cases of small-pox, was made of scarlet fever,
diphtheria, and measles in the following streets, which
were chosen as examples of the worst, from a sanitary
stand-point, in the city: Division Street, Washington
Street, Rivington Street, Mulberry Street, West Sixteenth
Street, West Twelfth Street, East Seventh Street, East
Twelfth Street, East Forty-sixth Street, East ro2d Street,
and East 113th Street.
Let us first take scarlet fever. From January 1, 1888,
to October 1, 1889, 626 cases occurred in the above-
named streets in 453 houses, and 135 secondary cases oc-
curred in 87 houses.
Of the 135 secondary cases, 106 occurred within five
weeks of the beginning of the primary cases, to the direct
contagion of which they were presumably due. ‘This
leaves but 29 cases, out of a total of 626, that were possi-
bly due to contagion left in rooms and apartments after
disinfection by means of sulphur dioxide after termina-
tion of each case.
During the same period (January 1, 1839, to October 1,
1889) 515 cases of diphtheria occurred in 382 houses,
and 114 secondary cases occurred in 80 of these houses.
Seventy-nine of the secondary cases occurred within four
weeks of the beginning of the primary cases, to the direct
contagion of which they were, therefore, presumably due.
This leaves only 35 cases, out of a total of 515, that were
possibly due to contagion of diphtheria left in rooms and
apartments after disinfection by means of sulphur dioxide
after the termination of each case.
In the case of measles, 557 cases occurred in 361
houses, and 163 secondary cases occurred in 95 of these
houses. One hundred and twenty-two of the secondary
cases occurred within five weeks of the beginning of the
primary cases, to the direct contagion of which they
were, therefore, presumably due. ‘This leaves only 41
cases, out of a total of 557, that were possibly due to con-
tagion of measles left on the premises after disinfection
by means of sulphur dioxide performed after the termina-
tion of each case.
These figures are interesting when carefully considered,
and they show the relative efficiency of sulphur dioxide
in the case of each of the diseases. ‘The gas is most de-
534 THE MEDICAL RECORD. [November 16, 1889
structive to the contagion of small-pox, and next, to that
due to primary cases. Some of these occurred nearly a
y
of scarlatina. ear after the first case.
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alg | siz (S228 gE Epil gks. asgad dare ¢ 12/9 $ji 2
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me —— --—; - S a ama Baa ace ah a OR a | Se
DirHTHERIA.
January 1, 1888, to October 1, 1888.. 237 | 180 , 37 50 15 7 2 24 8 7 o 2
October 1, 1888, to October 1, 1889.. 278 202 | 43 64 B tI 3 26 7 5 I 2 3 20
Toal wiser laweastios sees eae | Sts 382 80 114 33 18 5 50 15 | 2 | 2 2 5 28
SCARLET FEVER. i | |
January 1, 1888, to October 1, 1888..' 253 . 19t | 36 47 18 1I 4 25 8 6 3 2 o 3
October 1, 1888, to October 1, 1889..: 373 — 262 | 51 88 27 ` 25 3 36 . È3 1 èë 1r; 2 9 , 17
See yg ee ee | cae es "sw
WOW ibs cas sawssee ates >. 626 453 87 | 135 4S 36 7 61 21 , 16 4 4 9 20
Mapastes. | |
January 1, 1888, to October r, 1888..! 302 183 54 102 23 27 2 18 38 13 | 2 l a 14 16
October 1, 1888, to October 1, 1889..: 255 178 41 61 14 3 6 17 23 8 , 1 1 2 9
Total ces cesta ea siete des | $57 36t 95 163 37 40 8 35 61 21 3 2 16 25
In the discussion of this paper by the American Public
Health Association the method of fumigation was crit-
icised, it being alleged that not sufficient moisture was
present with the sulphur dioxide to insure the best re-
sults. A very important point in this connection was
brought out. ‘The use of alcohol to ignite the sulphur, as
described in the paper, adds materially to the moisture in
the air of the infected rooms. The amount of alcohol
used is, as I have stated, about four ounces to each charge,
say of six pounds. ‘This amount of alcohol will develop
fifty quarts of steam, approximately. To Dr. E. H. Bart-
ley, of Brooklyn, I am indebted for this estimation and
suggestion.
RACHITIC PSEUDO-PARAPLEGIA.'
By HENRY W. BERG, M.D.,
NEW YORK.
I am about to discuss a class of cases which have received
but little attention from writers upon rachitis. ‘The
bone lesions in this disease are so prominent, and seem to
be so essentially the disease, that all other phenomena
connected with the condition are overshadowed and far
less studied than would be proper from their intrinsic im-
portance. ‘The view that rachitis is a disease of the
bones fer se is no longer maintained. It is certainly rec-
ognized to be a disease of the blood, affecting all the
structures of the body, with lesions especially located in
the osseous tissues; not limited to these, however, but af-
fecting very materially the muscles and fibrous ligaments
and tendons. It is not my intention, in this paper, to
discuss all the effects of rachitis, but I shal] call attention
to those cases in which general rickets is accompanied by
an inability to use the lower extremities owing to muscu-
lar disability. ‘The symptomatology of this class of cases
is about as follows: A little patient, from two to four or
even five years old, is found to be unable to walk; or,
among the younger cases, unable to stand erect, or even
sit up. The amount of disability varying with the sever-
ity of the case and the youthfulness of the patient. The pa-
rents find that at an age when other children are creeping
their child makes little or no effort to creep—later on
there is no voluntary effort to stand erect; and when the
little patient 1s held erect by the arms, the knees bend
under the weight of the body. Voluntary attempts to
stand are not made at all, or made only when the patient
is long past the age when other children are running about.
Other, generally older, cases are found who, although they
stand erect when held, or when they support themselves
by holding on to surrounding objects, yet do not dare to
make the attempt to walk, or if they do attempt to walk
they go with their feet and legs spread wide apart, so as to
obtain a better basis of support, and with the body bent
forward in the effort to maintain their equilibrium. ‘Their
In the case of measles we have an explanation of the
comparatively large number of secondary cases. The
disease is a mild one, speaking comparatively, and many
cases are not properly isolated in the homes of the poor ;
consequently, rooms and materials are infected outside of
the apartment in which the patient belongs, and which
the disinfector fumigates. Moreover, during the past two
years we have had so many cases of contagious diseases
that measles have frequently not received the attention of
our inspectors and disinfectors that should have been
given it. scarlet fever and diphtheria taking most of the
time of the men.
The contagion of diphtheria would, from our statistics,
seem to resist the action of sulphur dioxide most, and to
be the most difficult to destroy. This is, in my opinion,
due to the manner of its infection. ‘The other three dis-
eases infect a room mainly by means of the medium of
the air, the contagion being exhaled or given off from the
body and deposited evenly over the surfaces exposed to
the infected air. In diphtheria, membranes and secre-
tions are also infected, and the contagion is protected by
being surrounded by a protecting medium into which sul-
phur dioxide cannot easily penetrate. ‘This is probably
the reason why biological experiments with SO, are not
satisfactory.
It is impossible to imitate in the laboratory nature’s
method of infection. ‘The power of penetration of SO,
into the culture-mediums cannot be very great. ‘The
medium must somewhat protect the culture within it, so
that only those cultures are affected that are on the sur-
face of the medium. Just as diphtheritic secretions pro-
tect diphtheritic contagion, so do culture-mediums, to a
less extent perhaps, protect cultures.
In nature’s method of infection the infected air is car-
ried by draughts and air-currents into cracks and corners
accessible only to a gas liberated under much the same
conditions as the contagion.
Conclustons.—It would seem that the proper and most
practical method of disinfection of dwellings, after the oc-
currence in them of exanthemata and of diphtheria, is by
means of sulphur dioxide, and that all clothing, bedding,
etc., used in direct contact with the patient, should be re-
moved to a disinfecting station, properly equipped, and
there subjected to heat of sufficient intensity to destroy
all contagious matter. ‘his in future will, I believe, be
the method pursued by the Health Department of the
City of New York.
ADDENDA.—The above table shows the details of the
cases I have given. It will be seen that a large number
of the secondary cases occurred three months and over
from the beginning of the primary case.
Many of these secondary cases occurred in other apart-
ments in the same house as the primary case, but were
probably not due to contagion from it. It is impossible,
however, to say that they were not caused by the first
case. I have counted them among the cases pussibly
I SSS Sh i lp SP i
1 A paper read before the Orthopedic Section of the New York
Academy of Medicine, October 18, 1889.
progress is accentuated by frequent stumbles and falls—
the little patient walks like a partial paraplegic. In short,
we have all grades of muscular disability, varying in de-
gree from total inability to use any of the muscles whose
function necessitates the partial or complete erect posture
of the body to a slight weakness in standing and walk-
ing. 2
Such is the history obtained from the parents. Exam-
ination of the patient shows a typically rachitic body ;
fontanelles wide open long beyond the age when they
should have closed, the bosse on the frontal and temporal
bones large and prominent, the other portions of the
cranial bones transparent and thin even to the point of
craniotabes. The junction of the ribs with the costal car-
tilages is marked by the so-called rachitic rosary. ‘The joint-
ends of the long bones are enlarged, and the abdomen is
large witha distinct upper boundary externally, correspond-
ing to the bony insertion of the diaphragm, which, in its
rhythmical action, has drawn the ribs inward. The pelvis
is flattened posteriorly in those patients who have not yet
learned to sit up. ‘The long bones of the leg show little
or no deformity, inasmuch as these patients have avoided
standing and walking. ‘There is no bow-leg or knock-knee
present asarule. In other words, the deformities due to the
us? of the lower extremities in the soft stage of the osse-
ous disease are absent. An important diagnostic point,
however, is that the bony prominences present at the mus -
cular insertions are felt to be exceedingly tender. . ‘Thus
there is pain on touching the patella, the external and
internal condyles, and the upper portion of the tibia. This
excessive tenderness at the points of muscular insertion
is due to a great extent to a chronic periostitis, which re-
sults in the thickening at the joint-ends to which I have
just referred. ‘There is in addition a certain amount of
tenderness in the body of the muscles; this is a factor to
a greater or lesser extent in all cases of rickets, but is
excessive in the paraplegic patients. Pressure of the
mass of the limbs, which ın other children causes laughter,
will here give rise to a cry of pain. ‘These children wish
to be let alone. Although many children suffering from
general rickets are fat and well-nourished in appearance,
with rounded cheeks, soft and flabby muscles, the cases
under consideration are, as a rule, pale and thin; the
skin excessively white, with the capillary vessels well
marked. The muscular tissue has little or no adipose
covering, which accounts, I think, for the hypersensitive-
ness of the muscular nerves of sensation ; the skin hangs
loose and flabby, and the little patients present all the
features of malnutrition, resembling often cases of mar-
asmus, without, however, giving a history of diarrhoea or
marked stomach affection.
Although presenting the more or less perfect paraplegia
to which I have referred, a careful examination of the
pelea in the recumbent posture shows that the little one
good control over the various movements of all the
joints. Beginning with an examination of the lower ex-
tremities we find that as the patient lies upon his back he
can flex, adduct, abduct, rotate, and extend the thigh,
these movements all being performed by the child in its
effort to remove the limb from irritations, such as pinch-
ing, pricking with pins, etc., on the part of the examiner.
When we hold the little patient’s attention and raise the
limb we will be able to demonstrate the presence of that
partial cataleptoid state common to infancy. ‘Thus in rais-
ing (flexing) the hip-joint the contraction of the psoas mag-
nus will retain the limb in the position in which it was
placed, for a few seconds. In this way we can demon-
strate the fact that every muscle retains its power intact.
‘The motions about the knee- and ankle-joints are per-
fectly and voluntarily performed, or are shown to be
present by the cataleptoid test. On the other hand, while
in healthy children, in the recumbent posture the whole
leg extended at the knee can be flexed on the pelvis, and
retained for some time in the straight position without
drooping, these little patients manifestly find difficulty in
keeping the extended limb flexed upon the pelvis, for even
p
535
a short time. Some will not make the effort, others will
allow the leg to fall immediately after having straightened
it. In other words, they are unable to support the weight
of the limb in the elevated position and as a result it falls.
From their inability to stand and walk these patients
are supposed by the parents to be paralytic. The physi-
cian is consulted, and it becomes of the utmost impor-
tance to be able to make a positive differential diagnosis
between these cases and the various forms of true paraly-
sis affecting infancy, the more so from the fact that
the prognosis in true rachitic pseudo-paralysis is excel-
lent for complete recovery, while that of paraplegia due
to lesion of the cord or brain, I need not say to this
audience, is in many cases a hopeless one.
I shall be excused, therefore, for dwelling unduly upon
the points of difference between paralysis due to organic
disease of; the nervous system and the functional paraly-
sis of rickets. At the same time the remaining symp-
tomatology of rachitic paralysis, which is chiefly negative,
will be brought out without the risk of otherwise una-
voidable repetitions.
Differential Diagnosis.—The most frequent form of
organic paralysis occurring in infancy is poliomyelitis of
the anterior horns. Cases of this disease in which the
paralysis is paraplegic might possibly be confounded,
in rachitic children, with rachitic pseudo-paraplegia. A
careful examination will serve to reveal the points of
difference. In poliomyelitis the limb is atrophied and
surface cold. In rachitis there is neither atrophy nor
cold surface; the patient may be thin, and ill-nourished,
but the appearance is not in any sense that of general
muscular atrophy. Examination of the patient’s power
in the affected limbs also shows the radical difference
that while in infantile paralysis there is real paralysis,
so that the patient has lost all power in the affected
muscles, in rachitic pseudo-paraplegia there is no paraly-
sis, but only weakness, so that the patient has perfect use
of the muscles except when these muscles attempt to
perform voluntary motions and support the weight of the
body and limb at one and the same time. The patellar
reflex while preserved to its normal extent in rickets, is
generally diminished in cases of paraplegia due to po-
liomyelitis. Finally, the battery will serve to differentiate
the two affections, the faradic current yielding no re-
sponse in the muscles affected by infantile paralysis, while
in rickets faradic contractility is preserved and normal,
so also the galvanic reaction of degeneration so charac-
teristic of all paralysis due to disease of the peripheral
motor nerves and anterior gray horns in the spinal cord
while present to a marked extent in cases of poliomyelitis
of the anterior horns, is absent in cases of rickets, the lat-
ter shows the normal reaction, Ca.C.C.> An. C.C., Ca.O.
C.< An. O.C., or entirely absent. These points of dif-
ference will readily serve to distinguish cases of infantile
paralysis from the pseudo-paralysis of rickets.
Not so readily distinguished, however, are recent cases
of post diphtheritic paralysis, and paralysis following cere-
bro-spinal meningitis. In the former, recovery is the
rule, because the lesion of the nervous centres is a tem-
porary one. Hence the reactions of degeneraypn and
atrophic appearances are absent ; furthermore, the paraly-
sis, while affecting both lower extremities and back, 1s fre-
quently partial and does not completely paralyze all mo-
tion in the affected extremities and back. ‘Thus the dis
ability, like that in rachitic paraplegia, is most marked
when the muscles are exerted in such a position that
they are compelled to support weight and perform motion
at the same time. The diagnosis will rest to a great ex-
tent upon the history of the case, recent origin of the par-
alysis, the preceding occurrence of diphtheria, above all
the involvement of the muscles of the naso-pharyngeal
and laryngeal region, resulting in difficulty in swallowing
and speaking, an examination of the faucial arches
showing paralysis of the anterior portions of the fauces,
and diminution of the patellar reflex. All of these points
will generally serve to distinguish the two affections. So
536
also in temporary paralysis following cerebro-spinal
meningitis, the history of the case, together with the
presence of real paralysis affecting the cranial nerves,
will serve as diagnostic features, while cases in which the
lesions of the nervous system have become permanent
will resemble those suffering from hemiplegia and para-
plegia due to cranial disease, with which rachitic pseudo-
paralysis can scarcely be confounded. Cases of tetanoid
paraplegia or spastic paralysis do not resemble rachitic
pseudo-paralysis in any respect, except that in both the
paralysis is not really a paralysis. Mild cases of spastic
paralysis might lead to a question as to diagnosis, but
the increased patellar reflex, the exalted muscular activ-
ity, apparently beyond the contro] of the patient, fre-
quently, retarded mental development as an accompan-
iment of the similar condition of the motor areas in
the brain, will differentiate these cases from those of
rachitic pseudo-paralysis. Cases in the early stage of
the paraplegia occurring in the course of Pott’s disease,
when the paralysis is due to the pressure of meningeal
exudation products upon the anterior portion of the
spinal cord, rather than to an organic affection of the
cord itself, might readily be confused with this affection,
particularly if the kyphosis, being but slight, had not been
noticed. Here the paralysis might develop very slowly,
and: would be but partial. The rachitic curvature of
the spine might help to confuse the diagnostician. A
careful examination of the spine will reveal the Pott’s
disease of the lower dorsal vertebree. The symptoms of
vertebral disease in this region, such as psoas contraction
and psoas abscess, also, occasionally, paralysis or weak-
ness of the bladder accompanying the paralysis of the
lower extremities, all of these, will aid in arriving at a
proper diagnosis.
The pathology of this condition is the pathology of
rickets. ‘The rachitic dyscrasia is the cause of the mus-
cular weakness in rachitic pseudo-paralysis. We must
not forget, however, that in rickets there have been ob-
served, by very reliable observers, cases in which paraly-
sis, evidently of cerebral origin and generally hemiplegic
in distribution existed. Post-mortem findings, however,
in these cases showed the lateral ventricles filled with
fluid, and the cerebral convolutions, about the motor area
particularly, flattened and compressed, so that these are
really cases of hydrocephalus accompanying rachitis.
It is uncertain, however, whether such a condition is to
be considered a complication or an effect of the rachitic
disease of the blood. Under no circumstances are they
at all comparable to the cases of idiopathic paralysis
which we are considering.
It becomes a subject for inquiry as to the pathogenetic
connection between the rachitic disease and the pseudo-
paralysis which we have described. ‘Io understand this
we must consider the mechanics of muscular activity.
When by the contraction of its muscles a limb is set in
motion and made to perform work, the sum total of
the work performed consists of the following elements.
1. Counteracting the weight of the limb to be moved.
2. Imparting to the limb or member the force necessary to
performgactivity. The sum of the two is the amount of
muscular work. It is evident that in standing quietly
the entire amount of work is spent in maintaining the
stiffness of the joints, and counteracting their tendency
to yield under the superincumbent weight of the body and
limbs, while in walking more work is performed, the
vody being supported and carried, at the expense of fric-
tion and other impediments, over space. Both of these
things simultaneously the muscular tissue, weakened by
the imperfect nutrition of the rachitic blood, is unable to
perform in some cases ; in others, while the utmost force
exerted suffices to support the body in the erect posture
there is not sufficient strength to carry that body over the
ground. If, however, the weight of the body is supported
by some other means, such as the hands of an assistant,
then the movements of walking are frequently very well
and even firmly performed.
THE MEDICAL RECORD.
[November 16, 1889
This explains why these patients can move their limbs
in every conceivable direction while in the recumbent
posture. Here they support only the weight of the
limb, and not of the whole body. So also these patients
can use the upper extremities, although it will be found
that when they attempt to lift weights such as other chil-
dren can readily raise they fail lamentably.
This disability is furthermore increased by the flaccid-
ity of the ligaments, the softness of the bones or levers
by which the muscles act, and the rachitic periostitis
present, particularly at the points of muscular insertion.
It is to this periostitis, I think, that much of the thicken-
ing at these points is due, and also the tenderness to
which I have already referred. Finally, the pain in the
muscular tissue is also an important element in the dis-
ability of these cases. While pain is present with every
motion the little patients instinctively prefer to keep
quiet.
Prognosis.—It is a gratifying fact that the treatment of
these cases is uniformly successful, and where an im-
proper diagnosis has been made, often very brilliant. These
are the cases that give such good results after circumci-
sion, not owing to any virtue in that operation, as far as
the rachitis is concerned, but because they uniformly get
well. Indeed, to recognize the nature of the disability
is of far more importance than the treatment.
One of my own cases, treated at the Orthopedic Dis-
pensary some three years ayo, may be interesting in this
connection. John S , two years and eight months of
age at the time of application at the dispensary, which
was September 23, 1885. At that time he suffered from
what the examining surgeon considered atrophy of both
lower extremities, which, however, appeared to me to be
the wasting of malnutrition and disuse. Patellar reflex
normal, or slightly exaggerated; contracted prepuce.
While under examination by the examining surgeon, there
seemed to bé some rigidity of the adductors of the leg
and the muscles about the knee-joint. The patient
was said by the parents never to have stood alone, and
certainly he had never made any attempt to walk.
The boy was therefore referred to the neurological class,
which was then under my care, with the diagnosis of
“slight spastic paralysis” upon his card. On examin-
atian I found him typically rachitic, large forehead, fon-
tanelles not yet closed, features delicate, skin abnor-
mally white, veins marked ; absolutely unable to stand
or walk, spine slightly curved, patellar reflex slightly
more marked than usual. Spastic condition of the adduc-
tors above referred to evidently owing to fear—patient
fearing the application of force in strétching the prepuce,
a former examination by an eminent Albany surgeon hav-
ing pained him very much. This surgeon had advised
circumcision as the only mode of curing the paralysis,
which he considered the reflex result of the long and
contracted prepuce. I made a tentative diagnosis of
rachitis with pseudo-paraplegia, put the boy under mass-
age by the parents at home, electricity, and anti-rachitic
diet.
In addition phosphorus was given alternately with iron.
In less than six weeks the patient was able to walk, and on
November 17, 1885, I find the note in dispensary records
that the patient walks very well, although awkwardly.
He was discharged perfectly cured in the spring of the
following year.
Such will be the result of proper treatment in all cases
of rachitic pseudo-paraplegia. And frequently these
cases would get well in spite of any form of treatment.
Treatment of this condition should be directed locally
to the weakened muscles, and generally to the system at
large to counteract the effect of the rachitic malnutri-
tion. I consider the latter indication more importat
than the former. Remove or improve fault of nutrition
and muscles will gain strength sufficient to perform their
physiological work. A proper diet is, of course, of the
utmost importance. ‘This I consider to be that form of
diet which will be most readily digested by these patients,
November 16, 1889]
THE MEDICAL RECORD.
537
without regard as to whether the articles of food are rich
in phosphates or not.. These children should have a
great deal of milk—no tea and no coffee. Cocoa, made
very thin, is desirable once a day. They should eat lean
meat not oftener than once a day, plenty of beef-broth, all
of the lighter cereals, and small quantities of the lighter
fruits. Nothing that is indigestible and which experience
has shown to be indigestible in any given case should be
given.
Goses ; it should not, however, be given in emulsion with
the hypophosphites, for these salts are not only utterly
inert, as I shall show, but being frequently mixed with
syrups are apt to interfere with the digestion of the oil.
As towmedicines, we have in rachitis one of the diseases.
for which experimental physiology has given us a remedy.
Iconsider that one of the most positive facts in thera-
peutics is the beneficial effect of phosphorus in the cure
of rickets. I make this assertion on the strength of Weg-
ner’s investigations. He fed young and growing animals
(rabbits and fowls) particularly, with small, non-poison-
ous and easily assimilated doses of finely-divided phos-
phorus during periods of many months, and arrived at
positive conclusions.
He found that in these animals thus fed, those portions
of the long bones in which the original cartilage becomes
ossified into cancellous tissue underwent a firmer form of
ossification than in animals that had not received the
phosphorus. In the former, instead of cancellous tissue,
spongy and filled with marrow, firm and compact bony
substance, like that formed on the outside of the long
bones, is found. But the cancellous tissue formed before
the administration of the phosphorus remains unchanged
at first; in animals killed later on this cancellous tissue
1s found be absorbed to form the medullary canal. The
bone formed under the influence of the phosphorus diet
was found to be well-formed bone. The microscope
showing not the large marrow-spaces of ordinary cancel-
lous tissue, but spaces contracted to the size of the Haver-
Sian canals in compact bone-tissue, and the cartilage-cells
converted not into marrow-cells, but into bone-cor-
puscles surrounded by the proper amount of intercellular
substance. If the phosphorus diet is continued the
whole of the cancellous structure is converted into com-
pact bone-tissue. Even the portion of the bone developed
from the periosteum, ordinarily hard and compact, was
found by the microscope, in phosphorus-fed animals, to
have become finer in structure, with the Haversian canals
smaller though never entirely obliterated. Even in older
fowls fed on phosphorus for a long time, the bones were
found to have the cancellous structure entirely absorbed,
and replaced by compact tissue, while the medullary canal
was entirely filled by compact bony tissue, so that the
bones were no longer tubular, but compact bony masses.
The chemical composition of bone in animals fed on
phosphorus for a long time was found to be unchanged,
there being neither more nor less phosphorus than
should be present in the normal composition of bone.
Wegner furthermore showed that animals thus fed on non-
poisonous quantities of phosphorus increased in general
size and strength, the muscles particularly, as well as the
bones of the body, becoming stronger. I do not think
that there is any other remedy in the whole range of
therapeutics for which experimental physiology has borne
so strong a testimony. I have, accordingly, since reading
Wegner’s investigations some five years ago, been accus.
tomed to give phosphorus as a nerve-tonic, and above
all, as a specific for rickets in children. So great an au-
thority as Dr. A. Jacobi, in this city, I have heard speak in
the most enthusiastic way about the action of phosphorus in
the latter condition. I do not give the phosphorus with
oil, but prefer, and have always had satisfactory results
from the use of Thompson’s Solution. ‘This, as you know,
is a solution containing x, grain to the drachm. I find
that the mixture made by Hazard, Hazard & Co., although
not in all respects like the original formula, is a very
good one, the odor of phosphorus being entirely absent.
Cod-liver oil, if digested, will do good in small -
The formula used by this firm is as follows :
B. Phosphort i oes s-cacee so teses eens bees gr. j.
Alcohol. absolut....... 00.0 esc cceceee ML ccecl.
Spt. menth. pip..............-. SETEN" TX.
Ot this mixture I give to a child, two to four years of
age, six rninims t.i.d., to be increased one drop weekly until
ten drops are given, larger doses I do not-think necessary.
For younger patients correspondingly smaller doses will
be best. |
Other tonics, such as iron, small doses of nux vomica,
etc., are indicated in the anzmia accompanying the
rachitis.
As to the local treatment it consists chiefly of massage
and electricity. Massage should include passive move-
ments of the joints and kneading and rubbing the various
individual muscles, remembering, however, the hypersen-
sitiveness of these patients, and accommodating the se-
verity of the treatment to it.
The most valuable agent locally to the weakened mus-
cles and limbs is undoubtedly electricity. It acts by
setting the muscular fibres into contraction without put-
ting the strain of voluntary muscular effort upon them.
Furthermore the electric current acts as a mild rube-
facient and general stimulant to the nerves and muscles.
For the purpose of muscular contraction, I use the
faradic current no stronger, however, than is necessary
to throw each of the muscles into contraction. The
principal muscles should be selected for individual treat-
ment and caused to contract a few times under the in-
fluence of the current. As a general stimulant galvanism
is indicated and should be used on alternate days with
the faradic current. I generally apply a descending cur-
rent, placing the positive pole on the spinal column at the
mid-dorsal region, while the negative pole is passed up
and down the extremities. Applications should not ex-
ceed five minutes in duration for each limb.
245 SEVENTH STREET.
REPORT OF A CASE OF CONGENITAL DIS-
LOCATION AT THE HIP.
By JOHN RIDLON, M.D.,
ASSISTANT SURGEON AT THE VANDERBILT CLINIC, NEW YORK.
D. K , female, aged ten and one-half years, came
under observation February 16, 1888. She is the eldest
of two children of healthy parents. When she began to
walk, at fourteen months, she limped, and it was noticed
that the right leg was shorter than the left. No cause
could be assigned ; she had never hurt herself sufficiently
to cry. Nothing had been done in the way of treatment ;
and she was brought for advice about a high shoe.
Examination —She walks with a very decided limp;
the right leg is rotated outward; the thigh is flexed on
the pelvis, and the lumbar spine is lordosed. It requires
a blocking under the foot of three inches to enable her to
stand fairly erect. (See Figs. 1, 2, and 3 next page.)
From anterior superior iliac spine to inner malleolus,
right, 26} inches ; from anterior superior iliac spine to
inner malleolus, left, 28% inches ; from great trochanter
to outer malleolus, right, 27 inches; from great trochan-
ter to outer malleolus, left, 273 inches. The right great
trochanter is 24 inches above Nélaton’s line. The head
of the femur cannot be made out. All movements at the
joint are normal, except extension and outward rotation.
I suggested an attempt to increase the length of the limb
by prolonged traction in bed, with the hope of eventually
reducing the dislocation. Some months later the family
came into town for this purpose, and the photographs,
from which §jgs. 1, 2, and 3 are taken, were made by Dr.
Ogden C. Ludlow, on February 24, 1888. Twu days
later, on February 26, 1888, the old pattern of the Taylor
extension hip-splint was applied and the leg elevated on
an inclined plane. From this on for one year the child
538
THE MEDICAL RECORD.
[November 16, 1889
Se
== —— >
Fic. 2.—Leg Blocked up Three
Inches. Shows flexion of thigh,
and lordosis of lumbar spine.
did not leave her bed, and no relaxation of the traction
was once permitted. The inclined plane was lowered
from time to time, and removed altogether after about six
weeks. During the first two months the elongation of the
Fic. 1.—Shows Shortening, Flexion, and
Outward Rotation.
reget '
sapiro totii ti
wren!
s
Zz
a
z
A
5
Fic. 3.—Leg Blocked up Three Inches. Shows prominence of right great tro-
chanter, ‘The upper lines are at the iliac crests, the lower ones at the great tro-
chanters, showing the upward displacement.
limb was rapid, an inch in length being gained in that
time ; afterward it was slow. After eight months the tis-
sues about the joint were thinned down sufficiently to
make it possible to locate the head of the femur, which
was found displaced upward and forward, lying almost
directly below the anterior iliac spine. ‘This position was
confirmed by Dr. Frank Hartley and Dr. L. W. Hotch-
kiss, who saw her with me in January of the present year
(1889). The head of the femur could then be brought
around directly over the acetabulum. To do this, how-
ever, it was necessary to rotate the limb inward a quarter
of a circle. It seemed as if, in the process of growth
with the femoral head in the abnormal position, the neck
had been twisted around to the front. As the #arents
would not consent to an operation to correct this twist, it
was thought wiser to be satisfied with the increased length
of the limb without a reduction of the dislocation, than
to further attempt to replace the head, and thereby cause
Fic. 5.—Same Position as Fig. 3.
without the Blocking Under the Foot.
Shows elongation of the leg and the
reduction of the deformity.
Fic. 4.—Same Position as Fig. 2,
with the Jointed Splint Applied, but
without Blocking Under the Foot.
Shows reduction of lordosis and elon-
gation of leg.
the foot to be rotated inward to a right angle with the
other foot. ‘To this end, then, a jointed splint was ap-
plied February 1, 1889, and the patient was allowed up.
At that time the difference in the length of the limbs, as
measured from the anterior superior iliac spine to the
inner malleolus, was an inch; at the present time this has
been reduced to one-half inch. (See Figs. 4 and 5, from
photographs by Dr. Ogden C. Ludlow, on September 2,
1889.) :
This case is interesting on account of the direction of
the dislocation (I have not been able to find another such
case recorded) and because so much improvement resulted
from the prolonged traction. I was disappointed, how-
ever, in not getting such a result as that reported by Dr.
Buckminster Drown, in his case reported in 1885.
PULMONARY PHTHISIS IN SOUTHERN Russia.—Accord-
ing to some statistics collected by Dr. Glavatski, the
number of deaths from phthisis in ‘Tiflis is about three
hundred and sixty per annum, or nearly fourteen per cent.
of the deaths from all causes.
November 16, 1889]
THE MEDICAL RECORD.
539
TUBAL PREGNANCY TREATED BY FARADIC
CURRENT.'
By HENRY F. WALKER, M.D.,
NEW YORK
Mrs. S—— had been for some time a patient. She was
twenty-three years of age, small, but of full figure, and
had, when nineteen, borne one child. Her labor had been
at that time a tedious one, finally an instrumental one,
and convalescence had been tardy, though she regarded
her final recovery as complete.
When her boy was three years old she became a pa-
tient of mine, and, as she and her husband greatly desired
increase of family, I made an examination to ascertain, if
possible, the reason of the acquired sterility.
A vaginal examination showed that there had been, at
some time, plastic effusion about the uterus. That organ
was slightly retroverted, and somewhat adherent by its
posterior surface, so that it could not be replaced without
some hazard. ‘There was also a slight cervical laceration.
The existence of these pointed out the probable cause
both of her slow convalescence after confinement and
the subsequent sterility.
The examination was made not long before the begin -
ning of the summer hegira, and treatment was suspended
till her return in the autumn.
For the illness to be detailed I was first called to see
Mrs. S—— September 24, 1888.
She had complained since August 12th. Menstruation
should have occurred on the 12th, but was deferred till
the z4th, when there was a slight show, which ceased
after two days, to reappear, but only as a stain, through
the remaining days of August and up to September roth.
She had just previous to this last date made the journey
to town, about twenty miles. The flow stopped two days,
and again began.
Besides the protracted, inconsiderable flow, the patient
suffered from constant heavy pain and tenderness in the
lower part of the abdomen, chiefly in the left inguinal
region.
My partner, Dr. Swift, saw Mrs. S—— at her country
home, August 27th, but she declined to have an examina-
tion.
September 8th, the date of menstrual epoch, she had,
as she described it, a dreadful attack of pain accompanied
yE followed by abdominal soreness, but no increase of
ow. °
September r1th she had another very violent and per-
sistent attack of pain. To her friends she seemed almost
in collapse. “She looked like a dead person, deep cir-
cles under her eyes, and her face drawn and pinched, with
cold forehead, nose, and chin.”
September 14th, she was removed to town, and was
seemingly somewhat improved.
September 24th, late in the evening, I was called to see
Mrs. S——, and found her in pain, which, to my judg-
ment, was very intense, though said to be less severe than
some previous ones. It was relieved by the hypodermic
needle with morphia ; and I made a vaginal examination.
This showed the uterus to be in right retro-latero ver-
sion, moderately fixed, and slightly enlarged. Save the
slight enlargement, the condition of the uterus was the
same as at the previous examination. .
On the left side, lying low down, but easily separable
from the body of the uterus, I could, by the bimanual
method, readily define a semi-fluctuating tumor, in size
and shape like the bulb of a Davidson's syringe, perfectly
movable, but exquisitely tender.
This was described as the site of all previous pain and
soreness.
I recognized it as a probable, extra-uterine tubal preg-
nancy. ‘This, I must confess, had not, until examination,
occurred to me as the condition likely to be found.
) S before the Practitioners’ Society of New York, November
1, 1889.
Inquiries made after this vaginal examination, brought
out the facts of quite constant nausea during the month
of August. ‘The breast signs were also those of preg-
cy.
I much desired a consultation with some of the ovari.
otomists, but I was afraid to have it. The consensus is
so far in favor of an immediate laparotomy that I feared
I might risk my patient’s life were this treatment adopted.
I determined to delay at least a day or two, treating the
patient, and holding the surgical procedure in reserve.
‘The sac, though very tender to touch, did not seem so
tense as to excite alarm that it would burst at once. I
waited for Dr. Thomas, who was still out of town, think-
ing he would agree with me in methods to be used.
September 25th.—With the patient on the back, brought
to the edge of the bed in the French obstetric position, I
introduced a metal ball electrode into the rectum, just be-
neath the tumor, and passed a current the full strength of
a freshly-fitted Kidder’s faradic one-cell battery through
the tumor. The positive electrode was a broad sponge
placed on the abdomen just over the tumor. The cur-
rent was used for fifteen minutes, and was well borne by
the patient.
Electricity was exhibited in this manner each day for
five days.
September 26th, the day after the first application, ‘the
patient had no recurrence of severe pain, and felt relief
from the general abdominal pain.
September 28th.—She had a very little pain, “ but of a
different character.”
September 29th.—The facial expression has markedly
changed, the anxious look has gone.
October 2d.—Dr. Thomas saw Mrs. S—— with me,
and said the diagnosis was undoubtedly correct.
I used electricity October rst, 4th, oth, and 13th.
After the first application of electricity there was no
increase of size of the tumor, but I could not appreciate
its decrease until October 20th, when it was markedly
smaller.
There was uterine discharge till October 2oth. This
was shreddy. It was not further examined.
This case adds one illustration to the established fact
that in extra-uterine foetations there is usually some ute-
rine misplacement. |
The position in which the enlarged tube was felt was
due doubtless to the special displacement and adhesions.
Otherwise the tube would have sunk into Douglas’ cul-de-
sac.
I report it, however, because it shows the efficiency of
the faradie current in destroying the misplaced foetus,
and arresting sac-growth. ` Many a physician has a battery,
and skill in its use, who has not the ability to do a suc-
cessful laparotomy.
If the electrical current is effectual, it is without hazard
to the mother, and in trying to°do good it is most desir-
able not to do harm.
The only possible objection is delay ; but if used before
the sac is so tense that stimulated muscular action in the
tube endanger rupture, it is safe.
At a later stage than my own case I should advocate
its use, and if growth were arrested should postpone lap-
arotomy till some threat of poisoning should come from
the retained foetus.
In early cases absorption is likely to be complete with-
out septic change. In the case narrated, at last examina-
tion no trace of the tumor could be detected.
LATE PREGNANCIES.—Dr. A. E. Mossman, of West-
minster, Mass., writes: “ As I notice continued reports of
late pregnancies, I will contribute one. Mrs. C , of
Westminster, Mass., married late in life, at the age of forty-
seven, and became pregnant and was delivered, at the age
of forty-nine years and ten months, by forceps, of a male
child weighing eleven and one-half pounds, in April,
1886.” A
540
THE MEDICAL RECORD.
[November 16, 1889
SURGICAL OPERATIONS FOR THE REPAIR | Setvance of a few points is imperative. What are the
OF RUPTURED PERINÆUMS.
By A. B. CARPENTER, M.D.,
CLEVELAND, O.
THE great number of articles that have, from time to
time, appeared in the medical press, taken together with
the very exhaustive descriptions in the text-books on this
subject, would seem to have covered the ground so com-
pletely as to scarcely warrant anything more in this direc-
tion ; yet, there having appeared recently an article on
this subject in a prominent English journal, the views of
which, I believe, differ so widely from those of the Amer-
ican gynecologists, that I have ventured to defend some
points that the author of the paper had taken the pains
to so strongly condemn. Also to mention briefly some
practical points that have come under my observation re-
garding the operation, as well as the after-treatment of
the case.
Dr. Fancourt Barnes published a very brief article, to-
gether with a report of a number of cases, in the August
number of the British Gynacotogical Fournal, wherein
he described the repair of these injuries by the flap-split-
ting method as devised by Mr. Lawson Tait ; and in or-
der that I may do him no injustice, I will take the liberty
of quoting him. He says:
“ It is now four years since I first resorted to Mr. Law-
son Taits method of restoring ruptured perinzeums by
flap-splitting. From the first, the operation gave such
satisfactory results, that I have treated every case which
has come under my care by this method. The
old plan of paring away the mucous membrane of the
vagina is most unscientific, as each time the operation fails
the patient loses some vaginal tissue, until in some cases
I have seen most of the posterior vaginal wall has disap-
peared. . >35,
“ I feel sure that medical men, who have only seen the
results of the old operation, naturally hesitate to advise
perinzorhaphy in cases of lacerated perinzeums, because
they know that it is always possible that the patient may
be in a worse condition after the operation than before.
‘ In cases where the rupture is incomplete, the
operation is indicated to prevent the occurrence of cysto-
cele, rectocele, or prolapsus.”
Before going on to a consideration of the statements
made by Dr. Barnes, I wish to say that I am an advocate
of the denudation method for the repair of lacerations of
the perineum, and I know of no operation that gives
greater relief, especially where the patient has suffered
entire loss of the pelvic floor. : That Dr. Barnes has se-
cured good results by the flap-splitting plan, I would not
for a moment pretend to question ; yet when he asserts
that “the old plan of paring away the mucous mem-
brane of the vagina is most unscientific,” a protest would
seem not entirely out of order.
That Dr. Barnes found it advisable to adopt some
method other than the “ paring ” one, is not at all strange,
for he says he “ feels sure that medical men naturally
hesitate to advise the operation, because they know that
it is always possible that the patient may be in a worse
condition after the operation than before.”
If his results were so unfavorable as one is led to infer
from the foregoing quotation, it is not at all strange that
he was inclined to abandon the “ paring” and adopt the
flap-splitting method. ‘The failure of the former plan in
his hands, 1 will venture to suggest, may not have been
so much in the plan as in the operator, and that a care-
ful observation of the general detail of the work would
possibly have prevented the medical men from hesitating
to advise, etc.
Be that as it may, I will try to place before the reader
a few points to substantiate the position I have taken,
viz., that for a majority of cases there is no method that
will give the results that can be obtained from the denu-
dation plan. But to obtain these results a scrupuléus ob-
points? a. Antiseptic precautions. 4. A smooth, even
o GATAIA IA IA: denudation. <. Continuous irrigation
during the paring. æ. Retaining the
E} fingers in the rectum until the sutures
$} are all in place and ready to be tied.
$ f c. The control of the bleeding from
= the denuded surface before the sutures
are tied. f. The number of days the
sutures are to remain before removal.
g. The method of removing them. +.
Attentiun to the bowels.
Antiseptics.—The patient should be
placed in a lithotomy position, with the
hips well forward to the edge of the
table, and a rubber cloth, or, what is
much better, a rubber cushion, as de-
vised by Dr. Howard Kelley (see Fig.
1), placed beneath the hips to conduct
Kelley's Rubber Cushion. the water into the jar beneath. By
the use of such a contrivance any
amount of water can be used, and at the close of the op-
eration everything remains neat and tidy. ‘The vagina
should be first thoroughly cleansed by a hot solution of
bichloride 1 to 3,000. ‘This cannot be done with too
much care. ‘The index and the second fingers of the left
hand are then introduced into the rectum, and the poster-
ior vaginal wall is again cleansed. ‘Two lateral retractors
are then introduced into the vagina and held in place by
assistants, and with the two fingers of the left hand still
in the rectum, with a sharp pair of curved scissors in the
right, the work of denuding is ready to be begun.
I usually make the denudation something after the
plan of Simon (see Fig. 2). I have adopted this method
Fic. 2.--Simon’s Method of Denudation.
for the reason that in my hands it has given me better
satisfaction than any other I have tried. By this plan
the vagina is narrowed to a greater degree, the uterus has
a much better support, and rectocele and cystocele are
less apt to follow than by any method with which I have
had experience.
During the process of denudation, the bichloride is al-
lowed to run continuously, and no sponge or other ab-
sorbing medium is made use of. Should the field be-
come obstructed by a clot, the thumb of the left hand can
easily brush it away. I carry the denudation up as high
as I conveniently can, but always beyond the crest of the
rectocele, and the entire field, as exposed by the retrac-
tors posteriorly, is made fresh. Great pains is taken that
no uneven places be left, or, what is still more important,
no undenuded points remain. As soon as the bleeding
has been stopped the sutures are ready to be put in.
With the two fingers still in the rectum, an assistant arms
a needle of proper curve and length with a braided silk
suture, and placing the needle in the holder, hands the
same to the operator, who inserts it into the highest part
of the denuded surface, taking pains to include only a
small portion of the mucous membrane at point of en-
trance and exit of the needle ; the remaining sutures are
November 16, 1889]
THE MEDICAL RECORD.
541
then placed in position, the two fingers in the rectum act-
ing as a guide for the needle (Fig. 3). When the sutures
are in place and ready to be tied, the fingers should be with-
drawn from the rectum and thoroughly disinfected. At- |
tention is now given to the denuded surface, and if there
is bleeding it must be arrested ; much depends upon this
point. Union by first intention is delayed when there is
blood left and included in the closing of the wound.
Pressure for a short time with a piece of damp absorb-
ent cotton or sublimate gauze, will usually leave the parts
in perfect condition for closing. The cotton or gauze
should be damp lest dry particles be left, thus proving ir-
ritating, and delaying union. When the sutures are all tied
and the ends cut, a row of knotted sutures will be found to
extend downward and backward toa point a little way in
front of the cervix, and directly in the median line of the
new pelvic floor. It is my custom to put in two sutures
through the integument and new perineal body for the
purpose of supporting the parts, and thus take the strain
off the inner stitches. The work completed, the rectum
is stretched, as the patient suffers less pain when this is
done. ‘The patient is put to bed and the water drawn
with a catheter. A gentle douche of tepid water once a
day, and a light diet, is about all that is required. I sel-
dom fasten the legs together, and aside from the patient
being instructed to be careful in all her movements, little
restriction is placed upon her:
Removal of Sutures.—I consider the removal of sutures
to be one of the most important points in the entire man-
agement of the case. When to remove and when zot to
remove, is a nice point. I believe many cas:s have proven
Fic. 3.—Manner of Suturing the Rectum.
failures that would otherwise have been perfectly success-
ful, but for the fact that the sutures were removed too
soon. ‘There can be no fixed time or number of days
given for the removal. Where union takes place with lit
tle or no pain, or where there is little or no inflammatory
action, removal can take place several days earlier than
when the opposite condition of affairs exists. I leave in
my sutures from twelve to eighteen days, according to
circumstances; preferring that considerable ulceration
and cutting take place around the sutures than that they
be taken out before strong adhesions have been formed.
‘They can be left in four days too long much safer than
taken out one day too soon.
Method of Removal of Sutures—As will readily be
seen, a row of sutures extend downward and backward in
the vagina, and in some cases it is difficult to remove
them without injury to the new perineum. My method
is as follows :
The patient is placed in the lithotomy position and an
Allingham rectal speculum (see Fig. 4) is introduced
into the vagina with the fenestrated part directly over the
row of sutures. The plug is withdrawn, when the sutures
will readily be seen, and with a pair of locked handle
| is, so far as I am aware, original with my-
_ self, and is in my opinion worthy of trial at
dressing forceps, the ends are one by one seized and cut ;
the speculum removed, the perinzeum not having been i in-
jured at all and the patient suffering nò
discomfort whatever.
This methoa for the removal of sutures
OO i,
the hands of men doing this work.
Care of the Bowels.—It is my custom to
keep the bowels moving. I do this by
means of a glycerine enema or suppository,
and I find the patient suffers much less by
having the bowels move on the second day
after the operation, by the method herein pic. 4. — Alling-
described. ham Rectal Specu-
The results of my operations have been !""""
satisfactory, and I have seen my patients restored to health ;
and in closing will say, I do not think that I shall change
to the flap-splitting method, neither do I consider the plan
of “paring” as “most unscientific.”
166 EUCLID AVENUE.
SACCHARIN AS A MEANS OF ACIDIFYING
THE URINE.’
By ANDREW H. SMITH,
NEW YORK,
WHILE it is usually not difficult to render an acid urine
alkaline, our means for rendering’ an alkaline urine acid
have heretofore been meagre and unsatisfactory. The
mineral acids when taken into the stomach are chiefly
eliminated by the intestinal mucous membrane,
and the only way in which they affect the reac-
tion of the urine is by liberating from their bases
the organic acids which in the form of salts they
may chance to meet in their passage through the
system. ‘The organic acids thus liberated may
or may not find their way through the kidneys.
¿ As a matter of fact, they generally do not suc-
ceed in running the gauntlet. Indeed, so slight
is their chance of doing so that in practice, in
prescribing a salt of an organic acid, we leave
the acid entirely out of consideration.
The only acid heretofore employed with any
degree of confidence that it would get beyond
the kidneys was benzoic acid. Even this does
not reach the urine in its original form, but is
converted into hippuric acid by the way. Never-
theless, it is in some degree useful in rendering
the urine acid, but its action is not as certain
nor as constant as might be desired.
When saccharin was first announced, it was
mentioned among its properties that it was unaf-
ected by the digestive fluids, and was eliminated unchanged
in the urine. Some time later, having had occasion to
manipulate somewhat with this substance, I was struck
with its strongly acid property, and it occurred to me that
so decided an acid, of such a stable composition as to
resist decomposition in the system and electing the kidneys
as its way of exit from the body, would supply exactly
the agent required for acidifying the urine.
An opportunity to put this idea to the test was afforded
by a patient in my wards at the Presbyterian Hospital.
This was a boy suffering with transverse myelitis, whose
urine, which required to be drawn with the catheter, was
ammoniacal and very offensive. A few grains of sac-
charin administered three times a day promptly changed
the reaction of the urine to acid, and did away completely
with the offensive odor. Not only so, but the irritation
of the bladder became less and the formation of pus was
diminished.
Shortly after this I was in attendance upon a case of
subacute meningitis in a child twenty months old. ‘The
M.D.,
! Readybefore the Practitioners’ Society of New York, November 1,
1889.
542
urine, which dribbled constantly into the diaper, was alka-
line, and its odor, though not ammoniacal, was peculiarly
sickening. Evéry effort was made in the way of cleanli-
ness, but the atmosphere about the bed was extremely
disagreeable. Small doses of saccharin were prescribed,
and immediately removed the fetor, to the great relief of
the parents and attendants.
On beginning my service at the hospital, on October
4th of this year, I found a young woman, aged eighteen,
in the ward who was suffering from acute cystitis, ap-
parently induced by suppression of the catamenia and the
absence of an evacuation of the bowels for seven days.
She had then been ten days in hospital. On admis-
sion, three weeks after the onset of her illness, the urine
was alkaline and contained a large amount of ropy mucus
and pus. An attempt to wash out the bladder was aban-
doned, on account of the severe tenesmus excited. ‘The
contact of the catheter with the wall of the bladder
caused hemorrhage.
Citrate of potassa was ordered, but gave no relief.
. When I came on duty I found the patient in so much dis-
tress that I suspected she had introduced some foreign
body into the bladder. October 13th, finding the urine
very alkaline, I directed the administration of five grains of
saccharin three times a day. ‘The following day the urine
was neutral, and in four days more it was acid, and con-
tained no mucus and but very little pus. October 23d,
the urine was entirely normal, the symptoms had disap-
peared completely, and the patient was discharged cured.
It is probable that a part of the efficacy of saccharin in
these cases is due to its being a powerful antiseptic in ad-
dition to its acid property.
Glinical Department.
AN EASY METHOD FOR THE REMOVAL OF
PLASTER-OF-PARIS APPARATUS.
By CHARLES H. RICHARDSON, M.D.,
NEW YORK.
I HAVE used of late a plan in the removal of plaster and
starch bandages which seems to do away with the annoy-
ance to the surgeon, and the discomfort, not to say dis-
tress, to the patient, attending removal by the shears.
It consists simply in the application of a piece of wire
under the bandage, which is made to out its way out when
removal of the apparatus is desired.
The limb is prepared for the bandage in the usual
manner, either by the application of a flannel roller or by
being well anointed with vaseline. A fine steel wire is
then laid the length of the limb, in the situation that it is
desired subsequently to cut, and firmly held in that po-
sition by an assistant. This is secured by a few turns of
the plaster bandage, and the apparatus finished in the
ordinary way.
The wire should project four or five inches at each end
of the bandage, so as to afford sufficient for a firm hold
when the time comes for removal. ‘These free ends of
wire may be bent down after the casing is completed, to
prevent the annoyance to the patient which the sharp
ends might otherwise produce.
When the removal of the appliance is desired it is nec-
essary to have the patient rest his limb on a table in order
that it may be perfectly steady, and while the lower project-
ing end of wire is held firmly in place, to prevent its slip-
ping underneath the bandage, the upper end is seized by a
pair of pincers and by firm traction made to cut its way
through the whole length of the casing. ‘The apparavus
may now be bent back and removed, the operation hav-
ing caused no discomfort, which can hardly be said of
the combined prying and cutting with a pair of plaster
shears.
To two points would I like to call attention before I
THE MEDICAL RECORD.
[November 16, 1889
close. ‘The first is that no attempt should be made to
remove the casing until it is completely and entirely dry.
The wire will not cut through wet bandage.
The second is, that while one wire will cut through the
ordinary light dressing, such as is used on the arm, yet
when an extra thickness is given to the apparatus, as in a
plaster jacket or in an appliance to the lower limbs, I
would recommend that two or even three wires be used,
to make the cutting easier and more sure.
If more than one wire be used, the second is laid as
nearly over the first as possible, after a few layers of band-
age have been applied, and a third over this if it be deemed
necessary. ‘Thus a layer of plaster and bandage will ın-
tervene between each of the two or three wires.
The method of cutting is evident. It is done in sec-
tions, by pulling the wires in inverse order to that in which
they were laid.
427 LEXINGTON AVENUE.
LIGATION OF THE ANTERIOR TIBIAL AJ--
TERY FOR TRAUMATIC ANEURISM.
By J. R. WILKINSON, M.D.,
GREENVILLE, S» C.
Mr. P. M. B. D—-, aged thirty-eight, a shoemaker ; has
been strong and healthy all his life, but has been drunk,
with but few intervals, for the last twelve years. About
October 1, 1887, while drunk, he picked up a scythe-
blade, and accidentally thrust the point into his left leg, at
about the juncture of the upper and middle third of the
tibia, about an inch to the outer side of the spine. This
was followed by considerable bleeding.
He stopped me on the street the following day for ad-
vice, upon which I told him to go home and lie down,
keeping his leg elevated. But he did not do so, and I de-
clined to assume any further responsibility in the cace.
On November 6th I was sent for in great haste, just as I
was ready to go to Sunday-school. Mr. D- was said
to be bleeding to death, and when I reached him he was
about to faint from loss of blood. I at once made press-
ure on the femoral artery, but not realizing at the time
the conditions that existed, I controlled the hemorrhage
by the free use of Moonsil’s solution on cotton to the
gaping wound, supposing that some vessel of medium size
had sloughed. One week later the third hemorrhage
came on, and was controlled as before. He lost not more
than half the usual quantity of blood.
1 then saw him every day, when on the 22d the fourth
hemorrhage came on, and was controlled as previously.
At this time a pulsating tumor of considerable size had
developed, and there was a well-marked bruit.
After careful examination I decided that an operation
was necessary, and on November 23d invited Drs. Wal-
lace and Bailey to assist me. Against the opinion of
these gentlemen, I decided to make an effort to save the
leg. I made a long incision, about five inches in length,
directly over the tumor, through integument and super-
ficial fascia, which opened into a mass of coagulated
blood and pus.
Many of the muscles of the calf were dissected apart,
this same mass being packed in between them, requiring
much time for its removal. A quart would, I think, be a
low estimate of the amount of this material. The tumor,
upon examination, proved to be an aneurism of the an-
terior tibial artery, about two and a half inches long, with
a diameter of about one inch. (I say about, because my
office-boy threw it out of the basin before I had made
actual measurement.)
I removed the tumor after ligating the anterior tibial
artery, about one inch above and below it, with carbolized
catgut. The wound was thoroughly cleansed with hot
carbolized water, dusted with iodoform, and wrapped in
| a thick cotton dressing.
November 24th.—Patient did well, except that there
November 16, 1889]
was some suppuration, until November 28th, on which
day a secondary hemorrhage occurred.
When I reached the patient he was almost exhausted,
and seemed on the verge of going off in a swoon from
loss of blood. Hemorrhage was controlled as on previous
occasions until I could get a bandage and compress and
assistants, which took some time, as it was late on Sunday
afternoon. |
The patient being anæsthetized, the whole wound was
laid open and cleansed with carbolized water (1—40), after
which it was thoroughly sponged out with spirits of tur-
pentine. ‘The artery was found to have sloughed at point
ligatured.
Believing that my mistake lay in the fact that I had
ligated the vessel in an open suppurating wound, I cut
down on it through fresh tissue about one inch from where
it emerges from the interosseous space, placed a silk liga-
ture around it, and sponged out the freshly made wound
with spirits of turpentine, with which I had previously
washed my hands. I then brought the parts together and
held them by deep silver sutures.
The patient now did well until December 31st, when
it was found that a large pocket had formed in the calf
of the leg where the muscles had been dissected up prior
to the first operation.
I made an incision four inches in length, opening up
the pocket, which proved very effectual in reducing local
irritation, also general œdema of the whole leg and foot.
January 13, 1889. I put the patient on chlonde of
gold and sodium, gr. +4, t.i.d., hoping by its effect to de-
stroy the desire for whiskey.
February 9th.— Walked out on street to-day. Leg and
foot still somewhat oedematous. Collateral circulation
going on well and gradually improving.
September 26th.—At this ‘time the patient is still
following his trade. Has good use of the whole leg.
Collateral circulation is well established, and he has no
‘trouble whatever. I advised him to wear constantly a
leathern fender as a protection to his shin, telling him
that any scratch would be hard to heal. He did not,
however, believe me until I had to keep him in bed for a
week or two on account of a slight bruise which made an
ugly ulcer.
The points in the case which I would call special atten-
tion to are:
1. The external coats of the anterior tibial must have
been incised at the time of injury, leaving the inner ones
intact.
2. ‘The several hemorrhages and infiltration of surround-
ing tissues to such an extent after dilatation of the walls
of the vessel.
3. The mistake made in ligating an important vessel in
an open suppurating wound.
4. The use of spirits of turpentine as a styptic and dis-
infectant.
5. Thorough irrigation in such cases twice daily with
hot carbolized water.
A LOST DRAINAGE-TUBE.
Dr. DeWitt Hitcucock, of Long Island City, writes :
“Since it is by recording the unfortunate errors in the
treatment of cases that we are cautioned and put on our
guard in the management of future similar ones, I relate
the history of a very interesting case which occurred in
my practice recently. On December 15, 1877, Edward
Fay, aged six years, Long Island City, was seized with
pleuro-pneumonia. The family physician was summoned,
but the disease was severe in its attack, and, in spite of
good care and treatment, left the little patient with em-
pyema.
“ On February 19, 1888, I was called in consultation,
and for the purpose of aspirating if I concurred in diag-
nosis. I found the patient anemic, elevated tempera-
ture, rapid pulse and respiration, profuse perspiration, to_
THE MEDICAL RECORD.
543
gether with all the physical signs of empyema. I
aspirated and drew off thirty-two ounces of purulent
matter, and recommended free incision. I left the case
in charge of the family’s physicians, and a few days later
they made a free opening into the pleural cavity, through
the left seventh intercostal space, posteriorly, and intro-
duced an ordinary No. 12 rubber catheter for drainage-
tube. On the afternoon of the same day the wound was
dressed by the attending physician, and the mother, as
well as the physician, noticed that the catheter seemed a
little shorter than when introduced, but they thought
that probably if any was gone it had been burned
with the oakum dressing. Drainage was kept up about
three weeks, when the tube was left out and the wound
closed up. But the patient’s condition grew rapidly
worse ; about eighteen days later they opened the cavity
in the same place, and a profuse discharge of pus fol-
lowed. At this time, fearful that a small piece of the
catheter was lost in the pleural cavity, search was made,
but availed nothing. Drainage was kept up until the
following November, when it was discontinued and the
wound again allowed to heal. On Chnistmas-day follow-
ing (December 25, 1888) it opened of its own accord and
discharged freely. A drainage-tube was again inserted,
and continued up to October 8, 1889, when he was
brought to my office and examined by Dr. G. B. Strong
and myself. The little fellow was very distrustful, and
had lost all confidence in physicians and the ‘healing
art,’ so much so that we could only get the history as re-
lated above, and note his general condition. He was in
very delicate health ; emaciated ; poor appetite; weak,
rapid pulse ; slightly elevated temperature ; night-sweats ;
more or less swelling of the feet (but no albuminuria), and
a troublesome cough. We concluded that there either
was necrosis of the rib, or else some part of the old tube
remained to keep up irritation and the continual dis-
charge. We recommended an operation as soon as his
health could be a little improved, and after a course of
tonic treatment we operated October 19, 1889. The
patient was etherized, and an incision made to examine
the rib. Finding no sign of dead bone, the incision was
enlarged into the pleural cavity sufficient to admit the in-
dex finger, and thorough exploration made. After
searching in every direction, and passing the finger to the
extreme lower part of the pleural cavity, we thought we
could detect a foreign substance, and with the dressing-
forceps, but not without considerable force to loosen it
from its partial impaction, we removed five and three-
eighths inches of. the lower end of the catheter introduced
March 19, 1887, for the purpose of drainage. The
wound was dressed with antiseptic precautions, and at the
present writing he is improving rapidly, with good pros-
pects of a speedy and permanent recovery.” i
CEPHALIC VERSION EIGHTEEN HOURS AF-
TER RUPTURE OF THE MEMBRANES.
Dr. W. Ciayton Dukes, of Memphis, Tenn., reports the
following case: “ When the patient was seen for the first
time it was about sixteen hours after the membranes had
ruptured. Upon examination I found an entire prolapse
of the left arm, the shoulder was firmly engaged between
the pelvic bones, the head was forced backward over the
left scapula, the face looking to the right and approximat-
ing a line drawn horizontally across the pelvis. Violent
contractions, tonic in character, were present from the ad-
ministration of a dose or two of ergot given by a woman
in attendance. The uterus was firmly retracted upon the
child, and the pains were frequent and expulsive. The
patient was thoroughly anesthetized, and the child’s fore-
arm was flexed upon the arm, which was used as a ful-
crum and pressed backward and upward as gently as pos-
sible until it was returned into the vagina, when it was ro-
tated and passed gently backward underneath the child
and to ‘ts normal position at the side. After this three
544
fingers of the right hand were placed above the head of
the child and pressed gently downward, the thumb rest-
ing upon the left shoulder and pressing backward. The
head was gently rotated and brought into the position of
a normal labor, and the child was born on the following
morning, about three o'clock, after one or two expulsive
pains. The tonic contraction of the uterus made this an
extremely difficult manipulation, but as the feet could not
be reached there was nothing else to do. In this case I
received most invaluable assistance from my friend, Dr.
W. B. Winkler, and take this occasion to express my
grateful thanks.”
Progress of Medical Science.
AUTO-INFECTION IN PUERPERAL CaseEs.—At the last
meeting of the German Society for Gynecology, Kalten-
bach expressed his belief that while in the greate majority
of cases infection comes from without, yet the innocuous
bacteria found in the vagina may invade the uterus and
become pathogenic, especially if the tissues be mechan-
ically injured or destroyed during labor, and absorption
of the products of retrograde metamorphosis follows
(Zhe American Fournal of the Medical Sciences, October,
1889). The attempt to sterilize the genital tract is un-
necessary and meddlesome, but a vaginal douche of bi-
chloride of mercury, 1 to 3,000, had done him good ser-
vice, and is used to advantage in protracted cases. ‘The
necessity for intra-uterine douches becomes very infrequent
when prophylactic douches are given. Fehling considered
many cases of fever in puerperal patients, examples of the
absorption fever common in surgical patients, in whom
absorption of disintegrating albuminoids, with or without
germs, was not rare. In the presence of an abundance
of such matter, harmless germs often become virulent.
He lays most stress on disinfecting the external parts ; the
vagina is irrigated only when foul lochia are present. °
Should the placenta or chorion be retained, interference
is demanded. In all labors care is taken that the mem-
branes do not rupture too soon ; that perineal tears are
avoided by episiotomy ; and that the forceps is used be-
fore the tissues have been injured by pressure.
IMMUNITY AND IMMUNIZATION.—Dr. H. Buchner has
recently published a new study of this subject, and Zhe
Sanitarian gives the following résumé of it: Immunity
in its full meaning signifies a condition of the body which
permanently opposes the development of infectious pro-
cesses. But there are conditions which act transiently in
the same way against the danger of infection already ex-
isting. Buchner exemplifies this by a person attacked
with typhus. In this case the disease, the continuous mul-
tiplication of bacilli, is not terminated before all tissues
acquire transient immunity against the fungi. But what
are the means by which the organism acquires immunity
in a permanent or transitory way ? ‘To answer this ques-
tion Buchner first refers to Pasteur’s protective inoculation,
the actual efficiency of which is generally admitted at the
present time. Buchner calls it a great triumph that it
should be possible to immunize a living organism in this
way without hurting its tissues. Again, another means of
immunization comes from France. Chamberland and
Roux have injected intra-peritoneally the chemical sub-
stances of bacteria (ptomainia) in experiments on animals
affected wlth malign cedema and with anthrax, without
taking the bacteria themselves. The animals were actually
rendered resistant to inoculation with living bacilli of the
corresponding disease. This discovery is practically very
important, inasmuch as the effects of chemical agents for
the purpose of immunization are certainly more accurately
measurable than those of living fungi. ‘Theoretically, the
discoverers neglected drawing the necessary consequences
from their results, and this has been done by Buchner
with zealous energy. He prefaces his developments with
a discussion of the means by which transitory immunity
THE MEDICAL RECORD.
[November 16, 1889
may be obtained. It might be possible to neutralize spe-
cific ptomaines in the organism by means of certain sub-
stances, just as Behring succeeded in decomposing the
ptomaine of cholera-vibrios, cadaverne, by means of
iodoform. Nature uses inflammation as an antidote
against the invasion of fungi. Ten years ago Buchner
pointed to this reaction of the organism by which it
acquires transient immunity, but at the present day he
disposes of proofs for his hypothesis. Ina former paper,
Buchner has described anthracic pneumonia produced by
the inhalation of anthrax bacilli. Its symptoms are those
of a sero-fibrinous hemorrhagic pneumonia. In the alve-
oli there is found an exudation abounding in cellules and
an immense quantity of anthrax bacilli. On the other
hand, the pulmonary capillaries and the larger vessels
were absolutely devoid of bacilli, the spleen containing
only a very few of them. For the purpose of investigat-
ing the modus by which the agents of infection are ar-
rested in their further invasion, Buchner has lately in-
stituted some experiments which led to the conclusion
that “inflammatory reaction not only possesses the power
of arfesting the passage of bacteria through the pulmonary
surface, but actually to cause degeneration of the infec-
tious bacteria, and consequent destruction.” We are not
permitted here to give in detail the interesting experiments
which Buchner, jointly with Dr. Schickhardt, has per-
formed on animals infected with anthrax bacilli. The
microscopical result confirmed Buchner’s hypothesis that
inflammation originates in consequence of the bacillus,
but that conversely, once originated, it induces degenera-
tion in the bacillus, and may doubtless cause its complete
decay. The latter hypothesis is corroborated by the
shapeless agglomerations of granules which are found,
and which represent a transformatior. of the bacilli. In
accordance with the fact of an antibacterial, immunizing
action of inflammation, Ribbert and Lahr have ascer-
tained, after injecting staphyiococcus avoreus into the
trachea, that the loca] inflammation prevents the bacteria
from penetrating into the organism, and subsequently
causes them to degenerate and to die. Emmerich, and sim-
ilarly Paulowski, have tried already to utilize these ex-
periences in a practical way, the former by his experiments
with injection of erysipelas-cocci in animals affected
with anthrax ; the latter by establishing the fact that even
simple saprophytic fungi have a restraining curative in-
fluence on simultaneous anthracic infection. It may be
possible in some other way, as tried already by Landerer
by means of Peruvian balsam, to create in the organism
a condition of excitation which might be used as a means
of immunization. ‘Through what kind of chemical and
microscopical conditions an inflammatory excitation, or
immunity acquired by protective inoculation, may act
deleteriously on the bearers of infection is explained on
the results of Metschnikoff’s well-known phagocytic theory.
In Buchner’s opinion this theory constitutes one of the
greatest additions to our morphological and physiological
science of infectious processes. Metschnikoff’s doctrine,
opposed from many sides, draws its principal importance
from the fact of having demonstrated that viable, patho-
genic bacteria may indeed be devoured by cellular ele
ments. It explains how leucocystic and other cellular
elements migrate into certain tissues in a condition of in-
flammatory excitation and exposed to infection, there dis-
play their phagocytic action. It is true, Buchner does
not consider everything explained by this process alone.
On the contrary, a certain chemical] reaction and concen-
tration of the different tissue-fluids seems to be necessary
for the debilitation and destruction of the fungi. Buch-
ner, on the ground of experiment, is inclined to suppose
the existence of fluid substances which, formed by the
febrile process, have an antibacterial action. ‘This ex-
planation being quite satisfactory for transient immunity,
there are other processes to be considered in permanent
immunity. Voit’s experiments in Buchner’s laboratory
have recently furnished the proof that the organism pos-
sesses in the living blood-plasma chemical properties of
November 16, 1889]
this kind, deleterious for bacteria. Living blood, gener-
ally, is an unfit alimentary substratum, but by a change of
its quality it may become a proper medium, and in this
case a morbid affection of the organism would take place ;
the period of incubation would then be the time in which
the blood is still possessed of those properties which ar-
rest the bacteria in their growth or, possibly, even destroy
them.. Immunity, then, would represent a permanent
power of the organism to maintain the period of incuba-
tion. The question, in what way transition to actual
morbidity is prevented, is answered by Buchner, availing
himself of the experimental results obtained by Chamber-
land and Roux, by the suggestion that it is the adaptation
of the organism to the specific virus which makes the lat-
ter gradually lose its pathogenic properties. This very
supposition of adaptation underlies protective inoculation
with attenuated specific fungi, as well as with dissolved
specific products of decomposition.
SUPPURATION WITHOUT MiIcroBES.—In a paper read
before the French Association for the Advancement of
Sciences, M. Steinhaus, of Varsovia, combats the notion
which has of late been gaining a strong hold of the pro-
fessional mind, that without microbes there can be no
suppuration. He cites the experiments of Straus, of Bary
and Christmas (among others), as giving results entirely
contradictory to the doctrine that supptration is abso-
lutely dependent on microbes. He has himself made two
hundred and forty-five experiments on dogs, cats, guinea-
pigs, and hares. As pyogenic agents, he has employed
chloride of zinc, chloride of mercury, pure mercury,
nitrate of silver, oil of turpentine, croton-oil, and culture
broths, which had contained the staphylococcus pyogenes.
All these substances were injected under the skin of ani-
mals, after having previously been sterilized in Koch’s ap-
paratus. ‘The results were as follows: In the guinea-pigs
and hares, only the chloride of mercury, mercury, and the
sterilized broths produced suppuration, while in the cats
and dogs, besides these substances, oil of turpentine, pe-
troleum, and nitrate of silver produced it as well. ‘These
results compelled the conclusion that suppuration may be
provoked by stenlized chemical bodies, and that it is pos-
sible without microbes.— Zhe Boston Medical and Surgical
Fournal,
A New TuRPENTINE ERuPTION.—Dr. Feiber, of Aix-
la-Chapelle, furnishes a clinical example of the rare con
dition of an cedematous and papular erythema following
the internal administration of a turpentine preparation.
‘The patient was under treatment for subacute gonorrheea,
and was taking eight grains of the essence of turpentine
twice daily. On the ninth day of the treatment, that is,
after the use of about seventy grains of the turpentine
preparatiop, the patient complained of severe pruritus.
On the following day an erythema, consisting of small,
acutely pointed papules of a bright red color, some of
which were excoriated by scratching, was found to cover
all the surface of the body excepting tle head and face,
being more pronounced on the lower than on the upper
limbs, and specially intensified on the abdomen and but-
tocks. The pruritus and rash disappeared in three days
on the cessation of the turpentine preparation. Being
desirous of ascertaining if the turpentine would again pro-
duce the erythema, Dr. Feiber again prescribed it. On the
fourth day violent itching returned, accompanied by an
eruption of similar papules ; but in addition to these there
were noticed on the abdomen and buttocks small red,
slightly raised spots, with patches about the size of a half-
dollar of the same bright red color, both in their centres
and in their peripheries. The urine was normal, and the
patient felt well. Dr. Feiber remarks that, whereas the
first eruption was exclusively a pure papular erythema—
roseola—the second, on the contrary, was a mixed form of
cedematous and papular erythema, an eruption described
now, as far as he knows, for the first time as consequent
on the administration of turpentine.— Zhe British Journal
of Dermatology.
THE MEDICAL RECORD.
545
NERAD Pain: ‘A New Form oF GASTRALGIA.—
Dr. Buch, of Finland, in a paper on this subject, states
that he has recently discovered. that, in the great majority
of cases of so-called cardialgia or gastralgia, pain, similar
to that of the attacks, can be elicited by pressure on the
vertebral column, through the abdominal parietes, while
abdominal pressure elsewhere is painless. ‘The sensitive-
ness to pressure sometimes extends the whole length of
the accessible portion of the vertebrz, in which case some
portions are usually more tender than others, or it may be
confined to certain spots, which are not always in the im-
mediate neighborhood of the apparent seat of the pain.
Thus he found that pain in the epigastrium and lower
sternal region was most frequently produced by pressure
about an inch below the umbilicus. It is often associated
with dyspeptic symptoms, and sometimes with painful
pulsation of the abdominal aorta. He considers the affec-
tion to be generally due to neurasthenia, sometimes to
chlorosis and uterine inflammations. Anatomically, he
believes the seat of the pain to be in the hypogastric and
aortic plexuses of the sympathetic with their connecting
branches. As a palliative for the attacks he has found
most benefit from hypodermic administration of antipy-
rin. The cure, of course, must depend on. treatment of
the fundamental affection.—A merican Fournal of Insan-
ity, October, 1889.
THE PHYSIOLOGICAL RESISTANCE OF THE PERITONEUM
To Inrection.—lIn the past year hardly a more interest-
ing series of experiments has been made in the interest of
surgical pathology than those of Rinne (Archiv für kli-
nische Chirurgie). Practically and clinically it has been
demonstrated that the peritoneal cavity under certain un-
known circumstances has the power of taking care of a
vast amount of filth. It remained for Rinne to harmo-
nize observed clinical facts with a priori deductions. He
found that large quantities of septic material and pure
cultures of pyogenic bacteria were absorbed, although in-
jected daily into the peritoneal cavity of animals, provided
that the peritoneal surfaces were uninjured. ‘The injec-
tions produced only mild symptoms in direct proportion
to the quantity of septic material used, and in no case was
there more than a moderate rise of temperature. The re-
sults were very different when there were coincident de-
fects in the peritoneum, exposing the subperitoneal con*
nective tissue to infection. ‘Then there invariably appeared
progressive suppurative peritonitis going out from the in-
fected connective tissue, which usually terminated fatally.
The practical import of these experiments can hardly be
overestimated. ‘They explain why the escape of pus into
the peritoneal cavity fgom the rupture of a pyosalpinx is
not necessarily fatal if the tube is promptly extirpated,
and the wound and stump properly treated. ‘They point
out that the incision is the point of greatest danger ın all
abdominal operations, and they would indicate that too
much care cannot be taken in coaptating the peritoneal
edges of the wound. ‘They explain why the removal of
abdominal tumors is so much more dangerous after adhe-
sions have taken place, because the resulting denuded
places offer less resistance to the invasion of septic bac-
teria. ‘They explain the success of those operators who
disregard the dictations of scientific bactenology, and
also the recovery of patients after abdominal section by
horned animals. ‘They teach us to consider cautiously
the evidence presented by the statistics of operators, and
await the demonstration of more exact methods as to the
import of their results. ‘They warn us that clinical evi-
dence is inadequate to overthrow the deductions of ex-
perimental physiology and pathology, and that our time is
provided with methods of precision which are yet imper-
fectly improved. ‘hey beckon the ambitious into fields
of activity and thought far less crowded, though more
promising than the operating room and the dead-house.
The resisting and absorptive power of the peritoneum is
beyond that of any other serous cavity. This is as we
should expect. The peritoneal surfaces are only a line
546
distant from the most filthy and prolific culture-medium
about the body. It is connected with this seething and
turbulent mass by the most active absorbent lymph-chan-
nels. Doubtless it is frequently invaded by septic bac-
teria from the intestinal contents. From these frequent
invasions an immunity has been developed which has been
perpetuated and transmitted by the working of the or-
dinarily recognized laws of evolution. Again, we are
taught to consider the causes which determine the locali-
zation of infection as more important than the quantity
and quality of infective material. Doubtless traumatism
is one of the most important of these causes, but we must
not forget that the depression of the general temperature
of the body, the interference with nutrition, and general
malaise, frequently observed after operations, are factors
which may speak for the life or death of our patient.
Not only should the abdominal section be made with the
greatest attention to cleanliness, but the peritoneal edges
must be accurately coaptated, the operation must be done
with the greatest celerity and delicacy, and depressing in-
fluences of starvation, over-medication, and deprivations
of every kind must be avoided if we would eliminate all
those causes which determine the localization of that in-
fection, which is still the greatest danger the operator has
to meet.— Zhe ‘Fournal of the American Medical Associ-
ation, October 12, 1889.
THE SYMPTOMATIC INDICATION AND THERAPY OF RE-
SIDUAL URINE.—According to Dr. Casper, under the term
residual urine we understand that portion of the urine
which, after urinating, remains behind in the bladder. The
healthy man has no residual urine—that is to say, he
empties his bladder at each act with the exception of a
few drops. We possess in the residual urine a measure
to indicate the functional condition of the bladder. The
lack of functional capacity can be caused by a variety of
circumstances—defect of innervation of the bladder, em-
barrassed or obstructed flow of urine. Furthermore, de-
generative or functional change in the muscles of the
bladder may cause a lessening of the contractility of the
vesical detrusor (atony of the bladder). Persistent abnor-
mal frequency of urination always leads to the presump-
tion of residual urine being present. The quantity of
urine voided shows only the power of secretion on the
part of the kidneys and not the expulsive power of the
bladder. Involuntary flow of urine almost always indi-
cates an excessive collection of residual urine, a retention
of urine, but not incontinence. It is doubtless true that
in certain cases of chronic retention catheterization is ab
solutely to be warned against, but the author endeavors
to free it from the suspicion of causing in many cases
severe cystitis and even the death*of the patient. The
cystitis is caused in these cases by the introduction of in-
fectious material, while the sudden death is due to the
Operation having been put off too long. The catheter
should be thoroughly cleansed and disinfected and intro-
duced with the utmost care. Soft instruments are pre-
ferred. For anointing the instrument, equal parts of
lanolin and vaseline well rubbed up together are recom-
mended.—Med. chirurg. Rundschau, August, 1889 ; Jour-
an of Cutaneous and Genito-Urinary Diseases, October,
1889.
ABNORMAL OR CONTRARY EFFECTS OF ANTIPYRETICS.
—Professor Heuchen, of Upsala, has frequently observed
in the academical hospital the so called contrary effects
of antipyretics, mostly of chinolin, but also of antipyrin,
antifebrin, and phenacetin (Zhe Lancet). He believes the
increase of temperature on administering these drugs to
be due to a variety of causes. In some of his observations
there might have been a spontaneous rise of temperature,
while in others the symptom is explained as being due to
an irritation communicated from certain parts of the body.
Professor Heuchen mentions several cases in which the
administration of chinolin resulted in vomiting or diarrhoea.
In these, however, the doses had been large enough to be
considered toxic. A similar explanation is suggested of a
THE MEDICAL RECORD.
[November 16, 1889
case mentioned by Laache, in which an extensive rash
was produced, the temperature sank, and the patient be-
came collapsed. A rash was observed by Heuchen only
in cases in which chinolin had no abnormal action on the
temperature. The best explanation of this singular oc-
currence is. however, probably to be found in the obser-
vation of Giegel of Wurzburg, who states that on ad-
ministering antipyrin or antifebrin the temperature always
first rises and then rapidly falls upon the appearance of
diaphoresis. He thinks that in those cases in which the
diaphoresis is slow in appearing the rise in temperature
has probably also lasted longer, so that this contrary effect
is due solely to the absence of diaphoresis.
A New Carpiac RemMepy.—The alkaloid discovered in
the common gorse, “whin,” or furze, of Europe (Ulex
Europea), termed ulexine, is of a most powerful character.
It appears to arrest all voluntary movements and reflexes
by paralyzing the motor tract of the spinal cord and the
trunks of the motor nerves. The heart-muscle is par-
alyzed, though preliminary thereto there is an increase of
arterial pressure. Further, it possesses a diuretic action
similar to that of caffeine, but more definitely marked.—
The Medical Age.
CLINICAL SIGNIFICANCE OF ALBUMINURIA.—In_ the
course of an article on this question the Zancet says:
“ It seems to us that rather too much has been made of
those cases of albuminuria appearing under forced and
unnatural conditionsin health. Extreme physica] fatigue,
intense mental excitement, and some other causes, have
been shown to be capable of producing temporary albu-
minuria, and this fact has been much relied upon by those
who advocate what may be regarded as the newer views
upon the subject. It is do-btful, however, if we are justi-
fied in drawing any definite conclusions from symptoms
appearing under conditions entirely without analogy to
those usually prevailing. A person ascends an Alpine
peak, and has an attack of hemoptysis. ‘This only proves,
what no one ever doubted, that a sudden and extreme
alteration in the conditions of blood-pressure may cause
hemorrhage, but it helps us little, if at all, to determine `
when hemoptysis occurring under normal conditions is
due to organic disease, and when it is independent of
such. A parallel reasoning may possibly apply to those
cases of albuminuria occurring under peculiar and highly
abnormal conditions. The fact is interesting and worthy
of careful note, but we must be very chary of reasoning
confidently from it. The abstruseness of the subject is
shown by the fact that even the presence of casts, so long
relied upon as absolutely diagnostic of organic disease,
does not justify any final conclusion. Their presence is
very noteworthy. If they are numerous and constant the
probability of Bright’s disease becomes almost a certainty.
Their character is capable of affording important guid-
ance. But the remarks already made upon albumin ap-
ply almost without alteration to casts—viz., that while
their presence is highly significant, we must note that
presence as only a most important element in our diagno-
sis, and not as conclusively determining the whole ques-
tion. Cyclic albuminuria, or cases in which albumen
appears in considerable quantities at intervals, the urine
being free from it in the interim, has attracted much at-
tention since it was first described by Dr. Pavy. It would
appear, as mizht almost have been conjectured, that such
cases are somewhat favorable relatively, and perhaps ap-
proach nearest to meriting the designation of “ functional.”
This term reminds us how much this question has been
one of nomenclature. Whether “ physiological ” albumi-
nuria isa justifiable expression has been hotly debated, and
it has been argued with much force that we might as well
talk of physiological epistaxis or physiological hzemoptysis
because bleeding from the throat and lungs may occur
under abnormal conditions in health. ‘The correctness of
the analogy may be contested, but probably Dr. Gairdner
is right in preferring the expression “ functional” albu-
minuria. This, we presume, involves no hypothesis be-
November 16, 1889]
THE MEDICAL RECORD. ©
547
yond the assumption that albuminuria occurs apart from
discernible organic disease, and that this occurrence must
be due to some aberration of function. These assump-
tions are hardly any longer contested. We may sum up
the present state of medical opinion on this most difficult
question by saying that the persistent presence of albumin
in the urine is a most grave symptom, and in the great
majority of cases is indicative of organic renal disease ;
that, nevertheless, this rule has some rare exceptions;
that we are only very slowly seeing our way to the detec-
tion of these exceptions, but that we may best hope to
avoid error by invariably taking a comprehensive view of
each case, by allowing each symptom its due weight and
avoiding the drawing of conclusions from one symptom
only, by postponing any important decision until time may
have helped to the clearing up of difficulties, and by deriv-
ing all the help we can from considerations of history and
etiology.
FATAL RESULT OF A Wasp-StTinc.—A farm-laborer,
aged twenty-eight, was stung on the right side of the neck
by a wasp, on August 29th last. He took no notice of
it; but the next day, late in the evening, both sides of his
neck began to swell, and on Saturday, the 31st, things
looked so serious that a physician was sent for. He
found the neck, cheeks, lower jaw, and even the pectoral
muscles attacked with acute cellulitis. Careful inquiry
elicited the fact of the wasp-sting, and that when he re-
ceived the lesion he had a boil under his left ear; also
that, though a very healthy-looking and well-nourished
man, he was sadly troubled with constipation, and a mem-
ber of a family among whom boils and abscesses were
very common—thus evidently showing a natural tendency
to suppurative mischief. The treatment consisted of the
use of antiseptics, both internally and externally, hot poul-
tices, milk ad /:bitum, stimulants as far as could be tol-
erated, and plenty of fresh air ; but, in spite of all, septi-
czemia, with violent rigors and delirium, supervened on
the sixth day, and he died on the ninth day after the re-
ception of the sting. No abscess formed, but the cervi-
cal tissues were very much indurated. August 29th was
_a very hot day, and, following as it did a period of rainy
weather, the conditions were very favorable to the rapid
decomposition of dead organic matter, whether animal or
vegetable, and it is highly probable the wasp may have
been feeding on some putrescent material previous to
stinging the unfortunate man. + As he had nothing what-
ever to do with the cattle, and as all the horses and cattle
on the farm where he was employed are quite healthy, it
is clear this was not a case of anthrax or malignant pust-
ule, but death due to a wasp-sting received when the sys-
tem was not healthy.— British Medical Journal.
_ FRENCH VIEWS ON THE ELECTRICAL TREATMENT OF
UTERINE Fisroips.—A long discussion has lately taken
place at the Société de Chirurgie on the electrical treat-
ment of uterine fibromata compared with the other
methods (Zhe Boston Medical and Surgical Journal,
October 10, 1889). The debate was introduced by Dr.
Lucas-Championniére, who read a note giving the results
obtained by him, conjointly with Dr. Léon Danion, a
well-known electrician in his service at the Hôpital Saint
Louis. If there still remains a good deal to study on this
subject ; if there are other indications to be investigated ;
if it is true, in fine, that surgery can alone pretend to the
radical cure of uterine fibromata—the conclusions of Dr.
Lucas-Championniére are not the less very favorable to
the treatment which he classes, without hesitation, in the
first rank among the medical means employed in the
treatment of this class of affections. This communica-
tion provoked a discussion in which several members of
the society took part—among them may be named Drs.
Bouilly, Schwartz, Kirmisson, Segond, ‘I'rélat, Le Dentu,
Berger, and Tillaux, all well-known surgeons, who have
supported, and some of them have even accentuated, the
conclusions of Dr. Lucas-Championniére. Others, a few
in number, with Drs. Terillon, Polaillon, and Terrier, ex-
pressed themselves as little or not at all favorable to this
mode of intervention. That which gives a great value
to the judgment of the principal members of the Société
de Chirurgie is, that nearly all of them are distinguished
laparotomists, and that the surgical successes of Dr.
Lucas-Championniére in particular are most remarkable.
Another circumstance which gives to this communication
a still more interesting character, is the fact that Dr.
Léon Danion, who for several years has endeavored to
examine thoroughly this question of electro-therapy, has
modified profoundly, in basing his investigations on physi-
cal and physiological grounds, the ordinary procedure
adopted by others. He acted, nearly always, simply in
the cavity of the uterine neck, and only utilizing intensi-
ties never exceeding sixty or sixty-five milliampéres. He
has, therefore, suppressed the higher intensities and the
intra-uterine action ; but he practises the reversing of the
current, which appears togive to the treatment a consider-
able activity, as testified by the history of eleven patients
whom he had treated in the wards of the eminent surgeon
of the Hôpital Saint Louis, besides a number of cases
treated by himself in private practice, and all of whom,
with only one exception, whose case was complicated
with rectal hemorrhages, have rapidly derived the most
complete benefit which the treatment has till now given.
Dr. Lucas-Championniére concluded his paper by re-
calling that he did not mean to attribute to the electric
treatment of uterine fibromata and other uterine affec-
tions a primordial importance ; but he wished to impress
upon his hearers that, in the cases where the surgical
treatment is not justified, it is the best of palliatives, and
it succeeds particularly at the period of the menopause.
He believes it to be not only unnecessary but positively
dangerous to employ high intensities; one succeeds as
well with the lower intensities, and there is no inconven-
ience to be dreaded. He himself never employs an 1m-
tensity exceeding ninety milliampéres. Moreover, he
remarks that Dr. Apostoli believes the intra-uterine
action indispensable, and thrusts the electrode into the
uterine tissue when he cannot introduce it into the uterine
cavity—a most condemnable practice. Dr. Lucas-Cham-
pionniére believes that, in this latter case, one should be
contented to apply it to the uterine neck. Finally, he
reminded the meeting that Dr. Danion attaches a great
importance to the reversing of the current ; and he be-
lieves it to be advantageous to practise the operation with
the speculum, after having thoroughly cleaned out the
vaginal cavity. .
THEOPHYLLIN—A NEw CONSTITUENT OF Tea.— This
new base, obtained from the alcoholic extract of tea,
agrees in its elementary composition, C,H,N,O,, with
that of theobromin and paraxanthin, but differs from both
of these substances in its melting-point, mode of crystal-
lization, and behavior with caustic soda. It gives no
xanthin reaction, but on evaporation with chlorine-water
leaves a scarlet red residue, which turns violet with am-
monia, and is decolorized by excess of caustic soda. This
body is described by Dr. Kossel, who discovered it as a
dimethylxanthin.— Therapeutic Gazette.
To Cure a Brack Eye.—There is nothing to compare
with the tincture or a strong infusion of capsicum annuum
mixed with an equal bulk of mucilage of gum arabic, and
with the addition of a few drops of glycerin. ‘This should
be painted all over the surface with a camel’s-hair pencil
and allowed to dry on, a second or third coating being
applied as soon as the first is dry. . It done as soon as the
injury is inflicted, this treatment will invariably prevent
the blackening of the bruised tissue. The same remedy
has no equal in rheumatic stiff neck.—S¢. Louis Poly-
clinic.
SAN Francisco has a Chinese physician, Li ‘Po Tai,
whose professional income is stated tobe $6,000 per
month. He has been established in that city "for thirty
years.
548
THE MEDICAL RECORD:
A Weekly Fournal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., EDITOR.
PROPRIETORS AND PUBLISHERS
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
New York, November 16, 1889.
INFECTION BY PHYSICIANS.
In the Centralblatt fiir Chirurgie for September 28,
1889, Professor A. Neisser, of Breslau, discusses the ques-
tion whether the physician who has been infected with
syphilis should on that account limit his surgical and ob-
stetrical activity. He cites the cases of four of his as-
sistants who had acquired a finger-infection, and states
that Fritsch had had eight assistants and six midwives
similarly infected, all of whom continued their work.
Other illustrations of infected persons and of transmis-
sion of syphilis by them are referred to.
Professor Neisser concludes that it is in the first two
or three years of the disease only that there is any danger,
and he believes that this danger is much lessened by ac-
tive treatment.
He warns especially against the infected person doing
obstetrical or surgical work with the specific eruption on
his hands. A syphilitic person, also, who has a non-luetic
eruption on the hand, should be extremely careful; fur-
thermore, Neisser inclines to the belief that in the first year
or two of syphilis the blood is infective, and that an acci-
dental cut of the surgeon’s hand would be dangerous.
However, with suitable precautions, the physician or
surgeon who is infected can safely carry on his practice,
and need hardly limit his work. The infected midwife is a
much more dangerous person, for she usually has not the
intelligence or honesty to recognize an affection if she have
one.
A much more serious source of danger, in obstetrical
practice particularly, is a puerperal fever of severe type.
The Northwestern Lancet recently, in discussing this sub-
ject, recalls the classical case of Dr. Rutter, of Philadel-
phia.
In the year 1843 he had forty-five cases of puerperal
fever in his practice, and in the next year twenty-five,
while the other physicians of Philadelphia saw little or
nothing of the disease. No amount of bathing, change of
clothing, even shaving the head, had any effect. At last,
in desperation, he went away from the city for ten days,
and when he approached his next patient wore entirely
new clothing and a new wig, leaving even watch and pen-
cil-case at home. Yet this patient, too, was infected in
the same way and died. ‘Thirty years afterward Dr. Rut-
ter’s frightful record was explained by the disclosure of
the fact that he was suffering at the time from a muco-
purulent nasal catarrh, probably an ozzna.
A writer in Zhe London Lancet describes two cases com-
‘THE MEDICAL RECORD.
[November 16, 1889
ing to his knowledge where medical men infected their
puerperal patients through septic discharges from their
own persons. In one case the source of infection was a
slight but offensive discharge from the middle ear, the
sufferer from which had a large midwifery practice with a
great deal of septiczemia.
The other case was one of interest in connection with
Neisser’s article to which we have referred. It was that
of an assistant who went to attend acase of childbirth in
the absence of his principal. ‘The*woman died of puer-
peral fever, and investigation showed that the assistant
was af§icted with tertiary syphilis and had an ozzna.
Such cases show us that physicians cannot be too care-
ful of their persons when attending obstetrical as well as
surgical cases.
THE PATHOLOGY OF SCANDALS.
THE unsavory enterprise of the modern newspaper is con-
stantly bringing to public notice instances of the weakness
and sinfulness of human nature. The clergy, as a body,
receive perhaps more than their share of notoriety, for if
any ordinary man lapses a little it 1s thought to be some-
thing reasonably to be expected. A clergyman, however,
who appears to have wandered from righteousness is the
subject of the biggest kind of head-lines. It has been
often said, among physicians, that strong religious feeling
is usually united with a good deal of erotic fervor. This
is, however, only measurably true. Religion appeals to
the emotions, and successful preachers must cultivate per-
haps unduly the emotional side of their character. The
sexual feeling rises with the common emotional tide, but
it is much less dominant than among artistic professions,
where pure zsthetics is made the chief end of life and
moral restraints are only secondary. The libertinism of
the votaries of art in its various phases is a thing about -
which there is not much dispute, and it is amusing to
learn that a certain prominent actor keeps a scrap-book
containing a record of all the clerical scandals published
in the daily press. :
. The practice of medicine tends to promote intellectu-
ality and mental equipoise, so that medical history is rarely
stained with records of misapplied confidence or scandal-
ous violations of decency. Yet no one better than the
physician knows how erring is human nature, and how full
of temptations is the lot of any man who gains any degree
of popularity or prominence. ‘There exist in society a
considerable number of men whose chief object in life is
the gratification of lust, and who spend much of their time
simply in devising ways of satisfying passion.
Such characters as Smollett’s Count Fathom exist
plentifully to-day, though modern novelists hardly vent-
ure to depict creatures so loathsome. These men are
generally originally depraved; and modern alienists
would place many of them among the moral imbeciles or
paranoiacs.
But there are, unhappily, women of the same type;
perhaps not so vicious, but much more weak. Large
cities contain many of them, and they develop among
the religious congregations as well as in the audiences of
theatres. When one of them is struck with an erotic
passion for her favorite clergyman, or actor, there is
trouble ahead ; and if the man is indiscreet or has ene-
mies watching, a scandal surely follows. One basis for
November 16, 1889] |
THE MEDICAL RECORD.
549
scandals is insanely erotic women, therefore, and not
necessarily bad men.
In justly estimating the merits of those cases involving
the character of men who have lived lives without re-
proach, the pathological element of nymphomania ought
to be considered. In some other cases the scandal is but
the evidence of an incipient insanity, as in the case of a
prominent lawyer who, in the early stages of paresis, went
about making improper proposals to several of his re-
spectable lady acquaintances. Scandal may be a sign of
disease as well as ot vice.
THE WAY TO EDUCATE MEDICAL STUDENTS.
THE continuous agitation by medical journals of the
subject of the faults of medical education in this country
has begun to bear some fruit. It is among the most sig-
nificant results that the public begins to show a little in-
terest in the matter. ‘The daily press often treats of
medical education editorially, and critical reviews publish
articles about it. ‘The North American Review has re-
c:ntly contained an article entitled ‘“‘ The Open Door of
Quackery,” written by three physicians well known as edu-
cators, Drs. Austin Flint and Eggleston, and Professor
Doremus. In this article some plain statements are made
regarding the deficiencies of American medical colleges.
Dr. Eggleston, for example, says—and with perfect truth—
“that there are not a dozen American medical colleges
out of the one hundred and seventeen that would be tol-
erated for a moment in any foreign country that pretends
to be civilized.”
When the public generally knows that the above state-
ment is correct, more care will be taken in selecting the
family physician ; and after a time it will, we trust, come
about that intelligent people will not patronize medical
men who have not had a thorough educational training,
any more than they would hire an engineer who had not
been carefully prepared for his profession, to build a dif-
ficult railroad, or to bridge a dangerous pass.
The two chief deficiencies in medical colleges just now
are lack of the requirement of a good preliminary educa-
tion and lack of facilities for clinical teaching and for
technical instruction in the special branches. ‘The latter
requisite is being supplied measurably by ‘post-graduate
schools, and by the multiplication of small hospitals. ‘The
question of preliminary education is, however, often a se-
rious one.
The physician needs to be not only a medical man with
technical skill, but a man of some general culture and
worldly knowledge. ‘These latter elements are almost as
important as the former. ‘The worst way to make a phy-
sician is to take a youth of sixteen, put him at once into
exclusively scientific studies, follow these up with medi-
cine in all its branches, hospitals, laboratories, clinics, un-
til by the time he is twenty-three he is a monument of
technica] knowledge. Such a course makes good opera-
tors in certain kinds of work ; it produces a narrow spe-
clalistic skill, but not good general practitioners.
Preparatory schools of medicine are, we sincerely be-
lieve, useless and pernicious institutions.
The best preliminary training is undoubtedly such as is
now given in our smaller colleges, but so modified in the
last two years that the graduate in arts can graduate in
medicine after two years of study in a medical college hav-
ing nine months terms. ‘Then, with a year or two spent
in hospitals or post-graduate courses, the student is ready
to do good work in his professsion, and he need not be
more than twenty-four or five years of age.
PROCURSIVE EPILEPSY.
A GooD deal has been written lately, in German and es-
pecially in French journals, about a peculiar form of epi-
lepsy which is termed “ procursive.” Drs. Bourneville
and Bricon have studied the disorder with great care, and
have published a large monograph upon it (Arch. de
Neurol., vols. xiii., xiv., and xv., 1887 to 1888). Drs. A.
Mairet and Ladame have also reported cases.
Procursive epilepsy is a form of epilepsy in which the
patient does not have the ordinary convulsive attack, but
instead of it suddenly runs forward, or in a circle. The
attacks are usually brief, they are not ordinarily followed
by somnolence or coma, and the patient does not
fall.
Procursive epilepsy has been described by the older
writers as Chorea procursiva, seu festinans, s. rotatoria,
Systematized impulses, etc. No doubt the disease has
often been looked upon as a form of hysteria or chorea.
Besides the true and typical procursive epilepsy there are
cases of ordinary epilepsy with a procursive aura, so to
speak. The patient suddenly runs forward, then stops, ut-
ters a scream, and falls into a.convulsion. In other cases
the running or rotatory movements follow the convulsive
attack.
The cases of epileptic automatism in which the patient,
mstead of having clonic and tonic spasms, goes through
certain familiar automatic movements, are very properly
considered as belonging to this category.
In several cases in which autopsies have been made by
Bourneville and Bricon, upon patients who had procursive
epilepsy, an atrophy, more or less marked, of one of the
cerebellar hemispheres, was observed, and it is believed
that the forced movements are due to some involvement
of this part of the brain. A case of Mairet’s tends to con-
firm this view.
Procursive epilepsy is usually associated with organic
brain defects, and it is, therefore, a pardicularly serious
form of disease. Its treatment does not differ from that
of other forms of epilepsy.
IMPERFECT INTESTINAL ABSORPTION AND ITS MAN-
AGEMENT. l
AMONG the most certain and satisfactory of chemico-
physiological tests is that of the absorption-rate of the in-
testines. This test was first described by Professor Ewald,
in 1887, when he detailed a number of experiments which
showed that salol was insoluble in the gastric juice, but
that it was decomposed into its two constituents, when,
after passing into the small intestine, it was subjected to
the action of the duodenal contents. Very shortly after
absorption into the circulation it passes through the kid-
neys, and is eliminated in the urine as salicyluric acid and
sulpho-carbolic acid, its presence being demonstrated by
the production of a red-violet precipitate when the urine,
after acidulation with hydrochloric acid and shaking with
ether, is tested with a solution of perchloride of iron.
55°
THE MEDICAL RECORD.
[November 16, 1889
Tests made by Ewald in 39 cases showed the presence
of the reaction in the urine—
After 30 minutes in, ........... ce eeeee I case
“ ss EEN OT 32 CASES
A DOO: Te Wennen eee e 6 "
Dr. Eccles (The Practitioner, October, 1889), repeated
Ewald’s experiments on fifty patients, and detected the
salol components in the urine.
After 25 minutes in... ......e eee eee eee 3 cases
Oe 30 1 eae decee ten eeeeatns 2 “
ss ss ee EE cece E wie ae seats 42 de
“ 6 e E E wesees i as
Thus it may be considered established that the average
time required for salol to pass into the duodenum, be de-
composed and pass through the kidneys is forty-five min-
utes. |
Now in muscular weakness of the stomach, and in dis-
ease of the intestines, this time is greatly delayed, and by
studying cases with the help of the salol test, the rate of
improvement and. the efficacy of remedies may be esti-
mated.
Dr. Eccles has attempted to measure the value of ab-
dominal massage in conditions of impaired digestion and
absorption by the salol test.
In two cases in which the reaction was not obtained
until an hour after injection of ten grains of salol (the
amount always used in the test), abdominal massage was
performed once daily for fifteen minutes for a week with
no result. General massage was then done daily for forty-
five minutes, for a week, when the salol was detected with-
in half an hour after its ingestion.
Two cases of tropical diarrhoea and two of dilatation of
the stomach were treated by general and abdominal mas-
sage daily. In one case treatment had to be abandoned,
but in the other the rate of absorption, or gastric move-
ments, which had been been abnormally slow, was brought
nearly to normal, with corresponding improvement in the
condition of the patients.
It may be considered proven that by vigorous and per-
severing massage intestinal absorption and the peristaltic
activity of the stomach are improved. Whether this mode
of treatment has a special value and reaches cases which
could not be helped by other means, remains to be estab-
lished.
THE INFLUENCE OF HEREDITY IN THE CAUSATION
OF TUBERCULOSIS OF BONE.
Ir is a matter of common observation that patients suf-
fering from tuberculosis of the bones and joints, as well
as those with the pulmonary form of the disease, not in-
frequently give a history of tuberculous troubles in the
immediate family, especially in one or the other parent.
Some observations recently published by Dr. Julius
Dollinger, of Budapest, in the Centralblatt für Chirurgie,
No. 35, 1889, tend to confirm the belief in an heredi-
tary predisposition which the general experience of
practitioners has established.
Dr. Dollinger found, upon making inquiry of the parents
or guardians of the children brought to him on account
of bone or joint tuberculosis, that in a large proportion
of cases one or more of the immediate ancestors had suf-
fered from pulmonary phthisis. Usually, however, it was
not the parents alone whe were the sufferers, but the grand-
parents also, and not infrequently only he latter. The
world.
` lint or soft linen.
writer concludes, therefore, that bone phthisis occurs not
in the children but in the grandchildren of those who have
died from pulmonary tuberculosis. The influence of the
tuberculous virus must be exerted through several gener-
ations before the normal resistance of the osseous struct-
ures is so far weakened that they become a suitable field
for the lodgement and development of the tubercle bacil-
lus. In other words, the author’s experience adds weight
to the common belief that the so-called scrofulous affec-
tions are a modified form of tuberculosis, and would seem
to justify the retention of the term scrofula as expressing
a mild, or at least a modified, form of the tuberculous
disease.
—————=—_————
Hews of the Geek.
MICROBIC EXPECTORATION STATISTICALLY STUDIED.—
Bollinger has shown the curious fact that a cubic centi-
metre of phthisical sputum contains from eight hundred
and ten thousand to nine hundred and sixty thousand tu-
bercle bacilli. In other words, in an ordinary copious
expectoration the consumptive deposits nearly a million
bacilli in his cup, and in an ordinary day he throws thirty
or forty millions of the micro-organisms out upon the cold
The, at a low estimate, ten thousand tuberculous
patients in New York City daily expectorate some 300,-
000,000,000 bacilli! ‘The yearly number would be—but
the imagination fails to follow such statistics. It takes at
least eight hundred of the microbes, however, to start up
tuberculosis even in a guinea-pig.
Five CHINESE LEPERS were shipped home from San
Francisco, October 29th, on a Hong Kong steamer.
Among them was a man who was sent to San Francisco
from New York, where he had been employed as a cook
for laborers on the Croton Aqueduct work.
A SEVERE INDICTMENT.—Lanphear’s Medical Index
says that Hot Springs, Ark., contains sixty practising
physicians. Of these, seven are regular, and the rest
thieves or quacks, or both.
ANOTHER OFFICE SNEAK THIEF.—Keep an eye on the
man who leaves a message to call on a fictitious patient,
and takes anything within his reach. Such an individual,
who is well dressed, tall, thin, and dark-complexioned, is
in the business. The best rule is never to allow any
stranger to “ wait for the doctor,” unless he or she is un-
der the eye of one of the servants. If this is impossible,
have nothing in the waiting-room that anyone can steal.
MORPHINE-VASELINE AS A LOCAL APPLICATION IN CAN-
CER.--In the Asclepiad, May, 1889, p. 147, Dr. Richard-
son states that morphine combined with vaseline forms
one of the best possible sedative applications in cases of
externa] malignant disease in which there is ulcerative
breach of surface with continuous pain. The author pre-
scribes it in the proportion of four grains of morphine to
an ounce of vaseline, with two drachms of chloroform.
The chloroform acts as a sedative, and causes the mor-
phine to be better distributed. Morphine-vaseline is most
conveniently applied thinly spread over a piece of fine
It is easily removable without injury to
the surface upon which it is applied, and should be re-
newed twice in the course of twenty-four hours.
November 16, 1889]
THE LATE Dr. Isaac E. Taytor.—“ The Faculty of
the Bellevue Hospital Medical College have the painful
duty of directing a record in their minutes of the death of
their first and only President, the late Dr. Isaac E. ‘Tay-
lor. His invaluable services in the organization of the
College, and his unflagging interest in its progress and suc-
cess need not be recorded here. ‘The same may be said
of his contributions to medical science and of his labors
in the various medical organizations of this City and State.
His refined, gentle, and kindly nature endeared him to all,
and especially to those associated with him in the Belle-
vue Hospital Medical College ; while his lovable personal
qualities protected him from the enmities which too often
attend professional success.—Ausrin FLINT, Secretary.”
At a meeting of the New York Obstetrical Society,
held November sth, the following preamble and res-
olution were unanimously adopted :
“* To the President of the New York Obstetrical Society:
“ Your Committee begs leave to present the following
resolution, as in some manner expressive of the pro-
found sense of loss felt by this Society in the death of
Professor Isaac E. Taylor, M.D. :
* Resolved, ‘That the members of this Society have
learned with deep regret of the death of Dr. Isaac F.
Taylor, one of its most distinguished Fellows. It is their
wish to express here their high appreciation of his pur-
ity of character, his enthusiasm in promoting obstetric
science, his lofty ideals, the kindness of his nature, his
self-sacrificing disposition, and his warm-hearted benevo-
lence. In recalling his life and character it is pleasant
to remember that the deeds of good men live after them.
—ForpycE BARKER, M.D.; WittiaM T. Lusk, M.D.;
WILLIAM M. Pork, M.D., Committee.”
“The council of the New York State Medical Associa-
tion sadly records its unfeigned sorrow for the loss of a
valued Founder, Fellow, and late President, endeared by
his personal qualities as he was admired for his scientific
attainments. An illustrious name is transferred from the
active list to the roll of honor of those who have bravely
borne themselves in the foremost rank, and fallen triumph-
ant. Untiring in industry, wise in council, affectionate in
friendship, steadfast in religious faith, beloved by his as-
sociates, and revered by the profession which acknowl-
edged him as one of its leaders, Isaac E. Taylor lived an
example for emulation by his survivors and successors,
and rests from his labor, leaving a reputation unassailed
by enmity, and beyond the reach of jealousy. By the
Council: Jonn G. ORTON, M.D., President ; E. D. FER-
GUSON, M.D., Secretary.”
DR. BLANC, OF AIX LES BAINS, France, is paying a visit
to this city, and is the recipient of many courtesies from
representative medical men here. Numerous dinners, pri-
vate and public, are tendered him, and he cannot fail to
appreciate that his distinguished professional standing ac-
cords to him a becoming recognition.
TREATMENT OF SPRAINS.—It may be observed that
a sprain is frequently treated with a liniment advised by
physicians. It is indeed painful to see a physician writ-
ing a prescription fur a sprain. There are but two indica-
tions in the treatment of sprains: 1, To provoke rapid
absorption of the fluid effused around and within the joint ;
and 2, to favor cicatrization of the torn parts by immo-
THE MEDICAL RECORD.
55!
bilizing the articulation. Now, the modes of treatment
hitherto in vogue do not fulfil these two indications.
Massage would seem to present some real advantages, but
‘it can be of little service in the case of severe sprains, and
mild injuries would probably do as well under rest alone.
An elastic bandage, the depressed parts being covered
with a layer of cotton so as to prevent too great a press-
ure over the prominence, and thereby causing sloughs,
will meet the first indication, and by its use in procur-
ing rest it will meet the second indication. This band-
age acts like massage in promoting absorption, and also
secures immobility of the joint. It is of equal service in
sprains complicated with rupture of points of insertion,
whereas massage would be productive of harm in cases in
which splinters of bone were torn away. ‘The practice of
relieving the mind of the patient by giving him something
to do in the way of applying bad-smelling liniments is a
pemicious one, and really shows an unprofessional or un-
scientific atterdant.—Canada Lancet.
ANNIVERSARY MEETING OF THE NEW YORK ACADEMY
oF MeEDicINE.—The Anniversary Meeting of the New
York Academy of Medicine will be held on Thursday,
November 21, 1889. The address will be delivered by
Dr. William M. Polk, entitled “ The Relation of Medicine
to Some of the Questions of the Day.” ‘This meeting is
public, and the laity—ladies and gentlemen—are particu-
larly invited.
PANPHOBIA.—Sanitarians will sometimes develop a cer-
tain degree of panphobia, and Dr. Baker, of the Michigan
Board of Health, appears to have become a little touched
with this affection. He has issued a circular, in which ] e
states that the autumn fires in the woods and fields produce
an amount of smoke which aggravates disease, causes sleep-
lessness, nervous disturbance, and general discomfort ;
and he adds that tonsillitis increased fifty per cent., and
inflammation of the brain twenty-five per cent., in the
month of October! Dr. Baker should live awhile in
London, one of the healthiest cities in the world, but en-
wrapped most of the time in a cloud of smoke. It is
sometimes wise to remember Punch's verse :
* Hygeia, thou’rt clever,
But, ’twixt you and me,
To fidget forever
Is fiddle-de.dee,”’
_ A SUBSCRIPTION has been started in Italy for the pur-
pose of placing a marble bust of the late Professor Loreta
in the hall of the University of Bologna.
Dress OF MEDICAL STUDENTS.—The Council of the
Senate of the University of Cambridge have recently
had before them the grave question of the proper aca-
demic raiment of Bachelors of Medicine. In future
the official attire of holders of that degree is to consist of
a black gown of the same shape as the scarlet gown worn
by Doctors of Medicine, and a hood like unto that worn
by Masters of Arts, but lined with pink instead of white
silk. It is to be hoped that this “ purple and fine linen”
will not turn the heads of the “new-made baccaleres” in
medicine.
STILL ANOTHER New Hypnotic is “Somnol.” It is
an ethyl-chloral-urethane (7H,,C1,O,N). It is given in
doses of about thirty grains. It has been discovered by
M. Radlauer, of Berlin.
552
A SAD COMMENT ON MEDICAL Non-Success comes from
Chicago in the shape of the suicide of Dr. Edward Deans,
at the age of seventy-one. He had been county physician
of Cook County from 1860 to 1863, but decreasing
practice and lack of means and old age induced the
suicidal act.
SYNTHETIC SOMNAMBULISM.—Dr. B. W. Richardson
says that inhalation of the vapor of amylene produces a
condition of somnambulism.
A New LISTER DREssING.—It is stated that Sir Joseph
Lister has devised a new form of surgical dressing and
new antiseptic fluids, which are to surpass all his former
achievements in this direction. He had intended to com-
municate a paper on the subject to the Congress of Ger-
man Surgeons, but was not ready in time. It is now
expected that he will describe his new methods at a
meeting of the Medical Society early in November.—Lon-
don Cor. Occidental Medical Times.
ELECTROMANIA.—No other term can be applied to the
condition of mind from which Dr. F. ‘T. Paine, of Texas,
seems to be suffering in connection with the use of elec-
tricity. This agent, according to the gentleman in ques-
tion, relieves the pains of labor, stops the pains of crying
children, produces a copious flow of milk from agalactic
mammæ, and in general is a wonderful and universal
anesthetic. That electrical currents sometimes relieve
pain and cause nervous sedation is a fact long well-known,
but their power is limited and the promulgation of ideas
like those of Dr. Paine simply bring disrepute upon our
science.
THE First CONGRESS OF PHYSIOLOGY, which was held
at Basle last month, 1s spoken of as having been a model
of what scientific gatherings should be, that is to say, it
combined the maximum of work with the minimum of
junketing and miscellaneous festivity. The idea of hold-
ing such a meeting emanated from England, and it was
taken up both at home and abroad with as much enthu-
siasm as physiologists could be thought capable of. The
task of organizing the Congress fell on Professor Miescher,
of Basle, who spared no trouble to make it a success.
The invitations were issued in January, and one hundred
and twenty-nine physiologists responded to the appeal.—
London Medical Recorder.
A TRuLY Woman’s HospiTaL.—We learn that under
the patronage of the Princess of Wales London is to have
still one more hospital, which is, however, to differ very
materially from those heretofore founded. Not only are
all the patients to be women, but all the physicians, sur-
geons, and apothecaries connected with the establishment
are to be of the softer sex.
STRICKEN WITH APOPLEXY.—Dr. Bancroft, Sr., of
Concord, N. H., formerly superintendent of the State
Insane Asylum, was recently stricken with paralysis while
conducting the meeting, in Boston, of the New England
Psychological Society, of which he is president; toward
its close he noticed that his left side was becoming grad-
ually disabled. With a singular fortitude under the cir-
cumstances, he continued his duties as presiding officer,
rising to make some concluding remarks, though leaning
heavily against the table for support, and even putting the
motion to adjourn after some of his associates had assisted
him into his chair.
THE MEDICAL RECORD.
[November 16, 1889
CEREBRAL HyPERAMIA is a term much heard of some
years ago, but it has of late been sinking into innocuous
nosological desuetude, and in its place are learned articles
about “ congestive neurasthenia.” ‘Terminology fluctuates,
but disease keeps about the same.
A MEDICAL COLLEGE IN CONNECTION WITH CORNELL
UnIveErRsITy.—President Adams, in his recent annual re-
port, suggests that a medical department of Cornell Uni-
versity, located perhaps in New York City, would be a
proper thing to have.
Vacancies Harp TO Fitt.—The Medical Examining
Board for the Navy, which convened in this city last
August, is still in session, and has so far failed to get any
successful competitors for its examinations. ‘There are
mine vacancies to fill and there have been only four ap-
plicants, none of whom have been able to pass the exam-
inations. It is stated that there has seldom been a time
when applicants for the medical corps examination were
so hard to obtain. It is nearly useless for a candidate
to present himself before the board unless he can show
his A.B. as well as his M.D. In other words, a candi-
date must have a thorough collegiate education, must be
more than ordinarily proficient professionally, and must
possess a good physique. As compared with other Gov-
ernment Services it is stated that last year ten vacancies
existed in the medical corps of the Navy and five vacancies
in the Marine Hospital Service. It was found well-nigh
impossible to get candidates for the Navy medical exam-
ination, whereas there were about seventy-five applicants
for the Marine Hospital Service. Candidates were afraid
of the former examination and preferred to try one
known to be easier. It is not an uncommon occur-
rence for two hundred candidates to present themselves
before the army boards when there exist not more than
two vacancies.
A MEDICAL JOURNAL WINS A PrizeE.—The Riforma
Medica, a daily medical journal published at Naples, has
just received the first prize in the section of medical pub-
lications at the Exhibition of Hygiene and Medicine re-
cently held at Padua.
A NEw OPHTHALMOLOGICAL SOCIETY has recently been
established in Paris. M. Chevalerau is president, M.
Chauvel vice-president, and M. Gorecki general secretary.
‘Is MAN LEFr-LEGGED ?—Dr. W. K. Sibley read a paper
before the British Association in which he argued that
man was naturally left-legged. Standing working with
the right hand, there was a tendency to balance on the
left leg. Race paths were nearly always made for run
ning in circles to the nght, and the majority of move-
ents (such as dancing, running, etc.) were more readily
performed to the right. In walking, it was natural to
bear to the right; crowds as well as individuals did so.
‘Troops started off with the left foot; the left foot was
placed in the stirrup or step of the bicycle in mounting ;
the left foot was the one from which a man took off in
jumping. From measurements made by Dr. Garson of
the skeletons of the two legs, in 54.3 per cent. the left leg
was the longer, and in 35.8 the right. From measure-
ments of 200 pairs of feet, it was found that in 44 per
cent. the left, and in 21.5 the right, was longer, while in
34.5 they were equal.
; November 16, 1889]
THE MEDICAL RECORD.
553
Society Reports,
THE PRACTITIONERS’ SOCIETY OF NEW
YORK.
Stated Meeting, November 1, 1889.
Francis P. KINNICUTT, M.D., PRESIDENT, IN THE CHAIR.
Dr. ANDREW H. SMITH read a paper (see p. 541) entitled
SACCHARIN AS A MEANS OF ACIDIFYING THE URINE.
Dr. WEIR said that he had resorted to the use of
saccharin in cases of alkaline urine about a year ago, and
had since used it for this purpose a number of times. ‘The
results obtained were not always satisfactory, but usually
he had been pleased with the action of the drug. He
had obtained the best results in cases of vesical trouble
following a gonorrhoea. Several years ago, Sir Henry
Thompson recommended the use of pure lemon juice in
cases of bladder trouble associated with alkaline urine.
The speaker had tried it in several bad cases of prostatic
cystitis, with very satisfactory results. The lemon juice
was not always well borne by the stomach, but when it
was the effect was generally very good.
Dr. BEVERLEY RoBinson asked whether the drug had
any toxic properties. It had been asserted that it was
sometimes productive of unpleasant effects.
Dr. SMITH said that he had never seen any unpleasant
effects from the drug, although he had used it quite ex-
tensively, and had also taken considerable quantities him-
self. He had not found that it caused any disturbance of
digestion, but, on the contrary, it had seemed to act as a
preventive of gastric acidity. A number of experiments
had been made upon dogs, with the result of proving
pretty conclusively that the digestion was in no way im-
paired by the administration of saccharin. Dujardin-
Beaumetz had at one time thought that it was a toxic
substance, but he had since, the speaker believed, as-
serted that the drug was harmless.
THE PRESIDENT asked whether the prompt effect of the
drug were not due as much to its antiseptic action as to
its acid properties.
Dr. SMITH replied that that was a possible explanation
of its beneficial effect in the cases referred to, yet saccha-
rin was a powerful acid, and was not broken up in the
body as were the vegetable acids.
Dr. H. F. WALKER then read the paper of the evening
(see p. 530), entitled
TUBAL PREGNANCY TREATED BY FARADIC CURRENT.
Dr. WEIR said that he had seen a case last spring in
which the faradic current had been tried and had failed.
Laparotomy was then performed, and the patient made a
good recovery. The age of the foetus was less than three
months. He asked what result was to be looked for in
these cases when no interference was attempted. Did
not the foetus often die of itself, recovery then following ?
Dr. CLEMENT CLEVELAND said that a German writer
had recently collected reports of a number of cases in
which the foetus had died spontaneously. In one case
the pregnancy had occurred fifty years before the death of
the woman, the dead foetus having been carried all that
time without giving rise to any serious symptoms. The
trouble in these cases is to make a diagnosis early enough
to allow of proper treatment. ‘The speaker had seen a
case about two years ago, with Dr. Hawley, in which the
patient complained of a good deal of pain, and examina-
tion revealed the presence of an abdominal tumor. They
came to the conclusion that the case was one of extra-
uterine pregnancy. Laparotomy was performed, and the
mass was removed without rupture. On opening the sac,
a foetus, apparently somewhat over three months of age,
was found. The woman made a good recovery.
Dr. WALKER said that he did not regard it as safe
to leave an extra-uterine pregnancy without interference,
in the hope of spontaneous recovery. There were doubt-
less some cases in which recovery would take place, but it
was not right to trust to this. |
Dr. Weir asked whether the foetus at this age could be
killed by electricity employed in this way.
Dr. CLEVELAND said that it was certainly a well-au-
thenticated fact that electricity could destroy tne foetus.
Dr. C. L. Dana said that he had been struck, in look-
ing over the literature of electro-therapeutics, by the ab-
sence of any observations in which it was absolutely dem-
onstrated that the electric current commonly employed
for this purpose would kill the foetus. A faradic current
had doubtless often been employed on pregnant women
without killing the child. If the foetus could be killed by
an ordinary faradic current, how easy it would be to pro-
duce abortion. Theoretically, it ought to take an alter-
nating current of considerable strength to kill a foetus in
this way. So far as he knew, there had been no. careful
experiments made upon animals to determine whether
these small currents really would kill.
Dr. A. H. Smitu said that he had once killed a mouse
very promptly by passing through its body the current
from a faradic battery. He thought that a mouse would
have as much power of resistance as a foetus only two
months of age, or even younger.
Dr. CLEVELAND thought that the large number of
cases in which electricity had beem successfully employed
for this purpose was sufficient to demonstrate its practical
efficacy, despite the theoretical objections that might be
raised against it.
Dr. RoosEvELT thought that the death of the foetus
might be due to stoppage of the heart by the direct action
of the electric current.
Dr. Dana said that he would admit the strength of the
argument from experience, still he thought it was rather
strange that there was no record of any experiments
showing that the death of the foetus could actually be
brought about by the use of such mild electric currents.
Dr. GeorcE L. Peasopy presented a specimen of the
new hypnotic, |
CHLORALAMID,
and related his experience with it. He had been using it
in Bellevue Hospital for about three weeks, in cases of
insomnia of different kinds, from different causes and
varying grades of severity, often complicating grave or-
ganic lesions. Chloralamid is formed by a chemical
union between chloral and formamid. Of its manufact-
ure little or nothing has been published, because the drug
has been patented. It occurs in the shape of brilliant,
white crystals, whose taste is slightly bitter. It melts at
115° C., and by distillation is resolved into its two com-
ponents. It is very slowly soluble in ten parts of cold
water, and in one and a half part of ninety-six per cent.
alcohol. It is much more soluble in hot water than in
cold, but care must be taken not to use water heated
above 60° C., for the reason that a higher degree of heat
causes it to become decomposed into chloral hydrate and
formamid. ‘This resolution occurs with great uniformity
in the presence of alkalies, whereas weak acids do not af-
fect it. It is probably decomposed by the alkali of the
blood, and thus rendered potent as an hypnotic by the
slow liberation of chloral.
The advantages claimed for this preparation are chiefly
that respiration and heart-action are not affected by it: es-
pecially is blood-pressure lowered but little. According
to our present experience with it, it does not disorder di-
gestion. An effective dose is from thirty to forty-five
grains. It should not be forgotten, in using chloralamid,
that it contains over seventy-six per cent. of chloral, and
therefore it should not be used in doses larger than sixty
grains, or in daily amounts greater than one hundred and
twenty grains. In its action it is a less energetic hypnotic
than is chloral hydrate, and less prompt in the production
of its effects. It requires from half an hour to an hour
to make its influence felt.
In Dr. Peabody’s experience, a headache the next morn
554
ing was of frequent occurrence following a dose of this
drug ; but he had never known the stomach or digestion
to be disturbed by it. It has the advantage of being much
less irritating to the mucous membrane than chloral. It
can be well given in powder—being not deliquescent—or
dissolved in wine or spirits. Its solution becomes easier
if the vehicle is warmed. Its taste is less unpleasant
than that of chloral hydrate.
Dr. Peabody had found it useful in all varieties of in-
somnia which are not accompanied by pain. In phthisis
it had given good results in his hands ; also in alcoholism,
in fracture of the base of the skull, in intermittent fever,
in typhoid fever, in phthisis complicated by alcoholism,
in pneumonia, and in cerebral hemorrhage with very great
restlessness. In two cases of neuralgia with insomnia it
gave great relief. One of them was a pregnant woman
with severe neuralgic pains in the thigh ; the other was a
case of multiple neuritis of alcoholic origin. It had never
produced any alarming symptoms of any kind, and the
only unpleasant one caused by it in his hands was
headache. This headache usually passed off early in the
forenoon. There is no such drowsiness the next day as
there is after sulphonal, but it has not seemed quite as cer-
tain in its effects as the latter drug.
Dr. A. H. SMITH said that he had made a trial of this
drug at the Presbyterian Hospital the evening previous.
The cases in which it was tried were suffering apparently
from simple insomnia. ‘The house-surgeon had reported
that the result was not at all satisfactory. The action of
the drug seemed to be that of diluted chloral merely.
Dr. CLEVELAND said that he had tried it in one case,
that of a lady who had been taking sulphonal for some
time, and to whom he thought it desirable to give some
other hypnotic for a while. The effect was very unsatis-
factory. His patient said that the drug had failed to
give her sleep, but rather caused excitement, and she also
complained of headache. He had had to return to the
sulphonal.
Dr. BEVERLEY ROBINSON reported a case of
INTESTINAL HEMORRHAGE
occurring in a patient at St. Luke’s Hospital. For the
notes of this case he was indebted to the house-physician,
Dr. Wiliam H. Caswell. The patient was a married
woman, aged twenty-three, who was admitted to the hos-
pital on October 27, 1889. She gave a previous history
of languor and anorexia for one week or more, followed
by a rise of temperature from 102° F. to 105° F. There
had been persistent vomiting of the milk and lime-water
which had been ordered as the sole diet. ‘There had
been no blood in the vomited matters. On admission
the patient was able to talk intelligently, she had a pulse
of about go, a white-coated tongue, tympanites, and some
tenderness on palpation over the abdomen. ‘The vomit-
ing continued, and toward evening on the day of admis-
sion began to show some blood mixed with the partially
digested milk. The hzmatemesis continued through the
night, about two or three ounces being vomited at a time.
The bowels moved voluntarily four times during the
night and early morning, the motions being loose, of a
light yellow color, and unmixed with blood. The patient
died about noon the day after admission. A diagnosis
had been made of typhoid fever with intestinal hemor-
rhage, and after death a needle inserted into the left side
of the abdomen, as nearly as could be determined into
the lower part of the descending colon, showed the pres-
ence of dark-colored blood rather thick in consistency,
though fluid. No autopsy was allowed. ‘The case was
interesting from the fact that no blood escaped from the
bowel, but was vomited.
_ Tue PresipENT said that he had known of a case
within the last ten days, occurring in the person of a phy-
sician, in which the symptoms were typical of typhoid fever.
The patient died from hemorrhage. A large quantity of
blood was vomited, but none passed from the anus.
The Society then adjourned.
THE MEDICAL RECORD.
[November 16, 1889
NEW YORK ACADEMY OF MEDICINE..
SECTION ON OBSTETRICS AND GYNECOLOGY.
Stated Meeting, October 24, 1889.
J. E. JANvRiIN, M.D., CHAIRMAN.
Dr. R. A. Murray read a paper on
THE MANAGEMENT OF ABORTION.
He had become convinced from observation that no fixed
rules guided the general practitioner in the management of
abortion ; that the treatment was too frequently wavering,
hesitating, a waiting on nature. While the application of
antiseptic principles had been brilliantly successful in la-
bor at full term, it had been greatly neglected. in early
delivery or abortion. It should be borne in mind that
abortion, using the term to mean expulsion of the product
of conception before viability, was always a pathological
process.
In the early weeks the abortion was usually accom-
plished quickly, without very profuse hemorrhage, the
deciduous membrane coming away with or after the ovum.
The expulsion was not so much from uterine contraction
as from hemorrhage into the uterus. At the middle of
the second month the deciduous membrane was more
firmly attached and likely to remain, causing hemorrhage.
After this period the conditions were different; the pla-
centa having fully formed the miscarriage could be di-
vided into two stages: 1, The separation and expulsion
of the foetus; 2, the separation and expulsion of the
afterbirth. Here hemorrhage was not usually an impor-
tant factor before the expulsion of the ovum, unless trau-
matism were the cause. ‘The contractions determined
the expulsion, and as they were inefficient the case pro-
ceeded slowly. The hemorrhage taking place after ex-
pulsion of the fcetus usually ceased after a short time, to
come on more profusely afterward. The placenta was
often detached piecemeal. Hemorrhage was always pres-
ent in abortion, was likely to be profuse, was always so
when the expulsion was in two parts, the ovum first, then
the membrane. It generally preceded as well as accom-
panied expulsion of the ovum, and its continuance was
almost positive proof that the membrane or placenta had
been retained.
The treatment of abortion was discussed under the
headings prophylaxis or curative measures, and the man-
ageraent of complete or incomplete abortion. By proph -
ylaxis was understood the treatment of the various con-
Seitutionel and diasthetic causes which operated to produce
miscarriage, such as syphilis, lead-poisoning, urzemia, pro-
found anzmia ; also local conditions, as changes in the
uterus ; traumatic influences, as heavy lifting, etc., which
caused congestion of the uterus.
When abortion was threatened, shown by pain and
hemorrhage, the patient should take the recumbent posi-
tion, cool drinks be given, moral disturbances be avoided.
For pain, administer opium in full doses. Drachm doses
of compound extract of viburnum every two or three
hours, until the pain and hemorrhage had ceased, had
been useful. Chloral hydrate and bromide of potassium,
by stopping pain and relieving nervous excitement, had
contributed to allay uterine action.
If the symptoms continued, the cervix softened, there
was tenderness in the uterus and ligaments, particularly if
there had been an escape of the waters or any part of the
uterine contents, we were warranted in ceasing our efforts
at prevention and in hastening the abortion.
All examinations should be made with strict antiseptic
precautions. If the hemorrhage were not profuse and the
cervix not dilated, an injection of a solution of carbolic
acid might be made, and an antiseptic pad applied to the
vulva. To hasten the abortion a vaginal tampon was in-
troduced of iodoformized or borated cotton, closely
packed around the cervix by the aid of an applicator
used through a speculum, the patient being in Sims’ po-
sition. Where the hemorrhage was profuse alum might
be used, but it was objectionable in that it contracted the
November 16, 1889]
THE MEDICAL RECORD.
555
vagina, It possessed the advantage, however, of check-
ing hemorrhage or damming the blood back in the uterus,
causing the cervix to distend and enhancing uterine pains.
If not left in more than twelve hours it remained antisep-
tic, and was to be preferred to the colpeurynter. Ergot
might be given in moderate doses ; large ones caused ri-
gidity of the cervix and retarded expulsion. If, when the
tampon was removed, the os was dilated, the ovum could
usually be reached by the finger, in which case it was best
to proceed to empty the uterus. Thorough exploration of
the endometrium was facilitated by pressing the fundus
downward and forward with the other hand over the ab-
domen ; if the products of conception could be detached
by the finger, it should be removed by a placental forceps
passed up alongside the finger, grasping the loosened
structure, twisting it around, and withdrawing it. If any
portion remained it should be scraped off with the blunt
Thomas curette ; the operator should not be satisfied un-
til the whole endometrium was smooth. The uterus
should then be washed out with carbolized water, prefer-
ably thrqugh a double catheter, and the one he used most
was Fitsch’s, with asomewhat smaller curve than the origi-
nal. The current continued to flow as the tube was with-
drawn, membranes were washed from the uterus and va-
gina, and a pad then applied to the vulva. Hemorrhage
would cease entirely on completely emptying the uterus.
He had not had occasion to repeat the uterine injection ;
there had been no febrile or septic symptoms, no pelvic
peritonitis. If the single catheter were employed, care
should be taken that there was perfect egress of the fluid.
If the uterus had been depressed in the way mentioned,
one must not forget to lift it by the finger to the normal
position. No antiseptic, as iodoform, should be used in
the dressings which would obscure the odor should decom-
position afterward take place. Nor did he ever use bi-
chloride of mercury unless the products removed were
already decomposed ; in that event he employed 1 to
5,000, leaving none of the injection in the uterus. Such
was the course he pursued when he had seen the case from
the beginning.
In incomplete abortion the patient might give one of two
histories: 1, The products of conception having passed,
but not saved for inspection; 2, presence of pain and
hemorrhage, no knowledge of escape of the ovum, although
it might have taken place with the bloody discharge.
If the abortion were incomplete and the cervical canal
closed, what course should be pursued? This had been
a mooted question. Many authorities were in favor of
emptying the uterus at once ; others, especially the French,
advised the expectant plan. The author thought that if
the uterus was still large and the cervix soft, though but
slightly open, it would be far safer, although hemorrhage
may have ceased, to carefully introduce the blunt curette
or small uterine sound and gently explore for inequalities
of the endometrium ; if found, to dilate, remove the re-
mains, and use the douche. In neglected incomplete
abortion, with fetid lochia, retained placenta, intermittent
hemorrhage, septic absorption, the canal should be dilated,
the cavity thoroughly washed by an antiseptic solution, the
blunt or sharp curette used, this followed by another intra-
uterine and vaginal douche, the vaginal douche to be re-
peated if the fetor continued in the lochia. Such reme-
dies as alcoholic stimulants, digitalis, and quinine might be
called for. The author also discussed briefly the use of
galvanism and faradism for exciting uterine contractions.
He doubted their value, although he had had no personal
experience with them. He thought the curette was su-
perior to the use of the brush, or what was called grattage
by the French.
There was a large mortality from puerperal diseases,
due in considerable measure to neglected cases of abor-
tion. This would cease if physicians generally would ob-
serve the simple rules described in the paper.
Dr. A. F. CURRIER thought the treatment of abortion
was one thing in regard to which the profession had
reached a certain degree of exactness, and it was largely
due to advances made in antiseptics. There was little to
criticise in the paper. He thought, however, that uter-
ine contractions had more to do with early abortion than
the author had stated. He laid stress on the use of the
blunt curette in diagnosis, particularly as to the condition
of the endometrium after the foetus had been expelled ;
it was superior to the finger. After cleaning out the
uterine cavity, he applied to its surface pure carbolic acid.
He knew of but one exception to the course of treatment
by the use of the curette, etc. It was in a class of cases
like one he saw last summer, in which the patient, seen in
consultation, had become almost moribund from loss of
blood and exhaustion. She was extremely anxious to
have a child, and for that reason her physician had not
hastened abortion. When Dr. Currier saw her they tam-
poned the vagina ; in a few hours the foetus came away,
and, as far as he could determine, all the membranes.
Because of this fact and that of her exhausted condition,
he did not curette the uterus. She died in about forty-
eight hours. In addition to tamponing the vagina, spoken
of by the author, he thought it important also to insert a
plug into the uterus.
Dr. P. F. Munpé referred to a paper which he pub-
lished in 1883, taking positive ground regarding the im-
mediate removal of the secundines, and it elicited a good
deal of criticism. Speaking now of early incomplete
abortion, he would take equally positive ground ; seeing
that the foetus could not be saved, he would endeavor to
spare the woman all the blood possible by hastening dila-
tation. ‘That he would bring about by tightly tamponing
the vagina with iodoform gauze so that there could be no
escape of blood. ‘The gauze could be removed in twenty-
four hours and replaced if necessary. That was not al-
ways sufficient. It was sometimes necessary to dilate the ©
external os and rapidly complete the abortion, in which
case he would use a tupelo tent. Being able to introduce
one or two fingers, he would endeavor to remove the con-
tents of the uterus in tact. This, however, could seldom
be done, for the consultant rarely saw a case of abortion
in its incipiency, or before the foetus had escaped.
The class of cases which he usually saw was those in
which there was hemorrhage or septiczemia, and the canal
was usually large enough to adinit the finger; if not, it
could easily be opened. He then curetted with the blunt
curette, or, if necessary, Carl Braun’s curette. He had
long taken the ground that a woman who had incom-
pletely aborted was liable to one of two serious accidents,
namely, hemorrhage, which might be fatal, or septicaemia.
Consequently he contended that, notwithstanding some
physicians had seen many cases in which nature had saved
the woman, yet none should be allowed to linger and take
such grave nsks. Having curetted, he introduced a for-
ceps and brought down the membranes, then reintroduced
the finger to see that the endometrium was smooth. He
washed out the uterus with hot water through a double
catheter ; never employing corrosive sublimate, through
fear of poisoning. Out of some hundred cases he had
lost only one, and in that instance he believed the pelvic
peritonitis was due to sepsis developing before the com-
mencement of treatment. ae
Dr. Fry, of Washington, had been especially interested
in the advice to use antiseptic injections. Regarding vi-
burnum, he had not been able to satisfy himself that it
did any good. The tampon he used very little, or only a
very short time, believing it to be better to employ a di-
lator. Tents were objectionable ; even the laminaria had
been found to contain micro-organisms after a few hours
presence in the cervical canal. He preferred applica-
tions of equal parts of creosote and iodine to carbolic
acid, as the action of the latter on the lining membrane
was very superficial. Dr. Grandin had suggested that he
give his experience with electricity. He nad made some
experiment in this direction. ‘The faradic current was used
only with a view to increase the uterine contractions when
present, not to provoke them in the first place. He had
also made some experiments with the galvanic current to
556
THE MEDICAL RECORD.
[November 16, 1889
test the coagulating effect of the acid from the positive
pole as a means of cutting off the blood-supply of the
membranes and thus bringing about their expulsion ; this
pole was also known to eliminate oxygen and chlorine,
which were powerful antiseptics. His experiments had
not been completed.
Dr. Marcom McLean had found that the cotton
swab would often pick up shreds on the uterine walls
which the curette and other instruments would fail to
bring away. Shreds of considerable size sometimes came
away on the cotton swab wrung out of ninety per cent.
carbolic acid. He further spoke of valuable service de-
rived from Emmet’s curetting forceps.
Dr. H. J. Botpt thought the pad from a three per
cent. solution of carbolic acid was not sufficiently anti-
septic ; the bichloride pad was better. He thought the
finger was far superior to the curette in making a uterine
examination, and ought always to be given the preference.
He did not approve of the use of so much force in re-
moving the membranes as was implied in the recommen-
dation of some instruments. Better leave such pieces of
membrane to be dislodged by time. |
Dr. COLLYER could not understand how, during the
early weeks after the third month, one could remove all
the secundines without the sharp curette ; the finger or
blunt curette would not answer. He said that as soon as
hemorrhage occurred it would be impossible to stop the
miscarriage ; therefore he forcibly dilated the cervix and
curetted with the sharp curette, then used a cotton swab
dipped in a solution of bichloride, followed by tincture of
iodine on a cotton applicator, and finally a vaginal tam-
pon of antiseptic wads. ‘That was up to the third month.
After that period he employed open drainage or packed
the endometrium with iodoform gauze. He used bi-
chloride injections. He added that if peritonitis de-
veloped he applied ice-bags.
Dr. MunpDE remarked that he had often been called to
women who had lost some blood by threatened abortion,
the abortion, however, not becoming complete.
_ Dr. E. H. Grannin wished to place himself decidedly
in Opposition to the sharp curette, either after miscarriage,
abortion, or labor at full term. Traumatism, which was
liable to follow its use in the puerperal uterus, must be
strictly avoided.
_ Dr. KEARNEY gave some experience, apparently show-
ing the necessity for the sharp curette in certain cases.
He also related two cases in which there was retroflexion
with fixation, due seemingly to perimetritis ; but the in-
jection of hot water in one caused the uterus to spring
suddenly back and become anteflexed, showing, as was
shown by the post-mortem examination in the other, that
perimetritis did not exist.
Dr. Murray closed the discussion.
ae C. Coe then read the history of a case (see p.
47°) o
RUPTURED UTERUS AT TERM ; HYSTERECTOMY.
Dr. A. P. Duptey related a case of
EPITHELIOMA OF THE OVARIES AND UTERUS ; EXTIRPATION.
The patient was an Irishwoman, aged fifty-one, mother
of three children, had been in hospital about a year be-
fore she returned to him to have something radical done
for her relief. There were no objective symptoms of
malignant disease, the physical signs were those of uterine
fibroids, and he opened the abdomen with a view to doing
suprapubic hysterectomy. He removed the ovaries,
tubes, and uterus, in the manner which he designated the
intrapelvic but extraperitoneal method of treating the
stump. When the operation was completed it left a row
of sutures extending down the broad ligament on one side,
across over the stump through the peritoneum, and up
the broad ligament on the opposite side, while the stump,
consisting of the vaginal portion of the neck, lay beneath.
About the third or fourth day a little rise of temperature
was likely to take place, when he inserted a drain up
through the cervix, and the patient then went on. to re-
covery. He had so operated about five times, all the pa-
tients recovering. ‘The pathologist leaned to the diag-
nosis in this case of epithelioma of the ovaries and uterus.
Dr. Gorre had performed this operation successfully,
and thought well of it.
THE CHAIRMAN suggested inserting a drain before the
ve of temperature took place, indicatimg the formation
of pus.
Correspondence.
A PLEA FOR THE MASSEUR SERIOUSLY CON.
SIDERED.
To Tue EniTOR or THe Mepicat Recorp.
Sir: THE Recorp of October 26th issues a word of
warning against the masseur, who “is bearing down upon
unhinged humanity with a steady and relentlesg stride,”
and who, instead of losing heart on account of increased
competition, “ simply enlarges his field.”
The writer has had the audacity, though only a layman,
to engage in medical gymnastics and massage as a pro-
fession, but hopes that you, notwithstanding this, will al-
low him to say a few words on the subject.
Massage and medical gymnastics are practised by a
great many in this city, the majority of whom are quali-
fied for it neither by congenital intellect nor by acquired
education. They are practised by totally uneducated
persons partly on their own responsibility, partly and, I
must confess, largely on the recommendation of physi-
cians. If this is an evil, and everyone who has only a
little sprinkling of common-sense admits it to be, who is
to blame for it? Is it the public at large, who read the
advertisements of “ schools,” “ colleges,” and ‘ bureaus of
massage ” in the Medical Register and the medical journals,
and who know their medical adviser to prescribe massage,
many times allowing the patient to send for the “ rubber
doctor ” around the corner, because he is cheapest? Cer-
tainly not. Or are the men and women, trained or un-
trained nurses, to blame, who when tending a patient are
told by the physician to “rub” the paralyzed limb, to
“ press ” the painful nerve, or to “ knead” the constipated
bowels? Is there any wonder that these persons think
it a very easy way to make money, that they know it all,
and that they are full-fledged “rubbers?” Certainly
not ; this is only natural and to be expected. The blame
falls exclusively, or nearly exclusively, on the doctor who,
when prescribing massage, or “ Swedish movements,” rec-
ommends no operator at all, or one who has not proven
himself to be thoroughly versed in both the theory and
practice of his business. It falls on the physician who,
himself knowing practically nothing about this treatment,
recommends the first man who comes to his office pre-
senting a tolerable respectability in dress and manners.
That physician is also to blame who calls in a good mas-
seur or gymnast, but advises the patient to have a servant
to look on a few times, afterward to go and do likewise ;
and also on him who considers himself in learning and
social standing so far above these laymen that he does
not deign to talk or (I dare say it, though I imagine I
hear the sneer !) consult with the man engaged upon his
recommendation. If he did so, he would soon find, even
in this profession, men his equals in education and learn-
ing even if they never studied materia medica. He would
also find men whose ignorance in the rudiments of their
own science would show itself so plainly already at the
first conversation, that the physician should be very glad
to shun them in the future.
You also complain that the field of massage of late
has become so enlarged. ‘The masseur claims to be able
to accomplish very much! Well, yes! But a great part
of this enlargement is legitimate. ‘The skilful gym-
nast or masseur can really accomplish more nowadays
November 16, 1889]
than twenty-five years ago, just as the physician can. But
though I have seen men claim by massage to press the
adipose tissue out through the pores, or by magnetic ac-
tion to take the patient’s ailments in their own bodies,
and other things equally easy for them, I never yet heard
of massage of the heart, which you mention! But do
you mean general massage and systematic gymnastics in
cardiac diseases ?—if so this is certainly nothing worth
sneering at. ‘The benefit from this is perhaps greater than
from Oertel’s method, and it would perhaps not be totally
out of place for physicians to consider if this treatment
in many cases of atrophied, hyperrophied, or fatty heart
be not indicated.
And when the intelligent mechano-therapist gets a case
from a physician (and, as a rule, he takes no cases which
have not passed through the hands of an M.D.) he asks
for the history and the diagnosis, and then gives his opin-
ion whether he can do everything, anything, or nothing,
and his reasons for the opinion. If this opinion, perhaps
afterward, is found to be erroneous, what more! ‘This
happens to us all, and cannot be helped.
This letter may look as a defence against the attack
made by you on masseurs, but that is by no means my
intention : hit harder, if you please! Nobody will enjoy
it better than the able men in that profession. I join also
in your warning: “ Keep a close eye on the masseur ;” but
keep also a close eye on the massage to detect what can
really be accomplished by it, in order not to throw out
the child as well as the bathing-water.
Very respectfully,
M.
New YORK.
Army and Rany Mews.
Oficial List of Changes in the Stations and Duties of Cfi-
cers serving in the Medical Department, United States
Army, from November 3 to November 9, 1889.
O’REILLY, RoBertT M., Major and Surgeon. By direc-
tion of the Secretary of War will, at the expiration of his
present leave of absence, proceed to Fort Logan, Col.,
and report in person to the commanding officer of that
post for duty. Par. 6, S. O. 256, A. G. O., November 2,
1889.
MERRILL, JAMES C., Captain and Assistant Surgeon.
Relieved from duty at Frankford Arsenal, Pa., and or-
dered to duty at Fort Reno, Ind. Ter. Par. 6, S. O. 256,
A. G. O., November 2, 1889.
BLACK, CHARLES S., Captain and Assistant Surgeon.
Relieved from duty at Fort Sidney, Neb., to take effect
upon the expiration of his present leave of absence, and
to report in person to the commanding officer, Fort Du
Chesne, Utah. Par. 6, S. O. 256, A. G. O., Washington,
November 2, 1889.
PowELL, Junius L., Captain and Assistant Surgeon.
By direction. of the Secretary of War, leave of absence
for two months on account of sickness, with permission
to leave the Division of the Missouri, is granted him.
Par. 2, S. O. 258, A. G. O., Washington, November 5,
1889.
Jounson, R. W., Captain and Assistant Surgeon.
Leave of absence for one month is granted, to take effect
on or about November roth. Par. 4, S. O. 110, Depart-
ment of Arizona, Los Angeles, Cal., October 29, 1889.
Ives, F. J., First Lieutenant and Assistant Surgeon.
Granted two months’ leave of absence. Par. 3, S. O. 256,
A. G. O., November 2, 1889.
WILLcOx, CHARLES, First Lieutenant and Assistant
Surgeon. By direction of the Secretary of War, to re-
port to the commanding officer at Fort Columbus, N. Y.,
for duty at that station.
THE MEDICAL RECORD.
557
McVay, HARLAN E., First Lieutenant and Assistant
Surgeon now at Fort Mackinac, Mich. By direction of
the Secretary of War, to report in person to commanding
officer at that post for duty.
Frick, Euciip B., First Lieutenant and Assistant Sur-
geon. By direction of the Secretary of War, to proceed
from Philadelphia, Pa., to Fort Keogh, Mon., for duty
at that station.
Official List of Changes in the Medical Corps of the United
States Navy for the week ending November 9, 1889.
MACKIE, B. F., Surgeon. Detached from the U. S. S.
Ossipee, and placed on waiting orders.
PICKRELL, GEORGE McC., Assistant Surgeon. De-
tached from the U. S. S. Ossipee, and placed on waiting
orders.
Medical Items.
CONTAGIOUS DISEASES—WEEKLY STATEMENT. — Re-
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending November ọ, 1889:
Cases. | Deaths.
SZ YPOUS AVON Veitia a a S o o
WMO LONG 5 a ra NAE A ae Re aeo 35 8
CATIE IATE S aap r O a Aa anaa 47 2
Cerebro-spinal meningitis...........ccccccccscees 4 4
DOCMBIOD Fe! 6.6 0:96:06 E Mew E ceed saeeeee® 41 4
D tirrr 06 5a Fico io ba 4 SNR iowa O His cabe cate gI 15
SRI OE. di odo rant Se aslennwhsse eencbeekenan eines o o
P A ETA T E A O E A fe) o
ce]
‘THE STOMACH-BRUSH.—A dental journal publishes the
following, translated from the German: In 1713 there
was published a pamphlet entitled, “A Complete Ac-
count of the most Useful Stomach Brush which is now
to be had at the Brushmakers at the Old Court Sadler’s
Shop in Broad Street in Colln-on-the Spree.” Many a
one may have wished to be able once in a way to have
his stomach thoroughly cleaned out, and this speculative
brushmaker gave a practicable means to give effect to
this wish. In the pamphlet there is a- drawing of the
stomach-brush ; it resembles a pipe-cleaner, but, of
course, is larger. ‘The stalk is made of four wires twisted
together, covered with thread, silk, or small ribbons; it is
twenty-six inches long. The brush at the under end is
two inches long and one and a half broad, and is made
of goat’s beard hair ; but, when one has been accustomed
to use it for three or four weeks, a horse-hair brush is
substituted, this hair being somewhat stronger, and so
the effect is better. The application of this most excel-
lent brush is very simple. It is pressed through the
throat down into the stomach, which, by drawing up and
down of the brush, is cleaned ; thereafter cold water or
brandy is to be drunk, and the operation is repeated till
the cleaning is perfect. ‘The cure is to be repeated every
morning. The author says: ‘At first you will find it rather
troublesome to get the brush down, but when you put it
in your mouth and on your palate, draw in breath and
wind, and press it gently and gradually down, and, with-
out any particular trouble, it will reach the stomach.
After eight to fourteen days’ practice, it will come as
easily to you as eating or drinking.” Of course, the daily
application of the stomach-brush is the infallible remedy
or preventive of all diseases that can be imagined.
“ Whoever uses this cure requires no other medicine, for
it is good against all—cold, hot, and poisonous fevers, it
gives a good appetite for eating, it is good against asthma,
hemorrhage, headache, chest complaints, coughs, con-
sumptions, apoplexy, toothache, sore eyes, dysentery,
558
THE MEDICAL RECORD.
[November 16, 1889
quinsy on the tongue, quinsy in the throat, ulcers, ab-
scesses, cardialgy ; it favors digestion, strengthens the heart,
drives away pimples on the skin, is against choking in the
stomach, etc., makes too fat and asthmatical and swollen-
up people thin, and, on the other hand, makes meagre
and thin people fat. The great effect, however, is pro-
duced only when the use of the brush is combined with
that of an elixir. This is compounded of aloes, saffron,
rhubarbona, lark-mushroom, wormseed, eugian, myrrh,
theriac. After the stomach-washing, forty to fifty drops
of the elixir is to be taken in wine, and this preserves for
twenty-four hours against all poison and pestilence.”—
British Medical Fournal.
DisEASE-RIDDEN INDIANS.—Indian Agent Jones, of the
Berthold Agency, has made application to the Depart-
ment for a physician who shall remain constantly at the
Agency. ‘This request is the result of hurried examina-
tion of the health of the Indians. Mr. Jones was recently
appointed. He finds that disease runs rampant among
the entire Indian community. The Indians at this Agency
are in a most deplorable condition. In the past their
health has been neglected, they have been permitted , to
roam about the country and, as a result, some members
of the tribe have returned to their camps laden with dis-
ease, which has spread to nearly every Indian at the
Agency. It is understood that the request for a physician
has been granted, and that steps will be taken to prevent
the further spread of disease among the tribes. The condi-
tion of affairs at the Agency in the past has not only ruined
the health of the Indians, but has been a constant menace
to the whites with whom the Indians necessarily associ-
ated. So great became this danger that the county and
city authorities were alarmed, and the Mayor of Bismarck
was compelled to serve notice on the former agent that
if he did not keep his Indians on the reservation an in-
vestigation of the matter would be demanded.— Zhe
Fournal of the American Medical Association.
AN ARTIFICIAL LARYNGEAL Poucu.—One of the duties
of the army surgeon is to “spot” the professional malin-
gerer, whose wiles occasionally testify to the possession of
an amount of cunning and technical skill which, in civil
life, might prove highly remunerative if judiciously ap-
plied. Our “lobsters,” however, are mere bumpkins
compared to the artful Hindoo, who, “ for ways that are
dark,” can give him points in abundance. The profes-
sional thief in India experiences a great deal of difficulty
in finding a safe receptacle for his plunder, and it has
been recently discovered that many of them are in the
habit of bringing about the formation of a pouch-like re-
cess in the vicinity of the epiglottis, by allowing a leaden
ball to rest zm situ for long periods of time. When re-
peated at frequent intervals a pouch is formed, capable,
in some instances, of holding as many as ten florins or an
equivalent bulk of jewels without any obvious interference
with respiration or speech. An examination of the pris-
oners at Calcutta revealed the fact that upward of twenty
of them were provided with this convenient pouch.—- 7 he
Hospital Gazette.
PSYCHICAL AND PHYSICAL CHANGES FOLLOWING Re-
MOVAL OF THE OVARIES.—In an elaborate study of this
subject by Dr. Glaevecke (Archiv. f. Gyn., Bd. xxxv.,
Heft 1), the author says: “ After removal of the ovaries,
menstruation ceases permanently in eighty-eight per cent.
of the cases, either at once, or after a certain interval, while
in the other twelve per cent. the flow becomes scanty and
irregular. Vicarious hemorrhages are rare. In one-half
of the cases observed the menstrual molimen persisted
after the cessation of the flow. ‘The usual climacteric
phenomena, vertigo, irregular sweating, leucorrheea, etc.,
are common, as well as the atrophy of the genital organs
which follows the establishment of the menopause. Even
when the uterus is considerably enlarged, by reason of the
presence of chronic endometritis or fibroids, it commonly
returns to its normal size after odphorectomy, or even, be-
comes atrophied. ‘The general condition usually im-
proves after castration ;” in forty-two per cent. of his case-
the patient became stouter. Sexual desire was dimins
ished in the majority of the cases; in some instances it
was extinguished. The physical disturbances were most
marked, sometimes amounting to melancholia. ‘In short,”
says the writer, “ removal of the ovaries induces an artificial
menopause which is exactly similar to the natural one.”
AFRICAN JUMPERS.—Dr. Bennett. of Griqualand, writes
in the South African Journal an account of a peculiar
nervous affection which is met with among the Gnquas
and other natives and individuals of mixed descent living
in Griqualand. He suggests that*perhaps the affection is
similar to that prevalent among the French Canadians,
and known there by the name of “ Jumpers.” Dr. Ben-
nett says: “ The affection is entirely confined to the male
sex, and I have never seen or heard of a case in the fe-
male. ‘Ihe victims of this strange form of neurosis go
through the most extraordinary and grotesque antics on
the slightest provocation. A whistle, a touch, a shout—
anything, in fact, sudden and unexpected, will ‘set them
going.’ Some will stiffen their limbs, make hideous gri-
maces, and valse about as if they had no joints in their
body. Others will jump wildly about like dancing der-
vishes, imitating the particular sound that had acted as
an exciting cause. Some, again, will make use of the
most obscene expressions on a transient impulse, correct-
ing themselves immediately afterward, and expressing
their regret for having used such language, while others,
on the spur of the moment, will do anything they are
told to do. If they should happen to have a piece of
tobacco in their hand, and one should suddenly shout,
‘Throw it away1’ they will do so at Once, running away
for a short distance, and trembling all over their body.
I remember one case in particular ; it was that of a ‘ Bas-
tard’ boy, a mason by trade. He had been handed a
piece of tobacco, and the person who handed it to him
shouted out suddenly, ‘ Throw it away ; it is a snake!’
He first danced about wildly for a short time, and then
ran away as fast as he was able ; but he had not gone far
when he fell down in a ‘fit,’ and it was some time before
he recovered.” As to the probable cause of this affec-
tion, Dr. Bennett is disposed to ascribe it to the indis-
criminate intermingling of the blood of different racial
types, and the intermarriage of those standing in close re-
lationship to one another.
TREATMENT OF DANDRUFF.— The following suggestions
are sent by correspondents of the British Medical Jour.
nal. P. M.S. suggests the following ointment to be ap-
plied to the roots of the hair every night for a fortnight
or so. RB. Ung. hydrarg. nitr., 3 j. ; vaseline, 3 vij. The
hair to be cut short and well brushed every morning.
R. T. suggests the following ointment, used as a pomade :
Red oxide of mercury, ammoniated mercury, of each ten
grains ; spermaceti ointment, an ounce. Dr. H. Laird
Pearson writes: “ Personal experience enables me to rec-
ommend the following: I}. Hydrarg. perchlor., 3 ss. ;
glycerine, 3 v. ; eau de Cologne., 3 v. ; aq. ad 3 xx. M. Ft.
Lotio No. 1. . 8 naphthol, 31). ; alcohol. ethylic., 3 xx.
M. Ft. Lotio No. 2. B. Acid. salicyl., 3 ij. ; tr. benzoin
co., 3 jss.; ol. olive ad 3x. M. Ft. applicatio. Wash
the head thoroughly with terebene soap ; rinse well and
dry with a rough towel ; rub in some of the No. 1 lotion
and dry with a towel; next apply lotion No. 2, and al-
low it to evaporate off ; finally rub in thoroughly a small
quantity of the oily application. ‘The treatment should
be carried out daily for a month, and then every alternate
day for a fortnight. The dandruff disappears in a few
days, and the hair becomes vigorous and supple in a re-
markably short time.” E. Mansel Sympson, M.B., writes :
“I have used the accompanying formula with very good
results, both in simple alopecia, and that attended by, o!
perhaps rather caused by, dandruff. &. Tr. cantharidis,
ac. acet. dil. ia %ss.; sp. rosmarini, %j.; glycerin., 5 ss.,
aq. rose dulc. ad 3 viij. Ft. lotio. Let this be well
November 16, 1889]
rubbed into the roots of the hair with a small sponge or
a flannel, and let special care be taken not to wash the
head, for, as far as I have seen, washing only aggravates
the evil. Good brushingeand combing should be quite
sufficient to keep the hair clean. The formula given
above is slightly altered from one of the late Mr. George
Nayler’s.”
THE PARASITIC NATURE OF PAGET’S DISEASE OF THE
NIPPLE.—It is well known how intractable this affection
is, and how often, indeed almost invariably, it leads to the
development of cancer. Various theories as to its nature
have been propounded by Butlin, Thin, Dihring, and
others, some supposing it to be eczema of the nipple
spreading into the galactophorous ducts, others a disease
sui generis. Dr. J. Darier now claims to have. proved
that it is parasitic in character. If epidermic scales are
taken from the diseased surface and treated with dilute
ammonia or bichromate of ammonia, round bodies sur-
rounded by a refracting membrane will be seen among
the epithelial cells, and frequently within them. ‘These
bodies have a diameter equal or superior to that of the
cells ; their investing membrane contains a single mass of
protoplasm, or more or less numerous corpuscles. ‘These
bodies are certainly coccidia. In epithelioma of the
nipple the granulations contain similar parasites. M.
Darier suggests that this discovery may be the first step
toward the elucidation of the nature and mode of origin
of some epitheliomata.— Medical Recorder.
INHALATIONS OF CoLD AIR IN Hamoprysis.—Dr. P.
de Tullio, assistant to Professor Cantani in the University
Clinique at Naples, has lately suggested a method of ap-
plying cold air directly to the interior of the lungs in
cases of pulmonary hemorrhage. The apparatus consists
of a metal box through which run several tubes, which
communicate with an outer larger tube leading to a
mouthpiece, which the patient holds between his lips.
The box is filled with ice, or with a mixture of snow and
salt, so as to cover the tubes. Air is then pumped with
a suitable bellows into the tubes, and in its passage
through the box containing the refrigerant substance it
becomes cooled down to o° Centigrade. ‘This is ascer-
tained by means of a thermometer introduced into the
tube at some distance beyond the box, through an aper-
ture which can be closed with a cork. Dr. de Tullio re-
ports three cases in which severe hemoptysis was arrested
by this plan, when drugs, ice to the chest, and the other
usual measures had failed. It does not, of course, cure
the condition on which the bleeding depends, but it is an
effectual remedy for the symptom.—AMedical Recorder.
SCARLATINAL RHEUMATISM.—Ollivier, in a recent lect-
ure delivered in the Hopital des Enfants Malades, treats
of the swollen, painful joints which often complicate or
follow scarlet fever. As to the nature of scarlatinal rheu-
matism, he thinks that this is a complication, and not an
intercurrent affection ; in other words, we have here a
malady which has sprung up under the influence of scar-
let fever, and which is only an exaggeration of certain
phenomenon determined by this disease. Sennert came
near the truth when he said that toward the close of scar-
let fever the peccant matter attacks certain of the joints
and inflames them. Although Blondeau, eighteen years
ago, thought that he had established a parentage between
scarlatina and rheumatism, both having among their mani-
festations arthritis, sore-throat, endocarditis, and cutane-
ous lesions, the erythema nodosum being to rheumatism
what the scarlet eruption is to the other disease, there is
really nothing but a certain analogy to support this view,
while the two diseases are clearly separated by their origin,
their symptoms, and their effects. The view is much the
more probable that the arthritis of scarlet fever, like the
endocarditis and pleurisy which sometimes accompany
this specific fever, is but the manifestation of the exan-
thema on the serous system in general. ‘The most of these
arthrites, formerly called secondary rheumatisms, merit the
THE MEDICAL RECORD.
559
name of infectious arthrites. They are, in fact, pseudo-
rheumatisms, such as one meets in the course of divers
diseases : blennorrhagia, puerperal fever, dysentery, ery-
sipelas, even tuberculosis. By what processes are these
morbid phenomena of the serous membranes brought
about? It is probable that they are due to the irritation
determined by certain micro-organisms which penetrate
these closed sacs, being conveyed by the blood ; in fact,
recent bacteriological investigations have more than once
proved the presence of microbes in the joint liquids of in-
fectious arthritis. As for the prognosis of scarlatinal
rheumatism, it is relatively favorable, this complication
generally terminating in recovery. It will not do, how-
ever, to forget that the joints may suppurate, and that the
patient is then especially in danger of vegetant endocar-
-ditis, or of suppurative pericarditis.— 7he Boston Medical
and Surgical Journal.
THE TREATMENT OF DIARRHG@A IN PHTHISIS.—Dr.
Polyák, of Gérbersdorf, gives in the Orvosi Hetilap the
results of some trials he has made of two recently suggested
remedies in the diarrhoea of phthisis—viz., silicate of
magnesia in the form of talc which has been recommended
by Debove, and lactic acid recommended by Drs. Sézary
and Aune. About eight ounces of talc were well shaken
up in a pint of milk, and this or even a larger quantity
was given daily. As a rule, it arrested the diarrhoea after
having been used for a couple of days, but if it was left
off the diarrhoea returned. It was found, however, that
patients liked the milk mixed with talc even better than
ordinary milk, but it could not be taken for more than six
or seven days, as after that time complaint was made of a
troublesome feeling of oppression in the stomach and
bowels. Dr. Polyák thinks it quite impossible that long-
continued use of talc can heal intestinal ulcers. Lactic
acid proved in his handsa much more satisfactory remedy.
The initial dose employed was thirty grains per diem in
four ounces of water; this was increased subsequently,
but not more than seventy-five grains per diem were given.
On the third day the diarrhoea and the pain were generally
arrested, and during the next day or two the stools
assumed their ordinary character. It was found advisable
to continue to give small doses for some time longer.
The patients bore the treatment well; it produced no
diminution of appetite, and, unless continued for a long
time, gave rise to no disagreeable symptoms. Dr. Polyák
thinks it possible that even ulcers of the intestines may be
healed by this means.— Zhe Lancet, May 18, 1889.
TREATMENT OF DIPHTHERIA.—At a recent meeting of
the Société Médicale des Hépitaux, M. Gaucher men-
tioned the fact that he had cured seventeen cases of seri-
ous diphtheritic angina by a new method—namely, abla-
tion of the false membranes, and antiseptic cauterization
of the mucous membrane. He added that M. Dubous-
quet-Laborderie (St. Ouen) had treated 81 cases by this
method in four years; 4 of the patients succumbed to
croup, but they were under the age of five; and the false
membranes had already extended to the larynx when the
treatment was applied. There were no toxic symptoms
in any case, although the urine was black, showing that
the treatment acted generally as well as locally. M.
Gaucher employs a solution of 5 to 10 grammes of crys-
tallized carbolic acid in 10 grammes of alcohol, adding
7° centigrammes of tartaric acid to render the solution
antiseptic. After scraping the throat thoroughly with a
short-haired brush he applies the solution. This opera-
tion is repeated three times daily. Every two hours the’
mouth is washed out with a1 in 100 carbolic-acid solu-
tion.— British Medical Fournal.
A POPULAR REMEDY FOR ASCITES.—In some places a
popular belief is prevalent that dropsy may be cured by
drinking the fluid removed, and patients often submit to
a tapping for the sake of securing the fluid rather than be-
cause they have any faith in the curative effects of the op-
eration itself. Dr. Duhamel, not long ago, published in
560
eee a
the Gasette Médicale de Strasbourg a case in which this
method of treatment was put to a practical test, the result
being such as to justify to the full the high opinion pre-
viously held of its efficacy. ‘The patient was a man, aged
fifty-seven, who was admitted into the hospital with an en-
larged liver, due to excessive spirit drinking, and conse-
quent ascites and oedema. He was tapped, and a large
quantity of fluid withdrawn, but the peritoneal cavity
rapidly refilled, and it was found necessary to repeat the
operation at intervals varying from one to five weeks.
This treatment was continued for about two years, during
which period he was tapped fifty-three times. On the
last occasion the patient asked whether he might drink
the liquid that had been withdrawn, and though advised
against it, he nevertheless secured some of the fluid, and
drank about half a pint of it.
from his unpalatable potion, but on the contrary the
dropsy did not recur, the cedema cleared up, and in four
or five weeks the man was enabled to leave the hospital,
a firm believer in the curative virtues of ascitic fluid. He
reported himself some months later, during which time
he had resumed his employment, and neither the dropsy
nor the cedema had recurred, although the liver was still
perceptibly enlarged.
PROPHYLAXIS OF PHOSPHORUS NECROSIS.—At a recent
meeting of the Académie de Médecine M. Magitot read a
paper on phosphorus necrosis. From sixty-five cases
which he has observed in France and abroad, M. Magitot
concludes that the affection is produced by the phospho-
rus introduced into a special iorm of caries, which he
terms penetrating caries. The prophylactic measures con-
sist in thoroughly ventilating and isolating phosphorus fac
tories, and in suppressing or neutralizing the phosphores-
cent atmosphere. No persons of defective constitution
should be allowed to enter the factories, more especially
when the mouth is affected. If these measures be rigor-
ously observed all danger of phosphorus necrosis will be
averted.— British Medical Fournal.
Heroic TREATMENT OF PNEUMONTA.—The Russian
peasants have little faith in expectant treatment, and be-
lieve that disease is an enemy that can be overcome only
by powerful weapons. Nekrasoff, a Russian poet, in his
“ Red-nosed Frost,” depicts graphically the treatment that
is pursued in pneumonia, which is not very dissimilar in
some respects to that followed by some of our brethren in
Germany. When the patient came home sick, after be-
ing exposed in a snow-drift for several days, his mother
poured cold water over him from a watering-pot, and
then put him in a hot bath. But this brought no im-
provement, and then they called in the old women of the
village, and on their advice gave the patient a good rub-
bing and then put him several times in a sweat-box.
These measures failing, they gave him a cold bath by let-
ting him down into a hole in the ice, and followed it up
with a sweat in the hen-roost. ‘The poet remarks that the
poor man submitted to all this like a dove, but got no
better notwithstanding. Then a peddlar, who happened
to drop in, suggested that they put the patient under a
bear so as to have him well kneaded. At this point, how-
ever, the wife interfered, and forbade further torturing
of her husband, and the poor fellow soon after died in
peace.,
ERUPTION OF TEETH IN OLD AGE.—Mr. George E.
Fisher reports in Zhe Lancet the case of a lady, aged
sixty-four, who asked him to lance her gums as they were
very painful, having kept her awake for several nights.
On examining the gums of the upper jaw he founda
well-developed new canine tooth protruding, and the cor-
responding side full and painful, feeling to the touch dis-
tinctly as though a tooth were coming through. ‘The pa-
tient had lost her incisor and canine teeth in the upper
jaw some ten years before.
Lonc SLEEP FROM SULFONAL.—The case is related in
the Deutsche Medizinal Zeitung, No. 35, 1889, of a work.
THE MEDICAL RECORD.
He suffered no ill effects.
[November 16, 1889
man who took a tablespoonful of sulfonal in order to get
“a good sleep.” At the end of half an hour, as he felt no
effects from the drug, he took two tablespoonfuls more.
He then went out for some leer; but had taken only
about half a glass when he became so sleepy that he left
the balance and went home to bed. This was on Janu-
ary sth, and he knew nothing more until the forenoon of
the 8th, when he was awakened by being violently shaken.
He recognized the people about him, but fell asleep again
almost immediately. On the gth he was again awakened
by his wife, and remained awake from one o'clock until
eight. He then fell asleep again, after having eaten a
hearty meal with relish, and slept until seven o'clock
the next morning, when he got up and went to work,
feeling very well and much refreshed after his sound
slumber. |
ENGLAND AND THE Opium TRADE.—It was recently
moved in Parliament that, at the next revision of the
Tientsin treaty, the Chinese Government be allowed to
extinguish the opium trade if it thought fit. The resolu-
tion was, however, opposed by Dr. Farquharson, on the
strange ground that the opium habit was not as bad as the
alcohol habit, either in its effects upon the system or in
its relation to crime; and on the strength of this flimsy
argument the resolution was defeated by a vote of one
hundred and sixty-five to eighty-eight. ‘here are said to
be twenty-five million opium-smokers in China, and the
number of deaths directly attributable to the effects of
this poison reaches one hundred thousand annually.
When some thousands are drowned by floods in the
Hoang Ho Valley, the world is shocked, but the fact that
ten times as many people are sacrificed every year in con-
sequence of the forced importation of opium into China
moves the English merchant not a whit.
A POPULAR BELIEF IN THE CONTAGIOUSNESS OF PHTHI-
sis.—In a paper on the contagiousness of pulmonary
phthisis, read at the twenty-fifth anniversary meeting of
the Caucasian Medical Society, Dr. Babayeff mentioned
the curious fact that among the Georgians the name for
consumption is “ chiekki,” meaning “the contagious dis-
ease.” When one of their number is found to be suffer-
ing from this disease he is at once isolated, and is taken
to a hut or tent at some distance from the village. ‘The
care of these patients is entrusted to an old woman who
carries to them the necessary food and drink, and they
are never allowed to associate with the well.
An Honest Apmission.—‘ It is with the most pro-
found consternation that I have to report these five cases
of death, due without any doubt to the treatment em-
ployed by me,” is the way that an honest writer in one of
our foreign exchanges begins his article. It is often more
instructive to read of others’ errors than of their successes,
and it is a praiseworthy undertaking for one to report his
mistakes ; but not many would have the courage to do so
in such a blunt fashion.
VACCINATION ON THE LeEc.—A French practitioner,
in the course of a large number of revaccinations, was
struck with the fact that the operation was far more
successful whan performed on the leg then when the arm
was selected. He has since availed himself of an oppor-
tunity of verifying his first impression, and last year, hav-
ing to revaccinate 177 school children, he chose the left
leg in 99 and the left arm in 78, and carefully compared
the results obtained, dividing them into three groups ac-
cording as the eruption was typical, doubtful, or absent.
Of the 99 cases vaccinated on the leg, 23 were typical, 31
doubtful, and 45 unsuccessful, being equivalent to a per-
centage of 23.2 and 31.3, respectively. Of the 78 chil-
dren vaccinated on the arm, the numbers were 11 typical,
25 doubtful, and 42 failures, equal to 14.1 and 32 per
cent., respectively. The percentage of failures was 45.45
on the leg, as compared with 53.84 on the arm.— Medical
Press and Circular.
The Medical Record
A Weekly Fournal of Medicine and Surgery
Vol. 36, No. 21
-_——— rr ac ee
= ees -= T a
a eee e
Original Articles.
A NEW ANTISEPTIC DRESSING.
BEING AN ADDRESS DELIVERED BEFORE THE MEDICAL
SOCIETY OF LONDON, NOVEMBER 4, 1889.
By Sir JOSEPH LISTER, Bart., F.R.S.,
PROFESSOR OF CLINICAL SURGERY IN KING'S COLLEGE, LONDON.
Mr. PRESIDENT AND GENTLEMEN: When I last had the.
honor, five years ago, of addressing this Society, at the
request of its President, I brought before you an attempt
I had made to utilize the powerful antiseptic properties
of corrosive sublimate without the great disadvantages
attendant upon its highly irritating qualities. I had as-
certained that when corrosive sublimate precipitates al-
bumin, the precipitate is not, as had been generally
supposed, an albuminate of mercury, that is to say, a-
combination of albumin as an acid with mercury as a
base; in other words, that the albumin does not displace
the chloride from its combination, but that the bichloride
of mercury retains its properties intact, the albumin being
loosely associated with it, in a species of solid solution, if
I may so speak.
Further, I had found that this precipitate, even after
drying, is capable of being dissolved in the serum of the
blood, and that the solution in blood-serum is powerfully
antiseptic, while not irritating. I proposed and brought
before you a new dressing in the shape of what was
termed the sero-sublimate gauze, charged with a solution
of corrosive sublimate in the serum of the blood. ‘This
gauze gave very satisfactory results, both in my own hands
and in those of surgeons in places so far distant as Poland
and Spain. Nevertheless, it was not all that could be
desired by any means; it was somewhat harsh mechani-
cally ; it was not very absorbent, a serious defect, and
one of the materials of which it was made, the serum of
horse’s blood, was not always easily obtainable. I was,
therefore, well disposed to look for something superior.
A few weeks after that communication was made to the
Society, a firm of manufacturing chemists, Messrs. Gibbs,
Cuxson & Co., wrote to me saying that they had found
that if chloride of ammonium or sal-ammoniac in quantity
equal to one-fifth part of the weight of the bichloride of
mercury was added to the mixture of bichloride of mer-
cury and blood-serum, the result was a much more fluid
preparation than I had obtained. If I used a preparation
of one part of bichloride of mercury to one hundred of
blood serum, I got a thick liquid somewhat difficult to
diffuse in gauze. They therefore suggested that by adding
sal-ammoniac in that proportion I should get a much
more workable arrangement. On consulting chemical
works, I found that one-fifth of sal-ammoniac was exactly
sufficient to produce, with bichloride of mercury, the salt
long known to chemists as sal-alembroth, a double salt of
bichloride of mercury and chloride of ammonium. I nat-
urally wished to ascertain whether this addition of sal-
ammoniac would impair or even destroy the antiseptic
properties of the bichloride of mercury. I therefore made
experiments on the point, and I found that the sal-am-
moniac associated in the form of a double salt with the
bichloride of mercury did not by any means impair its
antiseptic properties ; on the contrary, it improved them,
so far, at least, as it concerned that which we have to dea:
New YORK, NovEMBER 23, 1889
= e mre ee eee
a ae —_—— aw ee ee ee aes
eS a a = _—_——— -
Whole No. 994
ee
with as surgeons, an albuminous fluid like the serum of
the blood. Sal-alembroth and bichloride of mercury
proved to be exactly equivalent, weight by weight as anti-
septics in such a fluid. Each had to be used in normal
serum of specific gravity of about 1.025 in the proportion
of nearly z;/55, to prevent altogether the development of
micro-organisms. Those who are acquainted with Koch's
researches will consider this a very high proportion.
Koch has shown that in a solution destitute of albumin,
<svses part of bichloride of mercury is sufficient to pre-
vent the development of organisms ; but when we have
albumin present in the solution, the case becomes alto-
gether altered. Albumin interferes with the antiseptic
action of corrosive sublimate, and thus in serum of the
blood of specific gravity 1.025 we require, as I have
already said, as large a proportion as about yyy instead
of Troon: i, .
When the .albumin is small in amount, less corrosive
sublimate proves efficient. Thus in a case of spermato-
cele, where the specific gravity of the fluid was exceed-
ingly low—only 1.007—I found that y5h55, Just imter-
mediate between the proportions required, blood-serum
and water, was efficacious. On the other hand, when
blood-corpuscles are mixed with the serum in the same
amount as in the circulated blood, making the albuminoid
substances much more abundant than in serum, we re-
quire proportionately more of the corrosive sublimate ; at
least 1 to 500 is required for the purpose of preventing
development. ‘This is a most important consideration
after an operation. In the first twenty-four hours the
discharge contains a large amount of blood-corpuscles as
well as the serum, while, at the same time, ìt Is the most
copious, more copious than it will be in any subsequent
day, provided all goes well aseptically. It is, therefore,
an exceedingly serious consideration that in the first
twenty-four hours we have a discharge which in both
these respects tests our antiseptic more severely than it
will ever be tested again, both from its abundance and
from its quality. Still the sal-alembroth, whether used
with blood-serum or with a normal mixture of serum and
corpuscles, such as that obtained by whipping the blood
of the ox so as to get rid of the fibrin, proved equivalent
antiseptically to bichloride of mercury.
I may, perhaps, say in a few words how the exper-
ments were conducted. For the purpose of ascertaining
whether a given antiseptic can or cannot prevent develop-
ment of organisms, a very simple mode of experimenta-
tion suffices. What we have to do is to ascertain whether
it is inhibitory ; not whether it is germicidal. ‘The only
special apparatus required for such experiments is a warm
chamber, which can be kept pretty constantly about the
temperature of the human blood. Beyond this a few
stoppered bottles, with well fitting stoppers—perhaps half-
ounce stoppered bottles—are really all that is required.
Into a series of such bottles serum of the blood, to the
amount, say, of one hundred and fifty grains, containing
solutions of the antiseptic of different strengths 1s 1n-
troduced. ‘These are all inoculated by means of a small
syringe pipette, with the same quantity, say qs of a minim
of some potently septic liquid such as blood-serum in a
state of advancing putrefaction. The bottles are placed
in the incubator, and then, if development takes place,
that is evidence that in the bottle in which it occurs such
proportion of the antiseptic as that bottle contains 1s m-
adequate ; if no development occurs we have proof of
antiseptic efficacy. The transparency of the blood-serum
562
THE MEDICAL RECORD.
[November 23, 1889
permits a recognition of the development of the organ-
isms, which invariably causes opacity. If we have no
change in this respect, if the serum maintains its trans-
parency, at the same time -keeping its odor unimpaired,
and, further, if microscopic examination of any little sed-
iment there may be shows that it contains no organisms,
we have clear evidence that the antiseptic in the propor-
tion concerned has proved efficacious.
Now, if the sal-alembroth was equivalent to the bichlo-
ride of mercury, weight for weight, that shows that the sal-
alembroth was really more efficacious as regards the quan-
tity of bichloride of mercury it contained. The bichloride
of mercury having the sal-alembroth added to it, and also
water in the double salt that is formed, is increased in
atomic weight very considerably ; and therefore if an
equal weight of alembroth is equal in antiseptic action to
bichloride of mercury, that shows that the bichlonde of
mercury is made more efficacious in the blood-serum by
the addition of the chloride of ammonium. The chloride
of ammonium in combination protects the bichloride of
mercury, so to speak, to a certain extent, from the inter-
fering influence of the albumin. |
At the same time, the sal-alembroth proved much less
irritating than bichloride of mercury. Experimenting on
my own skin, I ascertained that it has certainly not half
the irritating property of corrosive sublimate. The chlo-
ride of ammonium attached to the bichloride of mercury,
while it protects the bichloride in some degree from the
influence of albumin interfering with its antiseptic opera-
tion, prevents it also from acting so powerfully on the
human skin. And thus the union of sal-ammoniac with
corrosive sublimate had the double advantage of render-
ing it both more efficacious antiseptically and much less
Irritating.
Hence I was at first much pleased with sal-alembroth.
But it soon appeared that there were certain disadvantages
attending it. These depend very much upon its excessive
solubility. It is essential for a satisfactory antiseptic
dressing that the antiseptic should not be readily washed
out of it by the discharge. Sal-alembroth is so exceed-
ingly soluble that it is washed out with the greatest ease ;
thus we were always, even if we used large masses of
sal-alembroth gauze, in fear that when the discharge was
copious the antiseptic would disappear, say within the
first twenty-four hours, and then the septic mischief would
have an opportunity to enter. ‘There was another disad-
. vantage from this great solubility. When the discharge
entered a mass of the sal-alembroth dressing it dissolved
out the alembroth from it, passed into another part of
the dressing, and there took up another portion of the
sal-alembroth, and so went on from part to part of the
dressing until, if the discharge was copious and the dress-
ing large, as it must be when the discharge is copious, be-
fore the discharge got to the edge of such a dressing it
became so concentrated a solution of the sal-alembroth as
‘to be highly irritating. We have seen, for instance, after
the removal of the mamma, when the first dressing is
changed on the following day that there has been over
the scapula and the neighborhood a huge blister. No
doubt that was only a temporary ‘inconvenience. We =
never had the discharge again so great as in the first
twenty-four hours; but still it was a great inconveni-
ence.
Such being the disadvantages of sal-alembroth dressing,
I was disposed to seek for something better. I may say
that I myself have never published anything in favor of
sal-alembroth dressings ; I have never been satisfied with
them. It has leaked out that I have used them, and they
have come into extensive employment, but never with my
published sanction.
In the course of the following year I made various ex-
periments in the hope of rendering sal-alembroth more
useful in different ways, with which I need not trouble you,
but without much success. In February, 1886, my atten-
tion was drawn by Mr. Martindale, of New Cavendish
Street, to cyanide of mercury as possibly a valuable anti-
septic, and, if so, having this advantage, that it did not
coagulate albumin. I therefore proceeded to make ex-
periments with cyanide of mercury, and I found indeed
that in inhibitory power it was remarkably efficacious. I
have said that with blood-serum sal-alembroth or bichlo- ©
ride of mercury is required in about qy%yth part. I found
that the cyanide of mercury kept blood-serum, with only
qo$ooth part, perfectly free from organic development, in
spite of inoculation with potent septic fluid, for a month,
when the experiment ended. I may remark that we have
in cyanide of mercury a striking instance of the discord-
ance that there may be between inhibitory power and
germicidal power in an antiseptic. In inhibitory power
the cyanide of mercury is, as we have seen, exceedingly
high ; byt in germicidal power it turns out to be. very
low. Mr. Cheyne has made experiments for me, which
have shown that even ;,/,,th part in water is incapable of
destroying the germs of bacteria. Still the inhibitory prop-
erty of cyanide of mercury was a most important point
if in other réspects the salt were not disadvantageous ;
but, unfortunately, it proved to be so highly irri-
tating that the greater irritating property of the cyanide
of mercury more than counterbalanced its superior inhib-
itory power. It naturally occurred to me that the cyanide
of mercury might perhaps combine cyanide with some other
and form a double salt, having advantages correspondmg
with those presented by sal-alembroth as compared with
bichloride of mercury. I tried the soluble double cyanide
of mercury and potassium, but found it quite too irritat-
ing. I here again consulted Mr. Martindale, and he men-
tioned to me that in Watt’s “ Dictionary of Chemistry ” it is
stated that a double cyanide of mercury and zinc of very
slight solubility, may be formed by mixing together a so-
lution of the double cyanide of mercury and potassium
with a soluble satt of zinc, the zinc taking the place of the
potassium. I therefore obtained some of this matenal,
and proceeded to make experiments on it. I found, in
the first place, that it was quite insoluble in water. ‘This
seemed at first extremely unpromising. It was soluble in
about 150 parts of glycerine, but insoluble in water. I
found, however, that it was soluble in about 3,000 parts
of blood-serum, and therefore it was possible that it might
work antiseptically. I made experiments to ascertain
whether such was the case or not, and I found that this
zinco-cyanide of mercury, as we may call it, had really
most important antiseptic properties ; that in the propor-
tion of oəçth part it kept blood-serum perfectly free
from the development of organisms for eighteen days, in
spite of potent septic inoculation.
I then tried experiments with serum and blood-corpus-
cles as presented in the whipped blood of the ox. On in.
stituting comparative experiments between sal-alembroth,
cyanide of mercury, and this double cyanide, I found that
with the alembroth all proportions lower than ;4,th pu-
trefied within twenty-four hours after septic inoculation,
while with the cyanide of mercury ,1,th part sufficed to
preserve the serum and corpuscles from putrefaction.
At the same time, with the double cyanide I was much
surprised and much pleased to find that ;s1,yth, half as
little again, was sufficient to keep the mixture of serum
and corpuscles permanently free from putrefaction. It
may be said that the absence of putrefactive odor is but
a rude test; there may be organisms developed without
any putrefactive odor being present. That is perfectly
true. At the same time, if in a given experiment we find
that with one agent putrefaction occurs within twenty-four
hours with ,;},th part, while with another salt there is no
putrefactive odor after the lapse of weeks with ;,4,th
part, we have pretty conclusive evidence that, so far as the
mixture of corpuscles and serum is concerned, we have a
more efficacious antiseptic in the latter. I therefore pro-
ceeded to prepare dressings of this new substance, diffus-
ing it—for it is an exceedingly fine powder—in water with
a little glycerine added to fix it, to prevent it from dusting
out. If you simply diffuse it in water and pass gauze
' through it, with nothing more than the water, the result is
November 23, 1889]
THE MEDICAL RECORD.
563
that you have gauze which, with the slightest touch, gives
out the double cyanide in a cloud of dust, which produces
not only inefficacy of your dressing by loss of the proper pro-
portion of the substance, but becomes in the highest degree
irritating to the nostrils of those who are near. A little
glycerine, however, prevented the double cyanide from
dusting out. I proceeded tg try it in practice. I confess
I did not dare to use it lering its very slight solu-
. bility in serum—unmixe I associated with it some
of the very soluble cya f mercury ; and with this
cyanide gauze we tried v S experiments in the way of
dressing and got some admirable results. But then, on
the other hand, there were disappointments. We found,
for one thing, now and then very troublesome pustules as
the result of a peculiar kind of irritation. Another dis-
advantage was that occasionally we got suppurations, com-
ing on at a late period in the case, such as we had never
been accustomed to with our carbolic dressings. A case
might go on perfectly well for, say, ten days, and then
suppuration might occur about a stitch track and spread
perhaps farther ; and sometimes the healing of cases was
greatly protracted by this late suppuration. In conse-
quence of these two circumstances, I gave up the use for
the time being of this material.
I then directed my attention to biniodide of mercury,
which has been highly spoken of for its antiseptic powers,
and which has the advantage over alembroth of being
comparatively little soluble either in water or in serum. I
found that the iodide of mercury gauze answered our pur-
pose very well so far as its antiseptic properties were con-
cerned, but that it had the great disadvantage of produc-
ing irritation, which it was extremely difficult to control.
In order to control it we interposed between the iodide
of mercury gauze and the skin unprepared gauze, except
in so far as it was steeped in a weak solution of bichloride
of mercury (1 to 4,000). But we found that different
skins differed greatly in liability to this irritation. ‘The
iodide of mercury, which is so very slightly soluble, as
you know, in water, is much more soluble in serum, and
the solution in blood-serum becomes irritating. In con-
equence of this, we had the same disadvantages from ir-
ritation as we had with the alembroth ; and although, as
in the case of the alembroth, this was only a transient in-
convenience, I became dissatisfied with the iodide of
mercury gauze. ‘There was, however, one point of con-
siderable interest, both theoretically and (as it turned out
afterward) practically, which we found in this investiga-
tion with the iodide of mercury. If we simply charged
with iodide of mercury, say from a solution in spirit of
wine, and then applied the gauze so prepared, we found
that the particles of iodide of mercury tended to gravitate
down toward the skin, and there produce the most fear-
ful irritation. It was absolutely necessary that it should
be fixed. I tried various means, and among the rest a
solution of starch, and then there came out this remarkable
fact, that if a solution of starch is used with one of the in-
gredients employed for forming the biniodide of mercury
by mixing a solution of iodide of potassium with solu-
tion of bichloride of mercury—if you dissolve the iodide
of potassium in a weak solution of starch—the iodide of
mercury thus formed in the nascent state associates itself
with the starch particles in the most intimate manner and
becomes entirely precipitated along with the iodide of
mercury ; so that if you take a drop of the red fluid
formed by mixing these two solutions, and place it on a-
piece of calico, the watery material is absorbed by the
calico and passes into the surrounding parts without col-
oring them, while the red spot with its insoluble iodide
remains. If now you take a little iodine water, and ap-
ply it to the part of the calico moistened by the fluid that
has exuded, you find that the iodine water produces no blue
color of iodide of starch, showing that there is no starch
in the fluid that thus oozes out and leaves the iodide of
mercury behind ; whereas, if you take a simple solution
‘of starch and apply it as such to a piece of fabric, as far
as the fabric becomes moistened so far do you get a
blue color with the iodine. Here we have, as it seems
to me, a somewhat analogous case to the so-called
albuminate of mercury. We have the starch particles as-
sociated with the particles of iodide of mercury: the
starch remains as such, the iodide of mercury remains as
such ; still they are attached to each other. And so the
result was that when such a red solution produced by
mixing these two liquids was used for charging gauze, the
iodide of mercury was stuck to the gauze by means of the
starch, and we had a most satisfactory arrangement in
that respect. The iodide of mercury could not be washed
out by water, nor did it in the least dust out. ‘The value
of this observation with reference to our present subject
will appear shortly.
Being dissatisfied with the iodide of mercury, I turned
my attention. again to the doubie cyanide of mercury and
zinc. Looking back to my notes, I found such evidence
of its superior antiseptic properties that I felt that we had
deserted this material too readily. In the interval we had
had other experience of importance with the alembroth
gauze. Occasional late suppurations had at first occurred
under its use, just as was the case with the double cyanide
gauze. ‘These, however, had ceased to trouble us after
my attention had been directed to the expediency of al-
ways using mercurial dressings in a moist condition. If
they are used dry, the mercurial salt having no volatility,
and having no power therefore of destroying any micro-
organism in contact with it, however obtained, whether
derived from the manufactory or elsewhere, there « ould
be no security that the dressing when applied was free
from living organisms. ‘This important object could, how-
ever, be infallibly attained if the dressing were used moist
with an efficient germicidal solution. I put this idea’ into
practice, and during the two years that have since elapsed,
we have never on any single occasion had to complain of
these late suppurations. Might not the same immunity
attend our cyanide gauze if we adopted with it the same
expedient ?
The other objection to this double cyanide gauze had
been the irritation which it occasioned. Might not this
have been due to the simple cyanide, which, as I have
said, I used along with the double cyanide? ‘The simple
cyanide is highly irritating, and, just as with the sal-alem-
broth, being freely soluble, it can be taken up by succes-
sive portions of discharge, and, when the discharge is
free, may come to be in so strong a solution as to irritate.
On the other hand, experiments on my own person had
shown that the powder of the double cyanide might be
kept applied to the skin for an indefinite time, whether
moistened with water or with blood, without occasioning
any irritation whatever. If this was really the explana-
tion, and if the double cyanide could be trusted of itself,
we might easily get rid of all irritation by using a double
cyanide dressing moistened with a weak solution of bi-
chloride, say 1 to 4,000, which, while it is securely germi-
cidal, can never irritate. But here arose a new difficulty.
I have told you that when we tried this double cyanide in
a gauze at first, in order to prevent its dusting out, with
its great inconveniences, we used glycerine: but if we
moistened the gauze with 1 to 4,000 solution of corrosive
sublimate, we should run: great risk of washing out the
glycerine, and then the double cyanide would be free to
dust out on drying. And, besides that, it must be ad-.
mitted that the glycerine arrangement was not a good one,
independently of that consideration, inasmuch as when
the discharges flowed into the gauze they would wash
away the glycerine, and then the double cyanide might be
washed out also, and so fail in one of the most important
requisites of an efficient antiseptic dressing—the storage
of the antiseptic in the dressing in spite of the discharge.
How was this difficulty to be overcome ? |
Now came to our ald our experience with the iodide of
mercury and the starch. Might it be that the particles of
‘the double cyanide might attract starch as those of the
iodide had done? It did not seem very likely, seeing
that cyanogen is not known to have the special affinity
564
for starch that iodine has. Still, I thought I would try
the experiment. I prepared the double. cyanide by
mixing a solution of the double cyanide of mercury
and potassium with a solution of sulphate of zinc. I tried
this with one of the ingredients, dissolved in a starchy
solution ; and, to my great satisfaction, I found that the
precipitated double cyanide left a supernatant liquor al-
most absolutely free from starch, and that the particles
which thus fell, the double cyanide with the starch asso-
ciated, fixed themselves to a gauze in such a way that it
did not in the least dust when dry. Not only so, but im-
mediately after being charged with the precipitate diffused
in water it might be washed in the wet state without the
double cyanide being washed out of it, so closely did the
starchy particles stick the double cyanide to the fabric.
It is of great importance that in some way or other the
double cyanide should be washed, because at the same
time that an insoluble double cyanide is formed there are
produced other double cyanides which are soluble and
which are in the highest degree irritating ; they must be
washed out.
Well, I thought I had thus attained my object, and that
by mixing starch with one of the two solutions necessary
for forming this double cyanide and allowing the precipi-
tate to form, pouring in more water, and, after precipita-
tion, decanting and repeating the process another time,
so as to get rid of all the irntating soluble salts, and then
diffusing the precipitate through a gauze, I should have
all that I desired. But when I tried to get this done by
a manufacturer I found that I got blundering after blun-
dering in such a way as to make the thing practically
hopeless, ‘There was nothing for it but in some way or
other to get the double cyanide from the chemist as a
definite article, and then in some way devise a means of
fixing that powder of the double cyanide to the fabric.
I therefore naturally tried whether a solution of starch
would answer this purpose, whether the starchy particles
would associate themselves with the double cyanide par-
ticles, not only in the nascent state, which we had before
tried, but also when the already formed double cyanide
was mixed with the starchy solution. I found that it did
so; that when a starchy solution was stirred up with the
double cyanide in the proportion of one part of starch to
two of cyanide, the starch was almost all precipitated, and
the precipitate so formed adhered to the gauze in the
most satisfactory manner.
But though its adhesion was satisfactory enough, it
turned out that the precipitate thus formed aggregated
into a tenacious mass, which could not be diffused uni-
formly through the gauze, and here I was again at fault.
‘This difficulty was overcome by first charging the gauze
with the double cyanide powder diffused in water, and
then transferring it to a starchy bath. ‘[his at once fixed
the cyanide in the gauze; and whereas, before it was
placed in the starchy bath the slightest squeeze made a
milky fluid exude, no sooner had it been well penetrated
by the starchy liquid than you might squeeze it as you
pleased and nothing came out but a clear fluid. I was
much pleased with this, and it is in this way that I have
prepared the gauze that I have used for the last twelve
months, both in the hospital.and in private practice.
Still, this method had its disadvantages. When the gauze
had been passed through the fluid in which the double
cyanide had been diffused without any starch, it re-
quired very tender handling. If you gave it a squeeze,
out came a quantity of double cyanide ; and it was plain
that, although one might do it oneself satisfactorily, if we
trusted to the manufacturers there would be an utter un
certainty as to what quantity of material might ultimately
remain in the gauze.
Only lately has this difficulty been overcome. It oc-
curred to me that perhaps if the starch were first blended
with the double cyanide, and then dried and reduced to
powder, if water were afterward added to this dried dis-
solved starch associated with the cyanide, there might not
be the same tendency to lumpiness and difficulty of diffu-
THE MEDICAL RECORD.
[November 23, 1889
sion. I found that the process did not answer quite as I
hoped in the first instance, in this respect, that the dried
starch and double cyanide were extremely difficult to scrape
off from any plate on which they were put to dry, and also
very difficult to pound up and to diffuse for charging the
gauze. But I got rid of these inconveniences by means of
sulphate of potash, used for the same reason as in the
preparation of Dover’s p —an inert substance, but
with sharp, gritty particle ing a pretty strong solu-
tion of starch with the do nide powder, and adding
to this a quantity of poun ulphate of potash, the re-
sult is that you get a material which, after drying, is easily
scraped off by the manufacturer and easily reduced by him
to an impalpable powder, which is then readily diffused in
water, and makes a perfectly uniform gauze ; being mixed
in large quantity with water in order to charge the gauze,
the sulphate of potash is practically got rid of, and if any
of it remains it does not harm, because it is inert. ‘Thus
we have the means of easily charging the fabrics with this
double cyanide.
I have spoken of diffusing this preparation in water, but
in reality we employ for this purpose the 1 to 4,000 solu-
tion of bichloride of mercury, which fortunately does not
in any way interfere with the process. I may remark that
the double cyanide, like the simple cyanide of mercury,
though very efficient as an inhibitor, cannot be trusted as
a germicide. ‘There are different ways in which absorb-
ent gauze such as this may be charged. One is to pass it
folded in about sixteen layers through a trough, such as
the one before me, which I have myself used, having a
bar near the bottom to insure the gauze being kept well
under the liquid. It is then, as soon as you please,
squeezed to press out superfluous liquid, and then, if
wanted for immediate use, a simple way is to place the
masses of gauze—say, six-yard pieces—in a folded sheet,
turn the folded sheet over them, and roll it up. The
folded sheet then absorbs the still redundant liquid, agd
you have moist gauze ready for use in five minutes. For
the use of the ordinary surgeon it will probably be best to
have the gauze dried, on the understanding that it is again
moistened with 1 to 4,000 sublimate solution before being
used. Here is a sample of the gauze in the dry state,
which you see does not give off dust when freely handled.
Other articles may be charged as well as gauze with
this substance. ‘The double cyanide being perfectly unir-
ritating in its own substance, it is no objection to having
an excess of it. If you take, therefore, some of the prep-
aration and stir it up with water, so as to produce
opaque liquid, and put linen rags into it, and then place
them in a folded towel to take out the excess of liquid.
you have your dressing ready prepared for you then and
there. It can thus be very easily worked on an emer-
gency. €
We have seen that the double cyanide requires about
three thousand parts of blood-serum to dissolve it. If,
therefore, it is present in a gauze in the proportion of
about three per cent., you will easily understand that
blood-serum may soak through such a gauze time after time
without washing the ingredient all out; so that it Is a
material which is admirably stored up in the dressing.
That is one of its three great advantages, the others be
ing that while trustworthy as an antiseptic it is complete-
ly unirritating. In actual practice the few layers placed
next to the wound are washed in a solution of carbolic
acid; this washes out the corrosive sublimate which,
though present in small amount, might irritate the wound
to some extent. The carbolic acid soon flies off, and
there is left in the application next the wound merely the
unirritating double cyanide, and under this we find that
not only do wounds, the edges of which are brought ac
curately together, unite beautifully by first intention, but
even granulating sores heal by the gradual process of ci-
catrization from the edges—heal by scabbing in a way
that we have never seen under any other dressing.
Having satisfied myself that this was really a useful
material, I proceeded to request a manufacturing chemist
November 23, 1889]
THE MEDICAL RECORD.
565
to provide it for me on a large scale. Messrs. Morson
& Son, of Southampton Row, kindly undertook to do
this, and I have to thank them for the great pains they
have taken in carrying out experiments on this subject at
my suggestion. Their manager, Mr. Taubman, soon in-
formed me that in his opinion there was exceedingly little
mercury in this so-called double cyanide of mercury and
zinc. Very little inercury could be got from it on testing
in comparison with what would be obtained if it were a
true double salt. He asked if I was sure that the cyanide
of zinc was not after al thing that was efficacious ?
Was the idea of the double, cyanide altogether a delusion ?
I need not say how much pleased I should have been if
such had been the case—if we could have had the cyanide
of zinc without any poisonous mercury in it as an antisep-
tic. The cyanide of zinc was a perfectly definite com-
pound, there could be no mistake about it. I proceeded
to make experiments, and I found, indeed, that cyanide
of zinc has antiseptic properties. I made, for instance,
experiments of this kind—I took a piece of glass tube
hke that which I hold in my hand, and packed it with
gauze charged with cyanide of zinc only, and then, hold-
ing it vertically, poured serum of horse’s blood into it till
the gauze was fully moistened ; and then poured more in,
till a quantity dropped out from the lower end equal to
that which had produced saturation, the gauze being thus
thoroughly washed with the serum.
I then inoculated the top of the gauze with a potent
septic drop. I had another such tube with gauze that
had no cyanide of zinc in it, and I inoculated that in the
same way. I then put each intoa well-fitting stoppered
bottle, so as to prevent any evaporation, and placed them
in the incubator. At the end of four days I opened the
two bottles. That which contained the gauze without the
cyanide of zinc stank, and, on taking portions of the gauze
from either one end or the other, squeezing them, and ex-
amining under the microscope the fluid that escaped, there
were seen teeming multitudes of bacteria of various sorts.
The bottle with the cyanide of zinc, on the other hand,
had a pure odor of hydrocyanic acid, which this gauze al-
ways has. I then examined drops squeezed from both
ends, and I found no bacteria in the clear serum that was
pressed out, not only from the lower end, but even from
the upper end, in the immediate vicinity of the inoculating
drop, and where the gauze had been drenched repeatedly
with the serum.
Now that, so far, is a result such as no other antiseptic
had ever given me. ‘Take iodide of mercury, for exam-
ple. Comparatively insoluble as it is, if you pour blood
serum upon it in such profusion you wash the iodide of
mercury out, and if you inoculate septically the part so
washed you induce bacteric development. ‘The test ap-
plied was, of course, an extremely severe one. In actual
surgical practice the discharge which pours into the dress-
ing 1s pure to begin with, supposing the wound to be asep-
tic at the outset. The septic agency only acts upon the
dressing from without, and in a far milder form than here,
where a potent septic drop was used. Thus we had clear
evidence that the cyanide of zinc really is an antiseptic.
On the other hand, it turned out to be not so powerful
antiseptically as our double cyanide so-called. In order
to compare the two salts I made another experiment sim-
ilar to that last described. I packed three pieces of glass
tube with gauze in two inches of their length, one of the
gauzes being charged with cyanide of zinc, another with
the so-called double cyanide (neither of these gauzes hav-
ing been treated with solution of bichloride of mercury),
while the third gauze was unprepared. Serum of horse’s
blood was poured into the upper end of each vertically-
held tube till it thoroughly soaked the mass of gauze,
after which each gauze was inoculated septically at the
centre of its upper end. The tubes were then placed ver-
tically in stoppered bottles in the incubator. It happened
that in the septic liquid used for the inoculation that I used
there was, among other organisms, a species of streptococ-
cus which had a remarkable powey of producing an acid
fermentation in blood-serum. After four days I proceeded
to examine the contents of the three tubes. In the unpre-
pared gauze there was utter putrefaction ; in the gauze pre-
pared with cyanide of zinc only no putrefaction had taken
place, but acid fermentation had occurred. Both at the
upper and lower end of the gauze litmus paper was red-
dened on application to the serum. In the putrid gauze
turmeric paper was most intensely reddened, much more
so than by normal blood-serum, an alkaline fermentation
having occurred there. On the other hand, with the
gauze that contained the double cyanide, with mercury
as well as zinc, both at the upper and at the lower end
the turmeric paper was reddened exactly as it was by the
normal blood-serum. ‘This state of thi continued
the next day; but on the following day, six days after
the commencement of the experiment, I found that at the
upper end, in the vicinity of the inoculated spot, this
gauze purpled litmus, while at the lower end it still red-
dened turmeric. At the end of seven days the same con-
dition persisted. After eight days, however, both the
upper and lower end of the gauze purpled litmus. This
peculiar septic organism, with the power of producing
acid fermentation in serum, had gradually worked its
way, in spite even of the cyanide of zinc and mercury ;
but the cyanide of zinc and mercury, you observe, had
been much more efficacious than the cyanide of zinc
alone. The cyanide of zinc had prevented the develop-
ment of organisms that produced putrefaction, and only
permitted the growth of the coccus that produced acid
fermentation. Cyanide of zinc and mercury had for sev-
eral days prevented all development. ‘This was proof,
therefore, that the mercurial element in our compound
was valuable, and that we could not dispense with it.
It may be thought an unsatisfactory thing that there
should have been any organism able to work its way thus
through a gauze charged with our antiseptic. But I
may remark, in the first place, that we tested the mate-
rial exceedingly severely with our potent inoculation ; in
the second place, that it was a long while before the or-
ganism penetrated the gauze even for a short distance ;
and, in the third place, that penetration of micro-organ-
isms through such a dressing into wounds does not seem
to occur in practice, seeing that in the year during which
I have used this antiseptic in my surgical work at King’s
College Hospital we have had no single instance in which
we have had any reason to suspect septic change in the
deeper parts of our dressing ; we have had no instance in
which deep-seated suppuration has occurred in an opera-
tion wound made through unbroken integument. If we
have had any pus at all in such cases, it has been from
the surfaces exposed between stitches or at situations
where drainage-tubes have been inserted, and what I have
termed antiseptic suppuration has shown itself, and even
this in very slight degree. Such being the case, I feel
not only permitted but bound to bring this material under
the notice of my professional brethren.
As to the composition of this so-called double salt, it
is for the present uncertain. This much is already estab-
lished: that the cyanide of mercury is in very much
smaller proportion to the cyanide of zinc than Watts’
“ Chemistry ” would lead us to expect the double salt would
give. But what the precise composition of the salt is we
do not yet know. I am having it investigated by the
Pharmaceutical Society, who have kindly undertaken the
work.
There is another use for this material besides the charg-
ing of dressings. ‘The powder, moistened with a weak so-
lution of corrosive sublimate, may be rubbed into hairy
parts, when it will convert the hairs into an antiseptic
dressing. Not long ago a medical friend of mine brought
his wife to me with no less than seven sebaceous cysts in
the scalp, requesting me to remove them. Having washed
the hair with a 1 to 20 carbolic-acid solution, I simply
passed a comb over each tumor in the line where I was
about to transfix, without shaving at all; and, after tak-
ing out the cysts, rubbed some of the moistened powder
566
THE MEDICAL RECORD.
[November 23, 1889
into the hair in the vicinity. I then applied a dressing of
cyanide gauze, and I was glad to learn that all the seven
wounds had healed without disturbance.
We have now in the hospital a case of psoas abscess,
shown to be of spinal origin, not only by the history of
the case and the symptoms, but by the discharge of a por-
tion of both with the pus. ‘That case is pursuing a course
which, allow me to say, psoas abscesses will pursue in the
great majority of cases, if the surgeon uses a trustworthy
antiseptic, and takes the same pains with dressing to the
last as at the outset; that is, he will find his trouble re-
warded by the complete cure of these formerly incurable
cases. I say this because I grieve to think that these
psoas and lumbar abscesses still seem to be regarded as
hopeless affairs by many surgeons. In this man’s case the
temperature has never been affected in the least ; he has
put on flesh rapidly; the discharge, after the purulent and
curdy matter that existed originally in the abscess was got
rid of, has been of serous character, and is in small and
diminishing quantity. But the opening made for the dis-
charge is in the vicinity of the pubes, and the pubic hairs
used, under such circumstances, to be a constant source
of anxiety to us unless frequently shaved away. Here we
rub in at each dressing a little of the moistened cyanide,
and convert the hairs into an antiseptic application.
I will not at present enter into the details of the prep-
aration of this material ; these will be supplied in a note
on a future occasion.’
The sketch which I have given you of this investigation,
though it has, I fear, wearied you, conveys but a small
idea of the toil it has involved. ‘There are those who
still believe that the use of antiseptic substances in surgi-
cal practice is always useless, if not injurious. The germ-
theory of septic diseases is indeed now happily established
incontrovertibly. All now admit that septic mischief in
our wounds depends upon the development of micro-or-
ganisms in them derived from without. But the gentle-
men to whom I refer are, more or less logically, disposed
to trust everything to the antiseptic powers of human tis-
sues,
I believe I happened to be the first to direct attention
to the antiseptic agency of living structures, and there is
perhaps no one who attaches greater importance to it than
Ido. Without it surgery in former days would have been
absolutely impossible. Still I know too well from experi-
ence that it cannot always be trusted, and that the use of
antiseptic adjutants is in the highest degree important.
And I have the satisfaction of knowing that there is
among you a constantly increasing number who, when
they have operated on an unbroken skin, with a fair field
around for the application of their dressings, if they see
septic inflammation occurring in the wound with its at-
tendant dangers, know that it is their fault or the fault
of the antiseptic appliances at their disposal. To those
among you who are impressed with this conviction I offer
the dressing which I have described as the most satisfac-
tory that I have hitherto met with ; and I venture to hope
that you will regard it as a not unacceptable addition to
your resources.
“THE MEDICAL MIRROR” is the name of a new jour-
nal which is* announced to appear in January next. It
will be issued monthly under the editorship of Dr. I. N.
Love, and its place of publication will be St. Louis, Mo.
Dr. Love’s reputation as a medical journalist is sufficient
to insure a hearty welcome to his new venture.
THE STATUS OF COCAINE IN SurRGERY.—lIn the re-
port of Dr. Wyeth’s paper with this title read before the-
Virginia Medical Society, the strength of the solution, as
given in the report, was one drachm to the ounce, and
was said to approxima:2 a four per cent. solution. The
formula should have been: Cocaine muniate, gr. xx. ; bo-
ric acid, gr. iij. ; distilled water, 1 ounce.
2 This note will appear in our next issue.
FRACTURES OF THE BASE OF THE SKULL.
By FREDERIC S. DENNIS, M.D.,
NEW YORK.
Mr. CHAIRMAN AND GENTLEMEN : In thinking over a topic
upon which to address the Surgical Section of the Acad-
emy this evening, it occurred to me that a subject em-
bracing certain injuries of the head might not be inap-
propriate. I shall, therefore, invite your attention to
this surgical lesion, because -djgjS one of very great im-
portance, and also because the Special consideration of it
has not hitherto engaged the attention of the Section.
‘There seems to have been of late a tendency, or a fashion,
among surgeons to consider the new operations only, and
a trite subject like fracture of the base of the skull has
not received its share in the surgical discussions of the
day. The time has come when surgeons should direct
their attention toward modifying and improving some
of the olden methods of treatment, and not be carried
away entirely with the technique of some modern opera-
tions.
Fracture of the base of the skull has been one of those
injuries which the surgeon has treated purely upon the
expectant plan, and with the conviction that death is sure
to follow. This view of the lesion has been entertained
for years by hospital surgeons, and there is certainly a con.
sensus of opinion among surgical writers in regard to the
prognosis in this injury. All the standard text-books and
monographs are in accord in reference to the mortality.
During the past few years my attention has been especially
directed to a study of these cases of basilar fracture, and
I shall endeavor to demonstrate this evening that fractures
of the base of the skull are amenable to surgical treat-
ment. I shall also endeavor to point out the clinical fact
that the great majority of these cases die from causes
which can be wholly prevented by the surgeon. There
has been but little encouragement to the medical man to
attempt any treatment in these cases of basilar fracture,
when one reads, as he may, in the latest edition of a large
standard work on surgery, “that any treatment directed
to the lesion itself is out of the question.” I trust that I
can demonstrate this evening the incorrectness of this
view, which represents the opinions of most surgical au-
thors.
Fractures of the base of the skull may be situated in
any of the three fossæ of the cranium. ‘They may be
divided into three varieties :
1. Where the fracture involves the antenor fossa, the
roof of the orbit, or the nasal cavity.
2. Where the fracture involves the middle and poste-
rior fossz.
3. Where the fracture involves the posterior fossa.
The first variety is seen in falls upon the forehead, or
by an umbrella or cane thrust through the roof of the
orbit.
The second and third varieties, where forces act from
below, as a fall from a height where the patient strikes
upon the tuberosities of the ischium or upon the vertex of
the skull.
The signs and symptoms of fracture of the base of the
skull slightly vary according to the seat of the injury.
There are, however, three signs and symptoms that are
nearly always present. These are, 1st, hemorrhage ; 2d,
escape of cerebro-spinal fluid; 3d, coma. There is no
value to be attached to any one of the three; but when
they are found together, the diagnosis is certain. In re-
gard to hemorrhage, the source of it is most important to
consider. If the anterior fossa is the seat of fracture, the
bleeding occurs from the nose or from the mouth, and
usually there is subconjunctival ecchymosis ; if the mid-
dle and posterior tossz are involved, the hemorrhage 1s
from the ear and occasionally from the nose. It must be
noted that, in cases of non-rupture of the membrana tym
—
1 Read before the Surgical Section of the New York Academy of
Medicine, November 11, 1889.
November 23, 1889]
pani, the blood may escape into the nose and pharynx
and enter the stomach. Hemorrhage in such a case may
exist, but there are no external evidences of it. The
first intimation that the surgeon has of the existence of
hemorrhage is hematemesis. Absence, then, of hemor-
rhage from the ear or nose is not conclusive evidence of
the non-existence of a basilar fracture. On the other
hand, the presence of bleeding alone from the ear is not
in itself a diagnostic sign of any value as indicative of
fracture of the base. At one time I collected sixteen
cases of hemorrhage from the ear, in no one of which did
a fracture of the base of the skull exist, and in all of the
cases recovery took place. The late Dr. Lomng was
kind enough to go with me, and he made some interest-
ing observations upon this point at the time. ‘Ihe blood,
in some of these cases, came from a lacerated membrana
tympani, and in other cases from a wound of the soft
tissues in the canal. When the hemorrhage occurs in
basilar fracture the source of it must be from the petrous
portion of the temporal bone, from the internal carotid,
or from the lateral sinus. If from the last two named
sources, the cases terminate fatally. Extravasation of
blood near the mastoid process, or in the suboccipital
region, 1s significant when there is no externa] bruise to
account for the ecchymosis. The difference between a
black eye and subocular extravasation must be made. In
the orbital extravasation due to fracture in the anterior
fossa the blood is behind the conjunctiva, and is greatest
in amount in the posterior part of the orbit. This variety
of ecchymosis usually appears suddenly, and if it does it
1s strongly in favor of fracture of the base. ‘The black-
eye ecchymosis is chiefly in the lid or in the connective
areolar tissue just beneath the orbital ridge. The ecchy-
mosis 1s not present immediately after the injury, but
comes on any time from a few hours to a few days.
The second sign is the escape of cerebro-spinal fluid.
This is a valuable diagnostic sign. The fluid escapes by
a transverse fissure in the petrous portion of the temporal
bone, and through a tear in the arachnoid membrane that
surrounds the auditory nerve. The fluid may even escape
from the nose in fracture of the antenor fossa. ‘This I
have seen also in cases of fracture in the middle and
postenor fossze where the membrana tympani was not rupt-
ured and the fluid was directed through the Eustachian
tube. In another case the cerebro-spinal fluid emerged
from the mouth; but this is exceedingly rare. The cere-
bro-spinal fluid comes from the ears in considerable
quantity, and the discharge continues for many days. If
the fluid is examined, it is found to be nearly all water
with a specific gravity of about 1.002, and holding in so-
lution a large quantity of chloride of sodium, little or no
albumin, but a trace of sugar. Saliva has been mistaken
for the cerebro-spinal fluid. ‘This has happened in cases
where the condyle of the lower jaw has fractured the
meatus, and under these circumstances saliva may es-
cape into the canal. The small amount of the fluid and
its composition enables the surgeon to distinguish it. It
was formerly supposed that the liquor Cotunnii from the
internal ear supplied this watery discharge, and by some
the discharge was thought to be filtered serum. Both of
these views have been proved to be incorrect. The cere-
bro-spinal fluid has been seen associated with the escape
of slight shreds and minute particles of brain-substance.
This complication makes the diagnosis absolute.
Deafness is a condition dependent upon the escape of
the cerebro-spinal fluid, and is probably caused either by
pressure on the nerve from hemorrhage, or else by lacera-
tion of the nerve, although at the time the patient is not
E in a state of mind for this symptom to be of any
ue.
Coma is present in a greater or less degree, according to
the severity and situation of the fracture. ‘There is noth-
ing peculiar in this symptom in basilar fracture, except
perhaps that the coma is associated with more jactitation
and restlessness than in coma the result of cerebral hemor-
rhage. The paralysis is connected with the cranial nerves
567
ee gD
oe a A A, o i A ——e —
rather than those which are affected in hemiplegia. The
local cranial nerve affections are usually obscured by the
coma. A study of the functions and movements of each
cranial nerve in fracture of the base is very difficult dur- `
ing the existence of coma; but a careful study of the
physiological action of each cranial nerve will reveal ap-
proximately the extent to which the lesion affects the on-
gin of that nerve. It is thus, by collective evidence, that
knowledge can be acquired as to the extent to which the
brain has been injured in connection with fractures of the
base of the skull.
With a view to simplifying the general] subject of basilar
fractures, I shall advance two propositions, and shall at-
tempt to prove the correctness of these propositions.
1. That fractures of the base of the skull should be
considered ighe same category as compound fractures
of the. vertex Of the skull or of the long bones.
2. That since fractures of the base of the skull possess
the same essential characteristics as other compound
fractures, they should therefore be treated by the same
exact principles of aseptic surgery.
In regard to the first proposition, that a fracture of the
base of the skull should be considered in the same category
as compound fractures of the vertex of the skull, and the
long bones. Some surgeons may dissent. It is evident,
however, that every compound fracture has air admitted
to the seat of the fracture, and this is the case in reference
to fractures of the base of the skull. If the anterior fossa
is the seat of lesion, air gains entrance through the nasal
cavities. If the middle and posterior fossz are involved,
then air gains access to the seat of fracture either by the
external auditory meatus, or by the Eustachian tube
through the pharynx and nasal cavity.
The entrance of ai to the seat of fracture, which is a
sine qua non for the existence of a compound fracture, is -
not the only point that basilar fractures possess in common >
with all other compound fractures. The basilar fracture
is associated with hemorrhage, with laceration of nerves,
with venous thrombosis, with septic phlebitis, with fat-
embolism, with cerebro-spinal shock, with pyeemia—in fact,
with all the complications that arise in other compound
fractures. The visceral lesion is not confined to basilar
fractures, because it occurs in fractures of the vertex. It
is thus evident that fractures of the base do not differ in
any essential particular. The view may be even advanced
that the local lesions in vertex fractures may be more se-
vere than basilar fractures, because in the latter variety the
cerebro-spinal fluid in a measure protects the brain from
direct violence and lessens the shock.
I trust that I have made conclusive the points involved
in the first proposition. And now, as to the second propo-
sition advanced, viz., that since fractures of the base of
the skull possess the same essential characteristics as other -
compound fractures, these fractures should be treated ac-
cording to the same exact principles of aseptic surgery.
A discussion of this second proposition naturally brings
us at once to a consideration of the treatment of com-
pound fractures in general.
It is wholly unnecessary in this paper to refer to the
management of compound fractures. All surgeons are
agreed upon the following principles : Antiseptic cleans-
ing of the wound, immediate immobilization, proper drain-
age, and permanent fixation. It remains to be shown
that these same principles can be applied in fractures of
the base. ‘The technique is simple. Every patient suf-
fering from fracture of the base, if the immediate shock
is not too profound, should be removed to the operating-
room if a hospital patient, or to a room especially pre-
pared if in private practice. I have always insisted upon
this point, because the hospital ward is not the place to
dress a compound fracture. ‘The risks of suppuration are
too great to expose such a wound to the air of an ordinary
surgical ward. Every outside preparation having been
made to make the toilet aseptic, the head should be held
firmly and the entire scalp shaved, after which it should
be thoroughly washed with soap and water, and then irri-
568
pem woe a a - oe
ternal auditory canal and tne nasal cavities. Both: of
` these should be rendered thoroughly aseptic, after which
the ears should be packed with iodoform or bichloride
gauze and some absorbent cotton plugs placed in ‘the nose.
‘Fhe air can filter through cotton, but micro-organisms can-
not pass through it. In irrigating the nasal fossæ the
surgeon must exercise great care, lest the fluid enter the
stomach and produce toxic effects. ‘There remains now
only one other possible channel of infection to the seat of
fracture, and that is the Eustachian tube. This may carry
sepsis to the interior of the cranial cavity in a fracture ‘of
the base. The arrangement of the ciliz in the tube is
such as to propel air and mucus toward the nasal cavity ;
but during the act of deglutition the curreggy may be re-
versed and infection thus reach the base of fffe brain. In
the ordinary form of fracture of the base, where the mem-
brana tympani is ruptured, the discharges make their exit
through the auditory canal. In the exceptional cases
where the membrane is not ruptured, the blood, serum,
and cerebro-spinal fluid find their way into the nasal cav-
ity and the pharynx, and thus these cases are most exposed
to sepsis. Ifthe unruptured membrana tympani is ex-
amined in a basilar fracture, the membrane will be puffed
out on account of the presence of fluid behind it, and the
membrane will have lost its natural lustre. ‘These are the
circumstances under which it may be wise to puncture
the membrana tympani, and thus allow the blood and the
cerebro-spinal fluid to escape through the external audi-
tory canal. ‘The diversion of the discharge from the Eu-
stachian tube into the ear makes it possible to keep the
fluids permanently aseptic. Having now rendered the
head and all the avenues of approach to the intracranial
cavity aseptic, it remains to apply a dressing that will keep
these parts permanently free from any source of infection.
This object is best accomplished by the use of a cap made
of wet loose bichloride gauze or carbolized wool, over
which absorbent cotton should be placed and a bandage
applied. ‘The cap should completely surround the entire
head, cover in the ears, and protect every channel leading
down to, and communicating with, the seat of fracture, and
the cerebral viscera from the entrance of septic germs.
This same dressing should be made from time to time
during the repair of the fracture, and under the same strict
and rigid rules of antiseptic surgery. ‘The head should
be held firmly by some dressing described in monographs
upon bandaging under the name of the ingale dress-
ing. ‘This insures fixation to the head, and keeps the
fracture as quiet as possible during the repair.
The reasons for dressing fractures of the base of the
skull with a scrupulous attention to the minutest detail
in antiseptic surgery are at once obvious. If a patient
survives the immediate shock of the fracture and lives
twenty four hours, he is almost certain to die shortly
after from causes which can be directly attributed to
sepsis. Among these causes may be mentioned basilar
meningitis, cerebral abscess, pyzemia, suppuration in pe-
trous portion of temporal bone, septic phlebitis, encepha-
litis, lepto-meningitis, and other complications due to
infection. 3
If the surrounding parts and the discharges can be
kept aseptic, then sepsis cannot occur, and this removes at
once all the causes of death due to this agent. I do not
pretend to state that it is impossible for a patient with
fracture of the base to die except from a cause due to
sepsis ; but I do state that nearly all these cases terminate
fatally from causes which are due to sepsis. A reference
to statistics will demonstrate that deaths occurring in
fractures of the base of the skull independent of sepsis
are extremely rare, and that nearly all these cases die
from causes that can be prevented by the surgeon. There
is nothing original in this plan of treatment except that it
is a report of my cases in which an application of anti-
septic surgery has been made to a new class of fractures.
I would even go further, and recommend that all cases
THE MEDICAL RECORD.
[November 23, 1889
I have seen many cases where there was no reason to be-
lieve that a fracture of the base of the skull existed—and,
in fact, it did not exist—but where a hemorrhage occurred
from the ear or nose, and in the course of ten days a
meningitis developed and the patient died. Every practi-
cal surgeon can recall cases such as I have mentioned,
and I believe that the meningitis in these cases had its
origin in the septic contamination of the hemorrhagic
or other discharges.
The old and good rule in surgery, “ never to look
lightly on any injury of the head, however trifling it may
appear,” is one that, if observed to the letter, may be a
means of saving a life where otherwise that life might be
sacrificed.
With a view to making a practical demonstration of
the principles involved in the management of these cases
of fracture of the base of the skull, I have requested a pa-
tient who received a fracture of this kind, and who has
since recovered, to come here this evening.
During the past few years I have had in my hospital
experience a large number of fractures of the base of
the skull. Most of these cases died from shock within
twenty-four hours, but there are six patients who have re-
covered from this injury under the plan of treatment that
has been suggested. I will briefly read the history of the
case here this evening, and then present the patient to the
Section for examination.
Albert James D , aged twenty-five, admitted to the
Harlem Hospital, December 8, 1888. Patient fell from
top of a freight-car, striking his skull upon the rail. The
ambulance surgeon found him insensible. ‘There was
hemorrhage from the nose, both ears, and from the mouth,
and post-conjunctival ecchymosis of left eye. Left tem-
poral region severely contused. Pupils dilated, breathing
stertorous ; pulse, 75 ard strong; temperature, 98° F.
Associated with the head-lesion was sprain of left knee-
joint. Patient was very restless and at times very noisy.
The following day was tied in bed and was wildly delin-
ous. From both ears there was a discharge of a white
fluid which upon examination was proved to be cerebro-
spinal fluid. A few days after the accident he suffered
from a severe glossitis which, with oedema, threatened his
life. ‘The glossitis was the result of injury to the posterior
end of third frontal convolution and contiguous part of as-
cending frontal. For the following fourteen days from the
receipt of the fracture of the base, there was a discharge of
cerebro-spinal fluid from both ears. Magendie’s solution,
bromide of potash, and other sedatives were used. The
patient was kept for some time in a straight jacket on ac-
count of the traumatic delirium. It is an interesting clini-
cal fact that the patient now is oblivious to the accident,
and he has no recollection of the time he spent in the
hospital until he began to recover. ‘This is certainly a
test-case for any plan of treatment, for there was cerebro-
spinal fluid escaping for two weeks, during which time the
surrounding parts and the discharges were kept aseptic.
Tue STAINING oF Gonococc!.—Dr. J. Schütz, of Frank-
fort, gives a method of coloring gonococci that may prove
useful. ‘Ihe method is founded on the known resistance
to acetic acid possessed by the gonococcus after staining
with methyl blue. After the cover-glass is covered and
spread with a thin film of the suspected substance, it 1s
passed three times through a flame. It is then allowed to
remain from five to ten minutes in a saturated solution of
methyl blue in five per cent. carbolic water. It is then to
be washed in water. Itis then for one moment, or as long
as 1, 2, 3 can be counted, to be dipped in acetic-acid
water (acid. acet. dil., M v.; aq., 20 c.c.), and immediately
washed off in water. As the acetic acid solution decol-
orizes all other organisms more rapidly than the gono-
coccus, all except these will have lost their color while
they remain distinctly blue.— Zhe Medical Press.
November 23, 1889]
A CASE OF SARCOMA OF THE DURA MA-
TER—LIGATURE OF THE LONGITUDINAL
SINUS.’
By FREDERIC KAMMERER, M.D.,
NEW YORK.
THE patient whose history I desire to relate this evening
was a man sixty-eight years of age. Three weeks before
his admission to the German Hospital he noticed a small
tumor on the occiput. This had been incised a few days
previous, but further interference was wisely deferred, when
it was noticed that the swelling showed faint pulsations.
The swelling was situated exactly in the median line,
apparently at the upper angle of the occipital bone, was
of the size of a walnut, and projected only slightly over
. the level of the skull. Its size was not diminished by
pressure. The patient presented no symptoms of a
general or local character referable to the brain. There
was no history of syphilis. As the microscopical exami-
nation showed the growth to be a round-cell sarcoma, and
as the lack of cerebral symptoms made it probable that
the growth had developed to no great extent within the
cranial cavity, the diagnosis of a periosteal sarcoma was
made, and an attempt to remove the same was deemed
justifiable. I accordingly circumcised the tumor, about half
an inch from its border, down to the bone and chiselled
off a corresponding part of the skull, laying bare the dura
and the attachment of the growth to it immediately over
the longitudinal sinus. ‘The opening in the skull, which
was larger internally than externally, the firm adherence
of the growth to the dura mater, coupled with the knowl-
edge that sarcomata developing from the dura on the
convex surface of the brain have rather a tendency to
immediate perforation of the skull, now made it evident
that we had here to deal with a sarcoma starting from
the dura itself. ‘The greater part of the growth was
readily removed, but its base, about the size of a silver
quarter, was firmly implanted on the longitudinal sinus.
As the removal of the entire mass would have necessitated
the excision of the superior wal] of the sinus, and as the
extreme thickness of the skull suggested even at this
time the possibility of a mistaken diagnosis, I decided to
interrupt the operation and to put the patient on large
doses of iodide of potassium. ‘This was continued for
several weeks, with the result that new tumor- masses
rapidly filled up the opening in the bone. During this
time I had, on several occasions, attempted to dissect the
dura of the longitudinal sinus into two layers in the ca-
daver without opening the sinus itself, but had very im-
perfectly succeeded. At all events, I had received no
encouragement to attempt this in the living. Three
weeks later I operated a second time. As a preliminary
step, the further removal of a ring of bone, to again ex-
pose such parts of the dura as were sound, became neces-
sary. I then incised the dura on the left side and elevated
it toward the middle line. This was easily accomplished
at the superior margin of the growth, but at its inferior
border, near the torcular Herophih, very free venous
hemorrhage occurred on attempting to prolong the in-
cisions through the dura. I now tried to approach the
falx cerebri from the nght side, as I had done from the
left, my intention being to ligate the sinus and to raise
-the tumor, cutting through the falx toward the confluence
of the sinuses. Unfortunately, the longitudinal sinus did
not lie in what I had calculated to be the median line,
but more to the nght. Several attempts to get beyond it
were unsuccessful, even after removal of some more bone.
The patient was now in such a state of collapse that I
was compelled to abandon the operation immediately. | I
returned the flap of dura on the left side, and, after tam-
poning the opening in the skull, I quickly loosened and
withdrew the hemostatic forceps from the sinus, making
light compression with the dressings. Although there
was immediate oozing through the latter, no further hem-
1 Read before the Surgical Section of the New York Academy of
Medicine, November 11, 1889.
THE MEDICAL RECORD.
569
orrhage ensued. Three weeks later I ligated the longi-
tudinal sinus, having enlarged the opening in the skull to
the right. The flap of dura previously raised on the left.
had become intimately attached to the cortex cerebri,
and in raising it a second time the upper layers of the
cortex came away with it. The sinus was ligated with
two strong silk ligatures and was cut between them, and
an attempt was made to extirpate the tumor, as before
suggested. This proving impossible on account of impli-
cation of the confluence of the sinuses, the greater part
was removed with a sharp spoon and the wound tamponed
as before.
On the second day after the operation, when the patient
to rally from his collapse, he complained of an im-
pairment of vision. Only with great difficulty could he
count fingers at a distance of several feet, and he could
scarcely see the clock on the wall opposite his bed, on
which he had always been able to tell the time. The
powers of vision were much more defective in the nght
than in the left eye. As was anticipated, ophthalmos-
copic examination revealed nothing abnormal. At about
the end of a week his sight began to improve steadily and
almost regained its former power. About a week after
the last operation the patient began to complain of con-.
tinual headache. Antipyrin gave some relief, as did alsa
galvanization, but on the whole the pains became more
severe, in spite of all attempts at their alleviation, until the
patient’s death, which occurred seven weeks after the
ligature of the sinus. ‘Two days before his death he be-
came restless. On the day preceding it he was unable to.
speak, and his attention could not he attracted. No motor
or-sensory disturbances were recorded. He continually
attempted to roll himself out of bed on the right side.
He died the following morning.
The post-mortem examination showed marked nervous
congestion of the convex surface of the cerebrum ; na
meningitis ; the tumor, that had been almost entirely re-
moved at the last operation, had again developed to a
considerable extent, encompassing the median region
above the torcular and projecting to either side as a
spherical mass, a little more voluminous to the left, where
it measured about one and one-half inch in diameter.
The tumor had to a certain extent compressed the cortex
cerebri in the region of the first occipital gyrus, and also
invaded the cortical substance in this area. It had not
reached beyond the parieto-occipital fissure anteriorly, and
the sulcus interparietalis laterally, and had left the angular-
gyrus entirely intact. In the substance of the left occip-.
ital lobe, but more especially on the anterior aspect of
the tumor in that location, an extensive recent hemor-
rhage was discovered. The longitudinal sinus was filled
with adherent blood-clots, which extended into the affer-
ent veins.
It appeared to me of some interest to attempt to ex-
plain the visual defection by the pathological conditions
found. We know, from the experimental researches of
Ferrier and others, that the centre of vision is lodged in
the occipito-angular region, that the greater portion of
both occipital lobes can be removed in animals without
causing any appreciable impairment of vision, but that
destruction of the angular gyri will lead to complete blind-
ness, non-persisting, however, when the experiments have
been conducted on an antiseptic basis.’ Ferrier comes to
the conclusion that blindness following destruction of the
occipital lobes only depends upon “ direct implication or
secondary extension of the lesion into the angular gyrus.”
I believe that, following the last operation in my patient,
during which the cortical layer of the left upper occipital
gyrus was almost entirely destroyed and the brain sub-
jected to many unavoidable mechanical insults, also on the
right side, inflammatory reaction spread into the angular
gyri and was the cause of the visual impairment. As this
condition subsided, his sight became almost fully restored.
Some time after the last operation, the brain being fully
1 Ferrier: Functions of the Brain, 1886, page 271 et seq.
57°
THE MEDICAL RECORD.
[November 23, 1889
exposed in the region of the upper occipital and, as I
thought, perhaps also of the angular gyrus, I applied both
the faradic and galvanic currents to the brain-substance
with, I regret to say, negative results, even though the
currents finally employed were very uncomfortably felt at
the tip of the tongue.
Ligature of the longitudinal sinus has, to my knowledge,
been only once attempted heretofore." The case was one
of traumatic injury, where, after the removal of loose
pieces of bone, severe hemorrhage set in from a rent in
the dura at about the highest point of the skull. The
operator compressed the opening in the sinus and closed
it, as he expresses himself, with sutures sufficiently deep
to include the entire sinus. No untoward symptoms fol-
lowed, and the patient made a perfect recovery. That
wounds of a cerebral sinus can heal, and generally do so,
without interruption of the continuity of the lumen, has
been amply demonstrated by clinical experience as well
as by experimental work.” It would appear that the ma-
jority of all lesions of the sinuses heal in this manner.
In our times of antiseptic surgery, when we have learned
to avoid the most dreaded sequence of traumatic throm-
bosis of a sinus, viz., infection, and on that account are
less fearful in surgical manipulations of wounding it, such
wounds generally heal without giving rise to any unfavor.
able symptoms later on. Whether this is also the case
when a sinus, especially the longitudinal sinus, becomes
completely obliterated, seems to me a question still sud
judice. Bergmann’ says, in this regard: “ Partial or com-
plete obliteration of the larger sinuses does not necessarily
lead to persisting disturbance in the functions of the intra-
cranial organs ; indeed, they can exist a long time without
any such.” Not a very definite statement. We know that
cases of idiopathic thrombosis, if I may thus express my-
self, of the large sinuses, especially the longitudinal sinus,
generally terminate fatally. Motor excitation symptoms,
mental depression, sleepiness, apathy deepening to coma,
occasionally delirium, are the symptoms of marantic throm-
bosis. Very frequently cephalalgia, assuming an unusu-
ally severe character, is present. I suppose that in my
case the severe pains in the head were directly attributa-
ble to the venous stasis after the ligature. The veins
from the cerebral surface open into the longitudinal sinus
in the main part posteriorly; before entering it, they re-
ceive the small branches from the mesial surface of the
hemispheres. ‘These, an occasional anastomosis of the
superficial veins over the gyri of the convexity of the
brain, and an emissary vein through the parietal bone,
seem to be the only collateral branches available, when
the longitudinal sinus is occluded near the torcular.
As a result of these anatomical conditions, sudden closure
of the sinus by ligature ought to give nse to the symptoms
of thrombosis and their pathological substrata (venous
stasis, meningeal hemorrhage, and capillary hemorrhages
of the cortex) even more rapidly than thrombosis which
is non-traumatic. Certain authors * have taken the view
that when mental depression and apathy are the only
symptoms, the obliteration is only a partial one. Neither
in my own, nor in the case previously cited, if that be one
of complete ligature, did any immediate symptoms de-
velop. May not the extreme anzmia in my own case ac-
count for this? As the patient gradually recovered and
began to sit up in bed, thus making muscular efforts, pains
in the head set in and increased in severity from day to
day.
i regard the operatiye procedure in my case in the light
of an important factor in the causation of the intracranial
hemorrhage, of which the patient died. Exactly where
the hemorrhage occurred I am not prepared to state. It
must have been from one of the larger vessels of the cor-
' Navratil: Beiträge zur Hirnchirurgie, 1889, page 48.
2 Schellmann: Ueber Verletzung des Hirnsinus, Dissertation gies-
cen, quoted by Bergmann, Die Lehre von Kopfverletzungen, Deutsche
Chirurgie.
3 Loc. cit., page 369.
‘Henle: Gefåsslehre, page 337.
+ Nothnagel: Ziemssen, Pathologic und Therapie, XI. i., page 208
tex or the subjacent white matter, considering its location
in the occipital lobe, or perhaps even from one of the
meningeal veins, and directly dependent on the venous
stasis. As a matter of fact, extensive hemorrhage does
frequently occur in thrombosis of the longitudinal sinus.
In conclusion, therefore, I would say that ligature of
the longitudinal sinus, as recommended by Heinecke ' and
Navratil,’ is not an indifferent surgical procedure, and one
the admissibility of which is still to be determined by fur-
ther clinical observation, and chiefly by experimental re-
search.
FIVE REASONS FOR FAILURE IN TREATING
CHRONIC RHINITIS.’
By THOMAS F. RUMBOLD, M.D.,
ST. LOUIS, MO.
THERE are numerous reasons why some physicians fail
to successfully treat chronic rhinitis, but I will mention
only five, any one of which would alone account fur com-
plete failure.
Since the last annual meeting of the American Rhino-
logical Association, at Cincinnati, I have visited quite a
number of offices of physicians who daily treat rhinal dis-
eases. Of these offices I am permitted to speak plainly
concerning the armamentaria of five. Each of these phy-
sicians has seen a copy of my criticisms, and is perfectly
willing that my remarks shall be published pro dono pub-
lico. These physicians have a liberal education, literary
and medical. All of them have the degree of A.M., and
all of them have visited European hospitals. I say this
to show that I am certainly taking a good average of in-
telligence of the profession, and men who have had better
opportunities to study these diseased conditions than the
great majority of physicians who attempt their treatment.
If, in speaking plainly of these physicians and their in-
struments and apparatuses, I seem too severe on others, I
hope that it will be taken in good part, for I give-it in the
most kindly spirit, and because I have the advancement
of my profession at heart.
The first reason for failure that I will mention is that
of defective instrumentation.
There are three prominent faults connected with the
instruments and apparatuses of these physicians that nec-
essanly must cause their failure.
First. Not one of these physicians had a tongue de-
pressor that would not cause the patient to retch as soon
as it was introduced into the mouth. The blades of all
these instruments were too wide to go between the teeth,
and they were much too long also, being about six inches
in length. These instruments were seldom used in ex-
aminations; the exceedingly defective method of drawing
the tongue out with a napkin was employed instead.
When these physicians used the right kind of a tongue
depressor on themselves, while they were patients of
mine, they were surprised at the marked contrast of the
effects of the two instruments, for I had been careful to
request them to try the effect of their own six-inch blade
tongue depressor before using the one I had with me.
A serious fault in the manner of using this instrument was
that they applied it themselves on their patients’ tongues,
instead of allowing the patient to use it, thus almost com- -
pelling the patient’s throat to spasmodically close, and in
this way prevent any application to the pharyngo-nasal
cavity and the posterior portion of the nares.
Four of these physicians declared, voluntarily, that my
success was largely due to the use of the right kind of a
tongue depressor, and because I allowed the patient to
hold down his own tongue.
Second. The spray-producers that these physicians
used were made for watery solutions only; they did not
———— i ee — ——— Se — ee
' Heinecke : Die chirurg. Krankheiten des Kopfes, Deutsche Chi-
rurgie, IJI., page 198.
2 Navratil: Loc. cit.
3 Read before the American Rhinological Association, October 9,
1889, at its Seventh Annual Meeting, held in Chicago, NI.
November 23, 1889]
possess an instrument that could throw warm vaseline.
Liquid cosmoline was found in every office. While this
remedy is far superior to tannin, iodine, nitrate of silver,
or any of a dozen other agents commonly found in of-
fices, yet it is very much inferior to warm vaseline. The
fact that the cosmoline 1s in a fluid state is one of its at-
tractive properties. In this shape the physician is spared
the trouble of heating it, a sin of which the profession is
frequently guilty, namely, avoiding any inconvenience,
even to the neglect of the proper treatment of the pa-
tient. Although it is far more convenient to employ a
cold liquid, yet it too quickly leaves the mucous mem-
brane ; besides this, heat is a very valuable adjuvant in
the treatment of these chronic inflammations.
I doubt very much if one could cure a rhinitis of a
man, thirty-five years of age, even with liquid cold vase-
line, while cosmoline in any form is more or less irritat-
ing. Liquid vaseline will not remain long enough upon
the mucous membrane, certainly not longer than one or,
at most, two hours, as I have found after careful observa-
tion, while common vaseline may be found in the nasal
secretions, by the aid of the microscope, forty-eight to
eighty hours after it has left the instrument. Of course,
treating rhinitis with aqueous solutions must end ih
failure.
Third. The compressed air used was taken from a con-
tainer of a capacity of from three to four or five gallons.
Air enough was forced into this reservoir to show a press-
ure of from thirty to seventy pounds. ‘The reservoir
was filled by an air-pump whose barrel was made of
brass ; the piston was packed with leather, which is par-
tially decomposed animal tissue, and it was lubricated
with rancid oil of some kind.
I asked these physicians if they had taken into con-
sideration the comparatively large quantity of brass, as
well as innumerable bacteria, emanating from the par-
tially decomposed leather and positively decomposed
lubricant that the compressed air had absorbed—cer-
tainly a hundred-fold more than would be absorbed by
_ uncompressed air, and which was instantly deposited on
the mucous membrane of the air-passages upon the re-
moval of the high air-pressure. fi f anyone will try the
experiment of passing air of this kind into a bottle of
beef-tea, then pass air compressed by means of water-
pressure into a similar bottle, he will see, by the aid of
the microscope, the astonishing differencé of the two
airs. If he was to have one of these airs forced into his
own air-passages, he would quickly decide to have the
air that was not contaminated with the brass, leather,
and rancid oil. One needs but allow some of this con-
taminated air to escape before his face, when his olfactories
will soon detect the odorous qualities of the stream.
It is needless to say, to those who are acquainted with
the subject, that the lowest air-pressure used by these
physicians is fully three times greater than that which
should be employed—ten pounds being the greatest
pressure that the mucous membrane can stand without
producing irritation, while by far the greater majority of
patients require from only six to eight pounds’ pressure.
The object to be accomplished by the compressed air is
to blow the secretion off the mucous membrane, and also
to forcibly apply the medicament upon the cleanest sur-
face. ‘This it should do without causing the least irri-
tation. All irritation, however slight, tends to retard
recovery, if it does not increase the inflammation. In-
spissated secretion requires a force of about ten pounds
to completely coat it over. This force will remove but a
small portion of the hardened secretion ; to remove all of
it would require a much greater force, but that force will
cause Irritation, which must not be instituted. With the
reduction of the inflammation, aided by the softening of
the secretion by the vaseline, the surface will soon be freed
of the inspissated accumulation. Thick, purulent secre-
tion wil require from eight to ten pounds to blow it from
its lodging-place ; flowing muco-purulent secretion may
be removed with a pressure of from six to eight pounds,
THE MEDICAL RECORD.
57!
and watery secretion, as is found in pruritic rhinitis, from
four and a half to five and a half pounds.
The question may be asked : Were these five physi-
cians less amply supplied with the proper kinds of instru-
ments and apparatuses than most physicians who assay to
treat these diseased conditions? Not at all. Their ar-
mamentaria are about as good as could be found in well-
supplied offices in this country, Great Britain, or any other
part of Europe. They are wealthy, ambitious, honorable
men, and they had such instruments and apparatuses as
their instructors in New York and Europe had themselves
employed.
In closing my criticisms upon these physicians’ meth-
ods, I ask : How is it possible to treat the posterior por-
tion of the nasal passages when the tongue depressor that
is employed is of such a shape and used in such a man-
ner as to almost certainly cause the patient’s throat to
contract to its severest degree, thus shutting off all op-
portunity to reach the posterior nasal openings, for the
upper and posterior portion of these passages cannot be
properly treated through their anterior openings? Even
if they could reach the diseased surfaces, they had noth-
ing with which to treat but instruments that threw watery
solutions or powders, or vapors. Again, if these very seri-
ous defects did not exist, the excessively high air-press-
ure would be injurious to the highly inflamed nasal pas-
sages. The patient might not complain at the time of
the application, as many of them expect, or do not object
to pain while under treatment ; but it should be borne in
mind that the anesthetic condition of the membrane aids
in covering any distress for the time being, but the next
day the patient will complain of some new symptoms,
which should be charged to the treatment received the
day before.
There are comparatively few offices that have a suffi-
cient number of instruments and apparatuses for the treat-
ment of the diseases of the upper air-passages. No one
would think that a man who intended to make a good
living in selling dry goods, hardware, or anything else, was
extravagant if he filled his store with from $5,000 to
$50,000 worth of stock ; but I have seen offices of physi-
cians that would not bring $500—books, instruments, and
furniture—even if sold at first cost, yet these men propose
to earn a livelihood from this small outlay. Economy,
with many well-to-do physicians, takes a prominent place
when an instrument is to be purchased. Of course, effi-
cacy is not entirely forgotten, but it does not, as it should
do, hold a paramount place in their minds. A physician
should not take into consideration his own convenience or
his pocket when instruments, or apparatuses, or methods
are to be selected ; every consideration is due to his pa-
tient. ‘The question that should be asked is, “ Is this
instrument or apparatus or method the best for the pa-
tient?” The cost or inconvenience cuts no figure what
ever. |
The next reason for failure is an anatomical one. I
mean, by this, an error in locating the disease. Innumer-
able clinical observations, and almost innumerable post-
mortem examinations prove conclusively that rhinal jn-
flammation invariably commences on the superior and
middle turbinated processes and extends in all directions
in the nasal passages and into the passages connected
with them, except on the floor of the nasal passages or
so-called inferior nasal meatuses. It should be jalways
borne in mind that these two portions are seldom affected
with inflammation. ‘There is another important fact well
known to anatomists ; that is, that the under surfaces of
the four diseased turbinated processes cannot be thor-
oughly cleansed or treated through the anterior nasal
openings, approach by way of the posterior nasal open-
ings being absolutely necessary.
The only instruments I saw that could treat these sur-
faces were the posterior nares syringe and black rubber
spray-producers, both throwing aqueous solutions. ‘The
syringe had generally been discarded because of the pa-
tient’s vigorous protests against its use, and the black
572
rubber instrument was having the same kind of reflection
cast upon it, the low temperature of the solution used, no
doubt, being one of the causes of the unpleasant effects.
A few still employed the nasal douche because of its for-
mer reputation, and because they do not know its injuri-
ous effects or were seriously impressed with the injury it
does, besides being ignorant of the fact that it does not
remove the secretion, and not knowing anything else that
has the reputation of cleansing the coated cavities.
Another method of cleansing, as well as of medication,
is the slender probe. ‘This instrument is armed with a
roll of cotton, plain or medicated ; it is then thrust into
the anterior nares, the first time being made to pass along
the floor of the nasal passages, or the so-called inferior
nasa] meatuses—where there is little or no diseased mu-
cous membrane—it is then made to pass into the middle
nasal meatuses, and then into the superior nasal spaces,
that is, if the patient could tolerate its passage six times.
After these applications every patient’s eyes were suffused
with tears; the great majority blew a small quantity of
blood from their noses. Another probe, bent nearly at
Tight angles, was made to pass up behind the soft palate,
and, when there, was made to wipe out this cavity.
The employment of these probes proved either that
they were ignorant of the location of the disease, or were
too easily satisfied with the futile attempts to reach the
diseased surfaces. If these physicians had one thousand
` patients, and treated them all in this way, they necessarily
must fail one thousand times to even ameliorate the com-
plaint, and the great majority of chances are that they
would injure everyone of the one thousand patients.
Yet this is the method that many physicians have made
extensive trips to Europe to learn. I have seen this
method employed in Berlin and Vienna. ‘This is not
slander. In England but two or three men, up to 1884,
recognized chronic nasal inflammation, and one distin-
guished writer says, in all earnestness, that this:complaint
is peculiarly American. Of course, he is mistaken.
Rhinal disease is far more frequently seen in London
than in any city I have ever visited. The fact is that the
disease is recognized by but few English physicians.
In every case where there was a dry hacking cough,
and, especially if the voice was affected, the probang was
thrust down into the larynx, or toward it. As the dis-
ease was not in the location where the pro was
passed, the patient would not be even relieved. If the
patient persisted in visiting the physician but did not im-
prove, the case was pronounced one of tubercular laryn-
gitis, and he was recommended to live in a more salubri-
ous climate. This is also transatlantic treatment.
Several patients who had a gagging cough in the mom-
ing were treated for stomach trouble. Nothing whatever
was done for their nasal disease that occasioned the se-
cretion that lodged behind the soft palate that in tum
caused the gagging cough.
Fourth. The physiological reason.
The physiology of the nasal passages should be as con-
stantly borne in mind as that of any other important
organ of the body. Respiration, in health, is carried on
almpst exclusively through the nasal passages. When
constant mouth-breathing is necessary, the victim is con-
stantly in distress, not only physically, but mentally.
Now this is about the only function that the very large
majority of operators seem to regard. As soon as par-
tial or complete nasal stenosis is discovered, an operation
for its relief is instantly urged, but, while restoring the
function of nose-breathing, they utterly disregard every
other function possessed by this organ. They attack the
hyperplasia as though that alone was the disease ; in fact,
nothing else is done or recommended. The cause of the
growth is not mentioned. Under these circumstances
the patient, while relieved of the “stuffiness” of his nasal
passages, is not in the least relieved of his rhinitis; on
the contrary, the operation may have been so severe as to
greatly aggravate the rhinal inflammation, as I have seen
it in a number of “persons who have come under my care
THE MEDICAL RECORD.
[November 23, 1889
after such operations. The fact that the function of the
mucous membrane had become greatly impaired long be-
fore the formation of the growth that closed the passage
existed, did not seem to enter the mind of the operator.
It is well known that scar-tissue does not perform all
the functions of mucous membrane. While the air may
be heated, or even overheated, yet the proper amount of
moisture that is requisite for the pharynx, larynx, trachea,
bronchial tubes, and air-cells is not present, consequently
irritation of all of these lower organs commences from
that time, and continues while the normal condition of
the nasal passages exists. Not only this, but the nasal
passages themselves will, because of their dry condition,
give new evidences of new inflammation, which will
greatly increase the whole trouble. ‘This new inflamma-
tion will give rise to a superabundant flow of muco-puru-
lent secretion. To check this we find the majority of
physicians employing other means and other methods
that again prove their ignorance of the functions of the
nasal mucous membrane. For this trouble a few will em-
ploy inhalers, but by far the greater number use insuffia-
tors. I have seen, during the last year, at least a dozen
varieties of instruments for throwing powders into the
nasal cavities. All of them were nearly equally injun-
- ous, but those that threw the powder under the turbinated
processes were by far the most injurious.
It is well known, but apparently forgotten, that the
functions of the inflamed nasal membrane are but par-
tially performed ; it is also well known, and also appar-
ently forgotten, that the normal condition of the mucous
membrane is the moistened condition, yet these powder-
blowing physicians attempt to restore the functions of this
diseased mumbrane by drying its surface with a powder.
A more preposterous act could hardly be conceived.
We are now ready to take up the fourth, the pathologi-
cal reason.
How can these physicians escape the verdict of igno-
rance of the pathology of chronic nasal inflammation when
they employ inhalations of vapors and insufflations of pow-
ders to cure this condition? Does the vapor or powder
cleanse the thickly coated surfaces—surfaces that must be
cleansed to be cured?” Do they think that these appli-
cations fall upon the diseased surfaces? Do they not know
that these agents take effect only upon the surfaces that
require the least treatment? Do they not know that the
surfaces that most require treatment are not treated at all ?
It appears to me as though they must either plead igno-
rance of the pathology of this region or acknowledge mal-
practice.
Fifth. The etiological reason.
Inflammation of the surfaces under consideration is
due to an enlargement of the blood-vessels, also to a very
great increase in their number. This increase is more ap-
parent than real, for these vessels existed long prior to the
apparent increase, but they did not carry red blood-cor-
puscles, consequently they were not visible even under
the microscope. This is readily demonstrated in the
mesentery of the mouse, the foot of the frog, and the
rabbit’s ear. ‘To permit the red blood-corpuscles to flow
through vessels of a smaller calibre, the sympathetic
nerves that control the muscles that surround these and
all other blood-vessels are debilitated ; they are in a pa-
retic condition. This condition is due to injury done to
sensory nerves by colds principally, but by other agents
also, such as tobacco, alcohol, carbolic acid, etc. Unless
the irritation was caused by these agents the sensory nerves
would not act reflexly upon the sympathetic nerves, caus-
ing them to take on the paretic condition spoken of, and
if this condition did not take place, there would be no
such phenomena as inflammation, proliferation, hyper-
plasia, atrophy, oedema, ulceration, etc. In other words,
without irritation inflammation and its sequences would
not, nay, could not, exist. Keeping in mind that every ir-
ritation produces inflammation, what are the indications
for treatment of chronic rhinitis?
1. The diseased secretion, which is always acrid, there-
November 23, 1889]
fore irritating, should be removed. If morbid growths are
present, as these also are irritating, they should be re-
moved, thus removing the local sources of inflammation.
2. The new secretion, that is, that which is to be formed
upon the surfaces that have been cleansed, should be pre-
vented from becoming acrid, thus preventing another
cause of inflammation.
3. Hygienic and sanative measures should be insisted
upon. This is to prevent a continuance of the imitation
to the sensory nerves, that are located upon the surface
of the body and the mucous membrane, by colds and
other irritating agents, thus removing the originating
causes of the inflammation.
This is all that is required of the physician, or, far more
correctly stated, that isall that hecan do. Vis medicatrix
nature performs the cure, if it is possible. The recovery
will be rapid in the young, and slower as old age is
reached.
Now, let us see if the methods and remedies mentioned
will fulfil these three essential indications. They must ful-
fil all three, or a failure ts sure to follow.
As already stated, the douche and the posterior nares
syringe have very properly been abandoned by experi-
enced physicians, because they do not remove the diseased
secretions. The same must be said of the probe passed
into the anterior nares, and up behind the soft palate, for
the cotton cannot cleanse even the surfaces that they do
reach, without, at the same time, producing excessive ir-
ritation, while the secretion under the four turbinated pro-
cesses is not touched, and the secretion that is removed
from the pharyngo-nasal cavity is not formed there, but
originally comes from the upper portion of the posterior
surfaces of the nasal passages, a region not attempted to
be reached by the cotton applicator, and if attempted,
would surely fail, as a portion of the parts affected and
coated with purulent secretion cannot be seen except by a
post-mortem section of the head. |
_ It is evident that to fulfil the first indication—removing
irritating secretion without causing additional irntation—
is a complete failure. Yet this is about all that is done by
men in this country and Europe who have a world-wide
reputation for being scientific practitioners.
I claim that it would be truly wonderful if they cured
a single case of chronic rhinitis. In fact, nature would
be compelled to change her laws in order that she could
perform a cure for them.
The second indication is not th ought of ; certainly not
mentioned by any of the books, domestic or foreign.
Maybe someone would say that the insufflation of a powder
proved their attempt to prevent the secretions from be-
coming more decomposed, but the degree of irritation due
to the powder that covered the surfaces that had no
catarrhal accumulation, surfaces that did not require
treatment, is greater than the benefit that could accrue
from preventing the unremoved secretion from becoming
further decomposed. Besides this, the irritation of the
clean surfaces, due to the action of the powder, will cause
the whole of the mucous membrane to pour out a super-
abundance of mucus, so as to wash out all the catarrhal
accumulation on which the powder was lodged, thus put-
ting a stop to the necessity of the corrective action of the
powder.
I am much pleased to notice that the books published
in this country during the last few years are calling atten-
tion to the third indication, namely, hygienic and sanative
measures. Still, these measures are so slightly enforced
by the physicians that the patients are not impressed with
their importance. A great many physicians are victims
of some of the habits that are conducive to catarrhal in-
flammation, consequently consistency prevents them from
enforcing rules against tobacco-smoking, chewing, snuffing,
the use of beverages that contain alcohol, keeping late
hours, short hair-cutting, etc.
What relationship is there between the effect of iodine
applied to the pharyngo-nasal cavity and the etiology of
the inflammation in this cavity? a diseased condition
THE MEDICAL RECORD.
573
that is due to a flow of secretion from still more diseased
surfaces located two inches above it. Is this a scientific
application? No one will claim that the iodine allays ir-
ritation. Its curative property depends, I believe, on its
being an antiseptic, that is, correcting the acridity of the
secretions to be removed. Even if this secretion should
be allowed to remain and be corrected, does this allay the
inflammation in the upper portion of the posterior nares,
the location that originated this secretion? Supposing
that the secretion is removed by the same instrument
that applies the iodine, then there is nothing for the iodine
to correct. The very same may be said of nitrate of sil-
ver, iodoform, preparations of mercury, etc. All of these
agents injuriously affect the sensory nerves of the in-
flamed mucous membrane, these nerves act reflexly upon
the sympathetic nerves that go to the blood-vessels of the
same membrane, and in this way give rise to additional
inflammation, the very opposite of what is intended.
It is seen that the mucous membrane of a patient treated
in this way has three sources of irritation: First, the origi-
nal one, from the sensory nerves of the integument, caused
by colds; second, from the acridity of the secretion
formed upon its surface ; and, third, from the iodine or
nitrate of silver or the insufflated powder.
What use is there in cumbering a book with the etiology-
of a disease if it does not guide one in the use of medi-
cines or methods for its alleviation? If one reads the
pathology and etiology of the nose and throat in foreign
and domestic works, they will see no more relationship
between these important subjects and the practice recom
mended than there is between a railroad time-table and a
sheet of opera-music. It is a pure waste of time to read
them, if one expects to be assisted in comprehending the
course laid down for treatment. I have not seen a physi-
cian that read them more than once, and not one of these
was reminded as to the means or methods of the treat-
ment while reading them.
To conclude: When medical men fail to use instru-
ments that will reach the location of the disease, when
their efforts at treating the disease demonstrates that they
do not know its location, when they are seemingly regard-
less of the function of the mucous membrane, when they
treat a coated catarrhal surface with a vapor or a powder,
and when their local applications and operations show
that they have no etiology to guide their practice, nothing
less than failure] should be expected. Under these cir-
cumstances it should not be expected that a case of com-
mon chronic rhinitis would be ameliorated, not to say
cured. It is innumerable fruitless efforts of this kind that
has filled the world with expressions of positive doubt as
to the curability of this disease. It is quite common for
intelligent persons to say: “ I fear that nasal catarrh can-
not be cured. I have not seen a person that was cured,
nor have I ever heard of one that was cured.”
SEEKING A RESTING PLACE FOR THE DeEabD.—Efforts
have been made on various occasions to provide mortu-
aries in Paris for persons who, for any reason, were not
domiciled anywhere at the time of their death. A pain-
ful instance of the inconvenience resulting from the want
of them occurred recently. A journalist, in the last stage
of phthisis, feeling better one day, took advantage of this
to"induce his brother to bring him in a cab from the out-
lying suburb, where he had been residing, into Paris. He,
however, succumbed soon after passing the darrtére, and
then began, for the brother, a tedious and hornble prom-
enade. Refused at his own hotel, declined at the hos-
pital, on the ground that it was not a mortuary, rejected
at the Morgue because only the unidentified dead were
received there, the whole night was passed in perambulat
ing in the cab the dead body of his brother that nobody
would receive. It was only by a derogation from the
rules of one of the hospitals that the brother was enabled
to find a temporary resting place for the deceased.— Paris
Correspondent Medical Press and Circular.
574
en ee aaee
THE MEDICAL RECORD:
purnal of Medicine and Surgery.
OF THE
GEORGE Re PHRADY, A.M., M.D., EDITOR.
SoN cry WO
PROPRIETORS AND PUBLISHERS
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
e - ep
New York, November 23, 1889.
SOME OF THE RECENT APPLICATIONS OF
MENTHOL.
Ir is only within a few years past that menthol has been
used to any extent in medicine, and even now its employ-
ment is rather restricted—more so, perhay&, than its merits
deserve. What these merits are, and in what conditions
menthol has been found to possess some curative proper-
ties, it may be profitable briefly to consider.
The most familiar employment of this camphor is as a
local application for the relief of pain, and menthol cones
are prepared and sold in the shops for this purpose. The
relief obtained by such applications is usually but tempo-
rary, yet in some of thé milder forms of facial neuralgia
and so-called rheumatic pains the remedy is of real ser-
vice. In pruritus also the analgesic properties of the drug
have been turned to good account. It is employed for
this purpose in ointment, spirit, or liniment, in the strength
of from one part in twenty to one part in ten. A very
good preparation for this purpose is that recommended
by Eloy, of a solution of fifteen grains of menthol in one
ounce of forty per cent. alcohol. Still another use for
the remedy, as externally applied, is in the treatment of fu
runculosis, and more especially of furunculosis of the ex-
ternal auditory canal. Here the bactericidal properties of
the drug, as well as its analgesic action, come into play.
Dr. Cholewa has made trial of menthol in these cases and
commends it most highly. He applies it by means of a
pledget of cotton moistened with a twenty per cent. solu-
tion and inserted into the canal. The application is said
to cause a little smarting at first, but this is soon succeeded
by entire relief of pain and a speedy subsidence of the in-
flammatory process.
Ringworm of the scalp is said by Dr. Malcolm Morris
to yield more promptly to applications of menthol than
to any of the ordinary remedies employed for this purpose.
One part of menthol, four of chloroform, and twelve of
olive-oil is the formula recommended in such cases.
In the treatment of various affections of the upper air-
passages, also, good results have been obtained by local ap-
plications of menthol in the form of solution, vapor, or
spray. Rosenberg and others have claimed quite a large
percentage of cures of laryngeal phthisis by this means.
In this country Potter, Knight, and others report very de-
cided improvement after the use of menthol in this dis-
ease, but they have not observed any actual recoveries.
In nasal and pharyngeal catarrh much benefit is often de-
rived from sprays of menthol dissolved in oil or fluid vas-
THE MEDICAL RECORD.
Eve! ovember 23, 1889
eline in the strength of jim onae to ave or thicty per
cent. In hay fever William Hill, of Lon7on, has found
menthol to serve an excellent purpose as a substitute for
cocaine. He applies a ten or twenty per cent. solution in
olive- or almond-oil to the sensitive area within the nose
by means of a brush or atomizer.
In the chronic bronchitis of old age Nyes speaks favor-
ably of inhalations of menthol, which, he says, not only
facilitate and rapidly diminish the expectoration, but also
allay the cough and reduce the number of paroxysms.
These inhalations have also been use2 with good effect in
whooping-cough. Finally, the same mode of application
has proved useful in Jores’ hands in relieving asthma. He
reports a case for which all the usual and most of the un-
usual remedies had been tried unsuccessfully. Inhalations
of a twenty per cent. solution in olive-oil were then tried,
with the most satisfactory results—the rattling rales dis-
appeared almost immediately and the respiration soon be-
came normal.
Menthol has not yet been employed to any great ex-
tent internally, although it is said to act efficiently when
so given in controlling certain painful affections. Dr. C.
L. Dana has so employed it, with fairly satisfactory re-
sults, in migraine, supra-orbital neuralgia, and anzmic
headaches. The dose for internal administration is from
fifteen to sixty grains per day. These are some of the
uses to which this drug has been applied, though they are
by no means all. If the effects obtained should be found
to be uniformly produced, we might well be justified in
placing menthol among the most valuable of the minor
therapeutic agents.
INTRATRACHEAL INJECTIONS OF OIL OF CREOSOTF.
Dr. Louis Dor, of Lyons, has contributed to the Revue
de Médecine an article ypon the above subject. Over a
year ago Beehag stated that he had successfully injected
mentholated oil into the trachea of persons suffering from
phthisis. ‘The injections were made directly through the
tracheal wall by means of a hypodermic syringe. ‘This
method, however, was too barbarous ever to be widely
adopted, even if good results could be obtained. Dr. Dor
therefore decided to make injections directly through the
larynx, by means of a syringe specially constructed for
the purpose. He also chose creosote in preference to
menthol because of its stronger anti-microbic power.
According to Bouchard about one-tenth per cent. solu-
tions of creosote (0.80 per 1,000) kill the bacillus in pure
cultures, while, according to Guttmann, one gramme to the
litre retards its development. The solution used by Dor
consisted of 5 grammes of creosote to 100 c.c. of steril-
ized olive-oil, and of this from eight to thirty drops
were injected. The injections caused, in some persons,
temporary choking and distress, and sometimes vomiting,
but never hzemoptysis. The patients generally soon be-
came accustomed to the medication and ceased to be dis-
turbed by it. Experiments made upon rabbits showed
that the oil gradually reached the alveoli of the lungs, and
was not entirely absorbed for several days. Dr. Dor
does not report any brilliant cures, but, ike most of the
new methods of treating phthisis, it gives relief to the
cough and causes improvement in other symptoms.
Further and extended details are promised at a later day.
November 23, 1889]
PARENCHYMATOUS INJECTIONS OF SODQFORM-OIL IN
JOINT DISEASFS.
A FEW years ago a good deal was written concerning
the use of iodoform in the treatment of abscesses in
tuberculous joint diseases, and many cures were reported
as having resulted from injections of this substance.
Further trials, however, did not appear to substantiate
the claims of the early advocates of the measure, and for
a time little was heard of it. But lately the method, in a
modified form, has been revived, and several German
writers have published reports of cases which would seem
to show that it possesses, after all, some merit.
Dr. Wendelstadt, of Bonn, writing in the Centralblatt für
Chirurgie, September 21, 1889, reports several cases of
taberculous joint diseases in which parenchymatous in-
jections of iodoform-oil were employed with very good
effect. At first iodoform in ether was used, but this had
to be abandoned on account of the severe pain caused by
it. Then the drug was given in olive-oil, one part to
five, and was found to cause but little inconvenience. It
is important-to prepare the mixture each time that it is to
be used, as the iodoform soon decomposes and iodine is
formed. In some cases a slight rise of temperature was
` noted after the injection, but this was only temporary.
In 85 cases in which the method was employed and in
which the results were noted, an apparent cure was ob-
tained in 36, some improvement in 37, while in 12 no
benefit was apparent. The writer does not claim that the
treatment is ip the nature of a specific, but only that it
gives good results in most cases. He is probably correct
in regarding it as a useful addition to the resources at our
command in dealing with this class of diseases, but as one
which cannot be relied upon as positively beneficial in all
cases.
THE USE OF THYMOL-MERCURY IN THE TREATMENT
OF SYPHILIS.
Tue analysis of the various secretions of syphilitic patients
who are undergoing a course of mercurial treatment has
shown pretty conclusively that mercury when given by hy-
podermic injection is absorbed more rapidly than when
exhibited in any other way. Yet the disadvantages of
this method are so great that it has failed to find any spe-
cial favor, in this country at least, where practical avail-
ability is more regarded than is theoretical excellence. It
is not unreasonable to hope, however, that some prepara-
tion of mercury may yet be found whose ready solubility
and freedom from irritating properties will render it
peculiarly fit for introduction into the system by this often
most convenient method.
In the Archiv fur Dermatologie und Syphilis, Septem-
ber 15, 1889, Dr. Eduard Wellander, of Stockholm, pub-
lishes the results of some experiments made by him with
the acetate of thymol-mercury. He employed a mixture
of one and one-half grain in fifteen of liquid paraffin.
The injections were made usually every fourth day, and
each patient received an average of six or seven injections.
As a rule, the treatment was well borne, and it was seldom
that the patients complained of any pain; when this was
felt it was usually of very moderate intensity. In one
case a small abscess was noted, but it disappeared without
causing any trouble. Occasionally a slight induration
was noted at the seat of the injection, but in only one
THE MEDICAL RECORD.
575
case was it so troublesome as to lead the patient to ask
for a change in the treatment. Stomatitis was present in
a few cases, but this accident happened for the most part
in the earlier experiments, when the injections were given
every three days, and was much less troublesome when the
interval was lengthened to four days. The results were
in general very satisfactory, the symptoms disappearing
promptly within three or four weeks, although relapses
were noted in several instances. In two cases it was
found necessary to abandon the injections on account of
stomatitis and diarrhce1.
From his experience with this mode of treatment the
author concludes that thymol-mercury is much better
adapted for injections than is calomel, as it is far less
painful and is not nearly so apt to cause abscesses. He
regards the method as a great advance in the therapeutics
of syphilis, although he admits that the ideal treatment
of the disease cannot yet be said to have been discov-
ered.
THE PHYSICIAN’S FAMILY AND THE PROVISION THAT
HE LEAVES FOR IT.
Ir is a well-known fact, and as sad as it is notorious, that
physicians, even those accounted successful during life,
often leave very little behind them for the support of
their families. They may have enjoyed a good income,
but their expenses were proportionately heavy, and when
death overtook them they were found to have laid by
little for the future. We do not propose to draw a moral
from this, nor to preach the necessity of economy. ‘As
uneconomical as a doctor” is an expression that has be-
come almost proverbial, and preaching will not promote
thrift where thrift is impossible. Of course, we do not
mean to say that all doctors are improvident, but merely
that the lack of a prudent foresight is an all too common
failing among the members of our profession. In many
cases, moreover, it is impossible to get ahead, the daily
income sufficing only to meet the daily expenses, and so,
when sickness or death comes and the income ceases, there
is nothing left.
It is for this reason that physicians’ mutual benefit as-
sociations have been formed in many of our cities, and we
think it is the duty of everyone to join an association of
this kind if he has the opportunity. We say everyone, for
the larger the membership of such an association the
more benefit is derived from it by each individual mem-
ber. It is not only the needy who should join it, but the
prosperous as well. No one can tell when reverses may
come, and it is only the part of a wise man to provide for
any possible contingencies. ‘The same argument will ap-
ply to life insurance. If a man has his life insured when
he is young, the expense is small, and he will have the
satisfaction of knowing that his wife and children will not
be left destitute, even if he has been unable to lay any-
thing by for their support. Let him first of all join the
Physicians’ Mutual Benefit Association, if there is one in
the community where he lives, and then let him put aside
what he can every year in the shape of a premium ona
life-insurance policy, and he will not regret it.
If everyone of our readers would but follow this advice,
which we assure them is sound, there would be a saving
of much suffering to the widows and young children of
physicians who have died before their time. The incon-
576
THE MEDICAL RECORD.
[November 23, 1889
venience of acting upon this advice now will be slight, but
the future misery that will be averted by so doing is
great.
ANTISEPTIC TREATMENT OF SMALL-POX.
ALTHOUGH, fortunately, in this country and at this time
few practitioners are ever called upon to manage a case of
small-pox, the disease is yet by no means so effectually
stamped out that we can afford to ignore any advances
that may be made in its treatment. In countries where
vaccination is generally or universally practised the op-
portunity to study this disease is, as a rule, too restricted
to be productive of any satisfactory results, and we must
look, therefore, to other lands than ours for news of
progress in this field. Of course there are hospitals in
this city, as elsewhere, in which in the course of a year
or of a series of years, many cases of small-pox may
be seen, but the incentive to study the material there
offered is not great, since public interest in the result of
such study is but feeble.
There is, however, a country where the question is one
of absorbing and perennial interest, and where one may
be sure of finding an appreciative audience to listen to
any reports of progress made in the treatment of small-
pox. This country is Turkey, though throughout the
Orient much the same condition prevails, as vaccination
is so little practised there as to be almost unknown to the
natives in many districts. In Constantinople there is not
a physician who is not called upon to treat many cases of
the disease every year, and he often sees it in its most
dangerous and most loathsome forms. One may readily
understand, therefore, that the question of variola and its
treatment is not without interest to the resident of that
picturesque but insanitary city. It is, of course, among
children that the disease works its greatest ravages, since
here is to be found the best material for it to act upon,
and a large proportion of the mortality of young children
is due to this cause.
Dr. Lewentaner, of that city, writing in the Bulletin
Général de Thérapeutique, No. 32, 1889, speaks very en-
couragingly of the success attending an antiseptic method
of treating the disease which he tried in several cases.
This method consisted in the application of an ointment
composed of salicylic acid, three parts; starch, thirty
parts ; and glycerine, seventy parts. ‘The ointment was
applied to the face by means of a mask, and also to the
other parts on which the eruption was marked. Notwith-
standing that the eruption was confluent in many places,
large bullz filled with pus being present, the lesions all
dried up without rupturing, and left no cicatrices to mark
their site. {n addition to this external application, a
mixture of quinine in cherry laurel water, oil of sweet
almonds, and syrup of orange flowers, was employed. A
small quantity of this mixture was dropped on the tongue
and back of the pharynx by means of an ordinary medi-
cine-dropper, three or four times an hour. This served
to keep the mucous membrane of the mouth and pharynx
moist while supplying at the same time a certain amount
of quinine. ‘There was about one grain of this drug in
one and a half drachm of the mixture.
The advantages of this method of treatment are sum-
med up by the author as follows :
1. All the children treated in this way recovered, al-
though the ordinary mortality of the disease is forty per
cent.
2. The duration of the disease was decidedly short.
ened, the period elapsing from the commencement of the
eruption to the falling off of the crusts being twelve or
thirteen days. |
3. The disease ran its entire course almost without
fever.
4. The danger to those around the patient is greatly
lessened. In the author’s cases there were other children
exposed, but notwithstanding that they were not vaccin-
ated, they did not contract the disease.
5. The simplicity of the method, as compared with the
treatment by baths and cold applications, has much to
recommend it.
6. Esthetically, also, the antiseptic method of treat-
ment offers great advantages, since it prevents absolutely
all pitting.
THE PATHOGENIC PROPERTIES OF MICROBES FOUND
IN TUMORS.
M. VERNEUIL, of Paris, is not much known as a bacteriolo-
gist, but with the. help of Dr. Nepveu, who does possess
skill in this line, he has been studying the bacteriology of
tumors with some interesting results.
Neither Verneuil nor Nepveu find that there are any
specific microbes causing cancer, sarcoma, fibroma, etc.,
but they do find these tumors are often the geat of various
pathogenic organisms which may and do infect the sys-
tem, causing fever, phlegmonous inflammation, sepsis, etc.
It has been observed that sometimes after the ablation
of a tumor, despite all ordinary antiseptic precautions,
there develops a sudden septic infection, or fever. This
accident is due, according to Verneuil, to the fact that
the tumor contained in certain parts, or in its juices, path-
ogenic organisms which infected the wound. It has hap-
pened that after tapping an ovarian cyst the patient
rapidly becomes prostrated and dies; the bursting of a
cyst or its accidental breaking has seriously complicated
the progress of the case. Verneuil contends that there
are microbes or microbic poisons in the cystic fluid, and
that these cause all the trouble. He has made some ex-
periments to prove this point. Fluid from cysts was
withdrawn and injected subcutaneously into four dogs.
They all died in two to eight days, with septic symptoms.
Verneuil’s conclusion that microbes and microbic poi-
sons are often associated with malignant tumors is one
that is a priori very probable, and one belief in which
clinical experience confirms. His investigations teach,
he thinks, that malignant growths should be extirpated as
soon and as thoroughly as possible.
THE ‘‘CORN-STALK DISEASE.”
ALREADY the pathologist and the student of the ultimate
sources of disease have found in the study of the maladies
of animals an interest and a profit fully equal to that
which proceeds from the investigation of human disease-
changes. The articles of Frank S. Billings, in the Buffalo
Medical and Surgical Fournal, July to October, 1889,
upon the “ Corn-stalk Disease in Cattle,” are good speci-
mens of the scientific work which is now going on in this
department of medicine.
November 23, 1889]
THE MEDICAL RECORD.
577
The history of the epidemic is in each instance about
as follows: In late autumn or winter, cattle are turned
into fields of Indian corn, from which only the ears have
been removed, or which has been “ topped,” to clean up
the remnants of leaves and tops, and stalks, if they will
eat the latter. After a few days one and another of the
cattle is taken ill with a malady which may cause death
in from twenty-four hours to ten days, or may result in
recovery. It is an acute blood-pojsoning, with fever from
102° to 107.6° F. There is weak pulse and rapid respira-
tion. The animal may either bellow and chase other ani-
mals-—as dogs, hogs, and fowls—or may stand by itself
_ apart, depressed, and loth to move. All the sick retain
the power to swallow, and all drink. ‘There is frequently
constipation, which may in favorable cases turn to diar-
rhoea. The urine appears normal. ‘There is yellowish-
red congestion of mucous surfaces. The secretion of
milk slackens or ceases. The post-mortem macroscopic
changes are those of acute septic febrile disease. The
disease is not conveyed by one animal to another.
The farmers were sorely puzzled. Only certain fields
or parts of fields were dangerous. They could never tell
when a valuable herd would be decimated, if turned into
a fodder-field. Various theories, easily disproved by ex-
periment, were prevalent among farmers. It was held to
be caused by lack of salt and water for the cattle; by
dryness of the fodder; by smut (ustilago maids); but it
was seen in cattle which had water and salt ; and the dry-
food theory was shown to be false. Moreover, cattle fed
on large quantities of smut were not made ill.
The growing corn was now examined. In the diseased
patches the plants were stunted, if attacked in early sum-
mer. The lower leaves die, becoming yellow, with col-
ored streaks. The roots decay in the ground, even the
brace-roots becoming corroded. ‘The ears do not ma-
ture.
Microscopic examination of the leaf-streaks and other
diseased parts reveals the presence of an organism which
is now believed to be the cause of the disease. It is
never found far from parts which are plainly diseased,
and it invades the healthy tissues at the edges of the af-
fected areas.
The germ resembles very closely that of the Southern
cattle plague of wild-seuche, and of the swine plague,
It is ovoid, its length being about one-sixth the transverse
diameter of a red blood-cell. When stained it resembles
a small white bean, with both ends and two sides stained.
It moves by a sort of rolling action. Dr. Billings sup-
poses that the white, non-coloring substance is a secretion
of the two poles or coccoid ends, and that it may consti-
tute the ptomaine or essential poisonous pathogenic
principle of the disease, which gets into the fluids of the
animal body by the breaking up of its capsule, which
occurs as the germ becomes mature.
These organisms have been cultivated in media outside
the body, and the injection of the cultures into animals
has produced symptoms of “ Corn-stalk Disease.”
It is not known whether grasses and other grain-plants
are affected by the disease. It is probable that the grains
of the corn-ears may beé diseased as well as the plant
itself.
The diagnosis between the corn-fodder disease and the
other diseases in which similar micro-organisms are found,
is quite easily made by the history. It is most like the
swine plague, but swine are not subject to it.
The only treatment suggested is the early administration
of Glauber’s salts, to clear out the intestines, and reduce
the febrile congestion of affected organs. Methods of
prophylaxis readily suggest themselves, including destruc-
tion by fire of all discharges, and of all corn or other
plant-matter supposed to contain the germs of the disease.
Animals killed by it should be immediately burned.
The disease is found in many States, especially of the
North and West. It may attack horses, sheep, and goats,
though generally seen in the cow. It is said to cause
greater loss in cattle to the farmer of the great corn-rais
ing States of the West than all other causes combined.
DOCTORS AS BEGGARS.
THE physicians of Chicago are trying, we are told, to
establish a public library for the benefit of the profession.
They first tried to get the City Library to make sufficient
provision for their wants, but failed ; and they had equally
poor success with the trustees of the new Newberry Li-
brary. Now the doctors have ceased trying to get other
people to give them a library, and are taking hold them-
selves. Already $10,000 has been raised. We commend
the spirit thus shown, and trust that our brethren by the
lake will succeed in getting a great library. It is a good
plan for the profession to take care of itself just as much
as it can. We have always heretofore looked to outsiders
for help in building hospitals, colleges, laboratories, and
libraries, with the result that the doctor in most of these
institutions is but a minor factor in their management.
The medical profession deserves public help in its purely
scientific and benevolent work; but it can do a great deal
more for itself than is sometimes supposed.
Hews of the Week.
THE METAPHYSICAL COLLEGE OF MASSACHUSETTS, an
institution for teaching: Christian Science, has dissolved.
ONE OF THE BEST AGENTS TO ABORT A CORYZA, ac-
cording to Dr. Beverley Robinson, is carbonate of ammo-
nia, in frequently repeated and rather large doses.
Dr. WiLi1aM Cockcrort, of this city, died on Novem-
ber 18th, in the seventy-second year of his age.
A Death has been reported following the use of two
fifteen-grain doses of sulphonal, the doses being given an
hour and a quarter apart. The fatal result occurred forty
hours after the first dose. ‘The patient was a woman with
melancholia, aged twenty-eight. The mode of death
was apnoea.
THE Best ANTIDOTE TO CARBOLIC-ACID POISONING 1S
soap, which should be taken at once and repeatedly.
CREOLIN is being used to the exclusion of other anti-
septics in the Obstetric Department of the Fraucn Klinik
under the care of Professor Winkel, of Munich.
Tue Best Lotion for recent injuries, says Billroth,
is the ordinary lead lotion.
Dr. ROBERT GAMBLE CABELL, a prominent physician
of Richmond, Va., died last week, aged eighty.
578
THE MEDICAL RECORD.
[November 23, 1889
A Cuicaco DOCTOR has sued Miss Frances E. Willard,
President of the Women’s Christian ‘Temperance Union,
for $50,000, for some trouble connected with the jurisdic-
tion over a hospital managed, or sought to be managed,
by the Union.— Boston Medical and Surgical Fournal.
POLITICS AND CHARITY.—The Associated Charities of
Denver have opposed the building of a hospital by the
city, because of the danger that the management of a hos-
pital under the government of the city might be subjected
in an injurious way to political influence.
New YorK POST-GRADUATE MEDICAL SCHOOL AND
HospiraLt.—The Executive Committee of this institution
have established a clinic for diseases of the rectum, to be
under the care of Dr. Charles B. Kelsey, for the treat-
ment of poor persons suffering from these diseases.
Dr. FRANCIS J. QUINLAN of this city was recently ap-
pointed Lecturer on Diseases of the Throat and Nose in
the New York Polyclinic School and Hospital.
THE MIDDLETON GOLDSMITH LECTURE.—Professor
William Pepper, Provost of the University of Pennsyl-
vania, will deliver the Middleton Goldsmith Lecture be-
fore the New York Pathological Society, in the hall of the
New York Academy of Medicine, on Wednesday evening,
January 15,1890. ‘lhe subject of the lecture will be
“ Hepatic Fever.”
Dr. THomas H. BURCHARD, of this city, gave a dinner
at his residence on Monday evening, November 18th, to
Dr. Blanc, of Aix-les-Bains, France. A select number of
representative medical gentlemen were present. A pho-
nograph was on exhibition, enlivening the occasion by
songs and instrumental music. Dr. Burchard welcomed
the guest of the evening, and Dr. Blanc gracefully replied,
after which the phonograph recorded a characteristically
eloquent welcome from Dr. Lewis A. Sayre; and thus
wil] the coil echo his voice, tingle the ears, and warm the
hearts of his many friends across the sea.
Dr. CHARLES A. Powers has been appointed Assistant
Surgeon to the New York Cancer Hospital.,
ANOTHER HOSPITAL FOR CHRONIC INVALIDS, to be
called the Isabella Heimuth, will soon be opened in this
city. It is non-sectarian.
. Tue Late Dr. Ricorp, like many other eminent phy-
sicians, was a most benevolent man, but lacking in business
capacity. When the Empire came, it brought him royal
favors, wealth, and academical distinction ; but notwith-
standing his large income, which probably exceeded that
of any other French doctor of the time, Ricord was con-
stantly falling into debt, owing to his charitable disposition.
He not only attended poor patients for nothing, but act-
ually fed and housed them, and in the case of country
or foreign patients he often paid their expenses to Paris.
He was several times sold up, and even sent to prison
while imprisonment for debt was possible. He was re-
leased by the Emperor, who paid his debts,
AN ANTISEPTIC OINTMENT, certain in power and not
unpleasant in odor, is often desired, not only by the ob-
stetrician but also by the gynecologist. Dr. ‘Th. Parvin
‘says that benzoated lard, to which four per cent. of creo-
lin is added, will meet these indications satisfactonly.—
College and Clinical Record.
“ VASO-MOTOR CENTRE-ITIS” is the cause of puerperal
eclampsia when there is no albuminuria or renal trouble
to explain the convulsions. Such, at least, is the opinion
of Dr. A. D. Macdonald (Medical Press and Circular),
and he is certainly to be congratulated for giving us so
rhythmical an addition to polynymy, as well as in attach-
ing an actual anatomical disorder to a purely physiologi-
cal centre.
FIRE AT THE FACULTE DE MEDECINE.—The fire in the
grand amphitheatre of the Paris Faculty of Medicine
caused damage to the extent of some £2,800. ‘Three im-
mense pictures by Matout were destroyed. One of them
represented Ambroise Paré applying a ligature for the
first time, and was valued at £400. Of the two others,
one represented the first clinical lecture in surgery at the
Hôtel Dieu, and the other the first lecture on physiology
at the chapel of St. Julien le Panore. The bust of Hip-
pocrates, which has been gazed upon by so many genera-
tions of students, was also destroyed.
THE SURGERY OF THE LIVER.—Mr. Lawson Tait, writing
upon “ Surgery of the Liver” (Edinburgh Medical and Sur-
gical Journal), says: When first I attacked the liver by
surgical operation I certainly was in terror of hemorrhage,
for I thought that if an incision opened a large smus the
arrest of hemorrhage would be a matter of considerable
difficulty, but I was encouraged by an accident which be-
fell me in performing an ovariotomy, for there, on un-
doing an adhesion to the liver, I tore a cleft in the free
edge of the organ, certainly an inch and a half deep,
which bled freely, and I was greatly alarmed ; but I took
a small piece of solid perchloride of iron about the size
of a pea and rubbed it over the edge of the tear. The
hemorrhage stopped immediately, and my patient made
an easy recovery, so that my respect for the liver greatly
diminished. On one occasion I did open by my incision
a sinus of considerable size, but I passed a thread by
means of a fine needle down one side of it and up the
other, and tied the sinus between the two limbs of the
ligature. In this way the hemorrhage was arrested, and
I heard nothing of the ligature. I was alsoin fear of an-
other condition which, à priori, one might have expected
—~that it would be difficult to stitch the edge of the wound
of a friable organ like the liver to the abdominal wall, and
that the stiches would be very likely to give way. Asa matter
of fact, I have not found it so, and in not a single instance
has this given trouble. In my operations upon abscesses
of the liver all the cases have recovered but one.
THE Russian ACADEMY of Sciences offers a prize of
5,000 roubles ($2,500) for the best inquiry into the nature
and effects of the poison which develops in cured fish.
The competition is open to all. ‘The memoirs must be
sent in, either in manuscript or printed, before January 1,
1893, and may be written in any one of the following lan-
guages: Russian, Latin, French, English, German.
P#DERASTY IN ARISTOCRATIC CIRCLES.—A_ loathsome
scandal has occurred in London. . A number of depraved
members of England’s aristocracy took a house in a fash-
ionable part of the city and hired boys to assist them in
the gratification of perverted and criminal sexual in-
dulgence.
November 23, 1889]
Society Reports.
NEW YORK ACADEMY OF MEDICINE.
SECTION ON SURGERY.
Stated Meeting, November 11, 1889.
ROBERT ABBE, M.D., CHAIRMAN.
RESULT OF SUTURING THE TENDON OF THE QUADRICEPS
FEMORIS.
Dr. W. T. BULL presented one patient, and said he had
expected another, both illustrating the result of suturing
the tendon of the quadriceps femoris. The first case had
- been made the subject of a paper read before the Surgical
Society, but he had not had an opportunity to show the
patient in illustration of the result, which was satisfactory
union of the subcutaneously ruptured tendon and com-
plete restoration of the functions of the joint. ‘The boy
presented was aged seventeen, and was admitted to
the hospital in April last with a wound one and three-
quarters of an inch in length above the patella, made by
a circular saw. The tendon of the quadriceps had been
cut directly across immediately above the patella. An
incision was made three inches in length from the patella
upward, and the tendon was sutured with catgut, the joint
drained, and knee enveloped in an antiseptic dressing.
There was at no time any suppuration, and the patient
went about the wards with a plaster-of-Paris splint at the
end of ten days. At the present time the power of ex-
tension had become normal, and the joint movement free.
In such a case as this, he said, in which there was an
open wound, no one would hesitate to suture the divided
tendon, but in other cases in which the rupture was sub-
cutaneous the question of whether it was best to cut down
and suture, or to leave the ends to unite without such op-
eration, had not yet been settled. In view of the good
result in his first case he would be disposed to operate.
SUTURE OF THE RUPTURED PATELLAR TENDON.
Dr. R. G. WIENER presented a man who had been op-
erated upon five years ago by Dr. Sands for rupture of the
patellar tendon, with a perfect result. In December last
the man fell down-stairs and ruptured the tendon again.
He was transferred to Dr. Wiener’s service at Charity
Hospital in June last. He found the patella about four
inches above the joint-line ; power of extension entirely
gone. He made an incision nine inches long over the
joint, but found no remnants looking like patellar tendon.
He then tried to use tissue on the lower part, shaping it
somewhat like the tendon, but was unable to draw the
patella down, and consequently was obliged to mak: com-
plete section of the quadriceps tendon. ‘Then, in order to
bring the bone to its place, he had to drill and wire the
patella and tibia, and then suture together the remains
of the tendon on the two bones. Primary union took
place, and the patient left the hospital at the end of three
months, able to walk on the leg.
DOUBLE FEMORAL HERNIA IN A BOY.
Dr. MILLIKEN presented a boy who had a double fem-
oral hernia, the chief interest of which centred in the
rarity of the affection before the twentieth year of age.
Statistics showed only about one per cent. of hernia in
that locality in men before the twentieth year.
COLO-COLOSTOMY.
Dr. WILLY MEYER presented the woman on whom he
operated forty months ago for cancerous stricture of the
large intestine, and whose history was published in THE
MEDICAL Recorp. ‘The patient was still healthy in ap-
pearance, was stewardess on an Atlantic steamship,
and weighed one hundred and fifty-one pounds, being only -
four pounds less than what she weighed a year ago.
hard masses could he felt, showing an extension of the
THE MEDICAL RECORD.
Yet |
579
malignant process. This was the first case of which he
knew in which intestinal anastomosis had been success- .
fully performed between two parts of the colon.
LARGE VASCULAR SARCOMA OF THE NECK, OF FIFTEEN
YEARS’ DURATION.
Dr. F. S. DENNIS presented a man from whom he re-
moved a vascular sarcoma of the deep structures of the
neck, of the size of a child’s head, three weeks ago, the
tumor having been present fifteen years. Usually these
sarcomata terminated fatally inside of two years. ‘The
growth in this case extended beneath the carotid and up
to the base of the skull.
DRAINAGE OF THE KNEE FOR ACUTE SUPPURATIVE RHEL-
MATISM.
Dr. Dennis also presented a man who was transferred
to the surgical ward from that of Dr. Janeway in Belle-
vue Hospital, where the diagnosis had been made of acute
articular rheumatism affecting the knee, which went on to
suppuration. Suppuration also took place behind the
joint and below. The patient had a temperature of 103°
F., with chills. Dr. Dennis opened the joint freely in
three places, and inserted drains. Fully a quart of pus
escaped. ‘The patient was going about, and had a fairly
useful joint, although he had not yet attempted to move
it much.
PARALYSIS OF THE ARM AND SUBLUXATION OF THE SHOUL»
DER-JOINT FOLLOWING AN INJURY.
Dr. Dennis presented a boy for diagnosis. About three
months ago he fell from a horse and was supposed to
have dislocation at the shoulder, which was reduced.
When presented there was complete loss of motion in the
arm, and of sensation anteriorly, and what Dr. Dennis
believed to be subluxation of the shoulder-joint. Had
there been a tearing of the brachial plexus at the time of
the injury, or fracture of the coracoid process permitting
of subluxation of the humerus, while the nerves afterward
became involved in the inflammatory process? He thought
of cutting down and learning the exact condition present.
Dr. KAMMERER remarked that during the summer he
had seen several cases of sarcoma of the neck, and had
found them even more malignant than sarcoma of bone.
Dr. C. A. Powers said the last case presented by Dr.
Dennis showed apparently exactly the same features seen
in a woman at the Chambers Street Hospital two years
ago. Dr. Dennis’ patient, he thought, had atrophy of the
deltoid, relaxation of the capsular ligament, and the slip-
ping down of the head of the humerus was due to that
fact. He did not think the head of the bone left the
glenoid cavity entirely.
Dr. A. G. GERSTER said he had repeatedly seen paral-
ysis of the nerves composing the brachial plexus following
dislocations of the shoulder-joint and fractures of the hu-
merus, which had taken place in the vicinity of the shoul-
der-joint. He then recalled four cases in which that
symptom was observed, and in all, as subsequent events
proved, the paralysis was traumatic, so called, due to di-
rect injury or inflammatory changes following it. In all,
the function of the nerves was recovered. Ina boy there
was fracture of the neck of the scapula, which could still
be demonstrated after restoration of nerve-function had
taken place a year and a quarter subsequent to the acci-
dent. In the case presented he did not believe the plex-
us had been tom, and he thought it best to wait, submit-
ting the boy to such treatment as was known to hasten
restoration of function in disabled nerves, and if not suc-
cessful at the end of a year, cut down and unite the di-
vided nerves if that was the lesion present. He did not
think there was dislocation of the humerus, but simply a
relaxation of the tissues which held the head of the hu-
merus in the socket. As Dr. Powers had remarked, the
head did not go into the axilla.
With regard to the case of knee-joint disease, he thought
it might have been one of acute infectious osteo-myelitis
located near the joint, perforating into it, causing acute
580
THE MEDICAL RECORD.
[November 23, 1889
suppuration of the knee. The fact that abscesses were
found in the leg simultaneously with pus in the joint would
seem to favor that assumption. It was extremely rare to
find pus in joints affected by acute articular rheumatism.
It was oftener present in the gonorrhceic form, but even
in such cases it was not pure pus, but rather a sero-puru-
lent liquid. He did not remember ever to have seen a
case of acute rheumatism result in acute suppuration of a
large joint.
Dr. R. F. WER said the result in Dr. Dennis’ case
had heen so much better than he had seen in his own or
other surgeons’ treatment of chronic suppurative synovitis
that he thought it might be well to speak of Mr. Treeves’
method, which was somewhat similar, and gave like good
results. Mr. Treeves showed him several cases treated
for suppurative synovitis, and motion had been well pre-
served. The treatment had consisted mainly in opening
the joint and in continuous irrigation, plain water being
a to trickle through the joint continuously several
ys.
Dr. DENNIS said the irrigation in his case was kept up
from time to time not longer than twenty-seven days.
THE CHAIRMAN thought that if injury of the nerves was
to be sought for in the boy’s case, it should be nearer the
spinal processes.
EXCISION OF THE RECTUM FOR CANCER BY KRASKE'S
METHOD.
` Dr. ARPAD G. GERSTER presented a Hebrew laborer,
on whom he performed excision of the rectum for cancer,
February 17th last. Besides subjective symptoms, exam-
ination showed a rather irregular, nodular tumor, occupy-
ing the lower portion of the rectum and extending as high
as the finger could reach. ‘The sphincter was also in-
volved. Kraske’s method was adopted, consisting in first
removing the coccyx and part of the sacrum in order to
get at the rectum. ‘The amount of the gut removed was
about five inches in length. The difficulty of such an
operation was very great by the ordinary method, while
it was very easy after taking away a large portion ‘of the
sacrum, making the parts readily accessible. One could
easily control hemorrhage, and take the necessary precau-
tions, when the peritoneum was invaded. He thought the
method was not only valuable in operations for removal
of the cancerous rectum, but also in removal of the cancer-
ous uterus, etc.
In July he noticed a suspicious nodule near the margin
of the anus, which he removed, and drew the stump of the
rectum farther down. He again loosened its attachments
on another occasion, and drew it still farther down. The
man now had a sphincter which enabled him to retain
both hard and soft fæces.
Dr. F. S. Dennis then read a paper (see p. 566) en-
titled
FRACTURES OF THE BASE OF THE SKULL.
Dr. R. F. WEIR doubted the statement that in most
cases of fracture at the base of the skull death took place
from conditions known to arise from infection. In most
cases where death ensued it was from the primary effects
of the injury, and took place within twenty-four hours.
He cited a case in which there was a discharge of clear
fluid from the ear for some time, with loss of hearing, but
absence of hemorrhage and coma. In the New York
Hospital, when hemorrhage took place from the ear, they
washed it with an antiseptic fluid and introduced 1odoform
gauze and cotton, but they did not resort to the head cap
described by Dr. Dennis, although it might be an extra
precaution worthy of adoption. He once tried to render
the nasal cavity aseptic by plugging, but when he reflected
on the conditions there present he gave it up as practi-
cally impossible.
Dr. A. G. GERSTER said he had felt from the begin-
ning, when listening to the paper, that he could stand with
Dr. Dennis in the support of cleanliness and antiseptic
precautions in fractures at the base of the cranium when
such fractures could be considered compound. Some-
times, however, the fracture was simple, not compound,
and even this form might result in suppuration. In other
words, that suppuration might occur without communica-
tion with the air, and consequently in spite of antiseptic
precautions. But he did not mention these facts as vitiat-
ing the soundness of the principles of treatment laid down
in the paper. The necessity for antiseptic precautions
was shown in a case at the Mount Sinai Hospital nine years
ago. A man came who had hemorrhage from the ear
three days. The hemorrhage ceasing, the house surgeon
discharged him without any antiseptic precautions. He
was afterward brought back with meningitis, and died.
The post-mortem showed fracture at the base, rupture of
the drum-membrane, and purulent otitis which had com-
municated with the base of the cranium. Antiseptic pre-
cautions might have prevented the otitis, and consequently
meningitis and death. He doubted, ‘as Dr. Weir had
done, whether the nasal and oral cavities could be disin-
fected and kept so any length of time. He thought a
dressing covering the ear, temporal and mastoid regions,
and below, might take the place of the cap, and in the
case of ladies it might be necessary to spare the hair.
Dr. Jonn A. WYETH thought it might be well to try
drainage in case of fracture at the base by drilling into the
skull, as had been practised in one case of fracture of the
frontal bone, the surgeon establishing drainage by drilling
into the ethmoid.
Dr. DENNIS, in closing the discussion, said the simplest
way to keep the head clean was to shave it; the hair
would grow again. Regarding drainage, in fracture at the
base, it was already present and he thought we needed
simply to keep the parts aseptic. He still thought a plug
of cotton would prevent infected air from passing up into
the upper chambers of the nose and thus gaining access to
the cranium.
SIMPLE FRACTURE OF THE CARPAL SCAPHOID.
Dr. C. A. Powers presented the specimen, which had
been removed post mortem. It had the evidences of re-
cent fracture, without injury of the skin. But three cases
of simple fracture of the carpal scaphoid were on record.
He believed it was impossible to make a diagnosis of the
condition without an exploratory incision.
Dr. F. KAMMERER read a paper (see p. 569) entitled
OPERATION ON A SARCOMA OF THE DURA MATER, AND
LIGATURE OF THE LONGITUDINAL SINUS.
Dr. WEIR said he had twice ligated the longitudinal
sinus for hemorrhage. In one case the ligation was to
control hemorrhage from a gunshot wound received in the
war. ‘The patient died, but the ligation had nothing to do
with death. The other case was that of a child with
fractu'e of the vertex; in applying the trephine, he got
too n:ar the median line, wounded the longitudinal sinus,
ligated it, thus controlled hemorrhage, and the patient re-
covered.
AMERICAN RHINOLOGICAL ASSOCIATION.
Seventh Annual Meeting, held at the Palmer House,
Chicago, lll., October 9, 10, and 11, 1889.
WEDNESDAY, OCTOBER gTH—FirsT Day.
THE Association was called to order at 1o a.m. by the
President, Dr. John North, of ‘Toledo, O.
The following were elected Fellows of the Associa-
tion: Dr. E. L. Siver, Fort Wayne, Ind.; Dr. C. L.
Dreese, Goshen, Ind.; Dr. O. F. McGahan, Chattanooga,
Tenn. ; Dr. Ely McClellan, Chicago, Ill., and Dr. L. B.
Gillette, Omaha, Neb.
The next thing in order was the President’s Address,
which dealt, 1, with the relations that the physician bears
to the public ; 2, the relation of the specialist to the gen-
eral practitioner and other specialists, and, 3, what the
American Rhinological Association has done for the pub-
lic and for the profession.
November 23, 1889]
THE MEDICAL RECORD.
581
Dr. L. B. GILLETTE, of Omaha, read a paper entitled
REPORT OF A CASE OF BRAIN ABSCESS EMPTYING INTO
THE NASO-PHARYNX.
The patient, aged twenty, farmer by occupation, strong
and healthy, while working on an embankment in Sep-
tember last with a wheel-scraper, in driving along with it
loaded, it in some way became unlatched and the
handle, in flying up, struck him forcibly under the chin,
knocking him down a sixteen-foot embankment, where he
lay unconscious for thirty minutes. A week afterward he
noticed that something was wrong with his eyes. About
October 15th he went to work in a brick-yard, worked
three days, and then complained of being nervous and of
having a slight headache. On the evening of the third
day he got soaking wet in a rain, went home cold, had a
chill, followed by fever. A physician was called and
pronounced it malarial fever. Dr. Gillette being subse-
quently called to see the case found the patient suffering
with intense headache, the pain extending down between
the shoulder-blades, and particularly into the right arm.
Both pupils were widely dilated. ‘Temperature was 101°
F.; pulse, 105. He knew he had an inflammatory
condition to deal with. A day or two after his advent
into the case there developed marked compression of
the brain. ‘Temperature went down to 96°; pulse as
low as 42; respirations to 9 or 10. Complete paralysis
of right side and partially of left; complete loss of sen-
sibility as well as of consciousness. He also lost the
sense of sight, and remained in this condition four days
without any perceptible change whatever. ‘The patient
took his food and medicine regularly. He was surprised
one morning on finding that the patient had much im-
proved. ‘The mother told him that during the night the
patient had a violent attack of coughing and showed him
the character of the sputum. It was about an ounce of
green, stinking pus, mixed with mucus. From this time
the patient began to improve. There was an immediate
return of consciousness, a quickening of the heart’s action
and respirations, Examination of the throat showed that
the pus came from above. No pus came out of the Eu-
stachian orifices, and when the patient leaned forward it
would come out of the anterior nares. The discharge
lasted two weeks. Where it came from, or how it got
through, he could not tell. His opinion favored the eth-
moidal and sphenoidal sinuses. Asa result of this terrible
ordeal the patient, when seen three months since, was to-
tally blind, sense of hearing lost in right ear, has not got
the use of his right arm, and his mind is not what it was.
Could such results take place without some destruction
of the brain-tissue proper? Could the patient have the
same results from an intra-meningeal accumulation ?
In the treatment Dr. Gillette used opium, quinine,
mercury, cold applications to head, and cupping at the
back of the neck, and the triple bromides as they were in-
dicated. As soon as marked compression of the brain
had developed he began to use eighty grains of iodide of
potash each day, and kept it up for thirty days. Dhid this
treatment have anything to do with the results ?
Dr. THomas F. Rumso tp, of St. Louis, read a paper
(see p. 570), entitled
FIVE REASONS FOR FAILURE IN TREATING CHRONIC RHI-
NITIS,
The first is defective instrumentation. Not one of the
physicians whose offices he had visited had a tongue-de-
pressor that would not cause the patient to retch as soon
as it was introduced into the mouth. ‘The blades of all
the instruments he saw were too wide to go between the
teeth, and too long, being about six inches in length.
These instruments were seldom used in examinations, the
exceedingly defective method of drawing the tongue out.
with a napkin being employed instead.
2. The spray-producers used were made for watery so-
lutions only. ‘These physicians did not possess an instru-
ment that could throw warm vaseline. Liquid cosmoline
was found in every office. While this remedy is far su-
perior to tannin, iodine, nitrate of silver, or any of a
dozen other agents commonly found in offices, yet it is
much inferior to warm vaseline.
3. The compressed air used was taken from a con-
tainer of a capacity of from three to four or five gallons.
Air enough was forced into this reservoir to show a press-
ure of from thirty to seventy pounds. The reservoir was
filled by an air-pump whose barrel was made of brass;
the piston was packed with leather, which is partially de-
composed animal tissue, and it was lubricated with rancid
oil of some kind. Ten pounds is the greatest pressure
that the mucous membrane can stand without producing
irritation, while by far the greater majority of patients re-
quire from six to eight pounds pressure only.
The fourth reason for failure was an anatomical one.
He meant by this an error in locating the disease. In-
numerable clinical observations and post-mortem exam-
inations prove conclusively chat rhinal inflammation in-
variably commences on the superior and middle turbinated
processes and extends in all directions in the nasal pas-
sages and into the passages connected with them, except
on the floor of the nasal passages or so-called inferior
meatuses. ‘These two portions are seldom affected with
inflammation. ;
Keeping in mind that every irritation produces inflam-
mation, what are the indications for treatment of chronic
rhinitis ?
a. ‘The diseased secretion, which is always acrid, there-
fore irritating, should be removed. If morbid growths
are present, as these also are irritating, they should be re-
moved, thus removing the local sources of inflammation.
6. The new secretion, that is, that which is to be formed
upon the surfaces that have been cleansed, should be
prevented from becoming acrid, thus preventing another
cause of inflammation. |
c. Hygienic and sanative measures should be insisted
upon. ‘This is to prevent a continuance of the irritation
to the sensory nerves that are located upon the surface of
the body and mucous membrane, by colds and other ir-
ritating agents, thus removing the originating causes of the
inflammation.
Dr. A. DE Vuitaiss, of ‘Toledo, in opening the discus-
sion, differed from Dr. Rumbold in that he did not be-
lieve properly tanned leather readily decomposes. Rancid
oil for lubricating the air-pump is hardly ever used. Per-
sonally he used vaseline and naphthol as an application
to the mucous membrane. With regard to vaseline it was
used as a protector to the mucous membrane on account
of its density.
Dr. O. F. McGanan, of Chattanooga, heartily con-
curred in what Dr. Rumbold had said regarding vaseline.
Where we want the surface protected nothing will better
take the place of vaseline. He sometimes uses iodine in
weak solutions, and has not as yet had any bad effects
from it.
Dr. A. G. Hosss, of Atlanta, used the oil of vaseline.
First, for cleansing purposes, and, second, for its celerity.
He can warm it much quicker than the solid vaseline.
‘The danger and greatest objection to the douche in cleans-
ing the nasal passages is its liability to set up middle-ear
catarrh, which is sometimes produced by the post-nasal
and anterior nasal douche.
Dr. JoHN NORTH, of Toledo, did not favor the use of
tongue-depressors. Patients should be trained to manage
their tongues without them. When he did use one it was
a small wire tongue-depressor. He uses the oil of vaseline
for cleansing the nasal passages, with a little alkaline spray
or even with eucalyptus or some other antiseptic dissolved
in it. High pressure the rhinologist did not want.
Dr. C. L. DREESE, of Goshen, Ind., read a paper on
REFLEX SYMPTOMS OF RHINAL DISEASES, WITH REPORTS
OF CASES.
The first case was one of heart, stomach, and lung troubles
caused by sympathy from rhinal disease. The removal
582
of the latter affection was followed by recovery of the
former. The second case was one where incontinence was
a reflex symptom of chronic nasal catarrh, and was cured
by treating the catarrhal trouble alone. The third was one
in which epilepsy was a complication of rhinal disease.
Dr. C. H. Moore, of Indianapolis, contributed a
paperon -
OCULAR REFLEX SYMPTOMS IN NASAL DISEASES.
He had relieved a case of neurotic affection of the Eu-
stachian tube of the left ear by spraying the nasal passages
with vaseline. Hack mentions a number of cases of
hemicrania and asthma cured by the galvano-caustic de-
struction of the hyperplasia of corpora cavernosa of the
nasal cavity. Voltolini demonstrated that asthma may
be relieved by the removal of nasal polypi. A certain
group of eye symptoms, such as lachrymation, photo-
phobia, conjunctival hyperæmia, are observed in a number
of patients that come to the rhinologist, and yet the ex-
amination of their eyes reveals no anomaly. The vision
is normal, no eye strain, conjunctivæ healthy, the puncta
lacrymalia favorably placed, and the tear-ducts open.
For such cases a simple eye-wash has been ordered, cold
or warm applications recommended, general hygienic
treatment advised, without any relief to patients. Relief
of the rhinal affection in these patients was generally fol-
lowed by a cure. -
The cases he reported had the following symptoms in
common :
1. Burning and smarting sensation of the eyelids, espe-
cially in the morning.
2. Difficulty in distinguishing an object in ordinary
daylight.
3. Increased vascularity of the conjunctiva and lach-
rymation on exposure to the air.
4. The sound condition of the eyes and their append-
ages.
5. Failure of ocular and general treatment.
6. The efficiency of nasal treatment.
Dr. N. R. Gorpon, of Springfield, Ill., said his rule
of p ing with such cases is to examine the eyes
for irritation or the condition of refraction, and if the
latter is normal, and no other source of inflammation can
be found in the eye, he examines the mucous membrane
of the nasal passages, and very often the cause is to be
found there.
Dr. E. R. Lewis, of Indianapolis, said there was
no doubt but that a number of such cases are being con-
stantly referred to the rhinologist. It should be deter-
mined that there is no error of refraction requiring treat-
ment before the rhinologist accepts the case. About
one-third of his cases were sent to him by Drs. Thomp-
son and Stllson (oculists), but not until the eye trouble
had been corrected, after which he commenced to treat
them for rhinal troubles. This he believed to be the
logical course to pursue in such cases.
Dr. E. FLETCHER INGALS, of Chicago, related the
case of a lady which illustrates the possibilities of eye
trouble being caused by nasal disease. She came to him
with hypertrophic rhinitis. He proceeded to cauterize
the turbinated bodies, and before she left the office she
asked him if he could not do something for her eyes, that
she was unable to use them more than five minutes at a
time for the last three years. He referred her to an oc-
ulist that she might get relief. She did not return to his
office for two weeks ; on her return she said she had not
been to an oculist, but that the next day after the nose
had been cauterized she was able to read at night and it
did not affect her eyes.
Dr. N. R. GoRrDON read a paper on
THERAPEUTIC MEASURES IN RHINOLOGY.
He said that after the surgical removal of hypertrophied
tissue a curative local treatment, continued at short in-
tervals for one or two years, or even longer, is necessary.
This should consist of the oil of vaseline, with a small
THE MEDICAL RECORD.
[November 23, 1889
amount of eucalyptol or something of that character.
Astringents do but little, if any, good. Where the oil of
. vaseline fails, salt and water in proper proportions, with
a small amount of Listerine, or Dobell’s solution, are suit- .
able remedies. ‘To prevent mouth-breathing during sleep,
he recommends his patients to wear a little instrument
made of celluloid, that fits nicely between the teeth and
lips.
oe atrophic catarrh, after the removal of all secretion
on the surfaces, where the mucous membrane is very thin
or even ulcerated, he finds the application of a solution
of resorcin, one drachm to the ounce, to be exceedingly
beneficial. In the most unyielding and obstinate form of
nasal catarrh he uses a glycerine suppository composed
of ninety-five per cent. glycerine and five per cent. stearin.
The solidified glycerine is placed so as to come in contact
with the atrophied or ulcerated portion of membrane.
The glycerine soon asserts its well-known affinity for wa-
ter, and the result is an abundant flow of thin mucus.
‘THURSDAY, OCTOBER IOTH—SECOND Day.
Dr. C. H. Von KLEN, of Dayton, O., read a paper
entitled
ATROPHY, HYPERTROPHY, AND DEVIATIONS OF THE SEPTUM,
in which he said he had examined the nasal cavities in
over six hundred patients, and found not exceeding two
per cent. to have an absolutely straight division of the
nares. In almost every case he observed deformities of
some sort, either atrophy, hypertrophy, or deviation of the
septum.
The causes which are most common to deviation of the
septum occur to people when they are in their babyhood.
When children commence to creep and walk around, pass-
ing from chair to chair, they fall, and nine times out of
ten it is on their nose. Personal observation leads him
to believe that atrophy of the septum is confined to the
cartilaginous portion. Hypertrophy, on the other hand,
is confined to the osseous portion of the septum, and these
conditions are generally caused by such injuries as may
occur to any other part of the bony system. A stroke or
fall on the osseous portion of the septum may produce
hypertrophy.
Dr. C. F. McGauan, of Chattanooga, read a paper on
THE TREATMENT OF CHRONIC NASAL CATARRH,
in which the author said the remedies for its treatment
comprise almost the whole materia medica. Formerly it
was treated principally with strong astringents—for exam-
ple, strong solutions of nitrate of silver by the post-nasal
syringe, sprays of tincture chloride, tannic acid, etc.
Where we have polypi the first thing to do is to remove
them, which can be done by the snare or the galvanic
cautery. Where the polypi are located in the anterior
chamber he prefers the cautery ; but when they are in
the posterior chamber of the nose, the snare. Acids he
did not like in the treatment of hypertrophies, as it 1s 1m-
possible to control the exact amount of tissue they will
destroy, and then the pain is always more intense than
after the use of the cautery. The hypertrophy being re-
duced we have simply a case of chronic catarrh with
moderate hypertrophy to combat. —
At the outset we should spray the nasal cavity thor-
oughly with Dobell’s solution, or the combination with
Listerine, which is recommended by Leffert. Seiler’s tab-
lets are convenient and effective. He has the spray tubes
of Sass, Rumbold, Davidson, and Richardson in his office,
but prefers the DeVilbiss, for with one of the DeVilbiss
make for aqueous fluids, and another of the same make
for oils, the rhinologist can apply nebulz to any part of
the nasal cavity. Having cleansed the nasal cavity thor-
oughly we are now ready to apply our medicament.
When there is moderate hypertrophy he generally used
about three times a week a spray of vaseline with a com-
bination of the iodides, or with iodine and carbolic acid.
November: 23, 1889]
ee ————
The liquid albolene (as manufactured by McKesson &
Robbins) is by far the nicest vehicle he had.as yet used,
_ although it does not remain upon the tissues as long
as vaseline, and when used for its protective effect the
vaseline was preferable. He now uses the iodine and
iodides dissolved in albolene, first as a spray for their
alterative effect, and then spray in just pure vaseline to
protect the tissue from air or any particles that may be
suspended in the air. After cleansing the nasal cavity
thoroughly, he usually sprays the parts with vaseline com-
bined with a few drops of eucalyptol or oil of gaultheria,
sometimes a drop of carbolic acid to the ounce of vase-
line. On account of the hydragogue effect of glycerme
upon the tissues it occurred to him some time ago that
in hypertrophic conditions of the nasal cavity it may be
_ useful in drawing the water from the tissues and thereby
reducing them in size. He had often seen it advised in
combination with other drugs in the different sprays, but
his way of using it was similar to that of the gynecologists
when they apply it on tampons for different hypertrophic
conditions of the uterus. ‘he cavity having been thor-
oughly cleansed he applies to the hypertrophic membrane
a tampon soaked in a solution of glycerine one part, wa-
ter four parts, which he allows to remain in from one to
four hours. As the membrane becomes accustomed to
the glycerine he rapidly increases the proportion of it in
the solution until he uses equal parts of it and water. He
advises plugging the anterior nares with absorbent cotton,
which prevents the tampon from being expelled. He has
been experimenting with this treatment for the past six
months, and thinks it is of great benefit in reducing many
cases of hypertrophies.
_ Dr. A. De Vizaiss, of Toledo, contributed an interest-
ing.paper, entitled
SURGICAL TREATMENT IN DISEASES OF THE NOSE,
in which he said until recently few diseases have caused
more dissatisfaction in their treatment than chronic nasal
catarrh. He did not wish to be understood that in every
case of nasal catarrh there is a demand for surgical inter-
ference, but in every case that demands operation a ca-
tarrhal condition of the nasal passages was usually found
to exist. He had given relief from frontal headaches,
mental depression, etc., by ‘the removal of hypertrophic
tissue from the middle turbinate. He believed the time
was not far distant when the sphenoidal sinus, frontal
sinus, post and anterior ethmoidal cells (after death) would
be looked into and examined to find a special cause for
certain symptoms that existed during hfe and the answer
found. Schwable, Axel, Key, and Retzius have demon-
strated the fact that not only can the lymphatics of the
nasal mucous membrane be injected from the subdural
and subarachnoidal spaces, but if force be used the fluid
will pass through the lymphatic canals to the surface of
the nasal mucous membrane. Permanent nasal stenosis
should be relieved by an operation, as it is due to either
traumatism, hypertrophic tissue over turbinate bones,
thickening of tissue or deflections of nasal septum, gelat-
inous polypi, adenoma of vault of pharynx, fibromata or
sarcomatous tumors, and the only source of relief is their
removal or correction of misplaced parts. Preparatgry
to operating he always cleanses the nasal cavities of acrid
matter and protects the cut surfaces after operation by
keeping them covered with iodized or carbolized albolene
or vaseline. Hemorrhage, if necessity demands it, he
controls by cotton plugs. If the source of hemorrhage is
well back in the nasal cavities he uses small cotton plugs
tied with a string in the form of a kite-tail, which are
easy to introduce and easy to remove.
FRIDAY, OCTOBER I1TH—THIRD Day.
At the solicitation of Dr. Seth S. Bishop, of Chicago, a
committee was appointed by the President to co-operate
with the United States Hay Fever Association, with refer-
ence to the investigation and treatment of hay fever, to
report annually.
THE MEDICAL RECORD.
583
Dr. R. S. KNoDeE, of Omaha, contributed a paper on
the
IMPORTANCE OF CONSTITUTIONAL TREATMENT IN RHINO-
PHARYNGEAL INFLAMMATION,
in which he said the rhinologist ofttimes becomes dis-
couraged with all the means at his command when he
finds that patients do not improve as he would hke them
todo ; but if the history is carefully looked into there
would be found some diathetical condition at the bottom
of the nasal trouble, which, if the rhinologist could relieve,
would cause a subsidence of the local inflammation. This
catarrhal condition frequently extends into the stomach
and intestines, and from the duodenum to the ductus
choledochus, in which we have the combined symptoms
of gastro-intestinal catarrh, associated with jaundice, and
when the nutritive system becomes implicated there is a
wide range of sympathetic disturbances which invanably
follow.
The principal sympathetic phenomena transmitted from
this condition is sick headache, depression, melancholy,
sleeplessness, hypochondria ; the heart’s action is often
disturbed ; there is sympathizing dyspnoea, and to these
may be added languor, lassitude, and irritable temper.
The general principles in the treatment of such cases
would be a properly restricted diet, consisting of milk,
stale bread, soft-boiled eggs, and well-cooked rice. If
milk is not well tolerated, ıt should be peptonized ; foods
containing little starch and largely diluted with water are
the best tolerated. Among the internal agents may be
mentioned the alkaline carbonates, combined with purga-
tive salines, especially where the nasal trouble is associated
with disease of the stomach, which is a frequent compli-
cation in’ malarial districts; and in these regions no
treatment is effective until we diminish the engorgements
of the liver and spleen, and nothing accomplishes this so
well as the use of alkaline and saline laxatives, and these
may be assisted by small doses of mercurials. Carlsbad
and other mineral waters have been extolled, but phos-
phate of soda and rochelle salts, if perseveringly used,
may take their place. General hygienic treatment in all
cases must be insisted on.
Dr. E. L. Stver, of Fort Wayne, Ind., read a paper,
entitled
REFLEX INFLAMMATION OF THE NOSE AND THROAT.
The author reported a case of laryngitis, with aphonia,
which lasted two weeks, and which, he thinks, arose from
a deflected septum and posterior hypertrophy of the in-
ferior turbinated bone.
Dr. A. G. Hosss, of Atlanta, read a paper on
CATARRHAL NEURALGIA,
by which he meant to include not only the headaches and
browaches that are caused by the pressure from nasal
hypertrophies or foreign bodies, but all reflex pains that
have for their origin pressure in the nasal cavities, whether
they be located in the forehead, the temples, across the
bridge of the nose, or over the cheek-bones. ‘That such
reflex pains do occur, and have for their cause pressure in
the nasal cavities, was known long ago. If they were only
occasional, or of short duration, they might not demand
so much attention, but in many cases the pains are more
persistent than the neuralgias from any other cause, and
they, many times, produce a more profound impression
upon the general system, indicated by a sense of lassitude,
a haggard expression, a malassimilation, and a decided
loss of weight. He had no statistics bearing upon the
comparative frequency of catarrhal and ocular neuralgias
other than his own note-book of the last three years. In
it he found fifty-four cases under the combined headings :
Catarrhal neuralgia, ocular headache, and catarrhal and
ocular neuralgia combined ; thirty-six cases occur under
the first caption, fourteen cases under the second, and
four cases under the third.
After recognizing the etiology of a case exhibiting these
reflex pains, on account of the severity of the pain, tem-
584
porary relief should be given the patient by the applica-
tion of cocaine sprays, or, in the case of complete stenosis,
the cotton probe saturated with cocaine first, then the
sprays. The effect should then be to reduce the pressure
permanently by the means that is most rapid.
If the pressure be due to a polypus, extract it; if toa
deflected septum, remove the deflection, and if it be (as
is most likely the case) due to an hypertrophy, reduce it
with the galvano-cautery, the snare, glacial acetic acid, or
chromic acid. He most frequently resorts to the latter.
After the removal of the pressure, pain ceases to a great
extent, if not entirely; then the more soothing treatment
of vaseline sprays, in combination with cocaine, pinus
canadensis, oil of terebene, or oil of eucalyptus, daily or
tri-weekly, will complete the resolution.
He knew of no class of cases that apply to the rhinol-
ogist for relief in which treatment gives more prompt
and satisfactory results. Indeed, when there is no mis-
take made in the etiology the result is absolutely sure, if
means are resorted to that are effectual in removing the
pressure upon the terminal sensitive nerves that are dis-
tributed to the nasal mucous membrane.
Dr. Ely McClellan, of Chicago, read a paper on the
“ Physiological and Therapeutic Action of Certain Drugs
in the Treatment of Affections of the Upper Air-pas.
sages.”
THE ELECTION OF OFFICERS
resulted in the choice of the following :
President—Dr. A. G. Hobbs, Atlanta, Ga. ; First Vice-
President—Dr. A. B. Thrasher, Cincinnati, O.; Second
Vice-President—Dr. E. R. Lewis, Indianapolis, Ind. ;
Secretary and Treasurer—Dr. R. S. Knode, Omaha,
Neb. ; Librarian—Dr. John North, Toledo, O. ;- Member
of Councit—Dr. C. H. Von Klein, Dayton, O.
Next place of meeting, Louisville, Ky., 1890, in con-
junction with the Mississippi Valley Medical Association.
NATIONAL ACADEMY OF SCIENCES.
Regular Meeting, held at Philadelphia, Pa., November 12
fo 14, 1889.
SEVERAL of the papers read at this meeting were of great
interest to the medical profession.
PROFESSOR WOLCOTT GiBss and Dr. H. A. HARE pre-
sented a further report on the results of the
SYSTEMATIC STUDY OF THE ACTION OF DEFINITELY RE-
LATED CHEMICAL COMPOUNDS UPON ANIMALS.
‘These experiments are made with phenols of various com-
position. Their former report treated of ortho-, meta-,
and pora-phenol ; the present one of di-nitryl and tri-ni-
tryl phenol. The effect of these substances on the heart
and vagus nerve was carefully noted and described.
One remarkable effect is the length of time between
heart-beats, amounting in some cases to ten or even fifteen
minutes, the animal being apparently dead, but kept alive
by artificial respiration. These compounds kill quicker
than the series previously reported on, and are more
deadly in proportion to the amount of nitrogen contained.
The position of NO, in the compound appears to deter-
mine the physiological effect of it. If this is so, it sould
give a clew to the physiological effect of drugs, and tend
to place therapeutics on a scientific, instead of the pres-
ent largely empirical, basis.
PROFESSOR WILLIAM H. BREWER, of Yale, read a paper
on
HEREDITY OF ACQUIRED CHARACTERS.
He combats the view of Weissmann, who has published
a volume in support of the proposition that characteristics
acquired by individuals are not transmissible. Weiss-
mann supports this proposition by experiments on mice,
whose tails he cut off for successive generations, without
inducing a tailless diathesis in their offspmng. Brewer
discussed four kinds of variation: 1, variation in size ;
THE MEDICAL RECORD.
` stration.
[November 23, 1889
2, variation caused by exercise, training, and education ;
3, variations due to disease; 4, characters assumed as
the result of accident or mutilation. It is well settled
that abundance of food affects the development and size
of the individual, and of the offspring. All cattle-breed-
ing proceeds on this postulate. A good example of the
second class of variations is afforded by the evolution of
the trotting horse, which began during the present cen-
tury, and has proceeded so far as to produce a breed of
horses which have actually lost the instinct to run, and
trot even while they are young. Variations due to dis-
ease are equally powerful, but less susceptible of demon-
An example is ringbone in horses, caused by
accident to the individual, but transmitted to offspring.
As regards heredity of mutilations, numerous instances
are cited, among which were enumerated several cases of
malformed fingers in offspring of parents whose fingers
had been injured by accident. Conspicuous instances of
sports developing into varieties are certain forms of me-
rino sheep, and sequoia-trees of a certain type of foliage.
PROFESSOR BROOKS, in discussing the paper. opposed
Brewer's view, and said that adaptations of nature have
been evolved for the good of the species, not for that of
the individual ; hence they are not ordinarily transmitted,
and the inherited effect of the influence of environment
bears no appreciable effect on the evolution of species.
Thus the larva of worker and drone bees is protected by
an envelope of silk all around, while that of the queen bee
leaves the abdomen unprotected, for the obvious purpose
of enabling the mature queen to sting her larval rival
when the swarming season is over, thus sacrificing the in-
dividual for the good of the community. The generation
of polymorphic hydroids is an instance where the func-
tions of generation are not exercised by the working mem-
bers of the group, so that instincts acquired by experience
are not transmitted.
The bodies of all animals are similar polymorphic ag-
gregations of cells. ‘he cells of the body which are ex-
posed to external influences and vicissitudes are outside
the line of succession in generation.
Dr. H. C. Woop, of Philadelphia, also opposed
Brewer's conclusions. He
DOUBTS WHETHER THERE IS SUCH A THING AS HERED-
ITARY DISEASE.
It is not the disease, but the liability to disease that is in-
herited ; in other words, the lack of power of resistance
to external irritation. Consumption, for instance, is
caused by the presence of an organism, the bacillus.
This bacillus is certainly not inherited. We all breathe
it, but not all become consumptive. Persons who have
not sufficient power of resistance are affected by disease.
These persons have inherited a weak constitution, or their
powers of resistance have been weakened. This is all the
heredity there is about it.
Dr. Wood also read a paper on
HYPNOTIC CASES WITHOUT SUGGESTION.
Hypnotism, he says, has long been used as a remedy by
quacks and pretenders. After putting a patient in a hyp-
notic state, they make suggestions to him as to his physi-
cal condition, and on awaking from that state his con-
dition is found to have improved in accordance with the
suggestions offered. ‘Thus we appear to have an altera-
tion in nutrition without emotion, which is much more
difficult to understand than alteration due to emotion.
Nervous shocks affect the nutritive system, as numerous
examples show. It seems more rational to suppose that
the effect of hypnotism is due to the emotions felt while
going into the hypnotic state than to suggestions made to
the patient while in such state. There is nothing more
uncanny than a room full of people in various stages of
hypnotism, engaged in preposterous feats at the suggestion
of the operator. ‘The effect of such a sight was powerful
even on the speaker (Wood). How much more so then
on the uneducated.
November 23, 1889]
THE MEDICAL RECORD. |
585
This theory was tested on two patients, one of whom
was paraplegic and the other affected with paralysis agi-
tans. He hypnotized these, but made no suggestion to
them, #.¢., said nothing about curing them, or that they
- would experience such and such sensations as the result
of treatment, as mesmerists usually do. ‘The first patient
was cured by two applications of the treatment, the sec-
ond by seven or eight.
Hypnotism is not efficacious in nerve diseases where
the nerve-tissue has undergone changes that may be de-
tected by the microscope. It is applicable to cases of
hysteria, using the term in a broad sense, to include a
large class of nervous diseases, such, for instance, as St.
Vitus’ dance and many others.
In this country, he can only hypnotize about half his
patients ; in France and Germany, nearly all.
Correspondence.
OUR LONDON LETTER.
(From our Special Correspondent.)
CHOLECYSTOTOMY—GLYCOSURIA AND ITS ASSOCIATIONS—
PROPOSAL FOR FURTHER DRAINAGE LEGISLATION—THE
ROYAL COMMISSION ON VACCINATION—NEW. ANTISEPTIC
METHODS.
Lonvon, November 2, 1889.
THE first meeting of the Clinical Society for the winter
session was held last week. The evening was occupied
in discussing the subject of cholecystotomy. Mr. Mayo
Robson, of Leeds, read a paper in which he gave an ac-
count of fourteen cases in which he had performed the
operation. Eleven were cases of gall-stones, one was a
case of émpyema of the gall-bladder, and in the other
two cases the operation was performed to relieve disten-
tion of the gall-bladder ; the distention was found to be
due to cancer of the head of the pancreas in one case,
and in the other to cancer of the bile-duct. All the
patients operated on for gall-stones recovered. Recovery
also ultimately ensued in the patient operated on for
empyema of the gall-bladder, though: when operated on
she was apparently dying from acute peritonitis; a biliary
fistula remained for some time after the operation, but
this was closed by cholecystenterostomy. The case of
cancer of the pancreas terminated fatally on the eighth
day from hemorrhage ; the latter was due to a constant
oozing of blood from the interior of the gall-badder and
from the suture-punctures. In the case of cancer of the
bile-duct, though there was intense jaundice there was no
subsequent bleeding or other complication ; of the cases
operated on for gall-stones, six paticnts had sought advice
in consequence of the presénce of a tumor combined
with other symptoms ; five cases were operated on solely
on account of symptoms, no tumor being detectable. In
the former cases the operation was usually simpler, though
in one case, where an apparently solid tumor was exposed
which was due to the matting of the viscera surrounding
the gall-bladder, so that the mass appeared at first to be
a malignant growth, it was found impossible to shut off
the general peritoneal cavity by suturing the parietal peri-
toneum to the gall-bladder, as the latter was practically
destroyed by suppuration ; drainage, with sponge-packing,
was resorted to, to prevent general peritoneal infection.
Mr. Robson remarked that operations performed on the
strength of symptoms alone (no tumor being present)
were not always easy, as the gall-bladder was often very
small and could only with difficulty be brought to the
surface. In one of his cases it was shrunk to the size of
the last joint of the thumb, and was lying very deeply
under cover of the liver, so that when he had incised it
and removed several gall-stones from the duct, the lower
part of the opening could not be made to reach the pa-
rietal peritoneum, and a piece of omentum was brought
up and sutured’on the one hand to the gall-bladder, and
` to have more than one stone in it.
on the other to the parietal peritoneum, thus shutting
out the general peritoneal cavity. Mr. Robson said he
thought that omentum-grafting would often be found
useful in abdominal surgery. It was first proposed by
Dr. Sena for enterorrhaphy, but had not, he thought, been
hitherto performed to overcome a difficulty of the kind
he had met with.
Dr. Churton said he had undertaken a number of ob-
servations, in the post-mortem room and elsewhere, and
had noticed that in most cases where the gall-bladder was
small and closely packed with gall-stones, these could be
reached by a needle through the liver. He had nuticed
that it was rare for a gall-bladder containing much mucus
The thickening some-
times present in the neighborhood of the gall-bladder of-
ten looked much like cancer, and he had seen more than
one operation abandoned on that account. Mr. Knows-
ley Thornton remarked on the difficulty of distinguishing
between a distended gall-bladder and a tumor of the kid-
hey. The most difficult cases were those in which there
was thickening or suppuration around the gall-bladder.
In one case he had cut through an inch and a half of
thickened tissue, wondering all the time whether it was
malignant. It was wonderful how rapidly this thickening
cleared up after operation. ‘The proposal to make the
bile-duct open into the intestine he regarded as monstrous,
and not one to be resorted to under any circumstances.
Mr. Barker referred to a case in which he had operated
for “impacted gall-stones ” (diagnosed by two well-known
physicians) and found nothing abnormal beyond a slight
adhesion to the liver ; the patient, however, had no more
symptoms after the operation. Mr. Black alluded to a
case in which there was jaundice, and which had been
diagnosed as gall-stones, which turned out to be lead-poi-
soning. Several other gentlemen also took part in the
discussion.
At the Medical Society of London, on Monday evening
last, a discussion took place on diabetes and glycosuria,
led off by a paper by Dr. Ord on “Some Obscure Points
in Connection with Glycosuria.” Dr. Ord laia special
stress on gout, nervous strain and irritability, and bad
habits of life—particularly chronic alcoholic indulgence
—in the etiology of glycosuria. He also claimed that
there existed some distinct corelationship between obes-
ity <nd glycosuria, and between cardiac valvular disease
and the same disorder. Some cases of glycosuria, oc-
curring in association with Raynaud’s disease, were men-
tioned. In all his cases of glycosuria, plus syphilis, he
had been enabled to detect signs of hepatic disorder, but
he was unable to formulate any definite conclusions there-
from, and he deprecated concentrating the attention upon
the liver in considering the nature of glycosuria. Several
cases of glycosuria in association with angina pectoris
were referred to.
Dr. Pavy questioned the existence of any connection
between obesity and glycosuria, but agreed that glycosuria
was often associated with an enlarged or contracted
(granular) kidney ; the influence of the latter, however,
was rather to diminish the amount of sugar in the urine.
There was an analogy between the gangrene of diabetes
and Raynaud’s disease, and he mentioned cases in which
glycosuria was associated with exophthalmic goitre; He
declined to locate the seat of diabetes in the liver. Dr.
Ralfe also thought we should look beyond malassimila-
tion by the liver. The association of the disease with
angina pectoris might be accounted for by diabetes lead-
ing to arterial and cardiac changes ending in degeneration.
Dr. Savage observed that while both diabetes and insan-
ity were directly hereditary, and it was common in insane
persons to get a history of diabetes in the parents, yet it
was rare to meet with glycosuria in cases of insanity
(except puerperal insanity). Dr. Samuel West thought
granular . kidney rarely coexisted with diabetes. Sir
William Roberts said that the variety of diseases with
which glycosuria had been shown to be associated proved
that they were still far from having grasped the essential
586
nature of the disorder. Dr. Mitchell Bruce suggested
that some cases of diabetes were due to peripheral
neuritis. Dr. Maguire thought that though gout might
be the connecting link between some cases of granular
kidney and glycosuria, yet there was a connection between
diabetes and a certain degree of granular kidney in which
no gouty element was present. When albuminuria oc-
curred in diabetes it indicated a hardening of the kidney,
and did not suggest a bad prognosis; it was, on the con-
trary, likely that the condition of the patient would im-
prove. |
The newly constituted governing body for London (The
London County Council) has decided to apply to Parlia-
ment for powers to be given to the metropolitan vestries
and district boards to enable them to inspect the drains
beneath houses and to execute such works as may be nec-
essary.
It is estimated that the inquiry being carried on by the
Royal Commission on Vaccination will last about two
years. It is to be hoped that the results may repay such
an expenditure of time and labor.
New antiseptics seem ever to the fore. Sir Joseph
Lister is to deliver an address at the Medical Society, on
Monday next, on “ A New Antiseptic Dressing.” As new
antiseptic methods seem so constantly needed, one can-
not help making the reflection that the old ones cannot be
wholly satisfactory. But perhaps this is unjust.
OUR PARIS LETTER.
(From our Special Correspondent.)
IMMUNITY FROM MICROBIC INFECTION—DIABETES AS IN-
FLUENCED BY THE CONDITION OF THE PANCREAS—-THE
MOVEMENTS OF THE TRACHEA—FATAL ACUTE HYDRAR-
GYRISM—-THE CAUSES AND PROPHYLAXY OF TUBERCULO-
SIS— THE TRANSMISSION OF SYPHILIS THROUGH SURGI-
CAL INSTRUMENTS—INJURIOUS EFFECTS OF MILK DIET
IN DIABETES.
Panis, November 8, 1889.
Ar the last meeting of the Academy of Sciences, Pro-
fessor Bouchard read a memoir on the influence and the
mechanism of the local lesion. His researches were made
in conjunction with Dr. Charrin. The experiments un-
dertaken established that among refractory animals, many
of them destroy the microbes and thus create a localized
inflammation. Dr. Bouchard then analyzed a work by
Drs. Charrin and Roger, relative to the influence of the
serum on the development of microbes. ‘These experi-
menters show that, in the serum of diseased or vaccinated
animals, the pathogenic microbes are developed less easily
than in the serum of healthy animals. Not only are the
microbes affected in their function of reproduction, but
their functions of secretion are notably diminished, and
are sometimes even suppressed, in the liquids of diseased
or vaccinated animals. Even the form is altered. It re-
sults from this work that immunity partly consists in chem-
ical modifications.
At the same meeting a work by Dr. Dujardin-Beaumetz,
entitled “ Pancreas and Diabetes,” was submitted. ‘This
memoir was published some time ago, but the author
wished to submit it to the Academy because it contained
considerations which have been recently confirmed by au-
thors in other countries. Dr. Dujardin-Beaumetz had
already maintained several years ago that glycosuria re-
sulted from the total or partial suppression of the pan-
creas.
Dr. Nicaise recently published a note on the movements
of the trachea, which he studied by graphic tracings.
He observes that formerly it was thought that there were
constriction and shortening during expiration, and, in-
versely, dilatation during inspiration ; but, according to
the author, it 1s just the contrary which is the case.
Dr. Legrand publishes, in the Annales de Gynécologie, a
case of fatal acute hydrargyrism, resultir.g from two intra-
uterine injections of a r per 2,000 solution of corrosive
THE MEDICAL RECORD.
[November 23, 1889
sublimate. The author states that this case may be added
to a certain number of others recently published, and
showing that the employment of these injections after
parturition may frequently be followed by death. In the
case under notice, only two injections were practised, at -
an interval of three hours, with ten litres of the mercurial
solution as above indicated, the recipient being placed
about one metre above the level of the bed. ‘This injec-
tion was followed by one of boric acid. The next day,
the first phenomena of intoxication manifested themselves,
and death took place three days later. ‘The autopsy showed
the existence of characteristic lesions in the intestines.
Dr. Legrand believes that in this case the intoxication
was produced by the penetration of the sublimate direct
into the circulation. ‘The retention of the placenta in a
little-developed uterus probably favored the gaping of the
uterine sinuses. A slight pressure caused in a very short
time the penetration of the fatal dose of the poison. The
practical conclusion is, that the corrosive sublimate, even
in weak solution, should be employed for intra-uterine in-
jections with great circumspection. Its use is dangerous,
particularly when there is retention of the placenta in the
uterus incompletely developed, as in cases of abortion.
In any case, it is prudent to make only feeble pressure,
exactly determined, and never surpassing a column thirty
centimetres high. Finally, the free escape of the liquid
should be attended to with great care.
In the debate that has been going on at the Academy
of Medicine on the causes and prophylaxy of tuberculosis,
Dr. Lancereaux spoke of the influence of alcohol on this
affection. He stated that the effect of alcohol on the or-
ganism, in retarding metabolic changes and checking com-
bustion, diminishes the appetite, and renders the tissues
an easy prey to the attack of the tubercle bacillus. ‘Tu-
berculosis in alcoholic subjects always presents about the
same features. It usually begins on the right apex behind,
though this localization is not altogether special to this
form of disease. Hzemoptysis is often an early symptom,
and tends to recur. In certain cases it is the first symp-
tom to be met with in persons of apparently robust health,
indicating the advent of the disease which is shortly to
carry them off. ‘The course of the disease is often very
rapid, though intermissions are occasionally met with.
Some time ago Dr. Lancereaux brought to the notice of
the Academy the possibility of the transmission of syphilis
through surgical instruments. ‘This he has just demon-
strated by a note on two cases, which he read at the
meeting of the Academy this week. In the first case, the
patient had been inoculated by an aurist who had sev-
eral times practised catheterization of the Eustachian
tube. Dr. Lancereaux observed that this was not the first
time that such an accident occurred, and that it will not
be the last if the specialists do not take the trouble to
minutely disinfect their instruments. In the second case
it was a lady, who was infected by a dentist who had prac-
tised on her a certain number of operations for the fixing
of artificial teeth. Dr. Lancereaux here remarks that not
only dentists, but also hair-dressers and barbers, should
disinfect their instruments, and the employment of a disin-
fecting solution should be ordained by law. In fact, the
same may be applied to all surgeons, as among them some
are not scrupulously particular in this respect.
In a note on the injurious effects of the milk-diet in
diabetes, Dr. Mascarel relates the case of a patient, a
man aged forty-eight, who for a year past had been suf-
fering from rheumatism and herpes, associated with an
intolerable thirst, to assuage which he had been advised
to drink large quantities of raw milk (four or five litres
in the twenty-four hours). He was emaciated and the
tongue was coated. He complained of anorexia, con-
stipation, and a dry, hot skin. ‘The pulse was small, roo.
The secretion of urine was excessive, and the urine itself
was clear and free from albumin. A few days later he
was found dead in bed. At about the same date a young
man of twenty-seven was in the habit of drinking from
four to six litres of milk daily to assuage his thirst. This
November 23, 1889]
patient had been examined and found to be suffering
from diabetes. After three weeks of the exclusive and
excessive use of milk he died suddenly with cerebral
symptoms. Dr. Mascarel concludes that the only cir-
cumstance in which diabetics should be ordered milk is
when the urine is found to contain albumin as well as
sugar.
THE JOHNS HOPKINS HOSPITAL AND THE
DISPENSARY ABUSE IN BALTIMORE.
To THe Eottror or Tur Mepicat RECORD.
Sır: Your notice on page 487 of THE REcoRD is not
unsurprising, and the great “ Johns Hopkins Hospital” is
_ possibly zof an “unmixed blessing” to our profession ;
but the members thereof have themselves alone to blame in
the matter. Tempora mutantur, et nos mutamur in tllis—
Massaria, who “ preferred to err with Galen rather than be
in the right with someone else,” has indeed passed away ;
but abject devotion to authority still shows itself in our
own as well as in other callings—simply as the result of habit
rather than reflection. The “Johns Hopkins” was long
in process of incubation, and each step in its progress,
ffom the embryo to the fully developed mastodon, was
duly noted, discussed, and examined, and finally earnestly
indorsed and recommended by the regular profession as
the summum bonum of everything that might conduce to the
best practical application of ‘at art to which all appeal
for health, strength, and life. ‘These are unquestionable
facts ; and there should therefore be no complaint when
the new-comer, duly and truly prepared, having all the
testimonials of merit that name and fame can give, goes
right to work, like a regular South Sea Islander, and de-
liberately eats up and devours his own progeny and pro-
genitors, without the slightest compunction—and finds
plenty of food.
Respectfully yours,
B. F. Grove, M.D.
209 East PRESTON Streat, BALTIMORE, MD.,
ovember 4, 1889
———_—
Army Hews.
Official Last of Changes in the Stations and Duties of Cfi-
cers serving in the Medical Department, United States
Army, from November io to November 16, 1889.
Macautey, C. N. B., Captain and Assistant Surgeon.
Granted leave of absence for one month, to take effect
about the 2ọth instant. Par. 2, S. O. 166, Department of
the Missouri, Fort Leavenworth, Kan., November 8, 1889.
Maus, Louis M., Captain and Assistant Surgeon. By
direction of the Secretary of War, having relinquished the
leave of absence on surgeon’s certificate of disability,
granted him in S. O. 249, October 25, 1889, from this of-
fice, will, upon being relieved from duty at Fort Porter,
N. Y., as directed in S. O. 242, October 17, 1889, from
this office, proceed without delay to Fort Stanton, N. M.,
and report in person to the commanding officer, Depart-
ment of Arizona. Par. 8, S. O: 261, Headquarters of the
Army, A. G. O., Washington, November 8, 18809.
Crampton, L. W., Captain and Assistant Surgeon.
From Fort Lyon, Col., to Fort Sheridan, IIL Par. 3, S.
. O. 167, Headquarters Department of the Missouri, Fort
Leavenworth, Kan., November 9, 1889.
CorsusieR, W. H., Captain and Assistant Surgeon.
From Fort Hays, Kan., to Fort Lewis, Col. Par. 3, S.
O. 167, Headquarters Department of the Missouri, Fort
Leavenworth, Kan., November 9, 1889.
Ires, F. J., First Lieutenant and Assistant Surgeon.
From Fort Lyon, Col., to Fort Sill, Ind. Terr. Par. 3, S.
O. 167, Headquarters Department of the Missouri, Fort
Leavenworth, Kan., November g, 1889. |
THE MEDICAL RECORD.
Medical Atems.
CONTAGIOUS DIsEASES—WEEKLY STATEMENT. — Re-
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending November 16, 1889:
Cases. | Deaths.
Typhus fever ....... PEET re eer ae o
o
Typhoid fever .......osssesenenoneooecese oeseseo 33 11
Scarlet [evef 2c cessed. denies deea a a 34 2
Cerebro-spinal meningitis................-0seseee 2 I
Measles eeens oie Va) cece nied aa else rats oo eee sae oes 34 3
Diphtheria cs. sds acswcc ca vis eiocesw ae wees eee ees 76 16
SMA DOK os iiss scak eyes vc aw iows ee ceee ss vs ooo o o
Yellow fever..........ccses..ssssesssocsesesessso o o
Choleraiii eck 0k. s0ds- weeiseu r peones sasen ces o o
THe PATHOLOGY OF HEART-FAILURE.—In a paper read
before the British Medical Association on the subject of
cardiac failure, Dr. Mott insisted that the whole circula-
tory system must be taken into account in considering this
important subject, not only in the cardio-vascular system,
but in the contained blood also. In all cases of failure of
the circulation there was some alteration in the nutrition
of the cardio-vascular system. The heart itself, which
acted as the force-pump, was in every case disorganized.
In myocarditis, fatty degeneration, and some other con-
ditions there was usually coronary obstruction. This was
very important, as in forty-nine out of fifty cases examined
there was organic disease of the. myocardium. It was
necessary to examine the coronary arteries, not only at
their openings into the coronary sinuses, but also for some
distance from the mouth, as it was frequently found that
there was constriction at as much as one inch from this
point. In partial obstruction the degeneration was not
usually fatty, but was often merely a part of a widespread
degenerative process associated with chronic inflamma-
tion, affecting the cardio-vascular system, especially the
heart and kidneys. In these cases the termination was
not sudden, and was quite different from those cases in
which there was sudden failure from imperfect filling of
the cerebral and coronary vessels, as when the patient sat
up suddenly. In most of the cases of complete obstruc-
tion of a principal branch of one of the main trunks, with
partial occlusion of the other, there had been a syphilitic
history. Of five such cases four had died suddenly from
syncope due to fatty degeneration of the myocardium.
Dr. Mott then discussed the conditions met with in chronic
alcoholism, in which there was no affection of the coronary
arteries, but in which fatty degeneration had been followed
by sudden and fatal syncope. In cases of fatty degenera-
tion he pointed out how the arrangement of the muscles
led to imperfect action of the valves—the musculi papil-
lares, in which the process is best seen, being the continua- .
tion of the figure-of-eight bundles of muscular fibres in the
walls of the cavities of the heart. This explanation might
be readily adapted to Mr. Williams’ theory of “ delirium
cordis.” In no case was it sufficient to make a diagnosis
without the aid of the microscope, and he recommended
that osmic acid or Pal’s modification of Wright’s method
should always be used in order to determine the amount
and distribution of fatty degeneretion in the myocardium.
Fatty degeneration alone did not produce angina pectoris,
as was evidenced from those cases of pernicious anzemia in
which the fatty degeneration was well marked, but where
there was no angina at any stage of the disease. A de-
scription of acute and chronic myocarditis was given, and
it was pointed out that the former .was invariably asso-
ciated with acute fatal pericarditis.—- Zhe Lancet.
SENILE CHANGES IN THE Bones.—In the J//lustrated
Medical News, March, 1889, Professor Humphry con-
tributes an article on the changes in the bones in old age,
and illustrates his remarks with some valuable illustra-
tions. ‘To the naked eye these changes consist in an ab-
588
sorption of the cancellous structure, commencing in the
parts which are most cancellous, that is, where the bony
plates are thinnest, where the marrow is most abundant
and most vascular, where the leucocytic and other agents
in absorption are most abundant, where, accordingly, we
might expect the processes of absorption to be most ready
to take advantage of any failure in the nutritive and re-
sisting qualities of the bony tissue. In the early condi-
tion the several parts of the skeleton are solid ; as they
become hardened and added to at the exterior they be-
come hollowed out in the interior into cancellous spaces,
medullary canals, and air-containing cavities; this change
continues through life in gradually diminishing degree ;
and, as old age advances, the subtraction from the inte-
rior exceeds the addition to the exterior, and the bones
gradually decrease in weight and strength. ‘The muscles
at the same time become weaker, so that it is almost as
rare to have a spontaneous fracture of a bone from mus-
cular action in old age as it is in youth or middle age.
‘The author shows by diagrams how in old people the
head of the femur becomes thinned and liable to fracture.
This predisposition to absorption in the cancellous parts
is met with in the ends of the long bones in all aged peo-
ple, which causes their liability to fracture. ‘The ten-
dency to absorption of the cancellous parts of the skeleton
is also seen in the alveolar processes of the jaws, whereby
the teeth are loosened and often drop out. In the body
of the lower jaw these changes are very marked ; the thin
lower bar alone remains with the mental foramen upon
or near the upper edge; in the upper jaw alveolar pro-
cesses become, in course of time, completely cleared
away ; the level of the palate is continued to the margin
of the bone, the whole maxilla (the walls of the antrum
more especially) becomes very thin, and the nasal spine
and the cheek-bones are left outstanding in relatively
strong relief. An exception to the progressive cancellous
absorption and diminution of weight in the bones of old
people is not infrequently to be found in the skull, more
particularly in the calvarium. ‘This part in some cases
becomes very thin and light, in others it becomes thicker
from deposit on the interior, consequent, probably, on the
lessening of pressure upon it associated with the brain-
shrinkage of age ; in some of these latter cases it is very
porous, the diploe being increased ; in others, however, it
is dense and heavy, as well as thick, the diploe being en-
croached upon and perhaps obliterated. The contrast in
some cases presented by the thick heavy calvarium, and
the thin light facial bones, is very striking, the skull of
many old people weighing many ounces over the average ;
and this is due to increased thickness and density of the
bones enclosing the cranial cavity. This senile thicken-
ing and “senile sclerosis ” differ from the changes in os-
teitis deformans, inasmuch as they affect the interior of
the skull and the diploe rather than the exterior. So far
as the author knows, the cranial wall is the only part of
the skeleton in which this process occurs. The increased
density ana weight of the skull when the rest of the skele-
ton is becoming less fitted to bear weight is a strange and
not easily intelligible anomaly.— Medical Recorder.
INCOMPATIBILITY OF ANTIPYRINE AND CHLORAL.—M.
Blainville, a pharmacist of Paris, was called upon to put
up a prescription containing four grammes of antipyrine
and five of chloral hydrate in fifteen grammes of water.
An oily precipitate was immediately thrown down which
resembled neither chloral nor antipyrine in taste, but re-
called somewhat that of coriander-seed. A mixture of
antipyrine and quinine is also incompatible, both sub-
stances being at once precipitated from the solution.
THE TRISTATE MEDICAL ASSOCIATION, recently organ-
ized by the physicians of Georgia, Alabama, and ‘Tennes-
see, held its first annual meeting in Chattanooga, Tenn.,
on October 16 and 17, 1889. ‘The meeting was called to
order by Dr. Wise, President of the Chattanooga Medi-
cal Society. After a prayer by the Rev. Dr. J. W. Bach-
THE MEDICAL RECORD.
[November 23, 1889
man, the address of welcome was delivered by Dr. G. W.
Drake. The following sessions were devoted to the read-
ing and discussion of scientific papers. The election of
officers resulted in the selection of the following: Presi.
dent, Dr. J. B. Cowan, of ‘Tullahoma, Tenn. ; First Vice-
President, Dr. A. Boyd, of Scottsborough, Ala. ; Second
Vice-President, Dr. James B. Edge, of Demond, Ga. ;
Third Vice-President, Dr. Lelwellyn Barber, of Tracy
City, Tenn.; Secretary, Dr. Frank Trester Smith, of
Chattanooga, Tenn. ; Treasurer, Dr. B. S. Wert, of Chat-
tan The next meeting of the Association will be
held in Chattanooga on October 21, 1890.
DouBLE PAROTITIS OF REFLEX ORIGIN.—At a meet-
ing of the St. Petersburg Naval Medical Society, Dr. Mi-
lonas communicated the following curious case. An ex-
ceedingly nervous and emaciated recruit, aged twenty. two,
fell ill with a severe attack of right-sided croupous pneu
monia. On the third day there supervened incontinence
of urine, alternating with retention, while on the ninth there
developed a prostatic abscess, determining a complete pro-
longed retention, and necessitating catheterization. The
latter proved to be extremely difficult, since, on one hand,
any attempt at introducing the instrument into the. ure-
thra gave rise to general clonic convulsions, while, on the
other, the end of the catheter deviated from the urethra
into the prostatic abscess. Several hours after those re-
peated and prolonged manipulations there suddenly ap-
peared rigor and pain about the right temporal] region,
which were swiftly followed by intense swelling of the
corresponding parotid, rapidly passing into suppuration. -
The patient’s micturition being at the time restored, no
catheter was used for the next six days. On the seventh,
however, another prolonged attack of retention of urine
took place, and catheterization was again resorted to. It
was most rapidly followed by the development of a left-
sided suppurative parotitis. The patient ultimately re-
covered, though but very slowly. Analyzing his case, Dr.
Milonas comes to the conclusion that on either occasion
arotitis was caused in a reflex way by the said intense
irritation of the patient’s genito-urinary tract. During a
discussion Dr. Balinsky adduced three similar instances
of reflex parotitis from his own practice, all referring to
women. In one of the patients, who had undergone some
operation for vesico-vaginal fistula in the morning, the
subsequent insertion of a catheter à demeure was followed
at nightfall by swelling of one of her parotids. In an-
other, suffering from uterine flexion, the introduction of
a sound into the womb gave rise on each occasion to a
rapid painful enlargement of the gland. In the third,
parotitis developed shortly after the amputation of the
womb, preceded by the introduction of a catheter into
the bladder.— The Journal of Laryngology and Rhinology.
A SECOND SARAH.—Under this caption the St. Louis
Post-Dispatch of October 15th prints the following special
from Fort Smith, Ark.: “ Yesterday a woman living in
the mountains here, named Sarah Gates, aged seventy-
one, proved herself a second Sarah by giving birth to a
well-formed and healthy male child. Two years ago Mrs.
Gates, then a widow, married William Gates, a young
hired hand on her farm. ‘The case is exciting a good
deal of interest among physicians.” A correspondent
from Little Rock suggests that this remarkable tale be in-
vestigated by some of the Fort Smith physicians, who are
said to be interested in the occurrence. We should be
glad to hear from anyone who has any knowledge of the
actual facts in the case.
GONORRHEA IN A Boy Five Years or Ace.—Dr.
Custer, of Manayunk, Pa., reports in the Medical and
Surgical Reporter of October 19, 1889, the case of a
boy, aged five, who was brought to him for treatment on
account of an vated case of gonorrhoea. The boy
was remarkably well developed for his age, and investiga-
tion showed that he had been sleeping with a young
woman who was suffering from leucorrhcea.
The Medical Record
rr — — — —- -
Vol. 36, No. 22
NEw
ee ee e 4s S Sy a i aapi E a e
Original Lectures.
ON VITAL AND MEDICAL STATISTICS.
By JOHN S. BILLINGS, M.D.,
UNITED STATES ARMY.
= ————
Lecrure. I.
I PROPOSE in these lectures to speak of vital and medical
statistics, and of some of their relations to each other and
to scientific and practical medicine and sanitation. The
discussion will include such points as, character of the
data required ; methods of obtaining them by the census,
by registration, and in other ways ; relations of physicians
to this kind of work ; methods of compilation and forms
of publication ; the best existing sources of such data ; and
some of the more common fallacies in drawing conclusions
from the data as ordinarily published.
These and other points will be considered in their
practical application to certain questions which, I hope, may
be of interest to you, both as citizens and as physicians—
as, for example : Is the average longevity of man in civil-
ized countries increasing? What data are required to
practically judge of the relative healthfulness of different
localities, or of the same locality at different times?
What are the relations of certain forms of disease to race,
to climate, to locality, to occupation? What is the rela-
tive tendency to increase of population in this country in
the white and colored races ? What is the statistical evi-
dence with regard to improvement in practical therapeu-
tics‘as arrived at from hospital data, from death-rates in
obstetric practice, etc. ?
Statistics, and discussions of statistical methods are, as
a rule, dry and uninteresting subjects, and it is with very
considerable doubt and hesitation that such a topic has
been selected for these lectures. I have no new discov-
eries to announce, and those who are practically familiar
with statistical research will find some of my statements
rather elementary ; but the subject is not one which lies
within the ordinary range of medical studies, the data
are widely scattered in literature, and I hope, at least, to
be able to remind you of some of the numerous points
which you may have once known, but which may have been
_ forgotten owing to the pressure of other studies and du-
ties.
Statistics are somewhat like old medical journals, or
like revolvers in newly opened mining districts. Most
men rarely use them, and find it troublesome to preserve
them so as to have them easy of access ; but when they
do want them, they want them badly.
‘The use of statistics may be compared to that of the
microscope or the spectroscope, as pointed out by Mr.
Hooper.’ He says :
“ It is found convenient to speak of the science of Spec-
trum Analysis, and of Microscopical Science, because
complicated scientific instruments require that their users
should understand them and be able to adjust them, and
the knowledge which enables the operator to use his in-
strument and put it in order is important enough to be
1 The Cartwright Lectures, delivered before the Alumni Association
of the College of Physicians of New York, November, 1889.
3 The Method of Statistical Analysis. A paper read before the Sta-
tistical Society of London, by Wynnard Hooper, B.A., January 18,
188r. Statistical Society of London, Journal, vol. xliv., p. 31.
A Weekly Fournal of Medicine and Surgery
YORK, NOVEMBER 30, 1889
Whole No. 995
termed scientific. In this sense it might be possible to
speak of a Science of Statistics. The knowledge suitable
for the purpose of practising the art of Spectrum Analysis
covers a wide field, necessitating a study both of the in-
strument itself and the phenomena which it reveals ; and
the same may be said of the knowledge needed for suc-
cessfully practising the art of statistical analysis, and in
this sense this knowledge may be termed scientific ”
If we choose to accept the definitions of French, Ger-
man, and many English writers, the term will include a
large part of sociology.
Circumstances have made it necessary for me to en-
deavor to ascertain the character and amount of the sta-
tistical data which have been published, and which are
available for those who wish to make special studies of
the relative frequency of certain diseases, deformities, or
disabilities; of their causes and results, especially as to
mortality ; or of the relations which exist between disease
and death, and such conditions as sex, age, race, soil,
climate, occupation, etc. ; and in the course of this investi-
gation it has seemed to me that many physicians are not as
familiar with statistical methods, and with existing sources
of information relating to vital statistics, as it is desirable
that they should be to enable them to judge properly
the value of the arguments and conclusions presented by
those who make use of such data, even though they them-
selves may have no desire or intention to use statistical
methods of research.
There are many fatlacies and errors connected with
vital and medical statistics as ordinarily collected and
used, and it is highly desirable that the physician should
be aware of the more important of these, since he is con-
stantly appealed to for decisions as to their true signifi-
cance and value. “It is as easy to tell lies with figures
as with words, and bigger ones ;” but while we occasion-
ally meet with deliberate falsifications of the records,
made for the purpose of magnifying or diminishing the
apparent mortality or prevalence of a particular disease in
a given locality, or to maintain an anti-vaccination thesis,
these are not so frequent as are the errors of involuntary
misstatement and misinterpretation into which those not
familiar with methods of collecting and tabulating statis-
tics are so liable to fall. Those who are not familiar
with the methods of obtaining and compiling statistics of
this kind are apt to be either unduly credulous or unrea-
sonably sceptical as to their real use and value—to use
the first figures which come to hand, and thence derive
conclusions which are not warranted, or to reject the plain
teaching of carefully compiled statistics in favor of gen-
eral assertions which have no firm foundation, but which
are in accord with preconceived opinions. My experience
with those seeking statistical data is that the majority be-
gin by looking for those data which are in favor of some
particular conclusion with which they commence. rather
than by selecting data with reference to their probable
completeness and accuracy, and accepting the conclusions
which may be legitimately drawn from them, whatever
they may be.
Those who are engaged in the collection and compila-
tion of official mortality and vital statistics are often at
first the most sceptical as to their accuracy and utility, for
their attention is so frequently and forcibly drawn to er-
rors in the individual data that they conclude that the
whole mass is unreliable ; and the difficulties in the way ot
obtaining complete and reliable figures are seen to be so
great that they incline to give up the whole matter in de-
590
oe — ee o o o
spair. Continued callers of the sauces however, shows
that many valuable conclusions or suggestions can be de-
rived from imperfect data, and that in large masses of
figures the errors either tend to neutralize each other, or
to produce a constant effect in one direction which can
be calculated and allowed for; so that those who have
had the greatest experience are most convinced of their
value. It is true that, in statistics, the inferences cannot
be more accurate than the data on which they are founded,
but we do not look for scientific exactness from them so
much as for an estimate of probabilities.
‘The methods which we have for advancing our knowledge
of the laws of human life, of the causes of abnormity,
disease, and death in man, and of means of sanitation or
therapeutics, may be grouped into two classes, viz., ob-
servation and experiment—which, however, are often com-
bined.
In the experimental method we seek to make a direct
test of the variation of one particular condition, or set of
conditions, upon the living organism, all other conditions
being kept uniform as far as possible. Some such experi-
ments can be made on man, but the greatest number of the
problems which we may hope to solve by this method, and
among these the most important, can only be approached
by experiments on the lower animals. Within the last
twenty years experimental physiology and pathology have
made great advances, and these methods, so far as they
are applicable, give more definite results, and are more
immediately satisfactory, than those derived from com-
parison of observations in which no definite experimental
variations have been made; but so far as regards causes
of disease, or the action of supposed methods of preven-
tion, or of remedies, it is unfortunately the case that we
cannot draw accurate conclusions as to what will happen
in man from what is observed to happen in animals. In
the first place, there are many forms of disease in man,
and those among the most important, as regards the suf-
fering and loss of productive power and of life which they
produce. which cannot, with our present knowledge, be
experimentally produced in animals, and which rarely or
never occur in them.
For example: Yellow fever is a disease which, from
analogy, we have reason to believe may be due to the
action of one or more specific micro-organisms, or, per?
haps, I should say, to the products of such organisms.
We find a dozen different kinds of bacteria in persons
suffering from yellow fever, and, by dint of much labor,
these have been isolated and cultivated outside the human
body. ‘The problem is to determine positively, and with
scientific precision, which, if any, of these is the true, es-
sential cause of the disease. The mode of doing this is
by producing the disease in a perfectly healthy person or
animal by the inoculation of the suspected organism.
But, thus far, we have failed to find any animal in which
a disease, which can be considered as specifically identi-
cal with yellow fever, can be produced by any method ;
and I need hardly tell you that inoculations of such a dis-
ease as this in a human subject, under conditions which
would make the results of such inoculation scientifically
trustworthy, are impracticable and unjustifiable.
‘Those forms of disease which are common to animals
and man, such, for instance, as anthrax, tuberculosis, tet-
anus, hydrophobia, the ordinary forms of suppuration,
and, perhaps, also typhoid fever, are being pretty thorough-
ly worked out by means of such experimental inoculations
as I have just referred to; and we are able to say, witha
great degree of precision, not only that these diseases are
due to specific forms of bacteria, but to determine enough
of the characteristics of these forms to be able to identify
them wherever they are found.
For the great majority of diseases, however, this experi-
mental method of determining the causes, and therefore,
necessarily, experimental methods of prevention and
treatment, cannot be employed in such a way as to dis-
tinctly isolate the effect of the particular agent or circum-
stance which we are investigating, and we must therefore
THE MEDICAL RECORD.
- Á ee ee
[November 30, 1089.
— = —— = —
resort to the other iode of dinine of knowledge which
has been referred to, namely, that of observing the phe-
nomena as they occur in man, and endeavoring to so
group the results of these observations as to determine
the influence of a particular condition or set of conditions
while all other circumstances remain uniform.
This method of observation may, for our purposes, be
again divided into two categories. The first is that which
is used in individual cases, being the form applied by the
physician to each case which he has to treat. It also in-
cludes the sort of investigation which may be made in a
single household, a small community, or a thinly popu-
lated district, to determine the course and cause of a par-
ticular form of endemic or epidemic disease, where the
conditions affecting each family or dwelling can be stud-
ied in detail somewhat as the detective of modern fiction
follows his clews. By the combination and comparison
of detailed studies of this kind the greater part of our
present system of diagnosis, prognosis, and therapeutics
have been evolved; but it has been and will be a slow
process, for each man differs from every other man in
structure and mode of function, and the conditions of
the environment are so multiform, and so variable in
space and time, that “experience is doubtful, and judg
ment difficult.” We must therefore try to supplement
the information thus obtained by that denved from the
second kind of observation above referred to, namely, that
of collecting a few data with regard to great numbers of
people, especially where these are accumulated in thickly
settled localities, forming what is called the statistical
method as applied to different communities. By the first
method we compare individual with individual, and do so
with considerable minuteness of subdivision of the condi-
tions studied; by the second method we compare the
vital phenomena of communities with those of other
communities, but only on broad lines and in relation to
circumstances easily noted.
The object of vital statistics is to classify and arrange
the facts relating to the quantity and character of human
life under different circumstances, for the purpose of de-
termining the effect upon it of each of these circum
stances taken singly, or of two or more of them acting to-
gether. The results thus obtained form an important
part of the scientific foundations of sociology, of political
economy, and of preventive medicine. It deals with
masses of men and not with individuals, and its conclu-
sions are, for the most part, applicable only to large bod-
ies of people ; yet its data are derived from individual
records, and its results are accepted in many cases as a
sufficient guide for individual action. ‘They do not, in
this respect, differ essentially from most of the motives
which actuate us in daily life. The farmer sows his seed,
the manufacturer builds his mills, the physician writes his
prescriptions, and you come to hear this lecture from mo-
tives of probability ; not carefully formulated in most
cases, or capable of expression by a formula, but, never-
theless, in accordance with the doctrine of chances as de
termined by previous experience.
‘The term “ vital statistics,” in the sense in which I use
it in these lectures, corresponds almost precisely to the
French term “démographie” or the German “ demo-
logie,” being applied to the circumstances of human life
only, in the sense of Korosi’s definition that it is the
science of the physical life of human society. We will
first consider briefly the sources of information and the
character of the original data available for this study ; sec-
ond, the methods of arranging and using these data ; and,
third, the value and applicability of some of the conclu-
sions which may be drawn from them, especially in that
branch known as medical statistics.
The essential data of vital statistics are derived froin
enumerations of the living population and from records
of births, marriages, and deaths.
The numbering of the people is effected by a census, a
term derived from the Roman Censors, a part°of whose
duty was to make such counts. Such enumeratioons
November 30, 1889]
A, ESSENTIAL REQUIREMENTS RECOMMENDED BY THE INTERNATIONAL STATISTICAL CONGRESS OF St.
Denmark.
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were made by Moses (1490 B.c.), David (1017 B.C.) ; in '
Greece, 650 B.C. ; and in Rome, beginning 566 B.c. ‘They
were probably made also in Assyria, but the Accad rec-
ords have not yet been found. In modern times the first
country to make a count was Sweden, in 1749. ‘The first
census in the United States was taken in 1790, as a neces-
sary means of carrying out the constitutional provision
that the basis of representation for the several States
should be the number of the population in each. ‘The first
census in England was taken in 1801, and showed the
number of persons, with distinction of sex, the number
of houses, the number of families, and a rough statement
of occupations under the general classification of agri-
culture, trade, manufactures or handicraft, and all others.
The first satisfactory English census, giving distinction
of age, sex, occupation and birthplace, the number of per
sons blind and deaf and dumb, was the census of 1851.
‘This was the first census whose data could be used in con-
nection with the general system of registration of births
and deaths.
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ea a e che e ge a e a a a WS, a.. oe
m ! ~ ~ ie v e = ~ ~ ma E ` ææ |- be (ey
oy Si Tik 'RYiv se) (aa) ! om m ag) ag) v =
be | a4 t no y he “8a '2 i tee ` he be be ' ka ba A
e e ares e ° Q s e = i -
Baul “($g80 Shae Fs £2 So SASS soise: +
w a: pod Oo ~ n~ n i 4 i wn is
E co | ' a EO Eom -!00 Gal Gao Ra 68/60, FO) Fo) vo
St mis a” yr woo YM yn oe eet o-oo y
S |E Es 8 ‘age B | 8 ig 18 iB jg le &
A lq «<A A A A |A A A IR A IA jG 5
Ea Nae ee ees eer i Pah le — See ot cae ae E
I I I 1 I 1 1 I 1 I T O EDS I
1 1 1 1 1 1 I 1 I 1 et iy I
1 F i
A| I 1 J J A A I I J A A J I
1 l I 1 I i 1 1 ia ie a, a ga
l 1 I t I 1 E E 1 1 1 | a I 1 I
a aa 1 1 1 I I ri ft 1 1 I ro 2 I I
1 I 1 a 1 1' 4 1 Ij l 1 1 l
1 1 si 1 | T I l TRE One
t i
w 1 Hi zs : | 1 a E: 1 r {4 1
ie Fe 1 I jo I 141 1 aed ieee
1 1 1 I I I ix I sf 1 ` I rj}. I I
Fey 1 I ak I | 1 1 I 1 I. I ‘fie
1 I 1 1 1 I I I I 1 1 |
. OTHER REQUIREMENTS RECOMMENDED BY THE INTERNATIONAL STATISTICAL CONGRESS.
I I
I I I 1 I
1 I l 1 I
1 I
1
I
|
bar tie a
oe
— et
æ m t
`
~~ m m p
I 1 I
1 I ae 1
1 t t
1 1 1
eee ee -
* Korosi, Juseph: Projet d'un recensement du mounde étude de Statistique Internationale, Paris, 1881, pp. 42, 43-
and the above table shows those now included in the
censuses of some of the principal countries of the world.
The relative importance of each of these details in
studies of vital statistics varies greatly according to the pur-
pose to which they are to be applied ; but to physicians, san-
itarians, and those interested in life insurance, the domi-
nating factors are age, sex, and race. ‘The power of
reproduction, the tendency to death, and the liability to
certain forms of disease, vary greatly at different ages in
. the two sexes, and this gives rise to corresponding varia-
tions in the disease- and death-rates of populations of dif-
; ferent localities, or of the same locality at different times,
The first attempts to take a census in a country have |
usually excited more or less suspicion and opposition,
from fear that the information obtained would be in some
way used to oppress the people. For example, several
attempts to take a census have been made in Hayti but
have always given rise to insurrection, and have always
been defeated, owing to the belief of the people that it
would in some way lead to their losing their liberty.
In the first censuses the object was to determine the
' over go are largely overstated, and the ages of women be-
number liable for military service or qualified to vote, oc
to fix rates of taxation, and the records were very brief.
In the first United States Census the only data called for .
on the schedules were, names of heads of families, free
white males over sixteen, free white males under sixteen,
free white females, all other free persons, slaves.
The record of age was first made in the English Census
in 1821, was omitted in 1831, and resumed in 1841. As
the census records came to be more and more relied upon
as a basis for legislation, additional details were introduced,
when these populations differ as to the relative proportion
of young and old, or of male and female, which they con-
tain. ‘These variations we must ascertain if possible, and
estimate the influence of, in order to make reliable and
useful studies of the effects upon human life of climate,
altitude, race, occupation, or other conditions of the en-
vironment. In the course of these lectures I shall often
have occasion to refer to this dominating influence of age,
and to point out errors due to neglect of this factor, which
is by no means an easy one to determine for many places,
at many times. Even the census data require corrections,
since people do not give their ages accurately to the enu-
merators. ‘The tendency is to answer in round numbers.
aS, 20, 30, 40, etc., and to a Jess but still marked extent,
aS 25, 35, 45, etc.; but the effect of this can be done
away with to a considerable extent by properly grouping
the individual data, as I shall explain presently. Ages
tween 25 and 50 are largely understated ; but these errors,
being comparatively constant, and influencing the data of
all communities, do not lead to erroneous conclusions of
importance in comparing different communities, if the
distinction of sex be observed.
One of the most interesting fields of study in vital sta-
tistics is the relation of race and color to birth-rate, to
certain forms of disease, or to the liability of death at
certain ages.
——
This country is, as you know, the great mixing ground
for different races of the human famıly, and, while the
mixture is rapidly becoming so intricate as to make it im-
possible to distinguish the several strains, it is still true
that there are in this country large groups of men of quite
distinct races, the record of disease and death in which
would form valuable material for study upon this point
were it possible to collect them.
From the sociological and political point ot view this
is particularly the case with regard to the negro and to
those having a mixture of negro blood ; and in the South-
ern States such questions as the following are of great
practical interest. Is the negro population increasing
faster than the white? Is the proportion of mixed bloods,
such as mulattoes, quadroons, etc., increasing in propor-
tion to the general population? Are the fertility and ex-
pectation of life of mixed bloods greater or less than those
of pure whites or pure blacks under the same circum-
stances of environment? We will return to these ques-
tions hereafter ; at present I merely refer to them as being
the probable reason for the introduction into the law for
taking the next census of a special clause providing “ that
the population schedule shall include an inquiry as to the
number of negroes, mulattoes, quadroons, and octoroons,”
an attempt to obtain information which has not heretofore
been sought in this way. In obtaining the records of
deaths occurring during the census year beginning June 1,
1889, an effort will be made to have the deaths of colored
persons distinguished into those of pure negroes and those
of mixed blood. It will probably be impossible to obtain
the data for either living population or deaths with the
minuteness of subdivision indicated by the words “ mu-
latto,” ‘‘ quadroon,” and “ octoroon”; but there is reason
to hope that in many sections of the country we shall be
able to distinguish those of mixed blood from the pure
blacks and the pure whites, and to give some opinion
with regard to their diseases and death-rates. ‘Ihe re-
sults of the last census, although imperfect, show such
marked differences as regards the mortality from certain
diseases, not only between the whites and the blacks, but
between those of English, Irish, and German descent, as
to make it certain that it will be worth while to pursue
this branch of inquiry more minutely as opportunity is of-
fered to us hereafter. ‘The following table, taken from
the last census, indicates the difference in the proportion
of deaths from certain causes to the deaths from all causes
in the white and colored population in the South aod in
those of Irish and German parentage in the North.
Irish German
|
White. Colored. Parentage. Parentage.
ADOND. s osio capirai encase EEES 0.9 1.4 0.5 0.8
Accidents and injuries. ....0 ..... ... 43.8 67.6 61.0 52.5
Alcoholism. ..........0-0000000.0 002 cee BOS 0.7 67 2.7
CANCER E EET as bbe bdows 19.1 7.8 24.3 25.8
Childbirth 0... sees once Rignnwews 13.9 24.8 | rgi 18.3
Consumption .. 126.2 139.1 ` 198.4 123.0
CLOUD erie Sus, Sacamtetadie te Ueda e win 26.1 21.8 15.1 23.2
Diphtheria, scsescereier ireen aerostat 39.8 17-4 42.1 72.7
Diseases of the bones and joints........ 3.1 2.0 3.1 2.5
Diseases of the digestive system........ | 460.8 49.6 43.8 47.1
Diseases of the nervuus system ....... | 119.1 96.9 94.7 Boo 4
Enteric fever............ 00... eines, 33.9 30.7 17.4 29.9
Heart disease and dropsy ............. 56.1 64.5 62.3 60.9
Hooping-cough............... 14.3 33-0 6.0 5.4
Infanticide ....... 000....00. Leo. 0.05 CELT 20... 0.02
Malarial fever... l,a 0000 0000.00. c0ee 30.7 48.3 2.9 | I4.1
Measles cea aretan eaa ak E a aa 9-1 ° 17.7 563 8.5
Peritonitis l... peneana, e aaah 49 | 21 6.8 | 6.4
Pleurisy occ ed anes aes: inet eR cue 2.7 3-7 2.9 2.6
Pneumonia 6 oeg cae o son. Vee wee owe | 82.5 | 105.5 8y.1 82.1
Puerperal septicemia ................. © 42.0 10.2 32.5 | 15-7
Scarlet MOVER gee aapa auaa ROD 3-9 24.0 : 30.1
Scerofula and tabes aaa 6.2 16.0 ie Game 2.6
Stll DOP se aasa ee vineihn) dae fe vas 36.4 39 © 24.7 | 34-9
PUMNCIDE 5) 255 ork tok et Sisk 3.2 O.5 27 | 7.2
Tetanus and trismus nascentium . ..... 3-1 9.3 1.6 | 2.2
Venereal diseases, ulnas ansoosansn u 1.7 3.0 I.4 | 1.3
The intluence of race upon mortality is especially mani-
fest in the death-rates of cancer. ‘Ihe number of deaths
from cancer per 100,000 population in certain portions
of the United States, with distinction of white and. col-
ored, was as follows : White, 27.96; colored, 12.67.
THE MEDICAL RECORD.
tion of deaths from cancer in proportion to 1,000 deaths
from known causes, with distinction of white, colored,
Irish, and German parentage, was as follows: White,
19.1 ; colored, 7.8 ; Irish parentage, 24.3 ; German parent-
age, 25.8.
It will be seen from these that the liability to death
from cancer is not half as great among the colored people
as it Is among the whites, and that there is a greater ten-
dency to death from cancer in persons of German parent-
age than in all the average white population, especially
between the ages of fifteen and sixty-five.
The relation of race to vital phenomena in general, and
to disease- and death-rates in particular, forms one of the
most interesting branches of what Galton calls the “ sci-
ence of heredity,” but it is a branch in which little pro-
gress has yet been made, and for the study of whieh the
United States offers greater opportunities than any other
country. “ The question of race influence is not merely
an abstract matter fitted only for well-rounded periods in
the discussions of the schools, but it profoundly affects
vital and national life.” It is a force which acts inces-
santly upon and menaces us, and, so far as we can now
see, it is mainly upon the outcome of the distribution and
prevalence of race that depend civilization, religion, and
the future of man upon this earth. ‘In so far as the
conditions of things tend to preserve the best types, pro-
gress is favored. In so far as they tend to destroy or to
debase them with inferior types, progress is hindered.
Not every mixture of race prevails, or persists, but there
has been a certain amount of mixture wherever there has
been progress in human affairs. Such mixture appears
to have been a consequence rather than a cause, yet it
may become an important secondary cause in changing
or modifying the course of human events.”
‘The census gives us a view of the population on a cer-
tain day, and, if well taken and properly compiled, it
gives a general view of the stream of life as it flows on
that day, with its variations of breadth and depth, from
which it is possible to calculate, within certain limits, the
velocity of the current, the rapidity of change, and the
probable rate of increase or decrease, especially if com-
parisons can be made with the results of a previous
census taken in the same way. It may also indicate pe-
riods of wide-spread disaster or of migration. For exam-
ple, look at the diagram on opposite page, showing the
proportions of the living population in 188o.
It shows that the decrease in the number living at each
quinquennial group of ages was tolerably regular for the
whole population for the native-born whites and for the
colored as we proceed from the lower to the higher ages,
as it should be under ordinary circumstances ; but that
there is one marked exception for the age-group 15 to 20,
in which the line makes a sudden angle indicating a rela-
tive deficiency in the number of persons living at this age.
It will be observed, also, that the age-group in which
there is the largest proportion of the foreign-born popu-
lation is that from 35 to 40.
Now, if we compare this diagram with a corresponding
diagram for the census of 1870, we find that this peculiar
deficiency in the age group, and the maximum propor-
tion of the foreign-born, occur in those age-groups which
precede by ten years the groups in which they occurred
in 1880. The break or step in the descending line is in
the age-group 5 to 10, instead of that of 15 to 20, and the
maximum proportion of the foreign-born is in the ago-
group 25 to 30, instead of that of 35 to40. Now, if we go
back between five and ten years from the census of 1870,
to see what special cause existed in that period for a di-
minution in the number of births, we find ourselves in the
period of our civil war. ‘These breaks or angles, then, are
the scars of one of the wounds which the war inflicted,
or, rather, they are like the spots and ridges on the finger-
nails due to serious illness or local injury, which gradually
grow out and disappear. ‘The shifting of the maximum
point in the line of the foreign-born population indicates
593
THE MEDICAL RECORD.
November 30, 1889]
ao 9 o LLL TTT Te
a0 » s8 FRR eeeeceeeee eee
BECRAARN Se ILLERA LEETE TEITEI
In general, we may say that the census indicates the
state of the population at a given period. Vital statis-
8
|
z
SRS b p E T oS Ree
EEEE EREEREER ee a P E EEE ETELE
E M Ea ae a N N A E E ]
RAMAAAMTAR” <o AHRENS CORR
ADN AEAN E? ae SABRE ROR A D A a a e e a a E
BERDA T d A E a E e a ee R E O a td
EELK CAs VSPA LLT EELE RASS TL
CeT Re? ARR TETCEET IELE CTIE EREA
bankokat a TT TTT ET TTT AT
ttt te Ce eet | | tf A
RESARETERERAMS RRR eee SPIRE ew
PREGNANT SR Ne RRO ROR ERR
RRSESREAS RARER RERR ERROR ROME eee
O 2 = 1S Peel ELIKA E
or =—
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= ©
8 Ẹ
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taining young children, which occurred be-
y great immigration of Irish and German
the unusuall
families con
Proportion, in 1,000, of Living Population at Certain Groups of Ages, at Census of 1880.!
tween 1850 and 1860, forming a wave whose crest is still
perceptible.
ea YO TELET ERCEL
i SF LS CErI
rae Save e ee
WD 1S SE DEG E RE I EE DS ET ER A
Toomas EE EEEE
[22 cele as SooRw
we
a
of the population, and therefore for these we must have
something more than the census, viz., a record of the
tics, however, consider both the state and the movement
TERK
= BRE ee
EE REN p oe eee l N,
HEE EEE eee tae N
tt
AFEERI PEPE Begee
I apun -H -HH HHHH
eaea FL we SEU M SORE Ree RRR GE ND
S/2/Slwlclalololo
ni
It is safe to predict that in a similar dia-
gram for the census of 1890, the break or step showing
Proportion, in 1,000, of Living Population at Certain Groups of Ages, at Census of 1870,"
QLOOO H/S/ioHlo
deaths and births occurring in successive periods, from
which we can compute mortality and natality rates.
group 25 to 30, and that the maximum proportion of the
deficiency in births will be shifted forward to the age
foreign-born will be in the group 45 to 5o.
Mortality, or mortality rate, refers toea ratio between
the number of deaths occurring and the number of living
All classes ; — — — — native white ; - — - — - — - foreign-
It is to be distin-
population furnishing those deaths.
colored.
1
born white; ......
594 THE
MEDICAL RECORD.
[November 30, 1889
guished from a statement of the number of deaths, since
to determine the mortality in a given population we
must not only know the number of deaths, but also the
population furnishing that number. M=?.
In the same way, natality does not mean the number of
births, but it means the ratio of the number of births to
the population in which they occur. N=3.
The relations between mortality and natality are very
important, as I shall have occasion to explain hereafter.
The value of such statistics depends, of course, on the
accuracy of the individual data, and the completeness
with which these data are gathered for the given locality
to which they relate.
Accurate data with regard to deaths can only be ob-
tained by a system of registration of deaths made at the
time they occur. Repeated experience has shown that it
is utterly impossible to collect, at the end of a year, by
any mechanism of enumeration, more than seventy per
cent. of the deaths which have occurred during the pre-
ceding year, and it is now well recognized that a complete
registration of deaths can only be secured by legislation
which forbids a burial until a permit has been granted
from. a central office, which permit is issued only on the
certificate of a physician, setting forth the cause of death
and other facts connected with it which are of impor-
tance, and which will be presently referred to. In the
great majority of cases it is comparatively easy to enforce
the law, even in thinly settled rural districts, and the com-
munity soon learns to consider any attempt at burial
without a permit as a suspicious circumstance, indicating
a desire to conceal either the death or the cause of death,
and justifying a special investigation by the authorities.
When it has been decided to require a burial permit in
all cases, it is not usually difficult to require the data for
registration as an indispensable preliminary to the issuing
of such permit.
Any system which depends upon the returns of under-
takers for a record of deaths gives incomplete and un-
satisfactory results. It is only where the permit must be
obtained before burial and the certificate must be filed at
a central office before the permit is issued, that a. com-
plete record of all deaths will be obtained. Any complete
system of death registration should’ include some method
of verification of the death and of its cause, which must
be certified to by some person having the special knowl-
edge which alone can enable him to give such a certifi-
cate. `
In the first place, we must have this verification to in-
sure the fact of a death having taken place. In its ab-
sence, in a large city, there is little or no difficulty in
having recorded the death of a person who may be either
alive and well, or non-existent, and the door is thus
opened to frauds of various kinds, some of which have
actually been attempted and discovered, while others, no
doubt, have been successful and remain still unknown.
Such verification is also necessary to insure the fact of
real as opposed to apparent death in any case, and thus
prevent premature burial.
The utility for this latter purpose is, of course, small,
for the popular idea as to the frequency of trance or other
conditions simulating death, so that the true state of af-
fairs is not detected, is, as you all know, grossly exag-
gerated. Nevertheless, this consideration may enter as a
factor into an argument in favor of such skilled verifica-
tion.
The main reason, however, for the verification of a
death by expert testimony as to its cause, is that it is ne-
cessary to establish the fact that a death has taken place
from what may be called natural causes as opposed to
criminal causes.
This verification of death, and of the causes of death,
may be made either by physicians employed for that par-
ticular purpose and paid by the State, or by the physician
under whose charge the deceased person has been im-
mediately previous to death ; in which latter case only
those cases which have not been under the treatment of a
physician are referred to a public medical officer, or the
coroner, for verification and determination of the cause
of death.
The first system is that which is employed in France,
Austria, and Belgium. ‘The second is the one made use of
in England and in this country.
All registration laws include the certificates of physi-
cians as an essential part of their machinery. Some do
this directly, requiring that physicians shall keep a list of
all deaths occurring in their practice, and shall forward
this list at stated times to the registrar. This method has
invariably proved to be a failure, as has also the similar at-
tempt to require of clergymen that they shall furnish lists
of the marriages which they have solemnized. It is utterly
impossible to enforce such laws under penalties, and not
fifty per gent. of either clergymen or physicians will carry
out their requirements under ordinary circumstances.
Where burial permits are required, a physician may be
made responsible for a certificate as to those matters only
with regard to which his special professional knowledge is
necessary, such as the cause of death, duration of sickness,
etc.; or he may be required also to certify as to the age,
birthplace, parentage, occupation, etc. The great major-
ity of physicians accept without hesitation the data fur-
nished on these points by some member of the family, or
whatever appears set down in the form of certificate
brought to them by the undertaker for signature. But
there are always physicians who question the propriety
of the law and object to certifying to that of which they
can have no personal knowledge, while some few may pos-
-sibly decline.
The requirements of a registration law impose upon
medical men who sign certificates as to causes of death a
very considerable responsibility, much more considerable,
in fact, than many of them probably realize. ‘The physi-
cian is to consider whether his knowledge of the case is
sufficient to enable him to determine whether or not the
death was due to what are called natural causes, whether
there is reason to suspect that violence, poisoning, crimi-
nal neglect, etc., may have been more or less factors in
the result, and whether any certificate as to the nature of
the cause is justifiable. The pressure upon the medical
man to certify to more, or sometimes less, than he knows,
is occasionally very strong, but the only course in doubt-
ful cases is to indicate clearly what one knows, as distin-
guished from what he merely believes on the faith of
statements made by others. In ordinary matters of daily
routine occurrence, in which there is no apparent motive
for falsification, we constantly do, and must, accept the
statements of others ; the physician acts as the primary
judge of the evidence submitted by relations and friends
as to the time of death, the age and race of the decedent,
the duration of the disease, etc., and is justified in certi-
fying to his belief in this evidence, very much as he is justi-
fied in certifying to the date of his own birth.
It has been objected ' that registration laws may do
very well for countries where people have been trained
for generations in that line of action, but that they are at
war with principles of democratic action and with indi-
vidual freedom, and that the reason why physicians do
not execute the law is because they not only have no per-
sonal interest in its execution, but because of a feeling of
revolt against the injustice of a law which inflicts a spe-
cial tax in the shape of time and trouble, and affords no
compensation for the extra labor and expense.
These views are not those held by the majority of the
medical profession, and it is not probable that the pay-
ment of a fee would add much, if anything, to the com-
pleteness or accuracy of the registration data furnished by
medical men. Nevertheless, these objections have some
weight from a legal stand-point, and should be borne in
mind in attempts at legislation. Any attempt to compel
a physician, under penalty, to report the age and birth-
place of his patients, would certainly be worse than use-
1 Dr. H. M. Lyman, in the Chicago Medical Journal, 1878, p. 252.
November 30, 1889]
THE MEDICAL RECORD.
595
less. The policy is not to call upon medical men to sub-
mit the information which should be demanded from the
parent or householder. Under the police power of a
State, certificates of the cause of death may be required
from physicians as being necessary to secure life and pro-
tect property, but returns for merely statistical p
such as of births, cannot be required of any other than
the parent.
There is no good reason why reports of births should
be required from medical men. But as regards reports of
deaths, it 1s to the interest of properly qualified members
of the medical profession that such certificates should be
demanded from them. Whenever and wherever certifi-
cates as to the cause of death are required from phy-
sicians, there must also be established some system of de-
termining who are physicians within the intent of the law.
At first it may be necessary to accept certificates from
anyone and everyone who chooses to call him or herself a
physician ; but the character of some of the documents of
this kind, which will come in, will very soon indicate the
necessity for some discrimination. Thus it is that the
certification of the causes of death by physicians is the es-
sential foundation, and it is the only essential foundation,
of legislation with regard to the qualifications which the
State has a right to demand from practitioners of medi-
cine.
‘The registration of marriages, births, and deaths is im-
portant to the individual, because it gives him increased
security in his rights to property and to life, by enabling
him to furnish proof of parentage and legitimacy, by in-
creasing the chance of detection of fraudulent claimants
to property of which he is the true heir, and by discour-
aging criminal attempts to shorten his life, owing to the
fact that evidence must be furnished that death was due
to natural causes, or a special legal investigation of the
circumstances will be made. Of the importance to the
community as a means of protection of health and life,
and to scientific men and physicians as a means of inves-
tigation of some of their problems, I need give no proof
to this audience.
We can hardly be said to have a complete system of
registration of births in any State or city in this country.
Probably the city of Providence, R. I., has the most com-
plete records of this kind of anyof our cities. As regards
the registration of deaths, Massachusetts, New Hampshire,
Vermont, New Jersey, the greater part of Connecticut and
New York, a large part of Alabama and Minnesota, and
most of our large cities, have now a fairly satisfactory
syşem and complete record. For the rest of the United
States, there is either no system of registration, or, if any
exists, it is a very imperfect and incomplete one, the re-
sults of which cannot be depended upon, and which can-
not be compared with the results obtained in the localities
above referred to as having a complete system; and the
only means which we have of estimating the mortality of
these localities is by the reports of deaths for the preced-
ing year collected by the census enumerators.
It is for this reason that the decennial United States
Census is a matter of such great importance to scientific
medicine, and to practical sanitation—of much greater
importance, in fact, than most physicians and health of-
ficials seem to fully appreciate. It is true that the death-
records thus obtained in the large areas of the country in
which there is no registration are incomplete, and, as re-
gards causes of death especially, inaccurate ; but they are
the best we have; they are becoming better at each cen-
sus, and the death-records in the registration areas serve
to measure their reliability, and to indicate to some extent
useful corrections.
As the value of statistics of deaths depends very largely
upon the possibility of comparing them with correspond-
ing statistics of the living population furnishing those
deaths, it is evident that the modes and times of obtaining
and of publishing the results of the census are matters of
great importance to medical and sanitary statisticians.
This is especially true as to the frequency with which a
census 1s taken, the units of area made use of in its pub-
lished tables, and the combinations of age, sex, race, and
occupation data given in connection with such units of
area.
Let us first consider briefly the time of taking the cen-
sus.
The conclusions of the various statistical congresses
with regard to the methods of the census are summed up
by Korosi in his project for a census of the world, pub-
lished in 1881.
The first of these conclusions was that the census
should be taken every ten years, in the month of Decem-
ber, and in those years the number of which terminates in
zero ; recommending, however, that intermediary censuses
should be taken at the discretion of different govern-
ments.
The taking of the census at the end of December has
the advantage that a relatively greater number of popula-
tión are in their own homes then than at any other time,
and that it corresponds to the termination of the calendar
year, at which date many State and municipal reports ter-
minate, so that all the figures, being for one date, are readily
comparable with each other. For a very large part of
this country it would be quite as easy to take the census
at the end of December as on the first of June ; but there
are some sections in which attempts to take the census in
the midst of cold and rainy weather, for a thinly scattered
population, would be made under very great difficulties.
In a paper read at the British Health Congress in May,
1889, Sir Edwin Chadwick urges the desirability of an
annual census for the improvement of public administra-
tion, referring to the fact that, “in commerce and in man-
ufactures, as in every large company, there is an annual
stock-taking, and upon that stock-taking a report and
declaration of the results is made to the stockholders.
But what is the state of the political administration which
has only attained toa stock-taking of the living people, of
the healthy and the weakly, on whom the power and the
prosperity of the county depend, which is only attempted
every ten years, and is only completed in three years,
leaving the numbers, meanwhile, to be got at by estimates,
necessarily erroneous—often widely erroneous? An an-
nual census of the more numerous animal stock has been
lately striven for and attained, and 1s worked out by the
Agricultural Department of the Board of Trade. Itis
some forty-five millions of the agricultural stock, while the
population of England and Wales is about twenty-eight
millions. Other nations, as France and the United States,
have halved the inconvenience of the stock-taking of the
human population.”
Sir Edwin is in error in this last statement, for the
United States Census is taken but once in ten years, and
but a few States have thus far taken the intermediate cen-
sus, which would make the enumeration come at quin-
quennial periods.
In the law providing for the last census, an attempt was
made to induce the States to take this intermediate census
by an offer that the United States should pay one-half of
the amount paid to all supervisors and actual enumerators
in the State, increased by one-half of the percentage of gain
in population in the State, provided that the schedule used
should be similar to those used in the census of the United
States, and that a full copy of all schedules returned, and
reports made, should be deposited with the Secretary of
the Interior on or before the September following.
This provision, however, has not had the effect de-
signed, probably for the reasons set forth in the report on
the census of Michigan for 1884, namely, that at least
two months are required to make the enumeration, trans-
mit the blanks to the Secretary of State and arrange them,
which leaves but one month (August) for correction of
errors and for making the full copy of the schedules. As
applied to the State of Michigan, this would require a
thousand or twelve hundred clerks for twenty-five days.
The amounts paid the supervisors and enumerators for
the United States Census of 1880 were $71,192.06, one-
596
THE MEDICAL RECORD.
[November 30, 1889
half of which, increased by one-half percentage of gain,
gives $42,401.99 as the amount Michigan would have re-
ceived from the General Government if its census had been
taken in conformity with the national census law. But it
would have cost from sixty to seventy thousand dollars to
copy the schedules and reports, or from eighteen to twenty
thousand more than the amount that would have been re-
ceived from the national treasury to compensate for the
work. A few sets of territorial schedules were sent in, but
nothing was done with them.
Sir Edwin, however, urges that even the quinquennial
census would be considered insufficient for business pur-
poses in the ordinary affairs of civil life, and refers to the
fact that the proposition for an annual census in the
European governments was discussed at the International
Statistical Congress at the Hague, having been proposed by
himself and strongly seconded by Professor Engle, the
head of the Statistical Bureau of Prussia. The matter
was appointed to be the subject of discussion at a future
Congress, but-in the meantime the meetings of the Con-
gress were interrupted, and the matter has never again
come up as a subject for international discussion.
Annual censuses have been tried and abandoned in
Canada. ‘Triennial censuses have also been tried, but the
eile conclusion seems to be in favor of five-year pe-
nods,
In Austria, Belgium, the greater part of the British Em-
pire, Denmark, Holland, Hungary, Italy, Norway, Swe-
den, Switzerland, and the United States, the census is
decennial.
In the Sandwich Islands a census has been taken every
six years since 1853.
In France a census was taken in 1801, 1806, and every
five years since 1821.
In Sweden every five years from 1775-1860.
In Germany every five years since 1866.
In Finland every five years since 1875.
In Sweden every three years from 1749-75.
In Baden every three years from 1818-67.
In Hanover every three years from 1830-64.
In Prussia every three years from 1834-67.
In Saxony every three years from 1834-67.
In Bavana every three years from 1834-67.
In Upper Canada (now the Province of Ontario) a
census was taken annually for nineteen years from 1824-
42.
In New Zealand nine censuses have been taken since
that of 1851, at intervals of from three to seven years, the
last interval being five years.
In Queensland there is also a quinquennial census.
While it is not probable that any agreement for an an-
nual census of the whole country will be made in the
near future, either by the United States or by State gov-
ernments, it is certainly quite possible that the desirabil-
ity for more frequent enumerations in the larger towns
and cities will soon become so evident as to lead to sys.
tematic arrangements for carrying it out. Even now,
many cities take what they call a police census, at irreg-
ular intervals of from three to five years, for the purpose,
mainly, of making rough subdivisions of the voting popu-
lations in the form of precincts, and of obtaining mfor-
mation for the purpose of levying taxes, more especially
for school purposes. These police censuses, however,
relate only to adult males, and upon them are based esti-
mates of the number of the remaining population, which
are used by the sanitary officials in computing death-rates.
‘These estimates, however, are almost invariably too high,
as 1s shown by the next State or National census, and, in
any case, afford no satisfactory basis for computation as
to the number of inhabitants in the different wards of the
city, owing to the great variations in the ratio between
the voting population and the rest of the people in differ-
ent classes of society and in different parts of a town.
By the use of proper schedules, somewhat on the Eng-
lish system, left at each house, there should be very little
extra expense over that of the ordinary police census in
collecting sufficient data with relation to the entire popu-
laton of a city, to give accurate data with regard to the
vital statistics of the population, and these, combined with
a good system of registration of deaths and marriages,
wouid give the means for a system of vital statistics of a
place such as, at present, no city in England or in this
country possesses.
The unit of area made use of in furnishing the census
data is a very important matter in connection with the
statistics of deaths, for, practically, these last must be
classified by the same areas. The census units of area
have usually been fixed by political considerations with
reference to votes, to taxation of various kinds, and to
military service. In this country the smaller unit is usually
the county or city, or, in some cases, the wards of a city,
the larger units being the State or Territory.
For the purposes of vital and medical statistics such
units of area are often of little or no importance, because
the boundaries of wards, of cities, of counties, and of
States are not fixed with reference to the peculiarities to
topography, drainage, character of habitations or of the
people, which are important factors in the causation of
disease and death, and which, therefore, require study, as
much so as with reference to dividing the population for
purposes of representative government. Moreover, in
the publications of the several censuses prior to that of
1880, the population of the smaller areas, such as cities
and counties, was, as a rule, given with distinction of sex
and of color only, while the most important factor in
vital and medical statistics, namely, age, was stated in
detail for States only. In the census of 1880 an impor-
tant advance was made in this respect, for, in connection
with the mortality statistics, the population of each county
having ten thousand inhabitants and upward, and of the
large cities, was given with distinction of age under one
year and under five years, for each sex of each color.
In the next census the population by counties will be
given with still further distinctions of race; it will be
given with distinction of age under one year and under
five years for wards, and in about two dozen of the largest
cities it is proposed to select certain areas which present
peculiarities as to topographical features, or as to the '
character of the people inhabiting them, and to give the
population of these by age, sex, and color, as a basis for
the study of the death-rates of these localities. Ina large
city like New York, even the ward is usually too large to
be a satisfactory unit of area for statistical study, since one
ward will contain some of the best and some of the worst
habitations, and include classes of people having very
different means, habits, and death-rates.
-In the annual report of the city of Brussels the popu-
lation, births, and deaths, are given by streets, courts, and
alleys. ‘This does very well for Brussels, where the streets
are short; but in our large cities, regularly laid out in
rectangles, where the streets are miles in length, and
traverse localities differing widely in topography and in
character of population, it does not seem to be appli-
cable.
The data required on individual certificates of death
should correspond to those required on the schedules of
living population, and, in addition, should give the cause
of death.
The death-rate, or mortality, is the ratio between quan-
tity of life and loss of life. It refers to a definite unit
of time, viz., one year’s life of one person, and the quan-
tity of life is the sum of the time lived by each of the
population expressed in years. ‘Two persons living six
months each, or twelve persons living one month each
have one year of life. If the population is assumed to be
stationary, that is, one in which the births and deaths, and
the emigration and immigration, are exactly equal to each
other and similarly distributed throughout the year, then
the number of the population multiplied into the time
under consideration, expressed in years and fractions of
years, gives the quantity of life.
A population usually, however, increases in geometrical
November 30, 1889]
THE MEDICAL RECORD.
597
progression, and in such case we must find, by means of
a well-known formula, the mean population of the period,
which will be less than the arithmetical mean of the popu-
lations at the beginning and end of the period and greater
than the population living in the middle of the period ;
but the differences are small, and, in most cases, either
figure may be employed.
For example, suppose we wish to calculate the death-
rate of New York City for the year 1888. By the cen-
suses of 1870 and 1880 we know the population on June
Ist in each of those years. From these we determine the
ratio of increase, and thence the population on January 1
and December 31, 1888, from which the mean population
can be computed, or the arithmetical mean be taken.
Or, we can compute directly the population on July 1,
4888, and it makes little difference as to probable accu-
racy which of these three estimates of population we take.
You will perceive that this method rests on the assump-
tion that the ratio of increase of a locality during ten
years as determined by the census continues unchanged
and uniform thereafter. ‘This is hardly ever true, and, for
many localities in the United States, and especially in the
rapidly growing West, it is very far from the truth, which
is a strong argument for more frequent counts.
Various methods are used by statisticians to correct
the estimates of population made for a city at periods
other than during a census year, as determined by a for-
mula of arithmetical or geometrical proportion, among
which may be mentioned the use of the ratios supposed
to exist between the number of houses or the number of
voters, or the number of school-children and the total
population. The number of houses is determined from
tax records or by a special count; the number of voters
by registration lists or by a police census ; the number of
school-children by a special census; and the ratio which
these bear to the whole population is guessed at or is cal-
culated from the data obtained at the last census.
The most useful and reliable of these methods is the
use of the average numbers of presumed occupants of in-
habited houses, the other ratios being of very little value.
This has been very well shown by Dr. Russell, Medical
Officer of Health at Glasgow, in a paper on “The De-
cennial Census as a Basis for Statistics in Intervening
Years,” Glasgow, 1881. In the case of Glasgow he con.
siders the estimate of her population based on the number
of inhabited houses and the estimate based on preceding
censuses, and finds that both methods give a population
above the actually existing one as shown by the next
census. ‘The error in the estimates based on the previous
census was due to a change in rate of growth. ‘The error
in that based on the number of houses was due partly to
incorrect data of the number of inhabited houses, and
partly to an error in calculation.
In the United States Census of 1870 the number of
persons in a dwelling in the large cities varied from 14.07
in New York to 5.20 in Toledo, these differences being
due, to a considerable extent, to the counting of large
tenement-houses containing numerous families as a single
dwelling.
If we take the data by families, we find in the same
census that the largest number of persons to a family
was in Kansas City, the number being 5.78, while in New
York it was but 5.07.
In 1880 the proportion of persons to a dwelling ranged
from 16.37 in New York to 4.68 in Memphis. In Balti.
more it was 6.54; in Boston, 8.26; in Philadelphia, 5.79.
‘The number of persons to a family was: In Baltimore,
5-8; in Memphis, 4.23 ; in New York, 4.96; in Phila-
delphia, 5.13.
It is evident that no value can be placed on estimates
of population of a city based upon the number of habi-
tations it contains if a cottage and a tenement-house are
to be equally reckoned as a habitation.
Estimates of the population based on police censuses,
on the number of school-children, or on city directories,
are of very little use, being, in almost every case, in ex-
cess of the truth. No general rules can be laid down for
the estimation of the population of a city at a period be-
tween two censuses. It 1s a special problem in each
case, for the solution of which there is needed an ac-
quaintance with the locality, to be sure that boundaries
have not changed, the information which can be obtained
from special local censuses, from the number of inhab-
ited buildings, from migration statistics, etc., all of which
must be applied to the data furnished by the last general
enumeration of the people, which, in any case, must be
resorted to for the ratios which are to be used.
It is to be observed that municipal statisticians and
registrars rarely make use of the means afforded by a gen-
eral census to correct the figures of population, and,
therefore, rarely alter death-rates which they have given
for the years intervening since the last census; yet it is
highly desirable that this should be done, in order to pre-
vent the use of misleading figures. For example, in
Chicago, in 1873, the registrar estimated the population
of the city at 400,000, and deduced therefrom the death-
rate for the year as 23.89. Comparing the populations in
1870 and in 1880, it was apparent that the true popula-
tion was about 350,000, giving a death-rate of over 27.
In Boston, in 1876, the estimated population at the
time was 352,758, giving a death-rate of 23.39, while the
true population, as shown by comparison of census data,
was about 313,000, giving a death-rate of over 26.
The shorter the period for which a death-rate is given,
the greater is the liability to error. The ordinary forms
of weekly death-rates reported for large cities are annual
death-rates ; that is, they represent what would be the an-
nual death-rate if the proportion of deaths to the popula-
tion for the week continued for one year. If, for ex-
ample, a town having a population of 100,000 reports as
its weekly death-rate for a given week 25 per 1,000, this
does not mean that during the week there occurred 2,500
deaths, but it means that if the population and number of
deaths each week are continued the same during the year,
2,500 deaths would have occurred in the course of the
year, or that for the week in question the number of
deaths was 2,500 divided by 52.17747. A weekly death-
rate is useful to show where the greatest variations have
been in the year’s mortality, but it is no indication of the
health of a town for a particular week, and it is useless as
a means of comparison of the healthfulness of one town
with that of another. This is largely due to the law of
probable deviation or error in mortality statistics in rela-
tion to the number of instances used as data without ref-
erence to their accuracy. This law of probable error in
relation to number of data is an exceedingly important
one, to be kept in view in all statistical inquiries, and es-
pecially in those relating to vital and medical statistics.
For example, suppose that in a village of a thousand
inhabitants there occur 25 deaths in the course of a year,
and in a neighboring city of 10,000 inhabitants there were
200 deaths in the same time. What is the probability
that the death-rate of 25 per 1,000 for the first, and 20
per 1,000 for the second, indicate the relative healthful-
ness of the two places, supposing the data to be perfectly
accurate, and that we have no other information in regard
to them than that stated ?
Or, suppose that during one year, in a population of
100,000 persons, there occur 2,000 deaths, what is the
probability that in a second group of 100,000 persons,
under the same circumstances, the number of deaths in a
year will not be less than 1,950, nor more than 2,050 ?
The answers to such questions as these are furnighed
by formulz derived from the mathematical laws of prob-
ability. The simplest of all these formule, and the one
most practically useful for rough and ready calculations
in cases such as that given in the first example, is, that
the mean or probable error is equal to the square root of
the number of the dead. By this rule the probable error
for the village of 1,000 inhabitants, for 25 deaths, would be
5, and therefore the mortality in this place might vary be
tween 20 and 30 per thousand, without any certain indica-
598
tions of variation in the sanitary conditions of the place.
In the city of 10,000 inhabitants, with 200 deaths, the
probable error is a little less than 15, the variation be-
tween 185 and 215 corresponding to an average mortality
of 18.5 to 21.5 per thousand, being a probable variation
of only 3 per thousand instead of 10, as in the first case.
It is very clear, then, that in comparing these two mor-
tality-rates, no positive conclusion can be drawn as to the
relative healthfulness of the two cities, seeing that the
probable variations overlap, as it were, for the rates rang-
ing from 20 to 21.5.
The formula that the probable variation in the number
of deaths is the square root of that number, gives results
that are somewhat too great, being merely an approxima-
tion to the true formula, which is of much more general
application, but requiring too much computation for gen-
eral use. I shall refer to this matter of the law of error
in more detail in speaking of medical statistics. For the
present, I only call your attention to the fact that it is
necessary to bear in mind the absolute numbers as well as
the percentages, and that, therefore, statements of ratios
only are insufficient for definite conclusions.
THE MEDICAL RECORD.
[November 30, 1889
of an annual calculation of birth-rates and their compari-
son with the deaths of children under one year of age, or
those born within the year. Wecan only obtain this data
for any large extent of country by referring to the census .
records.
The usual method of indicating the birth-rate is by
giving it as the proportion per 1,000 of births to the popu-
lation of all ages; but a much better and more satisfactory
mode of computation is to calculate the number of births
to the number of women between the ages of 15 and 50
or 55 living in the community referred to.
The general subject of birth-rates is interesting chiefly
in relation to social statistics, to the fecundity or rate of
increase of population or of people of different races ;
but, in relation to mortality statistics, it may also become
an important factor in the calculations.
There has been from time to time some controversy
between statisticians and health-officers with*regard to the
influence af birth-rates upon death-rates, or as to the pre-
cise relations which exist between the two. As the death-
rates of infants are much greater than those of the popu-
lation at higher ages, it has been claimed by some that
Diagram Showing the Effect of an Increased Birth-rate Upon the Death-rate, and the Average Age at Death.'
O Loa Z, x ~ 4 IE G9 í (2 20
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=< ae CEEE LEELCELLETITELELECLEELLLLLI LELTE
What isa fair or normal death-rate? Taking an av-
erage healthy rural district in the United States, where
there`is little migration, the annual gross death-rate for
the whole population will be from 13 to 15 per 1,000.
In towns of from 10 to 15,000 inhabitants, having a good
general water. supply and proper sewerage, the gross death-
rate should not exceed 16 per 1,000. In cities of from
20,000 to 100,000 inhabitants it should not exceed 17 per
1,000, while in cities of over 100,000 inhabitants it should
not exceed 19 per 1,000. ‘The great causes of high death-
rates are poverty, overcrowding, intemperance, excess in
heat and cold, with moisture, foul air, bad food, impure
water, uncleanness, contagion, ignorance, etc.
BIRTHS AND BIRTH-RATES.—The statistics of births are
of much importance in vital statistics, because of the in-
fluence of the birth-rate upon the sex and age-distribution
of the population. Unfortunately, in this country, as I
have already explained, hardly any locality possesses such
an enforced system of registration of births as to permit
Fixed birth-rate of 45 per 1,000 ; ——-—— fixed birth-
rate of 35 per 1,000.
where there is a high birth-rate there also is a high death-
rate ; but it cannot be said that this will invariably be the
case, or that the one is directly the cause of the other,
except in certain cases for a comparatively short series of
years. ‘Ihis will be best understood from the above dia-
am.
“aing with a population numbering in all 308,378,
supposing that there are no migrations, we will calculate
the progress of such a population for 100 successive years,
under two suppositions—the first for a constant birth-rate
of 35 per 1,000, and the second for a constant birth-rate
of 45 per 1,000. ‘The death-rate at the commencement
say iS 32.42 per 1,000. Under the influence of a constant
` birth-rate of 35 per 1,000, this death-rate will increase
during the first period of five years to 33.17, and after that
steadily sink until, at the end of 55 years, it becomes less
than the original death-rate, and at the period of 65 years
will sink below it; after which it again rises until, at the
end of 100 years, ‘it has reached the rate of 32.44.
Taking now the same population, under the same cir-
cumstances, at a constant birth-rate of 45 per 1,000, we
see that th: death-rate rises in the first five years to 36
November 30, 1889]
THE MEDICAL RECORD.
599
after which it steadily sinks as it did in the former case,
until, after the lapse of 60 years, it is only 32.01, after
which it again rises and finally comes down to a point a
little below that from which it started. In both these
cases, then, it is evident that the high birth-rate for a time
produces an increased death-rate, since there are no other
circumstances present to account for the change. But
after the first five years the proportion of those living at
the ages at which there is the lowest mortality has been
so much raised as to more than counterbalance the large
number living in the first years of life, and, therefore, the
death-rate steadily descends.
But, to understand the full effect of this change, it is
also necessary to consider the average age at death.
‘Taking the average age at death at 31.37, it will decrease
to 29.65 under the influence of a constant birth-rate of 35
per 1,000 ; while, with the higher birth-rate of 45 per 1,000,
it will diminish as the death-rate diminishes to the age of
65, at which period it will be only 23.02, after which it
will again rise as the death-rate increases.
As a rule, high birth-rates occur in cities, and in the
crowded parts of cities, among the laboring classes of the
population, where the causes of disease and death in in-
fants are especially prevalent.
On the other hand, it is to be noted that a high death-
rate among infants has some tendency to increase the
birth-rate, because the interval between child-bearing is
shortened by the early death of the infant ; and in the ef-
fort made by poor women to avoid frequent child-bearing,
a common means is to suckle the infant up to at least
two years of age, in order to prolong the interval between
pregnancies—which is a practice injurious both to the
mother and to the child.
If we had under consideration a community in which
there were no migrations, and in which the population
neither increased nor diminished, the relations between
birth-rate and death-rate and the average duration of life
could be expressed by a simple formula, in such a way
that, given either two of these quantities, we could deter-
mine the third. If, for example, in a population of 1,000
persons, five births and five deaths occur annually, and if
we assume that every individual lives to the same mean
age, evidently just 200 years would elapse before. the
whole of the original 1,000 would have died. ‘This 200
years would be the mean duration of life, and this
would be the case also if deaths occurred at different
ages, only in such a case many would die below the mean
age ; when some would greatly exceed it. This subject
has been considered by Dr. J. S. Bristowe in a paper “On
the Mutual Relations of the Birth-rate and Death-rate.” '
From the table which he gives I have extracted that part
which shows the mean duration of life under certain con-
ditions of birth-rate and death-rate, where the birth rate
varies from 3 to 5, and the death-rate from 15 to 35, ina
thousand.
Dr. Bristowe says: ‘ ‘There can be no difference in the
healthiness of two localities in one of which the death-
rate is twice as high as that of the other, provided other
conditions are such that in both cases the inhabitants at-
tain the same mean age; or, conversely, supposing differ-
ent populations to enjoy the same mean duration of life,
any differences which may be presented by their respective
death-rates are due to other circumstances than differ.
ences of health.” He also says that the average dura-
tion of life can be determined by the birth-rate and death-
rate taken together, but not from the death-rate alone. If
he means by healthiness mean duration of life, this state-
ment is equivalent to saying that, where the mean dura-
tion of life is the same it will be alike—an indisputable
proposition, though not a very instructive one. But if by
healthiness is meant the sum of the conditions of the lo-
cality as to altitude, drainage, cleanliness, etc., which tend
to lessen or increase deaths in the people living in it, then
+ St. Thomas’s Hospital Reports, New Series, vol. vii. London,
1876, pe 245. .
~same day.
the statement is incorrect, for it does not take into ac-
count age, sex, or race distribution, occupations, or migra-
tions. Setting the question of migrations entirely aside,
it is perfectly possible that two populations, attaining the
same mean age and having the same death rate, may live
in two localities, one of which is decidedly healthier than
the other ; so that, if the two communities exchanged hab.
itations, a marked difference in the death-rates and mean
age at death would result.
Putting aside all these purely speculative considera-
tions with regard to what might happen in a stationary
population where there is no migration, let us see what
the significance of death-rates is in our cities and rural
districts, as they now exist. We wish to know how much
of the death-rate is due to peculiarities in the character .
and occupation of the population itself, and how much
to peculiarities in the locality, and for each of these
classes we wish to know how much is necessary and un-
avoidable, and how much is due to causes which may be
modified or done away with. Precise knowledge on these
points we can never have, but we can obtain a sufficient
degree of probability to guide our action in the premises.
If we wish to study carefully the influence exerted
upon health and life by race characteristics, by residence
in a given locality, by marriage, occupation, social stand-
ing, etc., we must have the means of comparing results
given in different localities, or in the same locality at dif-
ferent times, or for different races, occupations, etc., un-
der like circumstances.
To accomplish this we must, as far as possible, esti-
mate the influence of other circumstances not connected
with the particular point which we are investigating, but
which, notwithstanding, exercise a powerful influence
upon sickness and death-rates ; and of these, the two most
important influences are those which differences in pro-
portion of sexes and ages of the, population to be com-
pared exert.
The means recognized as best calculated to eliminate
the influence of sex and age, by, as it were, reducing the
population to one uniform scale in these respects, is by
calculating the expectation of life at each age for all the
several conditions of locality, occupation, etc., which we
wish to investigate ; in other words, by the preparation of
what are known as life-tables. A life-table shows what
would be the tendency, or liability, to death at each age
in a population in which there is no migration, and in
which the births and deaths just equal each other, if such
a population were subjected to the same influences tend-
ing to produce diseases and death as have affected the
actual population under consideration, and from which
the data are derived. It is, of course, impossible to pre-
pare life-tables which shall be strictly accurate and ex-
actly comparable one with another, because it is impos-
sible to obtain strictly accurate data. A life-table is
intended to answer the question, “ Of a million children
born, how many of each sex die at each age ?” or, “ What
is the time which a man or woman of a given age may be
expected to live?” A strictly accurate answer to this
question could be given only if we knew the precise dates
of birth and death of each of a million of children, born
under the circumstances we are investigating ; and, strictly
speaking, these million children should all be born on the
Notwithstanding, by using large masses of
data which are more or less attainable, and by applying
certain well-known corrections, the individual errors tend
to ngutralize each other, and we can prepare tables which
will be quite accurate enough for purposes of compar-
ison.
A vast amount of labor has been expended upon, and
study given to, this subject ; for immense business inter-
ests and important points in the jurisprudence of inheri-
tance depend upon the existence and accuracy of these
tables. Hundreds of millions of dollars have been, and
now are, invested im life insurance on the faith that certain
life-tables truly represent the average course and duration
of the life of a particular class of the community—and
600
the result of more than a hundred years of experience has
been applied to their correction under the powerful stimu-
lus of urgent need, from a pecuniary point of view, to
have them as accurate and reliable as possible.
Probably the earliest form of such a table known is that
given in the Pandects of Justinian by Domitius Ulpi-
anus, commonly known as Ulpian, a distinguished lawyer,
who was the secretary of Alexander Severus, and who
wrote in the beginning of the third century of the Chris-
tian era. This table is found in an extract from his
writings given in the Pandects in a treatise by Amilius
Macer.
Ulpian states that in Rome registers of Roman citi-
zens, including the data of age, sex, and death, were
_kept by the city from the time of Servius Tullius to that
of Justinian, including a period of one thousand years.
From these data, which applied to the more prosperous
class, Ulpian gives a scale for estimating the purchase
value of communities according to the different values of
life at different ages, and sums it up in saying that it- is
usual to compute thirty years’ maintenance for all those
under thirty years of age, and that for all over that age as
many years are allowed as they lack of sixty.
In connection with the question of annuities, Ulpian
gives a scale for estimating them, which is apparently the
probable length of life of persons of the ages named.
The first life-table of modern times was constructed in
1692 by Dr. Halley, from the registers of the city of Bres-
lau for five years, and was printed in the “ Philosophical
Transactions” in 1693. ‘The data for this and for other
similar tables constructed in the eighteenth century were
too imperfect to permit of good results, and the first life-
table which was selected as of sufficient accuracy for
business purposes is what is known as the Carlisle life-table,
compiled by Mr. Milne in the early part of the present
century.
We now have a considerable number of life-tables ap-
plicable to the special classes of those who are likely to
insure their lives, derived from the experience of a large
number of insurance companies in Europe and in this
country ; and also.a number of life-tables derived from
the data of the whole miscellaneous population of the
country for England, France, Germany, Sweden, and for
certain parts of this country
In order to prepare a life-table for a given locality or
occupation, we must know the number of persons living at
each year of age, and the number of deaths at each age
which have occurred among these persons for one or
more years.
We assume that deaths have occurred at regular in-
tervals during the year for each age and proceed to com-
pute the number of persons at each age, who were living
in the middle of the period for which the deaths are
registered.
In using census data, however, we cannot directly com-
pare the deaths at each single year of age with the num-
ber reported by the census as living at that age, because
of the strong tendency of the average man or woman to
report ages either of the living or of the dead, but espe-.
cially the former, in numbers which are multiples of
ten or five, or in so-called round numbers. This will be
seen by examining the census record of 1880, with regard
to Massachusetts and New Jersey.
given are tor whites only.
An examination of these figures will show that the
death-rates calculated from them would indicate thatgthe
mortality at 25, 30, and 40 is much less than at the ages
immediately preceding and following them. Thus from
the above figures it would appear that in Massachusetts
the mortality of white males at the age of 5o is only 9.42
per 1,000, while at the age of 49 it is 16.11, and at the
age of 51 it 1s 19.16 per 1,000. ‘There is, however, no
such abrupt change in the law of mortality at the age
of 50 as these figures would indicaté, and it is neces-
sary, therefore, to make corrections for this source of
error.
THE MEDICAL RECORD.
The figures there .
[November 30, 1889
It is true that the error in the number of deaths reported
at the even decades is usually in the same direction as the
error in the number of the living population, and there-
fore tends to neutralize the error in the computation of
ratios ; but this is not always the case, as will be seen in
examining the deaths reported in New Jersey for females
at the ages 24-26 ; and as the ages of the dead are usually
reported more accurately than those of the living, the
error would be almost invariably in the direction of making
the mortality at the even decades too low, and for the ad
jacent years too high.
The error in question may be corrected in distributing
the excess reported at the even decades to the adjacent
years, by aid of the calculus; but the easier and usual
way is to calculate the mortality rates by groups of ages,
including five or ten years in each group—that is, for the
periods 20-24, 25-30, 30-34, etc., or for the periods 20-
29, 30-39, etc., or for the periods 25-34, 35-44, etc. Of
the three modes of grouping, the last is the best, because
it properly distributes the excess about the even decades,
which is the greatest.
If we take the group of ages 20-29, 30-39, etc., the
whole excess for the year 30 is distributed in the succeed-
ing years, whereas a part of it really belongs to the years
in the preceding group. ‘This objection applies to a
much less degree to the grouping of 35-44, 45-54, etc.,
for the excess at 45 is much less than at either 30 or 40;
still, it is well to remember that approximate life tables,
calculated as I shall indicate, give for this reason some-
what less than the true mortality, and somewhat too high
an expectation of life for adult ages.
This source of error affects all mortality statistics derived
from the results of a national census, and from the ordi-
nary system of registration, but it does not affect mortality
statistics derived from the records of life insurance com-
panies, in which it may be presumed that the ages of both
the living and decedents are accurately stated.
I do not propose to describe the methods of construct-
ing a life-table. ‘To make one sufficiently accurate to be
used for the purposes of life insurance requires elaborate
calculations and corrections, and the use of complicated
mathematical formule ; but the construction of an ap-
proximate life-table, in which no attempt is made to secure
regular gradation, is a comparatively easy matter, and
has been fully described by Mr. N. H. Humphreys in a
paper in the “ Journal of the Statistical Society ” for 1883,
which method was made use of in calculating the ap-
proximate tables given in the mortality statistics of the
last census,
A few words of explanation, however, are necessary
with regard to the headings of columns in the specimen
life-table which is before you. ‘The column headed Mx
is the mortality or death-rate of each group of ages as
shown in the left-hand column, which is obtained by di-
viding the number of deaths by the mean population of
that age. It signifies the mortality at any age, or group
of ages, x.
The column headed Px indicates the probability of
living a year at any given age, x
‘The column headed Lx shows the number surviving at
each year of age out of a given number taken as a start-
ing point. For example, during the census year, in New
York City the births of males and females were in such
proportion to each other that out of a million children
born, 516,385 would have been males and 483,615 would
have been females. Starting, then, with this number
516,385 males as living at birth, the age first in the col-
umn lx, we find that in the next year, by the action of the
death-rate shown in the column Mx, this number has been
reduced to 380,689.
The column headed Qx shows the number of years
which the persons who survive at that period of age will
live after that age, that is to say, the total quantity of life
remaining at any given age, x. From this is readily de-
duced the expectation of life ; that is to say, the average
mean after-lifetime of each individual.
November 30, 1889] THE MEDICAL RECORD. 601
a Na aE
Lire TasBLes.—APPROXIMATE LIFE TABLES FOR CERTAIN STATES AND CITIES.’
Life Table for Providence, Boston, and Massachusetts, for Years 1883-1887, a and for Following Ages.
o | 5 | 10 15 30 | 50 | 70
e ee Ree thas ret are |
t ' — | eee he Ne | gi
Providence .......... : 0.1748 0.0089 0.0039 0.0069 O.O11T 0.022
. | % £ .0225 0.0898
Mz.. 1 Boston ........5..... 0.2505 ! 0.0098 0.0043 0.0076 0.0132 | 0.0212 0.0686
Massachusetts ....... 0.2190 0.00724 s 0.00383 0.00654 0.01000 | 0.0149 0.0519
| { I
Providence .......... 0.8394 0.9611 0.9961 o |
. ; .9931 0.9889 0.9777 0.9140
Pr, 4 Boston ............ 0.7776 0.9903 0.9956 © 9925 | 0.9869 0.9790 0.9337
Massachusetts ....... 0.8026 0.9927 0.9962 0.9935 | 0.9901 | 0.9852 0.9494
Providence .......... 1,000,000 720,990 689, 360 6 |
1000, ’ , 75,920 593,880 ; 465,100 | 251,900
Lr. A Maon Eni ea 1,000,000 625,085 593,310 582,608 | 494,517 357,317 . 169,755
assachusetts ....... 1,000,000 702,037 676,745 663,751 I 584,836 i 461,070 | 263,310
Providence ......... : 40,814,885 36,843, 580 33,317,705 |
. 814, 843, 1317, 29,904,505 20, 349.305 9.744.005 2,446,75
Qer. 4 Boston .. ............, 33,273,508 29,661,144 . 26,620,157 23,675, 362 iy aa 7,078, 692 1 916,680
Massachusetts . 40,836,745 37,003, 338 33:571,710 30,220,470 20,876,424 10,393,055 2,985,142
eae ey a ee ee i e aaoo
New York City (Data for Three Years Ending June 30,
POrvLATION, JUNE 1, 1880.
1881).
|
EstiMATED Poruta-
TION, JULY 1, 1880.
Deatns FOR
1879-1880, 1881.
Female
Le
(NUMBER SURVIVING AT AGE .r).
; if
White and Colored. |
! EEEE.
| j
| Qz
| (Tora. NumBER or YEARS oF
Lire REMAINING TO SuRviv-
ORS AT AGE r).
White and Colored.
White and Colored. ; White and Colored. ; White and Colored. i eae a -| |
Ages. $ E Pani e Male | Female. | Male. Female.
Male. Female. Male. . Female. |! Male. | a aa = aa nee ae age
ea i ats te een” Ores eke, | 516,385 | 483,615 | 14,997,256 15,847,959
i | I. .| 380,689 375,232 {| 14,548,719 15,418,535
Ovseeeseee | 45,738 15,385 | 15,770 | 15,427 14,313 Bid ea usec e nias | 333,255 331,211 14,191,747 15,065,313
Radha 12,054 11,712! 12,079 ' 11,736 || 4,815 4,388 Fras tidatraehocs,, 315,647 314,673 |, 13,867,296 | 14,742,371
Qe cete 14,796 14,686 l; 14,826 | 14,716 (| 24i | 2,261 Hececcccee.e cos! 303,815 | 303,514 13,557,565 14,433,277
3 be Pare ee 14,199 ` 14,504 | oe : 1,605 1,541 Gir onseceswaee ey | 295,627 | 1245 33,257,844 . 14,133,397
seen wee f 13,753 | 14,058 ' 13,78: 1,152 1,002
| i | j : : BOA tis five Seatens | 278,814 | 280,377 ` 11,821,742 12,691,842
§-9....... ' 63,095 ! 63,385 l; 63,226 | 63,516 2,221 | 2,098 BS E AT | 273,048 | 274715 | 10,442,087 11,304,112
1O-l4...... | §6,462 | 57,087 i 56,578 ' 57:205 710 | 701 FOs anesan ewes | 144 266,890 ;; 9,098,347 9,950, 100
2? sereoo | 52,759 62,144 52,868 | ,272 | | LOIS ; 3,080 25 P ...| 250,497 254,662 | 7,810,985 8,646,220
a) ; i i | |
j aad ci a i; aps | nae E K EE EEA | 216,490 222,524 l: 5.476,050 6,260,290
25-34...... 107,360 110,951 107,581 — 1r1,180 |! 4,708 | 4500 r EE S bese | 177,174 188,186 |, 3:507,730 4,206,740
357-44...... 87,865 82,872 3,046 | 83,04 | 5:293 | 4176 en rey eee ‘334.373 152,860 ; 1,949,995 2,501,510
45-54...-.. $4,767 54,635 54.880 | 54,74 455 3.415 O5 essea eoesese ‘ 5,811 107,575 |! 9,075 1,199,335
55-64.. .... 26, 27,349 26,150 | 27.405 3,518 | 2,888 75 EAE l 34.842 52,783 . 245,810 397.545
6574.0 000. 9,322 11,840 9,341 | 11,864 | 2,524 2,533 Be aourt oaia | : 12,673 37,150 70,265
75-84.. ... 2,639 4,045 2,644 | 4,053 1,283 ` 1,732 O6 cet cea eta ues | 270 i 1,350 3,450
85 and over. 262 693, 263 ' 694 253 | 60a | aes
Total. i 615,785 | 591,730 | 617,053 52,309 ` 46,594 ,
i i . .
> Expectation of Life.
eee 2;
11,673
|
264,448
| 3
6,890
Mz | Pr White and Colored. White and Colored.
= | [PROBABILITY or LIVING ; a Mats
{= MORTALITY at AGk x). j! VONE VEAR AT ACE x: Ages. sae Ages. | .
2 BS. ae a a a ee et et | Male. | Female. | Persons.* : ' Male. | Female. | Persons.*
' SROV m E a eee, eee
White and Colored. White and Colored. Daaa i i
Ages ali eee Oni ao: 29.04 32.77 30.90 | 35-+--, 25.29 28.133 26.71
or | i « aa. s i EEN 38.22 41.09 39.66 : 40*...| 22.54 | 25.24 23.89
i Male. Female. Male. Female. Poues ; 42.59 | 45.49 44.04 45 ....' 19.80 | 22.35 21.08
i ee i 43-93 46.85 45.39 so*...: 17.16 : 19.36 18.26
l ining E = = ETET SHR Pn | uoa 47-55 oe sspe 14.51 | ae ee
Z o.i 44. 47.71 46.2 as 12.20 13.7 12.
O AT EE 0. 30253 | 0.25239 0.73722 0.77589 = een I E pate 43.84 65. a 9.89 | 11.15 10.52
Pale S EET 0.13288 0.12463 i 0.87540 o .88268 t5... 38.24 41.15 39.70 | 70%... 8.47 9.34 8.90
Beer ecereseeees 0.05427 O.0512t | 0.94716 0.95007 al | 34c4t 37.28 35.84 | 75 ne 7.05 7.53 7.2
enaa erui ih 0.03820 0.03610 0.96252 0.96454 25..... | 3r.18 33.95 32.56 | 8o*...! 6.22 6.54 6.3
A oe tareea eens st Sealed 0.04732 >: 0.02424 0.97305 0.97605 30° a 28.24 at oi 39.64 : 85 Ha 46 | ee, 546
SQ. ceeeeee ae, | O.OIIJI O.OIIOIL , o.98836 0.98905 bit, sat A ee eer
IOI ve sa sec cness i 0.00418 0.00408 0.99583 0.99593 * - f :
IS-19 swede acne: |! 0.00640 10 .00578 0.993 0.99424 Interpolated arithmetical means.
20-24 ............ 0,01084 0.00938 0.98922 0.99066 ! (To be continued.)
I | i
25734 chee ae ies | 0.01459 0.01349 0.98552 0.98660
Ciit e vi eevee es | 0.02004 0.01676 0.98016 0.98338 , aaan
E o ees o Pann eea PHILIPPE RICORD was not only a medical specialist of
S504 «0 ee 0.04484 0.03513 0.95014 0.9054 : °
ÉSA iniii tees 0.09097 0.07117 || 0.91381 0.93128 the first rank, but a man of cultivated mind and refined
ee, See eee ee 0.16172 0.14743 | 0.85038 0.86704 `
8s and over oas | ois 0.28897 | Sas ae: tastes. He had a fine collection of works of art, and had
Such records as those which you see on the tables
before you are the life of a nation or of a community.
They are hard to get, and not easy to read in many
cases, but nothing can take their place as a means of
judging of the effects which circumstances are producing
on the fertility, health, and vitality of the people.
1 The following tables are taken from my work on the Mortality
and Vital Stattisticis of the United States, Tenth Census, 1880, Part
I., 1886, p. 785.
a decided turn, if not for poetry, for graceful verse-mak-
ing. Only about two months ago he composed a quatrain
in honor of Mr. Edison’s visit to Paris. He was one of
the recognized wits of the French capital, and, like Fal-
staff, not only witty in himself, but the cause of wit in
others. His encounter with M. Crémieux, at that time
Minister of Finance, is well known. They met at a fancy
dress ball, both being in the ordinary evening garb of
civilized humanity. ‘You should have got yourself up
as Plutus” (the God of Wealth), said Ricord to the
Minister. ‘And you should have come as Mercury,”
‘was the retort.
602
THE MEDICAL RECORD.
November 30, 1889]
Progress of Medical Science.
Tue PartHoLocy or Erem Drieutuerra.—Criti-
cisms and theories on this subject are always accepted
as interesting if not instructive. Professor Bollinger has
been working zealously at the subject of diphtheritic pa-
thology, and more particularly the morbid changes occur-
ring in the cells of infection and the cellular tissues. The
change which first takes place is in the transformation of
the nucleus of the cell affecting both the fluid and solid
constituents, or its achromatic and chromatic properties.
Repeated fission takes place till the entire contents of
the cell are reduced to a fine granular consistence. Along
with this a chemical change proceeds, ultimately trans-
forming the nucleus and albumin of the cell into a fluid
substance, which Bollinger designates as decomposition
or necrobian change of the cell, that speedily reduces it to
ruins. The cells that may escape destruction in this way
will be observed to contain a number of nuclei, with no
appearance to increase but rather to retrograde. This
change in the cell substance appears to Bollinger to be
effected by the absorption of the infecting poison from
tke fluid that bathes the cellular tissue of the throat and
mouth, and the intensity depends on the amount of toxic
material present. When this necrotic cell product is
pent up in a large internal organ healing may take place
eby reabsorption, but when in the mucous membrane of
the mouth and throat the cellular débris is poured out on
the surface, forming the commonly observed pseudo-
membrane, the mucous membrane at the places of exuda-
tion is consequently changed, the fibrous sheath beneath
greatly infiltrated, and the walls of the blood-vessels un-
dergo a hyaline degeneration, while necrosed particles of
similar degeneration, fragmentary elements of cell destruc-
tion, with here and there a few healthy cells, are to be
found in the deeper fibrous tissues. The bacterian re-
search gives two different micro-organisms, the bacilli and
micrococci. Of the bacilli there are long and short, as de-
scribed by Löffler, while with the streptococci, diplococci,
and tetrado of micrococci, Bollinger thinks there is proof
of a compound mixture in diphtheritic infection com-
posed of specific bacilli and septic cocci. Oertel, in discuss-
ing the pathogeny of diphtheria, attributes the disease to
the decay and necrosis of the leucocytes, and the complete
transformation of the cell element into a fluid consistence
(hyaline degeneration), which he considers pathogno-
monic of the disease, although he does not deny the
supposition that other diseases may assume similar
changes. The infecting of other organs with the specific
disease he assumes to be due to lymph transfusion, blood
circulation, or the swallowing of diphtheritic products.
He assumes the disease to be local in the first instance,
and that after the destruction of leucocytes or cell ele-
ments the products of the débris become the vehicle of
contamination. Bollinger concurs in Oertel’s opinion,
and expresses the belief that the ptomaine arising out of
the cell degeneration of bacterian vegetation which pro-
duces the pseudo-membrane is the chief communicating
poison in diphtheria. From his own experiments he con-
cludes that the pseudo-membrane, is the first outward
sign of diphtheria, and that treatment should be specially
directed to disinfecting the infected area by means of
fluids or steam impregnated with some aseptic material.
—The Medical Press.
RECURRENCE OF CANCER OF THE BREAST AFTER AM-
PUTATION.—From microscopic examinations of carcino-
matous mammz amputated by Professor Küster, Dr.
Heidenhain predicted a return of the cancer in twelve
cases, because parts of the morbid growth had remained
in the wound. In the other cases he diagnosed a radical
cure, which diagnosis had proved correct up to the date
of the publication of his paper, because the operation had
removed the whole of the morbid growth. The usual
cause of the recurrence is that only microscopic parts of
the gland or the tumor remain on the surface of the pec-
toralis major. In thin women the whole mamma is firmly
attached to the muscle, but in obese subjects small glan-
dular lobules are generally attached to the fascia between
the mamma and the muscle, so that in amputation above
the muscle small particles of gland may easily be left.
Every mamma in which a single cancer node is found, ac-
cording to Heidenhain, is largely, perhaps #n /ofo, diseased.
He found the epithelial cells of the acini proliferating in
all parts of the mamma, and observed hypertrophy of the
periacinous connective tissue, and he believes that these
acini remaining in the wound form the origin of late sec-
ondary growths. In the retro-niammary fat there are, side
by side with the blood-vessels, lymphatics leading from the
mamma to the subjacent fascia, and the latter were, in
two-thirds of the cases, full of metastatic cancerous
masses. ‘The pectoralis major itself is only affected when
a metastatic cancer-node invades the muscle from the fas-
cia, or the original tumor attacks it by its own simple
growth. Heidenhain concludes that, to make amputation
of the mamma more successful, it is necessary, even n
freely movable carcinomata, not only to remove the whole
mamma, but also a superficial layer from the whole of the
pectoralis major, and in tumors which are closely con-
nected with the muscle to entirely extirpate the latter.—
The Lancet.
EXTIRPATION OF PELVIC TUMORS BY PERINEOTOMY.—
At the last meeting of the German Gynecological So-
ciety, Dr. Sanger, of Leipsic, said that by the name pen-
neotomy he meant the exposure of the ischio-rectal fossz
by the peritoneum for the removal of cysts, hzmatomas,
exudates, or other tumors having their seat in the connec-
tive tissue and Douglas’ cul-de-sac. A year ago he per-
formed such an operation on a woman aged forty-two, suf-
fering from a retro-rectal and recto-vaginal dermoid cyst.
‘This woman has been obliged in her last six labors to
have the help of a physician on account of the great de-
velopment of the tumor. He made an incision of three
inches, starting from the middle of the part separating the
right labia majora from the anus and extending beyond
this orifice ; he penetrated into the pelvis, where he found
a cyst having the size of a child’s head; this cyst was 1n-
dependent of the ovary. The patient was cured per-
fectly. Only ten cases of the kind has he been able to
find in the literature of the subject.— Zhe Medical News.
TREATMENT OF HYDRARTHROSIS OF THE KNEE.—Dr.
Georges Berne has adopted a plan of treatment of synovial
effusion, in those cases which resist the usual methods of
treatment, which has proved very successful. ‘The treat-
ment consists of a forcible rupturing of the synovial sac,
which he terms ¢c/atement, and which is followed by mas-
The knee is semiflexed, when it may be noticed that
the fluctuation is more marked above and inside the knee ;
the fluid is circumscribed, and the tumor formed is ren-
dered tense by pressure with the hand ; firm pressure with
the thumb, or percussion with the edge of the closed hand,
will produce an indentation, followed by a diminution of
fluid effused. There can be no doubt but that a rupture
or fissure of the synovial sac takes place at its weakest
point—perhaps at the level of its insertion ; the fluid per-
meates in the neighborhood ot the lymphatics and veins,
which are so abundant in the cellular tissue surrounding
the joint. ‘The rupture is easily effected in recent cases,
as the membrane has not become thickened, and possibly
the effusion is more liquid. After the éclatement massage
must be persevered with, directed from the knee toward
the groin, the form of massage being strong and deep cen-
tripetal pressures. ‘The method is as free from danger as
it is simple in execution.—Provincial Medical Fournal,
October, 1889. :
HEREDITY OF INFECTIVE DISEASES.—The question
whether pathogenous bacteria pass over from the mother
to the foetus has long been the object of scientific investi
gation. For this anthrax has offered the most attractive
November 30, 1889 |
THE MEDICAL RECORD.
603
field. The subject has again lately gone under review
by Professor Max Wolff (Zhe. Medical Press). In 1858
Brand inoculated pregnant sheep, the mother died, but
the progeny escaped. In 1869 Davaine, and in 1876
Bollinger, obtained like results. Since then Strauss and
Chamberland, who have worked in a different way, have
obtained different results. Professor Wolffs inquiry was
made with a view of clearing up the doubt that has been
raised by the experiments of the two previous investiga-
tors. His inquiry consisted in infecting some pregnant
guinea-pigs, and later on examining the organs of the
progeny after the mothers had succumbed to the disease.
In every instance the results were completely negative as
regarded microscopic examination; 150 cultivations were
then made from, the 29 foetuses, and of these 144 showed
no development of bacilli. In 6 such development was
obtained. Finally, 29 control animals were inoculated
from the ag foetuses, of which 26 escaped, and 3 were
attacked by the disease and died. Particular attention
was paid to the presence or absence of the bacilli in the
placenta and membranes, with the result that, although
they were found to be abundant in the maternal placenta,
they were not once observed in the chorionic fringes. A
second series of experiments was made with regard to
vaccinia, 20 pregnant women were vaccinated, 17 suc-
cessfully. The children themselves were vaccinated
from one to six days after birth, and all successfuHy, a
proof that the protection afforded to the mother by
vaccination does not pass to the child, even when zn
utero at the time that the vaccination is performed.
He finally attempts an explanation of the undoubted
fact that small-pox is sometimes communicated from the
mother to the foetus 7” ufero. He thinks infection may
take plate in one of two ways, either by hemorrhage tak-
ing place in the placenta, by which some of the ma-
ternal blood containing the variolous germs may enter
bodily into the foetus, or, in other cases, by contiguity.
On the same subject Zhe Lancet says, in a recent issue,
the question of the possibility of the direct transference of
the virus of infective diseases from the maternal to the
foetal organism has, since the recognition of the apparent
dependence of such diseases upon the presence of microbes,
given rise to more than one seriesof experiments, and some
interesting clinical and pathological observations. Among
the latter is a case recorded by Eberth, in which the pos-
sibility of such transmission of the typhoid bacillus was
raised. It was the case of a young woman, who, in the
third week of an attack of typhoid fever, aborted at the
fifth month. The fcetus was expelled within its membranes
intact, and macroscopically appeared normal; but in the
blood, and in fluid expressed from the spleen and lungs of
the foetus, there were found typhoid bacilli (recognized mi-
croscopically and by cultivation), which also occurred in
the intervillous spaces of the placenta. Drs. Eug. Fraenkel
and F. Kiderlen record a very similar case, in which, how-
ever, the abortion (also at the fifth month), though occur-
ring in the third week of an attack of typhoid, was associ-
ated with acute peritonitis, found to be due to an ovarian
abscess and double salpingitis. The placenta, foetal blood,
and spleen were examined for typhoid bacilli, but with a
negative result. On the other hand, cultures of staphy-
lococcus pyogenes were obtained from the spleen. ‘This
case harmonized with sorne others where there was a sim-
ilar absence of the typhoid organism in the fœtus ; but
it is pointed out that in all these cases the placenta was
normal. Jt would seem (as in Eberth’s case) that the
placenta must be diseased for such transference of patho-
genic organisms to take place, and the occurrence of
hemorrhage in the placenta appears to be a favorable
condition for the transference.’ In this case, however, al-
though typhoid bacilli were not transmitted, septic organ-
isms were derived doubtless from the suppurating foci in
the mother, and probably caused the death of the foetus
from septic infection.. Fraenkel, about two years ago, in-
jected subcutaneously cultures of the bacillus typhosus
into three guinea-pigs. ‘Two of them died in three days.
They were both pregnant, and the foetal part of the pla-
centa was found to be hemorrhagic. The placenta and
the foetuses yielded abundance of the microbes. ‘There
have been other and contradictory observations on this
subject of the transmission of microbes from mother to
foetus ; some asserting it to be usual, others that it re-
quires special favoring conditions. Netter found pneu-
monococci derived from the mother in a seven-months
foetus; Tizzoni and Caltani found comma bacilli in the
blood and serum of a five-months foetus. The observa-
tions are, however, too scanty to permit as yet of the
formulation of any definite notions on the subject.
CHRONIC TUBERCULAR ENDOMETRITIS.—Dr. Jouin says
that this form of tuberculosis is more frequent than tuber-
culosis of the other mucous membranes of the genito-uri-
nary apparatus. This may be due to the fact that the
mucous membrane of the body of the uterus is soft,
spongy, and rich in tubular glands, these conditions being
favorable to the development of an anzrobic parasite. It
has been observed and described to a certain extent by
Louis, Aran, Bernutz and Goupil, and Verneuil, but the
primary form has not been distinguished with sufficient
clearness from the secondary by any one of these writers.
Fernet described primary genital tuberculosis in a female,
and spoke of its origin from sexual contact with a tuber-
culous man. Cornil and Chantemesse have also produced
it artificially in rabbits by the injection of bacilli into the
ina. The author's studies included nine cases, in two
of which the disease followed sexual intercourse with men
suffering from genital tuberculosis. In two others the
husbands were tuberculous, but had no apparent genital
tuberculosis. In three others the cause could not be
ascertained, and in the remaining two the cause was also
uncertain. The diagnosis was verified once by the micro-
scope and twice by the peritoneal inoculation of guinea-
pigs. ‘The disease is primarily a tubercular degeneration
of the endometrium, but the uterine parenchyma and
perimetrium may also be involved. The predisposing
causes may be heredity and bad general condition, also
ruptures of the cervix and repeated attacks of inflamma-
tion. -The determining causes are the bacilli and sputa
upon soiled linen, or even upon various instruments, and
especially sexual relations with a tuberculous husband.
The fungosities upon the endometrium in these cases con-
tain bacilli, with which guinea-pigs have been successful-
ly inoculated. As to symptoms, the patient is the subject
of Jeucorrhoea, pain in the abdomen, scanty muictuntion,
constipation, and sterility. After a time the uterus be-
comes much enlarged and very sensitive to the touch,
also more or less fixed. ‘The cervix is red and perhaps
ulcerated, and a sanious matter is discharged from the
canal. The patients are much more prostrated than in
simple endometritis, and have emaciation, fever, sweat-
ing, and arthritic troubles. Without proper care this con-
dition will extend to the lungs, but it may be arrested by
local treatment. The diagnosis is to be made by histo-
logical and microbiological examination, but also by ob-
serving certain clinical phenomena. ‘The disease does not
begin after labor nor after blennorrhagia ; the patient may
not have had children, and the lungs may already present
tubercular lesions. The primary form of the disease 1s
not serious if properly cared for; the secondary form 1m-
plies tubercular disease elsewhere. In treating the disease
the patient should first receive creasote. Curetting may
be practised, if thoroughly done, and the mucous mem-
brane should then receive an application of creasote.
Pencils of iodoform may also be introduced into the ute-
rus, the organ having first been well dilated. ‘This should
be repeated every twelve days. Sexual intercourse
should be abstained from as long as the disease continues.
The hygienic and dietetic conditions must, of course, be
as favorable as possible.— Zhe New York Medical Four-
nal.
THE Use oF STROPHANTHUS IN CHILDREN.—Dr.
Demme has made a study of this subject, and has formu-
604
THE MEDICAL RECORD.
[November 30, 1889
lated the following conclusions (Archives of Pediatrics,
October, 1889). 1. Strophanthus, especially in the form
of the tincture, may be given to children after their fifth
year. In exceptional cases its use is followed by dyspep-
tic troubles. But as this agent in large doses may par-
alyze the cardiac muscle suddenly and unexpectedly, it
should not be given in larger than three-drop doses, four
or five times daily. 2. ‘The predominant action of stro-
phanthus is to increase diuresis, and consecutively to di-
minish the phenomena of venous stasis. ‘This effect is
produced by an increase in the blood-pressure, and is es-
pecially evident in connection with valvular lesians of the
left auriculo-ventricular orifice, while the strophanthus
does not, like digitalis, determine a compensation of the
valvular lesion. In affections which are accompanied by
exaggerated or even normal arterial pressure, the diuretic
action of strophanthus is wanting. 3. Strophanthus also
exercises a remarkable influence upon dyspnoeal phenom-
ena. This is due to the action which it also exercises
upon the respiratory centres, and is seen in cases of
chronic nephritis, and in such other diseases as bronchial
asthma, whooping-cough, etc. 4. While there are great
analogies in more than one respect between the effects of
strophanthus and those of digitalis, each one possesses its
own peculiar therapeutic action. Digitalis will be indi-
cated in cases in which one wishes to obtain with rapidity a
compensation for valvular lesions, with augmentation of
the blood. pressure, slowing of the pulse, and exaggeration
of the urinary secretion. If digitalis does not produce these
desired effects, they cannot be obtained with strophan-
thus. On the contrary, when a valvular lesion has been
compensated by the use of digitalis, and it eventually be-
comes necessary to act anew upon the heart, in order to
obtain a new increase in the blood-pressure, and a new in-
crease in diuresis ; when, in addition, dyspnoea becomes
an urgent phenomenon, strophanthus will give excellent
results. In such cases the combined action of digitalis
and strophanthus will be indicated. 5. In no case did
the author observe cumulative effect, nor weakening of
the action of strophanthus, even after it had been used
for a long time.
ANTIFEBRIN IN TONSILLITIS.—Dr. Sahli has found,
both from personal experience and from numerous ob-
servations on patients, that moderate doses of antifebrin
will almost invariably give great ease in cases of acute
tonsillitis, thus allaying the distress of the patient, and
enabling him to swallow food, stimulants, or medicine.
The dose he employs is seven and a half grains, which he
usually orders in a mixture with spirit and sirup, which
must be shaken up before being taken. This is sufficient-
ly agreeable to be taken readily even by children. Dr.
Sahli mentions that he has found great benefit from this
treatment in scarlatinal sore-throat.
REPRODUCTION OF GASTRIC Mucous MEMBRANE.—The
power of reproduction with which the mucous membrane
of the stomach is endowed is considerable. Professor L.
Griffini and Dr. G. Vasalle, after a series of experiments
upon fifteen dogs, formulated the following conclusions :
1. The mucous membrane of the fundus of the stomach,
removed in dogs, for a considerable extent and in its en-
tire thickness is always reproduced, including the peptic
glands. 2. The newly formed glands are developed
from the new epithelial layer which in the beginning
covers the wound. This epithelial layer itself is devel-
oped from the epithelium of the glands upon the borders
of the wound, thus demonstrating the possibility of the
development of an epithelial layer in its totality from true
glandular epithelium. 3. The pepsin cells of the newly
formed tubular glands are developed in the beginning
through a differentiation of the cells of the tubular glands
themselves, and this formation originates in the bottom of
the tubules, whence the cells are pushed upward. 4. The
reproduction process of the peptic glands finds its exact
prototype in the process of embryonic development. 5.
The reproduction was quite rapid in all the animals,
which were strong and healthy and placed amid favorable
surroundings. In one case the development was tardy,
owing to a considerable loss of tissue and an unsuitable
diet. 6. Perforation of the wall of the stomach never
followed removal of the mucous membrane, even though
the muscular tunic had been seriously injured.— The
Medical Bulletin.
ASTHMA AND THE UTERINE SysTeEM.—Dr. Peyer has
recently written on an affection which he terms sexual
asthma. He maintained that asthma was always neu-
rotic, and that in different subjects asthmatic convulsions
were brought on by the influence of different physical
functions. In two young married women coitus caused
violent attacks of asthmatic sneezing. In another case
the patient suffered from uterine fibroid, with severe
asthma, which disappeared after the removal of the tu-
mor. A patient was subject to violent asthmatic fits ; on
her becoming pregnant for the first time, the asthma was
completely cured. In a similar case of asthma, the pa-
tient suffered from chronic metritis. When the uterine .
affection was cured, the asthmatic complication disap-
peared. In all Dr. Peyer’s cases the patients were more
or less hysterical, and in two there was a distinct family
history of neuroses. The physician must be careful now
to distinguish between the possible coincidence of true
asthma and disease of the sexual functions and the alleged
form where.the former is an effect of the latter. In the
case of coincidence it is perfectly easy to understand that
any aggravation of uterine or ovarian disease and any irri-
tation of the sexual functions might aggravate the asthma.
The other condition is less easy to understand, and very
hard to prove in a scientific manner.— Zhe British Medi-
cal Fournal.
THE ULTIMATE RESULTS OF EXTIRPATION OF THE
Urerus.—Dr. Munchmeyer, of Dresden, said that at the
obstetrical clinic of Dresden, from 1883 to 1889, there
had been performed 110 extirpations of the uterus, of
which 80 were for carcinoma and 30 for other diseases.
Out of the 80 operated on for carcinoma, 4 died from
the immediate effect of the operation—that is, five per
cent. ; 1 died from strangulated hernia, 2 from septicemia,
and 1 from peritonitis. Out of these 80 operated upon,
10 died from a recurrence of the disease, 4 of intercurrent
affections, while others have had one recurrence. Forty-
one who have been operated upon during this past year
have had no return of their trouble, and in 17 women
operated upon two years ago the cancer has not reap-
peared. Among this last series 3 have had no recurrence
for three years, 1 for four years, and 1 for five years. He
thought it very important that the operations should be
performed as early as possible. Out of the 30 other ex-
tirpations, 17 were for myomas, 5 for prolapse, 5 for
severe nervous troubles, 3 for diseases of the annexes
of the uterus. Most of them were operated on by the
vaginal method, or supravaginal. . The vaginal method
leaves patients in a state in which they are less liable to
take cold ; and, on the other hand, certain women can-
not resist an abdominal incision, which is due to a weak
state of the cardiac function. Out of 110 extirpations
of the uterus, there were only 6 deaths—that 1s, 4.5 per
cent.—Mea:cal News.
A “VACCINE” FOR INFANTILE D1IARRH@A.—M. le
Docteur José ‘Triano, of Columbia, asserts that a drop of
balsam of copaiba, placed on the umbilical cord of new-
born infants after section, protects them from athrepsia
and choleraic diarrhoea. It acts as a vaccine, and is a
certain prophylaxis for these affections. Previous to Dr.
Triano’s discovery, the infant mortality resulting from
them in Columbia, like in France, was considerable, but
now they have almost disappeared.
‘THE NorTH Texas MEDICAL ASSOCIATION will meet
in Gainesville, ‘Tex., on Tuesday, Wednesday, and Thurs-
day, December 10, 11, and 12, 1889.
November 30, 1889]
THE MEDICAL RECORD:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., EDITOR.
PROPRIETORS AND PUBLISHERS
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
mene e a
New York, November 30, 1889.
ON ESSENTIAL TACHYCARDIA.
M. BouvereT devotes a long article in the Revue de
Médecine for September and October, 1889, to the de-
scnption of a curious and, as he thinks, distinct disorder
of the heart, viz., “essential paroxysmal tachycardia.”
It is a disease occurring in adults, and characterized by
paroxysms of cardiac palpitation in which the pulse goes
up to 200, 230, or even 300 per minute. The paroxysm
lasts from a few hours to several days. If it is short the
patient suffers very little distress. Absolutely no signs of
organic cardiac disease are recognizable.
M. Bouveret reports three cases of his own in detail, in
one of which death occurred. He succeeds in finding
nine other similar cases.
Tachycardia is common enough but M. Bouveret in-
sists that in “ essential paroxysmal tachycardia” there is
no organic disease, and moreover that it has the peculiar
characteristic of being accompanied with few or no symp-
toms pointing to the involvement of other organs.
The cases which are collected have been reported
by three English and five German physicians. We are
under the impression that American observations have
been made upon this subject but none are referred to by
M. Bouveret.
From an analysis of the reported histories it is found
that the attacks of tachycardia are of two kinds, viz.,
short and long. The short attacks come on with slight
prodromes of vertigo, epigastric distress, etc. No cause
is usually assigned. ‘The pulse runs up to at least 190
or 200 a minute. ‘There is a slight bruit often heard,
while in place of the cardiac impulse one feels on palpi-
tation a sort of vibration of the chest-wall. The patient
becomes pale and suffers a little dyspnoea but feels no
serious distress. ‘The attacks cease abruptly.
The long attacks usually last five or six days, but may
be prolonged several weeks.
The symptoms are much like those in the short attacks,
except that after a few days the patient begins to suffer
seriously from dyspnoea, cyanosis, and all the symptoms
of heart-failure. Percussion shows, also, that the heart
dilates very considerably. Among the eleven cases col-
lected by Bouveret, four died during the long attack. In
the other cases, however, the disease lasted a long time,
and during the intervals the patients suffered very little.
The cases observed have occurred in persons ranging
between the ages of nineteen and forty years, and the
disease has attacked the two sexes about equally. ‘The
THE MEDICAL RECORD.
605
only important etiological factor noted has been excessive
mental and physical strain.
Only one autopsy has been made upon the victims of
this malady, and in that case no lesion was discovered
either in the heart or nervous centres. Bouveret excludes
any bulbar lesion, for the reason that in all cases of rapid
heart-beat, due to such a cause, there are other symptoms,
and in addition, the pulse-rate does not go above 150 or
160.
Dr. Bouveret cites casesof paroxysmal tachycardia due
to organic disease of the heart, to gastro-intestinal disor-
ders, and to uterine and ovarian disease. He also recog-
nizes those forms of tachycardia described by Riegel and
by Rosenbach, in which there are associated pulmonary
and abdominal symptoms.
But he believes that there is a special type of tachycar-
dia in which the only primary symptom is the rapid heart-
beat.
The treatment recommended for the attacks is rest, digi-
talis, and a trial of compression of the pneumogastric in
the neck. One patient could abort or relieve the tachy-
cardia by taking a deep breath and holding it. In the
long attacks, with much cardiac dilatation, venesection is
suggested.
ENOPHTHALMUS TRAUMATICUS.
THIS condition—a sinking back of the eye into its socket—
is apparently very much less frequently observed than the
contrary condition of exophthalmus. Apart from those
cases in which it is seen in cholera, six writers have pub-
lished notes upon it, each having seen only one case. In
the Archives of Ophthalmology, September, 1889, a trans-
lation is given of a recent article by Dr. Gessner, in which
he describes and discusses three cases of enophthalmus
of traumatic origin, seen at the clinic of Dr. Nieden, of
Prussia. ‘The three cases presented very similar histories,
of which one may be given as a specimen. A miner was
knocked down and cut about the forehead by a piece of
coal or stone. He was rendered insensible for a time,
and was confined to his bed for three weeks, with swell-
. ing of the injured parts. When the swelling of the eye-
lids was sufficiently reduced to permit the eye to be seen,
it was found that this eye was farther back in its orbit
than the other, or, as the patient erroneously expressed it,
“ was smaller than the other.”
Upon examination the affected eye presented the ap-
pearance of an artificial eye. A scar, the result of the
injury, was found running from the incisura supraorbitalis
(supraorbital foramen [?] ) to the corner of the lid. ‘Ihe
upper lid was sunken, and drooped somewhat. ‘The pal-
pebral fissure was smaller than on the other side. The
eyeball lay several millimetres deeper than normal. Its
movements in an upward direction were slightly restricted,
and in other directions they were sluggish. The cornea
and other parts of the ball were apparently unaffected by
the injury, and no change could be discovered upon oph-
thalmoscopic examination. Pressure upon the ball gave
no pain. Vision seemed to be little or not at all affected.
The presence of microphthalmus could be excluded in
each case by the equality of the cornea, the refraction,
and also, in two cases, by the acuteness of sight in both
eyes.
‘The enophthalmus was probably the result of wasting
606
of the retro-bulbar tissue, the sinking back of the ball be-
ing, perhaps, aided somewhat by pressure of the lids upon
it. ‘The contused wound of the orbital margin would
naturally cause inflammation of the periosteum, which
would spread to the cellular tissue behind the eyeball.
Inflammation of the muscles of the eye need not to be
supposed as the cause of the restrictive motion of the
ball. ‘The sluygishness of the muscles is explained suffi-
ciently by their relaxation, caused by the sinking back-
ward of the globe of the eye.
NOTHNAGEL ON THE TREATMENT OF HEART DISEASE.
In an interesting. clinical lecture upon the above subject
(Medical Press and Circular) Professor Nothnagel dis-
cusses the various modern methods of treating heart dis-
ease, viz., the calomel treatment, the cardiac-tonic treat-
ment, the hydriatric and the Oertel treatment. He
speaks first of the use of digitalis and gives this drug
preferably in the form of a powder with quinine, e. g. :
B. Pulv. digitalis, gr. ss. ; quinize sulph., gr. iss. ; sacchar.
pulv., gr. vj. M. Sig.: j.q. 2h.
Nothnagel believes in the cumulative action of digitalis,
and there is no doubt a final tonic effect when doses are
kept up continuously every two hours. It is strictly en-
joined, therefore, that this indication be not continued for
more than five or six days. There is no drug equal to
digitalis when the cardiac muscle is not seriously in-
volved. If its effect becomes lessened, or it is necessary
to stop its use for a time, the digitalis treatment may be
alternated with a course of caffein. ‘This drug is better
given combined with a salicylate or benzoate of sodium,
and it is prescribed by Nothnagel in doses of five grains
five times a day.
Strophanthus is spoken of as a useful cardiac tonic, but
less powerful and certain than digitalis.
Considerable space is devoted to the calomel treatment
brought into notice by Jendrassik about three years ago.
Nothnagel is convinced of its efficacy but ventures no
opinion as to how the drug does its work. It should only
be used in properly selected cases and should not be em-
ployed until digitalis has been tried. The following pre-
scription is given: RB. Calomel, gr. iij. ; sacch. lactis, gr.
viij. M. Sig.: j. four times daily.
Nothnagel says: “For three, four, or even five days
the quantity of urine will remain unaltered, after which
time it may rise from 300 c.c. to 7,000 C.C., f.e., from
circa one-third litre to seven litres (one-half pint to two
gallons). In four days salivation will be produced,
which indicates a withdrawal of the drug. Chlorate of
potass or tinct. of rhatany as a gargle may be given. An
unhappy complication is diarrhoea, for which opium must
be given, but if constipation, jalap may be combined with
calomel. My own experience of a surprisingly small
quantity of urine passed, raised in a few days to 10,000
c.c., continuing at that for a few days till the dropsy dis-
appears, and then gradually reducing the quantity leads
me to believe in the efficacy of the drug. In many cases
I found the calomel refused to affect the system, and in
these cases the diuresis remained also unaffected, but
after waiting six days I have repeated the mercury, when
the effects were immediate. The opposite of this occurs
also. I have had perfectly satisfactory results for the
THE MEDICAL RECORD.
[November 30, 1889
first time, but after that the physiological effects of the
drug could not be produced. ‘The improvement from .
this treatment usually lasts about eight weeks, when it may
be repeated. I have had some cases where I have re-
peated this treatment eight times in a year with the best
results, but alas! after a time the calomel becomes inert
in the system, varying from one to a yéar and a half
when it gradually becomes useless, and life soon ebbs
away.”
The Oertel treatment has for its object: 1, To reduce
the amount of fluid taken into the body ; 2, to gradually
excite the muscles of the heart to contract.
“ Most physicians,” says Nothnagel, “are agreed to-day
that this method of treatment is not for valvular disease.
It is certainly excellent in dropsical conditions arising out
of myocardy, fatty heart, so-called beer heart, idiopathic
hypertrophy, or dilatation of the heart, in short, in all
cases where the muscle of the heart is at fault, but not
when the valve lesion is the cause. One factor in the
treatment is to work the muscle of the heart and thus in-
crease its muscular tissue, but where there is valvular im-
perfection there is much injury done by the treatment of
Oertel.”
If one is confronted, however, with a case of valvular
disease, where compensation has established itself, but by
some means or other the heart does not contract as well
as it might do, and that cedema of the limbs, etc., is be
coming ominous, the Oertel treatment may be tried to re
store the disturbance by more hypertrophy.
As to the second part of Oertel’s treatment, it 1s rea-
sonably good. It is well known that a great amount of
fluid swallowed must rapidly pass into the circulation, and
load the heart and impede its action. To reduce the fluid
taken in to the very minimum must have beneficial ef-
fects.
A NEW ADVANCE IN THE TREATMENT OF UNUNITED
FRACTURE.
Every surgeon knows how difficult it is in certain cases
to get a broken bone to heal by bony union. The ends
may be pegged and hammered and sutured indefinitely
without ‘success. In the case of fracture of the radius
there are oftentimes special difficulties, since resection—
the last resource of the surgeon—leaves a gap between the
ends of the radius, which is now shorter than the ulna
beside it, and so it is almost impossible to bring the bared
ends of the fractured parts into apposition and to keep
them there. Even if a piece be cut out of the unfract-
ured ulna, so that the inequality in the length of the two
bones is removed, a satisfactory result cannot always be
obtained. In Zhe Lancet, October 26, 1889, Professor
McGill, after commenting upon the above facts and re-
lating his failure with the last-mentioned procedure, ex-
plains a new method which h2 applied successfully in one
case, taking the hint from a suggestion made by Dr. Mac-
Ewen, who proposed, in case of destruction of the shaft
of the humerus by acute necrosis, that a new shaft should
be secured by transplantation of bits of new bone.
In Professor McGill’s case a man, twenty years of
age, had fractured both bones so that the ends of the
radius protruded through the wound on the radial side of
the forearm. The ulna healed quickly and well, but the
radius remained ununited, although the ends had been re-
November 30, 1889]
THE MEDICAL RECORD.
607
freshed and wired three months after the accident. Some
eight months afterward he came to the hospital. He had
a scar over the wound, and the ends of the radius were
quite movable; the usefulness of forearm and hand being
much impaired. An Esmarch’s bandage was applied and
_ an incision was made in the line of the old scar. The
ends of the bone showed no signs of union, but were
rounded and covered by a thick membrane-like periosteum.
When this had been filed away, an interval of three quar-
ters of an inch was left between the fragments. This in-
terval was filled with thirteen pieces of bone, each about
one sixth of an inch in length, chiselled from the femur
of a freshly killed rabbit. ‘The bones were not wired.
The skin-wound was tightly stitched, without drainage,
with catgut. Firm pressure was applied by means of
salicylated wool and bandages, and the forearm was placed
on an anterior splint. There was no suppuration and
very little discharge. The patient left hospital in six
weeks, with the bone firmly united. Three months later
the injured arm was as useful as the other. Is it not pos-
sible that this method used by Professor McGill may be
of service in the treatment of old ununited fractures in
other parts? It is possible that a more vigorous action
might be set up, by presence of the implanted healthy
bone, than would naturally occur in the fragments of a
fractured long-tone in a person of feeble constitution.
SANITARIA FOR CONSUMPTIVES.
Dr. PauL H. KRETZSCHMAR gives an account of the de-
velopment and work of the sanitaria for the treatment of
consumptives in the United States in a recent issue of Zhe
Medicat News.
Such institutions are, it is admitted, not as a rule neces-
sary for wealthy persons, but those of moderate means
can, in many instances, be best taken care of in special
institutions where the therapeutic measures can be applied
more.cheaply on a wholesale plan. In Germany there are
a number of hospitals in which consumptives receive
treatment. The recent general acceptance of the infec-
tious theory of phthisis has raised some protest against
the aggregation of this class of patients, but we do not
think that the objections made against them will stand.
Phthisis is but very slightly contagious, and it seems to
be admitted that those who contract the disease must
have not only the bacillus but a favoring soil for its devel-
opment. Besides this, the measures for preventing
spread of the contagion have been carefully studied out,
and are quite well known. ‘The sanitaria for phthisical
patients in this country, so far as known, are one at Sara-
nac Lake, one at Asheville, N. C., one at Lake Palmer,
Col., one at Colorado Springs, and a camping-out or-
ganization which has its headquarters at Santa Fé, New
Mexico.
The results of treatment at the Saranac institution, as
given by Dr. Trudeau, are certainly very encouraging.
He says: Up to the end of 1888, 146 consumptive
patients have been treated, and the results have been
about as follows: Deaths, 4, or not quite 3 per cent. ;
failed steadily, 25, about 17 per cent. ; stationary or slightly
benefited, 38, about 26 per cent. ; disease arrested, 63, or
43 per cent.; and cured, 16, or 11 per cent.
The results in the year 1888-9 are said to have been
even still better, about 14 per cent. having been
cured and 20 per cent. restored so that they could return
to work.
At Saranac the main reliance is placed upon the out-
door life. Among drugs, antifebrin and creasote are much
used. The pneumatic cabinet is also still employed. At
Asheville, oxygen inhalations are given, but creasote has
been entirely abandoned, according to Dr. Kretschmar ;
while Dr. Detweiler constantly uses alcohol, it is not
given at the Saranac institution and only moderately at
Asheville.
The following rules, which are placed in the hands of
every inmate of the sanitarium at Saranac Lake, can be
read with profit by all who have phthisical patients to treat :
Out-of Door Life — Patients gradually accustom them-
selves to leading an out-door life, that is, to remaining
eight to ten hours in the open air each day. ‘This should
be done gradually, and at first the clothing should be
heavy and the exposures to cold or inclement weather
moderate in duration. Little by little the open-air sit-
tings and walks are to be increased until the entire day
is spent out of doors in all kinds of weather. In stormy
weather the sheltered side of the verandas should be
used for walking or sitting. When feverish, patients are
urged to go out and remain sitting on the verandas well
wrapped in suitable clothing.
Exercise.—Violent exercise is injurious. When fever-
ish, patients will do well to make as little exertion as
possible. Fatigue, when induced in persons still having
active disease, is sure to be followed by loss of appetite,
fever, exhaustion, and even sweating. Severe exercise
in hot weather is injurious and may be dangerous.
Patients will be informed by the physician how much
exercise their case requires.
Food.—\f{ unable to eat at the regular meal hours,
patients will do well to drink milk every four hours.
Expectoration.—Patients are required always to use
the large spittoons in the public rooms and on the
verandas, and the pasteboard ones in cottages; the latter
should be burned every day in the stoves or fire-places.
Expectorating in handkerchiefs or on the floors, or even
on the grounds in the immediate vicinity of the buildings,
is strictly prohibited.
It has been found that while moist sputum is harmless,
when it becomes dried it will rise as dust, and may be
inhaled. ‘The above directions are given to guard against
this result. Patients, for their own welfare and in order
to assist in their rapid recovery, will strictly observe these
rules, and will be liable to dismissal for wilful disobedi-
ence in this matter, which involves not only their own
welfare but that of others.
Stimulants.—Stimulants are not allowed except un-
der medical advice. No smoking is allowed at any time
in the public rooms or on the piazzas. Patients are re-
quested not to smoke at all unless permission is given by
the physician.
As a REMEDY AGAINST “ ELECTRICAL SUNSTROKE,” as
the affection is called that attacks men exposed to the in-
tense rays of the electric arc by means of which metals
are fused and welded, is a veil or mask of glazed taffeta,
supported by a wicker head-piece, and provided with —
goggles of gray glass.
608
News of the Geek.
SIR MORELL MACKENZIE has been vindicated by the
Royal College of Surgeons. Though condemned by the
Council of the College for publishing his book concern-
ing Emperor Frederick, he had but one accuser at thé
general meeting.
THE Project OF BuyiING up a Country for purely
sanitary reasons, because it is a fitting one, is certainly
original, and has the merit of going to the root of the dif-
ficulty. Dr. Lee, of Philadelphia, proposes that the
United States buy up the island of Cuba and stamp out
the yellow fever there.
DEATH OF Dr. RupoLF Tauszxy.—Dr. Rudolf Tauszky,
at one time a well-known physician of this city, died on
September 21st, at Bloomingdale Asylum, where he had
been a patient for over three years, having been confined
there soon after making an attempt to kill his young wife
and to commit suicide. Dr. Tauszky was about fifty-three
years of age at the time of hisdeath. Dr. Tauszky, who
was born and educated for the medical profession at
Pesth, Hungary, came to this country in 1862, was a
hospital surgeon in Washington, and afterward served a
little time in the field. Hecame to this city in 1868 and
was successful in building up a practice. He served on
the Board of Health for a time and became interested in
the tenement-house problem, and lectured and wrote a
great deal on sanitary reform. He was for nearly ten
years connected with Mount Sinai Hospital. For some
years before his retirement he was frequently called as an
expert in cases of alleged insanity.
GONE OVER TO THE Quacks.—It is stated in the daily
papers that two physicians of Buffalo, formerly connected
as teachers with the medical school of the Niagara
University, have recently set medical ethics at defiance
and gone into the business of advertising themselves as
specialists. ‘They have been dismissed from the Faculty.
AN ASYLUM BuRNED.—The Idaho Insane Asylum was
destroyed by fire on November 25th, and eight lives were
lost.
AN ANGLO-AMERICAN VIENNA MEDICAL ASSOCIATION
has been formed for the purpose of furnishing informa-
tion to English speaking medical men coming to study in
Vienna. The office will be ‘at No. 12, Landesgerichts
Strasse. Membership will be open to any British or
American physician, or medical student, on payment of
an entrance fee of one gulden.
THE EIGHTH CONGRESS OF RUSSIAN NATURALISTS AND
PHYSICIANS will be held at St. Petersburg, from Decem-
ber 27, 1889, to January 7, 1890.
PROFESSOR BARDELEBEN.—A bronze bust of Professor
Adolf Bardeleben, subscribed for by his pupils and friends
on the occasion of his seventieth birthday, which he cele-
brated in March last, was unveiled on October roth.
STERILIZED Linr.—M. Regnier renders lint sterile by
heating it to a temperature of 120° C. (248° F.). M. Reg-
nier has tested the antiseptic value of lint thus prepared
in dressings applied after operations of various kinds with
good results. At the recent Surgical Congress he stated
that he considered sterilized lint equal to antiseptic dress-
ings.
THE MEDICAL RECORD.
[November 30, 1889
By M. Ricorp’s WILL a sum of ten thousand francs is
given to the Académie de Médecine, and five thousand to
the Surgical Society, to found prizes.
ORGANIZATION OF A STATE SOCIETY IN THE NEW
STATE OF WASHINGTON.—In response to a call by the
President of the ‘Territorial Medical Society, there was a
largely attended meeting of the profession at Tacoma,
October 21st and 22d. ‘The Territorial Society, as such,
adjourned sine die. The formation of a State Society
was then proceeded with, and the following officers were
elected : President, Dr. Edward L. Smith, Seattle ; First-
Vice-President, Dr. J.S.Wintermute, Tacoma ; Second Vice-
President, Dr. M. Pietrzycki, Dayton; 7reasurer, H. S.
Willison, Port Townsend ; Secretary, Dr. C. L. Flannigan,
Olympia; Board of Censors, Drs. Shaver, Heg, Crump,
Boswell, and Essig; Board of Trustees, Drs. Van Zandt,
Van Buren, Merrick, Libby, and Marion. ‘The regular
standing committees were also appointed. ‘There are
about sixty-five charter members of the Society. The
next meeting will be held at Spokane Falls on the second
Wednesday in May, 18go.
A PROFESSOR OF HYGIENE AND PHYSICAL CULTURE has
been endowed, in the sum of $25,000, at the Pennsylvania
College at Gettysburg, by the on of the late Dr.
Charles H. Graff.
MEMORIAL TO THE LATE DR. CABELL.—The new chapel
at the University of Virginia, in which the late Dr. James
L. Cabell took such active irterest, will contain a memo-
rial window in his memory. Contributions for that pur-
pose of not more than $3.00, by alumni of that institution,
may be sent to Dr. William C. Dabney.
AN EFFORT is being made to start another Woman’s
Medical College in Cincinnati.
Professor S. B. HoweLL has resigned his chair in the
faculty of the University of Pennsylvania. Edward D.
Cope was elected to succeed him.
DINTIRTION OF OFFSPRING.—A discussion is going on
in the columns of Kansas the Medical Journal upon the
subject of the “ limitation of offspring.” A correspondent
ventures to deny the accuracy of Burns’ “ Cotter’s Satur-
day Night,” and says that, in point of fact, “ at night the
brood comes training home, each with a dozen questions
to propound, and all begin at once, while she (the mother)
with aching limbs and throbbing head, becomes bewil-
dered and exclaims, ‘Getout! Goaway, you torments,
you,’ and no question gains attention.” Burns finds a
warm champion in the editor of the Journal however,
who shows by statistics that the presence and possession of
children prevents suicide and insanity. Arguments upon
this subject are of little weight. No person with any
moral sensibility or medical knowledge whatever would
ever attempt to justify foeticide and abortion.
AN AMERICAN HOSPITAL IN PERSIA.— The corner-stone
of an American hospital at Teheran was recently laid by
the Minister of the United States to the Court of the
Shah. ‘The proposal to erect the hospital originated with
Dr. W. W. Torrence, of Teheran, and funds have been
obtained partly by donations raised in America and partly
by subscriptions in Persia itself, many distinguished Per-
sians having made generous contributions.
November 30, 1889]
THE MEDICAL RECORD.
609
Society Reports,
SOUTHERN SURGICAL AND GYNECOLOGICAL
ASSOCIATION.
Second Annual Meeting, held in Nashville, Tenn., Novem-
ber 12, 13, and 14, 1889. -
First Day, TUESDAY, NOVEMBER 12TH—MORNING
SESSION.
‘HE Association convened in the Senate Chamber, and
was Called to order at 10 A.M. by the President, HUNTER
McGuire, M.D., of Richmond, Va. Prayer was offered
by the Rev. R. L. Cave.
The report of the Committee of Arrangements was
Oe through its chairman, J. R. Buist, M.D., of Nash-
ville.
Dr. R. B. Maury, of Memphis, contributed a paper
entitled
REPORT OF GYNECOLOGICAL WORK, WITH ESPECIAL REF-
ERENCE TO METHODS.
The paper presents a brief summary of the more impor-
tant portion of his operative work during the past year.
With four exceptions, all of the operations reported were
done in a private hospital, built especially for the purpose
and under his own control. ‘The summary embraces 21
laparotomies for the removal of ovarian tumors, or of the
uterine appendages, or for the relief of obscure disease
within the abdomen ; 2 laparotomies for ectopic gestation ;
28 operations for laceration of the cervix; 14 perineal
and vaginal prolapse operations; 5 rectoplasties; 4 an-
terior colporrhaphies.
Dr. Maury summarized the methods as follows :
1. An aseptic field of operation and an aseptic surgeon.
2. A small incision, in the case of inflammatory disease in the
pelvis, just large enough to introduce, and work with, two
fingers. 3. Aseptic silk ligatures, as fine as may be con-
sistent with safety in tying. 4. Enucleation of diseased
Structures, in spite of firm adhesions and even profuse
hemorrhage. 5. Irrigation by means of the siphon-trocar,
as a substitute in most cases for sponging. Using simple
hot water for this purpose and excluding all antiseptics.
6. Drainage often, and whenever one is in doubt as to its
necessity. 7. Careful replacement by spreading out of
the omentum before proceeding to close the wound. 8.
Inclusion of all the structures in passing the abdominal
wall sutures, and replacing the deep sutures half an
inch apart. 9. The use of means for moving the bowels
on the second or third day after removing the appendages,
and the avoidance, if possible, of opium. Discussed by
Drs Wathen, Price, Stone, Potter, and Johnstone.
Dr. W. O. Roserts, of Louisville, Ky., read a paper
on .
DIRECT HERNIOTOMY,
in which he reported ten cases,‘and did eleven operations.
Seven cases occurred in females, three in males. Three
were cases of umbilical hernia, three were femoral, three
inguinal, and one ventral. Six of the operations were
done during strangulation, while five were performed for
troublesome, irreducible hernias. In the six cases of
strangulated hernia the sexes were equally represented.
Three were inguinal, two femoral, and one umbilical. In
five of them the operation for radical cure was done.
The remaining case was one of strangulated hernia where
stercoraceous vomiting existed for eight hours before it
was seen. General peritonitis was evident at the time of
the operation. Much reddish stuff escaped when the
contents of the sac were retumed. Death followed in
thirty-six hours. He had since thought that if, after re-
turning the contents of the sac, he had done a low me-
dian laparotomy and washed out the peritoneal cavity, the
result might have been different.
The four cases of irreducible hernia were all in females.
Two were umbilical, one femoral, and one ventral. In
one of the former a second operation was made neces
sary by the hernia recurring at the end of six months. The
tumor also reformed, at the end of ninety days, in the
case of femoral hernia. ‘The remaining eight cases con-
tinue well to the present date.
In all the cases the sac was first cleanly dissected out,
and not opened until all hemorrhage was entirely checked.
Both in the ventral and umbilical hernias the integument
and fascia were divided by an elliptical incision. After
opening the sac all adherent omentum was tied with cat-
gut and excised. ‘The remaining contents were then re-
turned into the cavity. In one case of umbilical hernia
the neck of the sac was tied close to the margins of the
opening, and cut away immediately in front of the liga-
ture. The stump was then fastened tightly in the open-
ing with silk-worm gut sutures, and the wound finally
closed by interrupted sutures of the same material. In
this case no suppuration occurred, but the hernia recurred
at the end of six months. In both the other umbilical
and in the ventral hernias the neck of the sac was ex-
cised on a level with the abdominal opening and sutured
with catgut. The opening itself, after its edges were
freshened, was closed with the continued suture of chro-
matized catgut in the ventral hernia and aseptic corded
silk in the umbilical cases. The superficies were brought
together by silk sutures, which were continued down to
the aponeurosis.
In the femoral hernias he adopted the practice of
Mitchell Banks. In the cases of direct inguinal hernia,
after tying the neck of the sac just within the ring, and
removing all in front of the ligature, the ring was closed
with catgut sutures.
In the cases of oblique imguinal hernia he did Mr.
Ball’s operation, which consists in freeing the neck of the
sac up to the internal opening, ligating it, cutting away all
in front of the ligature, then twisting the neck upon itself
to effect closure of the peritoneal orifice, and finally
stitching the stump to the pillars of the ring to guard the
neck against untwisting itself.
Dr. Vircit O. Harpon, of Atlanta, Ga., read a paper
entitled —
THE ABORTIVE TREATMENT OF ACUTE PELVIC INFLAMMA-
TION.
He said the views held by gynecologists in regard to acute
inflammation in the female pelvis have, within the past few
years, undergone a radical change. The inflammatory
processes formerly regarded as idiopathic, or at least as
primary affections, are now almost universally recognized
as dependent upon antecedent disease in the ovaries or
Fallopian tubes, especially the latter. This change of
opinion has to a large extent been due to the result of
advances in surgery, which have enabled the conditions of
the pelvic organs to be studied in the living subject by
immediate inspection and palpation, instead of through
the medium of the vaginal tissues ; consequently it is even
that a change of opinion on this subject has been most
marked among those men who have had large experience
in abdominal work. The diagnostic value of abdominal
section, under such circumstances, is almost as great as
that uf post-mortem .examination, and hence the opinion
of the laparotomist is entitled to very great weight. As
a result of this mode of observation, the conclusion can-
not be avoided that acute pelvic inflammation is, at least
in the majority of cases, associated with septic, gonor-
rhoeal, tubercular, or some other form of inflammation of
the tubes. There are two forms of inflammation which
are recognized as occurring within the pelvis as a result of
tubal disease—pelvic cellulitis and pelvic peritonitis. In
many cases both forms of inflammation are simultaneously
present in the same subject, and it is not improbable that
in all cases when either is present, the other also exists in
a greater or less degree.
It is hardly possible, when one considers the anatomical
relations of the pelvic cellular tissue to the peritoneum, to
610
conceive of an inflammation of the one structure without
a greater or less implication of the other. In the major-
ity of cases one form of inflammation can be recognized
as forming the preponderating element of the disease, to
which the other plays only a secondary rôle.
The constitutional symptoms consist of acceleration of
the pulse, elevation of temperature, severe pain in the
pelvis extending down the thighs, tenderness of the hypo-
gastric region and inguinal region, a sense of weight and
fulness in the pelvis, difficult micturition, painful defeca-
tion. ‘These symptoms~are most marked in the acute
stages, and are somewhat diminished as soon as solidifica-
tion has taken place. ‘They continue, however, with les-
sened intensity, into the third stage of ‘the disease.
The treatment consists in the withdrawal of the effu-
sions from the cellular tissue by means of the aspirator,
etc. Where pus-tubes are present we would advocate
their removal.
Dr. JOSEPH Price, of Philadelphia, said his experience
was a little different from that of the essayist. Relief
from salines and the aspirator in the cases reported may
have been justifiable, but pus-tubes in every instance call
for abdominal section. He then exhibited some pus-
tubes, one of which was seven inches in length, and called
attention to their frequency in cases of pelvic inflamma-
tion. He said, thirteen years ago a woman living in
Pottsville was treated by a prominent gynecologist for
pelvic peritonitis. Sponge-tents were used, and the pa-
tient made a doubtful recovery. Eight years ago Dr.
Goodell effected drainage through several sinuses then ex-
isting, three or four being about the sacral region, two or
three in the groins, and one in the anterior abdominal
wall Six weeks ago Dr. Price evacuated two gallons of
pus in the same patient. A perfect recovery was brought
about in some of his cases only by abdominal section and
the removal of pus-tubes. The history and symptoms in
his cases were identically those mentioned by Dr. Hardon.
In the light of our present accurate knowledge, acquired
by a large experience in the pelvis, the conclusion is that
the entire subject of pelvic peritonitis and cellulitis will
have to be rewritten. ‘The sharp distinctions between the
one and the other are refinements that the surgeon no
longer seeks. Peritonitis the result of tubal and ovarian
disease is exceedingly common. Gonorrheea is the most
common cause of all.
Dr. GEORGE J. ENGELMANN, of St. Louis, said there
was a fascination in the results achieved by Dr. Price and
other operators, but he thought the pendulum was swing-
ing too far in that direction. He could endorse the sur-
gical treatment advocated by Dr. Price in dealing with
cases of pelvic inflammation which result from salpingitis,
or where there was pus in the tubes. Many of the cases
which were formerly called pelvic cellulitis are the se-
quences of salpingitis or pus in the tubes, and he was sat-
isfied there are cases which exist without salpingitis.
Dr. W. G. Ewine, of Nashville, said that when he be-
gan to practise he was on the conservative side, but is
satisfied that many of the cases which came under his
observation could have been dealt with surgically and suc-
cessfully. He favored early operative interference, and
said the surgeon should not delay in such cases, for by so
doing additional adhesions were apt to form with exten-
sion of the inflammatory process.
Dr. HARDON, in closing the discussion, said he feared
he had been misunderstood, but would now say that pus-
tubes admitted of but one rational treatment, and that
was their removal. He invariably recommends this to
be done, but what should the surgeon do with those pa-
tients who will not permit an operation ?
As regards pelvic cellulitis without disease of the tubes,
he could corroborate the statements of Dr. Engelmann,
and called attention to two cases he reported last year to
the Association which verified the fact. In these cases he
aspirated and withdrew several drachms of serum trom
the cellular tissue. Subsequent examination revealed ab-
solutely no disease of the tubes. He has examined these
THE MEDICAL RECORD.
[November 30, 1889
patients from time to time, but not the slightest evidence
of tubal disease could be found, and there has been no
recurrence of the pelvic inflammation.
Dr. W. D. HAGGARD, of Nashville, read a paper on
THE IMPROVED CAESAREAN SECTION VERSUS CRANIOTOMY,
in which he said that the improved Cesarean section
offers justifiable means of saving both mother and child,
and relieves the heart and conscience from the charge of
scientific murder. Embryotomy on a living child will
soon cease to be regarded a3 a scientific, or even a justifia-
ble, operation. ‘This seems to be foreshadowed by the
statistics of Caruso, who reports a case in detail by San-
ger and one by Zweiffel, and adds statistics up to October,
1888, comprising 135 cases. Six successful cases were
known in addition to Caruso, but the details necessary for
publication were lacking. German operators have per-
formed 74 of these operations, Americans 18, Australians
16, the results obtained by American surgeons being in-
ferior to those of German and Australian operators. The
results show a large per cent. of recoveries among mothers
in all cases, and a still larger per cent. in the case of chil.
dren. In three cases in which the operation was done a
second time, both mothers and children recovered. A
careful estimate of the results of craniotomy under anti-
septic precautions shows that 23.04 per cent. of mothers
recover. Selecting similar cases on which section was
performed, the percentage of recoveries in these cases was
89.04 and 100 per cent. of children.
Dr. W. H. WaTHEN, of Louisville, read a paper on the
TREATMENT OF ECTOPIC PREGNANCY.
He said, in order to adopt the best treatment in ectopic
pregnancy, it is necessary to know its correct pathology ;
failure in this particular has resulted in a variety of
methods of treatment, and gynecologists of good ability
differ widely in their views. But physicians who recog-
nize that ectopic pregnancy is probably always tubal in
its origin, are united in their opposition to the use of
electricity or other means to destroy fcetal life. They
prefer the removal of the gestation sac by laparotomy.
He referred to the fact that Thomas adheres pretty
much to the old classification of Parry and De Zeimenis,
and that he speaks of an “impregnated ovum attaching
itself primarily to the peritoneum, and of a foetus and
placenta entering the peritoneal cavity by rupture and
developing there.” He denied the possibility of an ovum
attaching itself primarily to the peritoneum, and said
that the placenta could not become separated from the
tube and then become attached to other structures ; the
ovum must be held immovably in one position before its
villi can penetrate the tissues; the placenta may become
slowly separated from its tubal attachments, and fasten
itself to other structures by making epiphytic inroads
upon the abdominal walls or viscera by stripping off the
peritoneum.
He did not believe that a classification based upon old
statistics of post-mortem examinations could be correct,
because these examinations were made by men not trained
in pathological and microscopical research, who could
not accurately distinguish the tissues, often matted to-
gether and entirely changed in physical appearance.
He divided the treatment of ectopic pregnancy as
follows: 1. The treatment before primary rupture of the
tube. 2. The treatment after rupture of the tube into
the folds of the broad ligament, and before the period of
foetal viability. 3. The treatment where the sac ruptures
into the peritoneal cavity. 4. The treatment after foetal
viability, and at the full period of gestation. 5. The
treatment after death of the foetus, at or before the full
period of gestation.
He did not believe that a correct diagnosis is ever
probable before primary rupture, and in no instance
would he use electricity to destroy foetal life. He pre-
ferred laparotomy, and claimed that the immediate and
subsequent results would be better. He said, that while
Dr. Harbert in 1849, Kiwisch in 1857, and Dr. Rodgers
November 30, 1889]
in 1867, had suggested the removal of the sac in tubal
rupture, he was probably the first to recommend its
removal, if the diagnosis is made before rupture. If the
tube has ruptured into the folds of the broad ligament,
and pregnancy has continued four and a half or five
months, he advised expectancy, and to operate after
foetal viability, but before the beginning of false labor.
He advocated the removal of the placenta and feetal
membranes where it is possible to do so, and control
hemorrhage by ligation en masse at the proximate end of
the large vessels. If this cannot be done, it is best to
leave the placenta to be absorbed and close the abdomin-
al wound aseptically, after the fashion recently described
by Mr. Tait.
| AFTERNOON SESSION.
Dr. W. H. WaTHEN, of Louisville, read a paper en-
titled “ The Treatment of Ectopic Pregnancy.” This
paper was followed by impromptu remarks on “ Perineor-
rhaphy,” by Dr. A. W. Johnstone, of Danville, Ky.
Dr. JosepH Price, of Philadelphia, contributed a
paper on
PUS IN THE PELVIS, AND HOW TO DEAL WITH IT.
By pus in the pelvis he meant pus that has its fons et
origo in the pelvic organs or their investment. ‘The rarer
cduses of pus in the pelvis may be said to be: 1, Carious
bone, as psoas abscess; 2, traumatism, sloughing, results
of electricity, direct violence, etc. ; 3, foreign bodies, as
extra-uterine bones, etc. The general rule is that pus in
the pelvis is always the result of diseased conditions of
the uterine appendages, whether it occurs as the result of
a ruptured extra-uterine pregnancy, a suppurating ovarian
or dermoid cyst, or salpingitis caused by gonorrhcea, par-
turition, dirty instruments, electricity, or what not. In
general, then, when the surgeon finds pus in the pelvis, he
will find its origin in the uterine appendages. He had
seen pus discharging from the rectum, from the bladder,
the umbilicus, and from the vagina. He had seen psoas
abscess, perforating appendicitis, idiopathic peritonitis, and
typhoid fever, and found the seat of trouble in the tubes
and ovaries. In all his experience he had never seen pus
in the pelvis independent of disease of the appendages.
To make the statement definite, he had seen more than
once double pyo-salpinx and double ovarian abscess con-
` tained in a pus-pocket in the peritoneal cavity, composed
of adherent intestines and inflammatory tissue—four ab-
scess cavities contained within a fifth. Again, he had
Seen.a single pus-tube with four distinct pockets in it.
Pus can burrow through the cellular tissue and find vent,
as before stated. How shall pus in pelvis be treated ?
The general principles of surgery for the treatment of
pus in any other part of the body apply with equal force
to the pelvis, namely—where pus is present evacuate it ;
and secondly, remove the cause of the suppurative process.
It is equally unsurgical and unscientific to allow pus to
remain in the pelvis as it would be to allow it to remain
in the brain, in the mammary gland, or under the fasciæ
in any part of the body. It is equally unsurgical to allow
a suppurating tube or ovary to remain in the pelvis as it
would be to allow a sequestsim of dead bone, or to allow
a necrotic placenta or membranes to remain in the uterus.
These principles do not admit of evasion. All sorts and
kinds of treatment have been tried without avail. Every
man of experience knows the futility of counter-irritation,
local depletions, or a general systemic treatment in the
vast majority of cases. °
There are only three methods of treatment common to
physicians to-day, namely—electricity, vaginal drainage,
and abdominal section with the removal of the diseased
parts, thorough irrigation of the peritoneal cavity, and
drainage.
The first of these methods need scarcely be mentioned
in cases where pus is already present. Electricity has no
place in the treatment of pus in the pelvis. Vaginal
drainage is a crude, inefficient method, and is not so safe
THE MEDICAL RECORD.
611
—— _ _- —
as some would have us believe. In abdominal section we
have the quickest, easiest, most exact, and therefore safest,
mode of treatment for pus in the pelvis. A small in-
cision, rapid enucleation of the offending tubes and
ovaries, the breaking up and evacuating of the separate
pus-pockets, the separation of adhesions, the thorough
washing out of the peritoneal cavity by copious irrigations
of warm distilled water, the placing of a glass drainage- .
tube in the most depending portion of the peritoneal cav-
ity, and the careful closure of the abdominal incision,
gives the patient the quickest relief, permanent cure, and
very often snatches her from an impending death. More-
over, here we attain the most ideal treatment, for at no
other point of the body can we enucleate completely an
abscess with its containing walls and pyogenic membrane.
However, we should always bear in mind that the prov-
ince of the surgeon is, first, to save life, then to relieve
suffering, rather than to perform ideal operations. Many
patients dying with pus in the pelvis need but a feather’s
weight to depress the beam. In such cases the indications
are to evacuate the pus, wash out the cavity, and wait
until a future time to remove the offending cause. .
Discussed by Drs. Hardon, Engelmann, Stone, Robine
son, Hadra, and Potter.
Dr. W. L. Rosinson, of Danville, Va., read a paper on
GYNECOLOGY IN ITS RELATION TO OBSTETRICS,
in which he spoke of the cervix uteri in its pathological
condition, predisposing to hemorrhage prior to labor, lac-
eration, and septic absorption. He could find no expla-
nation in medical literature of the cause of ulceration of
the cervix, non-specific and non-malignant, causing hem-
orrhage in two cases which came under his observation
within the last twelve months. He used the word “ non-
specific” because of the perfect health of the patients
prior to the pregnancy and since delivery—his knowledge
and intimate acquaintance for years with husband and
wife. The first case was seven months advanced, and she
was spending the summer in the mountains for the bene-
fit of the health of one of her children. She found her-
self unwell after a week, and the flow was sufficient to
soil the clothing and require napkins. A physician was
called who gave ergot and opium, which controlled it in
twenty-four hours. Two weeks subsequently the condi-
tions repeated themselves, and relief was obtained by the
same remedies. She returned to the city and was again
annoyed by a like hemorrhage, which came on about 7
P.M. daily'in spite of the efforts of the attending physician
to control it, which continued until the sixth day, the pa-
tient having reached home. Dr. Robinson was called
and made an examination with speculum. He found the
os granular, denuded of its mucous coat, and upon gently
opening the os with uterine dilators he discovered a small
clot adherent to the ulcer which caused bleeding when re-
moved. He applied carbolic acid to the ulcer, and dusted
the os and vagina with boric acid. He continued treat-
ment until the parts were in a healthy condition, and de-
livered tle woman at full term without hemorrhage, tear,
or any unusual sequelz. No placenta previa existed, and
not one drop of blood escaped after the first application
of carbolic acid until after delivery, and then everything
was normal. The second case occurred a few weeks sub-
sequent to the first, with history and result similar. __
He has for several years made it a practice to examine
his regular patients whenever a yellowish or dirty-white
vaginal discharge exists, especially if the vulva is irritated,
and almost invariably finds the os granulated, whether
lacerated or not, and he persistently treats them until re-
stored to a healthy condition, explaining fully to the pa-
tient the importance of such treatment.
Dr. BEDFORD Brown, of Alexandria, Va., corrobo-
rated the statements of Dr. Robinson by the citation of a
case. The patient had a bilateral laceration of the cer-
vix. She became bitterly hostile to sexual intercourse
with her husband, and had an intense dislike of his com-
pany and presence. ‘This preyed upon her mind to such
612
an extent that she became insane. He treated the case
with applications of nitrate of silver, and the lacerations
healed perfectly. After that all symptoms entirely disap-
peared. The patient regained her reason, her affection
for her husband, and had lost the hostility to sexual in-
tercourse which she had. She has since borne three*chil-
dren. He has examined the condition of the cervix after
each birth, and the repair is perfect.
The paper was further discussed by Dr. RICHARD
Douctas, of Nashville. `
EVENING SESSION.
The Association met in Broad Street Museum Hall, at
8 P.M. The Address of Welcome was delivered by Hon.
A. J. CALDWELL, the response to which was made by DR.
J. M. MaTHEws, of Louisville. Dr. HUNTER MCGUIRE
then delivered the Presidential Address, which was schol-
arly, timely, and well received.
SECOND Day, WEDNESDAY, NOVEMBER 13TH— MORNING
SESSION.
"Dr. GEORGE J. ENGELMANN, of St. Louis, read a paper
entitled
MENSTRUATION AND PREGNANCY AFTER REMOVAL OF BOTH
OVARIES.
The following are the conclusions drawn from the his-
tory and microscopical examination of Dr. Engelmann’s
cases, which are corroborated by numerous cases of
odphcrectomy and double ovariotomy now observed,
whose histories have been recorded for a sufficient length
of time after the operation :
1. That the continuance of menstruation after removal
of both ovaries is due to remnants of ovarian stroma left
in silu. 2. ‘That portions of the ovarian tissue, however
small, which remain after the removal of the greater por-
tion of the organ, whether or not the Fallopian tube be
preserved, may retain their activity and continue the func-
tions of the entire organ. 3. Even elongated pedicles may
contain ovarian stroma in which the functional activity of
the organ may be continued. 4. That remnants of ovarian
stroma do not necessarily preserve their vitality and func-
tional activity.
The deductions of practical value to the operator are
even of greater importance, and they are these: a. For
the successful performance of odphorectomy it iş requisite
that every particle of ovarian stroma shall be removed, if
the desired result is to be expected with certainty. 4. If
shrinkage of fibres, the limitation of hemorrhage, or cessa-
tion of annoying symptoms is to be accomplished with the
greatest certainty, both ovaries must be completely re-
moved, and not even a particle of ovarian tissue left in
situ. c. In the performance of double odphorectomy in
women not yet beyond the climacteric, and not suffering
from utero-ovarian reflexes, such healthy ovarian tissue as
may exist should be spared in order that function activity
may not be impaired.
Dr. W. D. HAGGARD, of Nashville, said it is very rare
for a woman to menstruate regularly after removal of
both ovaries and both tubes. He believed that the hem-
orrhagic discharges from the uterus after odphorectomy
depended upon some other cause than that of menstrua-
tion. It may depend upon some trouble connected with
the endometrium, as suggested by Dr. Engelmann, a
polypoid growth, or a congested condition of the blood-
vessels which supply the endometrium. In January last
he removed both ovaries and both tubes in a woman, and
it is barely possible bits of ovarian stroma were left be-
hind, as three months later the patient continued to have
hemorrhagic discharges which greatly annoyed her.
Dr. A. W. Jounstone, of Danville, Ky., held that
the ovary has no more to do with menstruation than the
clitoris has. To prove this he had left ovarian tissue be-
hind, yet menstruation had ceased. Dr. Johnstone gave
at length his reason for this theory.
THE: MEDICAL RECORD.
[November 30, 1889
Dr. Vircit O. Harpon, of Atlanta, Ga., had operated
on a patient, about eighteen manths since, for a bleeding
fibroid tumor, removing both ovaries, and in removing the
second ovary he feared he had not removed all the ovarian
tissue, as the precarious condition of the patient would
not permit a continuance of the operation. The patient
recovered from the operation, and has menstruated with
unvarying regularity from that time to the present.
Dr. RICHARD Douctas, of Nashville, said that Battey’s
operation of itself does not control menstruation, whereas
in Professor 'Tait’s operation, which consisted in the removal
of both ovaries and both tubes, the gynecologist embraces
in his ligature the nerve which controls menstruation.
Dr. A. V. L. Brockaw, of St. Louis, warmly took ex-
ception to the remarks of Dr. Johnstone, who was inclined
to give Tait the credit of first performing odphorectomy.
He said he admired Tait’s skill as an operator, but as a
man he did not, for with characteristic modesty he (Tait)
adds his name to operations that do not nghtfully belong
to him; as, for instance, the flap-splittiag operation.
Dr. W. H. WaTHEN, of Louisville, said gynecologists
were more familiar with the laws that govern menstrua-
tion in many respects than they formerly were, but that
we still require more scientific investigation, personal
observation, and experience to convince us that any one
cause controls menstruation. ;
Dr. A. W. JOHNSTONE arose to defend an absent
friend. The statement made by Dr. Brockaw, that Tait
was the originator of the flap-splitting operation is not
true. A full description of the method could be found in
a recent issue of Mundé’s journal. It is true, however,
that Tait has used it without knowing it had been de-
scribed some twenty years ago by a Dublin surgeon, but
he has given him due credit for the operation.
The paper was further discussed by Drs. G. Frank
Lydston, of Chicago, Johnstone, and discussion closed by
Dr. Engelmann.
Dr. Joun D. S. Davis, of Birmingham, Ala., then
read a paper on
AN EXPERIMENTAL STUDY OF INTESTINAL ANASTOMOSIS,
in which he reported thirty-two adhesive experiments on
dogs, and seventy-nine successful anastomotic operations,
by means of his approximation catgut mats and catgut
plates, for the purpose of illustrating the advantages of
denuding the coaptation serous surfaces, and the integrity
and absorbability of his catgut mats and plates.
He reported two applications of anastomosis to man,
The first, ileo-colostomy, for obstruction in the region of
the ileo-czecal valve, by means of catgut mats; the sec-
ond, jejuno-jejunostomy, for multiple gunshot injuries of
the jejunum, with resection and lateral approximation, by
means of catgut plates.
His paper was replete with suggestive advantages of
anastomosis over circular enterorrhaphy, based on expen-
mental facts. His anastomotic devices consist of catgut
mats and catgut plates—oval and horseshoe. The mats
are made of catgut in the following manner: A large
continuous four-nb catgut frame is held in an oblong
shape by four artery forceps, while the frame is being
interwoven into an oval mat, Of the desired size, by means
of a small catgut thread armed with a needle. The co-
aptation threads are fixed by passing a needle and thread
between the two middle nbs, and so returned as to loop
two or three of the small gut sutures used in weaving the
ribs together. The plates are made of any size, by means
of an ordinary pocket knife, from a large one-eighth inch
thick dry compressed plate of the uncut gut tissue—made
for the author by William Snowden, of Philadelphia.
The coaptation threads are fixed by passing them through
the plates by means of a needle, or better, by means of
an awl, and knotted to fix them. The horseshoe plates
are made from the oval plates by cutting out one end of
each of the oval plates. ‘They are used for closing, in a
hinge manner, extensive gunshot wounds of the convexity
of the bowel.
November 30, 1889]
æ
His paper closed with the following propositions: 1.
Approximation catgut mats may be made of any size in
less than an hour. © 2. Approximation catgut plates may
be made of any size in from ten to fifteen minutes. 3.
Approximation catgut horse-shoe plates are very valuable
in intestinal repair from gunshot injuries of the convexity
of the bowel. 4. Approximation catgut mats and plates
absorb away in from forty-eight to sixty hours in gastro-
enterostomy, and in from seventy to eighty hours in oper-
ations below the stomach. 5. Anastomosis by means of
approximation catgut mats or plates furnishes the best
conditions for the healing of the visceral wound. 6.
Anastomosis can be performed by means of catgut mats
or plates, without division of bowel, in five minutes ; and
with division or resection in fifteen minutes, including a
continuous outside safety-silk suture around the circum-
ference of the mats or plates. 7. Denuding the perito-
neum of endothelium at the seat of coaptation hastens
the exudation of plastic lymph, the formation of adhe-
sions, and the definite healing of the intestinal wound. 8.
When coaptation serous surfaces have been denuded of
their endothelial covering by mechanical scraping, plastic
adhesions readily take place, and definite healing—by the
formation of a net-work of new blood-vessels in the prod-
uct of tissue proliferation from the coaptation serous
surfaces—is initiated in eighteen hours.
Dr. A. V. L. Brockaw, of St. Louis, Mo., followed
with a paper entitled
INTESTINAL ANASTOMOTIC OPERATIONS WITH SEGMENTED
RUBBER RINGS, WITH SOME PRACTICAL SUGGESTIONS AS
TO THEIR USE IN OTHER SURGICAL PROCEDURES.
For many months the author has been experimenting
with segmented rubber rings in all the anastomotic opera-
tions, and such operations as gastrostomy, cholecystotomy,
duodeno-cholecystotomy, jejuno-cholecystotomy, and cir-
cular enterorrhaphy. ‘The rings used by him are rapidly
made, during an operation if necessary. All that is required
is some rubber tubing or a soft ordinary rubber catheter
and some catgut. He prefers tubing one-sixteenth to one-
eighth of an inch in diameter. A section of this, of suf-
ficient length to make a ring of the desired aperture, is
cut into four to eight segments. Passing heavy strands
of catgut through the lumen of these pieces, the ends are
tied tightly enough to bring the ends of all segments to-
gether, forming an oval ring. To the catgut strands are
tied from four to six silk apposition threads twelve to
fourteen inches long, and the attachment of needles to
these threads renders the ring ready for use. Another
method is to pass a heavy double strand of catgut continu-
ously through the segments several times, approximate the
ends of the segments, and push the ends of the catgut into
the tubing. This ring will have a better surgical finish,
and after the apposition threads are tied between the seg-
ments the ring will maintain its perfect form until the
catgut is absorbed. The rings were passed as early as the
fifth day in one of his experiments. In forming an anasto-
mosis, after ordinary No. 6 darming-needles are at-
tached to the apposition threads, compress the ring and
pass it through the opening made in the lumen of the
bowel, then pass the threads through the intestinal wall
from within outward. Ascertaining that the ring rests
well in place, proceed to the second in the same manner ;
appose, and after scarification of the marginal serous sur-
faces, as suggested by Senn, tie the apposition threads.
When possible, it is well to utilize omental grafts, which
add to the security. With two such rings circular enter-
orrhaphy may be performed, the rings corresponding in
size to the lumen of the bowel, care being taken that they
are not so large as to press too much upon the delicate
mucosa or to overstretch the bowel, as a local gangrene
might then follow. Introducing a ring at each end of the
gut at the point of section, the threads are passed through
the wall less than one-third of an inch from the divided
margins. The distal end of the gut is invaginated and
the proximal gut pushed into the distal, bringing the serous
613
‘The threads are then tied and a few
Lembert sutures added, the entire operation requiring less
than ten minutes. In one-half of his experiments with
this operation the result was excellent. Of the fourteen
dogs operated on by this method, in seven the results
were all that could be desired ; marked stenosis was found
in several cases, and in all a ridge at the seat of the opera-
tion.
In a recent paper the essayist mentioned
A NEW PROCEDURE FOR CLOSING LARGE WOUNDS OF THE
INTESTINE,
especially gunshot, whereby ordinary suturing stenosis
would result. ‘This method applies to wounds of the sur-
face of the intestine ; those of the mesenteric portion usu-
ally require resection. By this simple method wounds
the size of a half-dollar may be closed in less than five
minutes. The wound being trimmed and enlarged with
scissors, a ring two and a half inches in diarf€ter, made of
eight segments of tubing, with six apposition threads, two
on each side, so arranged that when the apposition threads
are tied the ring is held bent evenly on itself. Sucha
ring is introduced into the bowel, the end apposition
threads passed, then the lateral, using a single catgut sut-
ure in drawing the wound margins together at the point
of flexure, in order to prevent eversion. A few Lembert
sutures complete the operation. If two wounds are close
together in the same loop, a lateral anastomosis might bé
formed, if possible. With more than two wounds close
together, excision and lateral anastomosis will require less
time than circular enterorrhaphy or the sewing up of sev-
eral wounds. Other conditions where the single ring may
be used are perforating ulcers, fistulas, etc. The great
advantage of the segmented rubber rirgs over other de-
vices used is the simplicity of their construction and the
rapidity with which any number may be made. The large
aperture of segmented rings makes it possible to perform
ileo-colostomy by the following method, which the author
believes is original: The ileum being divided a short dis-
tance from the cecum, the divided end of the distal
bowel is invaginated into itself, and secured by a continu-
ous suture through the serous and muscular coats. Above
the proximal end a clamp is placed, and a ring adjusted
to the lumen ; a slit is then made in the convex surface
of the ascending colon and a rng introduced. ‘The
bleeding checked, the proximal end of the divided ileum
is inserted into this slit, the threads tied, and Lembert
sutures added. This operation may be quickly per.
formed, and is indicated in such cases as irreducible in-
tussusception of the ileum into the czecum, and malignant
diseases of the colon.
Appended is a series of operations with the results :
Gastrostomy, 2 experiments, 2 recoveries ; gastro-jejunos-
tomy, 3 cases, 2 recoveries, 1 death from peritonitis ; `
jejuno-ileostomy, 1 case, result perfect ; ileo-ileostomy, 2
cases, 1 death, due to perforative peritonitis; ileo-colos-
tomy, 2 cases, 2 perfect results ; colo-colostomy, 3 cases,
1 death ; ileo-rectostomy, 2 cases, perfect results ; circu-
lar enterorrhaphy, 14 cases, 7 deaths; duodeno-cholecys-
totomy, 3 cases, 2 deaths from peritonitis ;* partial duo-
denectomy, 2 cases, 1 perfect result ; partial jejunectomy,
2 cases, 2 perfect results; partial ileoectomy, 4 cases, 1
death ; partial colectomy, 2 cases, 2 perfect results.
Summary: Intestinal anastomotic operations, 14 cases, 3
deaths ; circular enterorrhaphy, 14 cases, 2 deaths.
The single ring, formed of eight segments of tubing, was
used in closing wounds varying in size from a quarter to
half a dollar in g cases, with 1 death. ‘The clamp de-
vised by him and used in the operations is made of No.
12 copper wire covered with unperforated rubber tubing
of small size.
Discussion postponed till afternoon.
(To be continued.)
— -o m Mu M a
! Dog tore one suture eight days after operation. l
2 This operation is difficult to perform on a dog for anatomical rea-
sons.
— = a;
Correspondence.
- eS
CONCERNING EXAMINATIONS FOR MEDICAL
OFFICERS OF THE NAVY.
To THe EDITOR or THe Mepicat Recorp.
Sir: In the last number of THE REcorRD, under the cap-
tion of “ Vacancies Hard to Fill,” there is an article which
may cause some misunderstanding among possible candi-
dates as to the character of the examination for admis-
sion to the Naval Medical Corps.
I refer to that part of the article in which the writer
states that it is almost useless for any candidate who can-
not show his A.B., as well as his M.D. degree, to present
himself before this Board for examination ; or words to
that effect. -
‘The naval Wanch of the Government service has never
required candidates for appointment as assistant surgeon
to show even their M.D. degree, being satisfied with its
own examination as the test of professional acquirements ;
and, as a matter of fact, I assure you that of the last fif-
teen candidates found qualified by this Board, three only
ssed degrees from literary colleges or institutions,
while twelve were without any degree whatever other than
doctor of medicine. Very truly yours,
E. S. BoGERT,
Med. Inspector U. S. Navy,
Pres. Exam. Board.
NavaL Mepical EXAMINATION BOARD,
U. S. NavaL HOSMTAL,
BROOKLYN, November 19, 1889.
‘THE ACTING ASSISTANT SURGEONS AND THE
CONTRACT SYSTEM.
To THe EDITOR Or. THe MenicaL Recorp.
Sir: Your editorial in ‘THE Recorp of November 2d
attracted my attention. You have headed it with “ ‘The
Hard Lot of the Acting Assistant Surgeon,” and you pre-
sent his case as one of severe hardship in a pecuniary
point of view. In fact, it is the burden of your remarks.
I fully agree with both the views of the “ Association of
Acting Assistant Surgeons U.S. A.,” and yourself. ‘hey
are not paid enough for their services. Yet there is no
compulsion for giving their services for the recompense
awarded. ‘The fact is that.a man, professional or
otherwise, must have a living ; if in the medical profession
he must take his chances against competition with his
fellows, or he must hire himself out for what he can get.
The Government, like any individual, should get its work
done as cheaply as possible. And evidently it has found
that it can get all the service of the kind for the amount
it proposes to pay I presume there are over twenty ap-
plicants for any vacancy or necessity that may arise. An
experience as a contract or Acting Assistant Surgeon
United States Army, a surgeon to a railroad company,
and a manufacturing association, has taught me one
fact, viz., that if I was not satisfied with the payment
received I should decline to perform the service re-
quired ; but those fifty Acting Assistant Surgeons decline
to serve the Government for the price stipulated. ‘There
are another fifty ready to take their places. It is im-
material what is required of them. ‘This they know be-
forehand, and if after making a trial they can, to use a
vulgar expression, “ get out,” the fault is not in the con-
tracting party of the first part. Certain duties are re-
quired for which so much money will be paid. ‘The
party of the second part is under no obligation to accept
unless he is satisfied that he cannot do better with his
property, viz., his accomplishments as a medical man.
‘The remedy is easy—let him not make such a contract,
and force the party of the first part to offer and give more
for the service required. ‘The fact is, there are too many
doctors for the work to be done, and hence competition
reduces the compensation. (Government knows this as
required for the price offered. The contract surgeon has
(if he chooses) an opportunity for outside work which
adds to his wages, and oftentimes he can resign, and, by
virtue of his previous position, enter upon a good prac-
tice in the neighborhood where he has been located.
From long observation the average doctor does not ex-
ceed $1,500 per annum, and were I to place it at
$1,000 I would not be far out of the way. ‘There
is no obligation to become a “contract surgeon,” and if
after a trial of a month the wages are not satisfactory for
the work performed, the remedy is easy. ‘The same
principle applies to all public offices: if the recompense is
not sufficient or satisfactory, resignation is easy, and the
vacancies can be readily filled. Whether private, pub-
lic, or governmental, I am satisfied I can furnish the
Government all the contract surgeons qualified for the
duties required, to fill all the vacancies that may occur for
insufficient compensation, and be glad for the opportunity.
Yours respectfully,
WILLIAM Bropig, M.D.
Detrroir, Mice.
‘Vo Tue Epitror or THe Mgpicar R ECORD,
Sir: I have read with a great deal of interest the article
which appeared in ‘THE MEDICAL RECORD of November
2d entitled “ The Hard Lot of the Acting Assistant Sur-
geon.” I think it must have surprised the readers to know
the humiliating position that educated, reputable physicians,
who are over twenty eight years of age, are placed in, if
they desire to enter the Medical Department of the
United States Army. ‘Ihe only office open toa physician
who is over twenty-eight years old, in the Medical De-
partment of the United States Army, is that of an Acting
Assistant Surgeon, United States Army, and the officer is
paid less than a second lieutenant—the lowest commis-
sioned officer of the army. It is almost incredible to
believe that, if the Acting Assistant Surgeon is wounded
and disabled in the service, while in discharge of his duty
as a medical officer, and obtains a leave of absence for a
short period on account of inability to perform his duty,
that he loses his pay for the time he is absent, and that
he is liable to be dismissed without trial or cause at the
whim of his commanding officer, and that he has not the
advantage given him of the civil service laws, which
prevent employees of the Government from being removed
without good and sufficient cause. This is certainly an
injustice and discrimination against medical men who like
army life, and are anxious to enter the service after they
have passed the age of twenty-eight years. Some of the
Acting Assistant Surgeons of the United States Army
have been in the service since the war, and are now too
old or so accustomed to military life that they have no
desire to commence the practice of medicine. I feel
as confident as you do that the Acting Assistant Surgeon
has the sympathy of the Surgeon-General of the United
States Army, and also the medical staff, in his efforts
to better his position and fix his status. ‘The medical
staff of the army is inadequately paid, and after the
question of the Acting Assistant Surgeon, which is the
most apparent injustice, is disposed of, the attention
of the medical profession of the country might be called
to it. From the World Almanac of 1889, page 175, I
notice that the salary of the Surgeon-General of the United
States Army is stated to be $4,500, while the salanes of
other brigadier-generals are stated to be $5,500. ‘The
latter salary would be very meagre for the accomplished
chief of the Medical Department of the United States
Army. ‘The petition of the Acting Assistant Surgeons of
the United States Army appears to me to be very modest,
and I cannot see how any lover of justice can object to it,
and I believe as you do, that they ask for too little. During
the late war of the Rebellion the Acting Assistant Surgeons
of the United States Army wore the uniform and insignia
of rank of first lieutenant, and performed the duties
of Assistant Surgeons and Surgeons, and in several in-
THE
—+ =
November 30, aN
stances had dare at United States General Hospitals
when the pay was very small and the responsibility very
great. The number of medical men who served in this
capacity, and who patriotically gave their services to their
country in its hour of need during the late war of the
Rebellion was 5,532, and I understand that there will be an
effort made at the coming Congress to commission and
muster them in from the date of entry into the service,
and muster them out or discharge them like commis
sioned officers at the date of the honorable termination
of their service.
THE MEDICAL RECORD deserves commendation for call-
ing the attention of the medical profession to the position
their medical brethren—the Acting Assistant Surgeons—
are placed in, and I think it is our duty, and I sincerely
hope we will be able, to aid them in their efforts to obtain
a living salary and the standing in the army that they
modestly seek. ‘Ihe Acting Assistant Surgeon of the
United States Army who is now in the service is so sit-
uated that he can be of little service in bettering his
position. He can only make a statement that will call
the attention of his medical brethren to the position he is
placed in, to obtain their sympathy and support, which I
feel confident will be cheerfully given. The article in ‘THE
MepicaL Recor on the “ Hard Lot of the Acting As-
sistant Surgeon,” I think, has voiced the opinion of the
medical profession on their petition, and I take the liberty
of informing you that it gave me great pleasure to read
the editorial which called attention to the position that
this class of very deserving medical officers are placed in.
, Very respectfully yours,
Jonn T. Nace, M.D.
47 EAST ‘Want y-FIRST STREET, New YORK.
” ial nad avy Hews.
Official List of Changes in the Stations and Duties of Cfi-
cers strvtng in the Medical Department, United States
Army, from November 18 to November 23, 1889.
_ _ Lorine, Leonard Y., Major and Surgeon. By direc-
tion of the Secretary of War the extension of leave of
absente on Surgeon’s certificate of disability granted in S.
O. 241, October 16, 1889, from this office, is still further
extended one month on Surgeon’s certificate of disability.
Par. 3, S. O. 268, Headquarters of the Army, A. G. O.,
November 16, 1889.
MosELEY, Epwarp B., Captain and Assistant Surgeon.
Relieved from duty at Whipple Barracks, Ariz., to take
effect upon the expiration of his present leave of absence,
and will report in person to the commanding officer, Fort
Clark, Tex., for duty at that station, reporting by letter
to the commanding general, Department of ‘Texas. Par.
4, S. O. 268, A. G. O., November 16, 1889.
FISHER, WALTER W. R., Captain and Assistant Surgeon.
Relieved from duty at the Presidio of San Francisco,
Cal., and will report in person to the commanding officer,
Fort Assiniboin, Mont., for duty at that station, report-
ing by letter to the commanding general, Department of
Dakota. Par. 4, S. O. 268, Headquarters of the Army,
A. G. O., November 16, 1889.
EBERT, RUDOLPH G., Captain and Assistant Surgeon.
‘The leave of absence on Surgeon’s certiticate of disabil-
ity granted in S. O. 109, May 11, 1889, from this office,
is extended six months on Surgeon’ s certificate of disa-
ah) Par. 13, S. O. 270, Headquarters of the Army,
A. G. O, November 19, 1889.
Official List of Changes in the Medical Corps of the Unsted
States Navy for the week ending November 23, 1889.
Rusu, W. H., Passed Assistant Surgeon. Ordered to
U.S. S. Saratoga.
MEDICAL RECORD.
615
eee ——— — e [m -- ~- —- 8 sey a
Uric, J. F., Assistant Surgeon. Detached from the
Coast Survey Steamer Gedney and ordered to the U.S
S. New Hampshire.
BRYANT, P. H., Assistant Surgeon. Detached from
the Norfolk Hospital and ordered to the Coast Survey
Steamer Gedney.
SMITH, GEORGE T., Assistant Surgeon. Detached from
the Army and Navy Hospital, Hot Springs, Ark., and or-
dered to the Naval Hospital, Norfolk, Va.
Strong, E. P., Assistant Surgeon. After examination
for promotion, await orders.at Boston, Mass.
Medical Atems.
Contacious DIsEASES—WEEKLY STATEMENT. — Rc-
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending November 23, 1889:
Cases. | Deaths.
Typhus fever ..............00.- Canim edie waters sakes o o
Typhoid {OVER 565624 cs eketeinccy netem rasu Sosan 32 10
Scarlet fever osses erena we Seek eccin tins ieee teak 43 5
Cerebro-spinal meningitis................ececoes 1 I
Measles ocorre Ca PSEN SOE SOS ws OKO Se RR URES 35 6
Diphtheria. cienne iue cea Sa ee ocak Cees 87 14
Small-pox pacsuck Sorte scene ood saws orcad.) cos o o
Variola ouere oe Waele e r TEE a SAT 3 o
o
CIRCULAR FOR THE INFORMATION OF PERSONS DESIR-
ING TO ENTER THE MEDICAL Corps OF THE U. S. Navy.
—The following circular, from the Honorable Secretary
of the United States Navy, is published for the iaforioation
of all concerned :
A candidate for examination and appointment in the
Medical Corps of the Navy must be between twenty-one
and twenty-six years of age, and must apply to the Hon-
orable Secretary of the Navy for permission to appear
before the Naval Medical Examining Board.
The application must be in the handwriting of the ap-
plicant, stating age and placg of birth, also the place and
State of which he is a permanent resident ; and must be
accompanied by letters or certificates from persons of re-
pute, testifying, from personal knowledge, to his good
habits and moral character, and that he is a citizen of the
United States. .
Form of Application.
» 1889.
To THE HONORABLE SECRETARY OF THE NAVY,
Navy Department, Washington, D. C.:
Sir: I request permission to be examined for an ap-
pointment as Assistant Surgeon in the United States
Navy.
I was born at — „ and was
—— day of
States, residing in
I enclose herewith certificates as to moral character,
habits, and citizenship.
years of age on the
, 18—, and am a citizen of the United
, county of ——, in the State of
Very respectfully,
If, in reply to the above, the candidate receive a per-
mit, he will notify the President of the Board of the fact,
and request him to appoint a time for his examination.
Candidates will be expected to present to the Board
testimonials of education and professional fitness.
The Board is required, under oath, to report on the
physical, mental, moral, and professional qualifications of
the candidate; so that the examinations are necessarily
rigid and comprehensive, though simple and_ practical,
and not beyond the attainments of any well-educated
physician.
616
mmnm
A successful candidate, upon the completion of his
examination, will be notified by the President of the
Board that he has been found qualified.
An applicant found “not qualified” may be allowed a
second examination after one year, but not a third.
No allowance will be made for the expenses of per-
sons undergoing examination, which, if uninterrupted, is
usually completed within a week.
Appointments will be made as vacancies occur, and in
the order of merit reported by the Board, but a qualified
candidate, not appointed within the year, must be re-ex-
amined. ,
The officers of the Medical Staff of the Navy are as
follows: Medical Directors, Medical Inspectors, Sur-
geons, Passed Assistant Surgeons, and Assistant Surgeons.
Vacancies in these grades (by death, or retirement at
the age of sixty-two years) are filled in the order of sen-
icrity, and for each step of promotion a physical and pro-
fessional examination is required by law.
The pay of an Assistant Surgeon in the Navy is $1,000
per annum “on leave or waiting orders,” $1,400 “on
shore duty,” $1,700 “at sea,” and, when: at sea, one ra-
tion at thirty cents per diem in addition.
Eight cents a mile is the allowance when travelling un-
der orders.
Order of Examination :—1. Physical.
Oral. 4. Clinical. 5. Practical.
The Physical Examination will be very thorough, and
the candidate will be required to certify, under oath, that
he is free from any mental, physical, or constitutional de-
fects, hereditary taint, or disability of any kind that would
be liable to interfere with the efficient performance of
duty.
Written Examination.—The candidate will be required
to address a letter to the Board of Examiners, stating
concisely—
1.. The date and.place of his birth ; the school, institu-
tion, or college at which he received his general educa-
tion ; the several branches studied, including his knowl-
edge of general literature, and of the ancient and modern
languages ; the exact title of the medical school or schools
at which he received instruction, and, ¿f an Alumnus, the
date of his graduation ; the name and place of residence
of his preceptor, and the time when he commenced the
study of medicine ; also, the title of the text-books stud-
ied or read on Chemistry, Anatomy, Physiology, Histol-
ogy. Materia Medica, Pharmacy, Therapeutics, Theory
and Practice of Medicine, Principles and Practice of
Surgery, Minor Surgery or Mechanical ‘Therapeutics,
Medical Jurisprudence, Toxicology, Obstetrics, Hygiene,
Biology, and Physics.
2. ‘The opportunities he has had of engaging in the prac-
tice of medicine, surgery, and obstetrics, or of receiving
clinical instruction ; or whether he has or has not been a
resident physician or interne in a civil or military hospital.
3. ‘The number of subjects or parts of subjects he has
dissected ; what opportunity he has had to become famil-
iar with minor surgery and bandaging, chemical and phar-
maceutical manipulations, and the physical properties of
2. Written. 3.
The candidate will append to this letter his name in
full, post-office address, and his local address at the date
of the examination.
A Thesis or Short Essay must next be written (without
reference to notes or books) upon some professional or
scientific subject indicated by the Board.
Written answers will then be required to twelve or more
questions, propounded by the Board, on the following
subjects :
Anatomy, Histology, Physiology, Surgery, Theory and
Practice of Medicine, Obstetrics, Materia Medica, Chem-
istry, Hygiene, Medical Jurisprudence, Toxicology, and
Physics.
Oral Examination.—Vhe candidate will be examined
orally upon his hterary and scientific acquirements, in-
cluding general history, natural science, and English litera-
THE MEDICAL RECORD).
[November 30, 1889
ture, and professionally upon Anatomy (general, special,
and surgical), Histology, Physiology, Theory and Practice
of Medicine, Principles and Practice of Surgery, Chem-.
istry, Legal Medicine, Toxicology, Materia Medica,
Therapeutics, Pharmacy, Obstetrics and Diseases of
Women and Children, Hygiene, Microscopy, and Physics.
Candidates possessing special knowledge of the higher
Mathematics, Astronomy, Geology, Botany, Zoology,
Literature, Art, and Ancient and Modern Languages, will
be given full credit for their proficiency.
The Clinical Examination of Patients will be made by
the candidate at a Naval Hospital, and will include the
use of the Microscope, ‘Thermometer, Laryngoscope, Oph-
thalmoscope, and other aids to physical diagnosis ; after
which he will be required to submit a written clinical re
port on one or more medical or surgical cases.
The Practical Examination will comprise surgical opera-
tion on the cadaver, the application of splints, bandages,
and surgical dressings, the use of the microscope (for
clinical purposes, and the recognition of pathological or
other specimens), and chemical and pharmaceutical ma-
nipulations. |
A candidate may withdraw at any period of the ex-
amination, with the consent of the Board, and may at a
future time present himself for re-examination.
The Board may conclude the examination—wnitten,
oral, or practical—at any time, and may deviate from this
general plan in such manner as it may deem best to in-
sure the interests of the naval service.
Dr. Morse K. TAYLOR died at his home in San An-
tonio, Tex., on October 2oth, after an illness of about
two weeks. Dr. Taylor was born in Watertown, N. Y.,
but was taken to Michigan by his parents while still a
child. He served in one of the Michigan regiments dur
ing the Mexican war, and at the close of that war began
the study of medicine at Ann Arbor, where he graduated
in the second class that left the medical department.
After practising for a while in Illinois, he entered the
Union Army as surgeon, and served in that capacity dur-
ing the entire Civil War. He then practised in Iowa, but
soon re entered the army, serving in the medical corps
until retired on account of age. He then made his home
in San Antonio, fiving with his son, Dr. F. M. ‘Taylor.
He had made a special study for some years of the cli-
mate of Texas, and at the time of his death had nearly
completed a work on the climatology of this State, which
is said by those who have seen portions of the manuscript
to be of remarkable scope and detail. Dr. Taylor also
wrote the article on the climate of Texas in the seventh
volume of Wood’s “ Reference Handbook.” His death
was due to prostatic disease.
A Five YEARS’ COURSE OF STUDY FOR ENGLISH MED-
ICAL STUDENTS.—The Committee of Management of the
Royal Colleges of Physicians and Surgeons of England
have recommended an extension of the period of pro-
fessional study to five years for candidates of qualification
by the Conjoint Examining Board in England, and their
recommendation has been accepted by the Council of the
Royal College of Surgeons; while the Fellows of the
Royal College of Physicians have referred the matter to
the Council for further consideration.
Tue Hyciene oF Russian WorksHops.—At the Con-
gress of Hygiene, held recently in Paris, Dr. Kacheva, a
female physician, drew a most astounding picture
of the horrors of the sleeping accommodation pro-
vided for workmen in Russian factories, which she char-
acterized as exceeding those of steerage passengers in old
emigrant ships.
A MepicaL SeNATOR.—Dr. Francisco Alonso Rubio,
some time physician to the Queen of Spain, and the lead-
ing obstetrician and gynecologist of the Peninsula, has
recently been named a life senator by the Spanish Govern-
ment. The appointment has given great satisfaction to
the medical profession in Spain.
Vol. 36, No. 23
Whole No. 996
Original Lectures.
ON VITAL AND MEDICAL STATISTICS.’
By JOHN S. BILLINGS, M.D.,
UNITED STATES ARMY.
LEcTuRE II.
THE term “ expectation of life” is used by different writ-
ers in different senses, and hence has often given rise to
confusion and misunderstanding. It should be used only
in the sense of the mean after-lifetime, that is, the aver-
age number of years which persons at any given age, in a
given place, may expect to live. In a stationary popula-
tion, where there is no migration, and where the births
‘are exactly equal in number to the deaths, the expectation
of life at any age would be found by dividing the sum of
the number of years which the whole population lived
after that age by the number actually living at that age.
Table showing Expectation of Life.
AGES.
o! 5 10.15.25 40 '60
|
|
-++-149.9 46.6/39.5|28.5/14.5
Massachusetts, 1883~-87............. Males .. 39.7°52.7149.3 45.1|38.2 28.2/15.3
Boston, 1883-87..............00.06 Persons. 33.3!47.2147.5144.7137.1(28.§ 16.7
Providence, 1883-87............... | Persons. 40.8 51.1|48.3144.2137.5|27.7 15.0
New York, 1879-81... .........04. iMales ..'33.3/48.0144.9,40.6/33 2/23.9/13.0
Baltimore, 1880, colored ............ [Males ..'21.0/4t.8 ae 36.8|31.0ļ23 Zire
Society of Friends, Philadelphia ..../Persons. 43.7|51.8|48.8|44.6|37.5|28.5|15 2
Society of Friends, England ........ Males .. 45.3/53.8]50.5146.4/39 gl29.2/14.4
Benedictine Monks, Pars ........e.|seeecees ee paces oe oes 144.0124 OF 18.7,
English Life Insurance .............|..ccceeeleee: 50.6] 45.6/40.6/34.0/24.5]|12.6
Dublin, 1841.......... PEPE Males ../23.8] 38.5] 37.2133 .4|27.0/19.8]11.0
BGP fe ak. ces Bede nok Soe ee Va Se Males .. 17.2] 44.¢/43.1139.5|32.0|22.0/ 10.0
The term “ expectation of life” is often confused with
the “ probable duration of life,” which is the age at which
a certain number of new-born children will be reduced
one-half; so that for any one of these children it is an
equal chance as to whether it will die before or after that
age. ‘The difference between the probable duration of
life and the expectation of life may be understood from
the following example: Suppose that of 100 children
born, 30 live one year, 20 live five years, 30 live fo
years, and 20 live sixty years. Then the probable dura-
tion of life is five years, because at the end of five years
just one-half of these children will be dead, so that at the
beginning it is an even chance for any one child as to
whether it wll die before or after the age of five years ;
but the expectation of life of any one of these children is
25.3 years, because these 100 children will in all live
25,300 years of life. In like manner, if ten of these chil-
dren were to die at the end of every five years, the prob-
able duration of life would be 25 years, and the expecta-
tion of life would be 27.5.
Another phrase sometimes used in vital statistics is
“ specific intensity of life.” This is the quotient of the
dividend of the number of persons living at any age by
the number dying at that age, that is, #, being the reverse
of the ordinary mortality ratio.
The chief source of error in an approximate life-table
constructed directly from the census figures and a regis-
1 The Cartwright Lectures, delivered before the Alumni Association
of the College of Physicians of New York, November, 1889.
New York, DECEMBER 7, 1889
od
ay ee ee
©
tration of deaths, without correction or adjustment, is due
to the fact that there is a very considerable error in the
number given of the living population in he first six or
seven years of life. Usually the census figures show that
the number of children two years old is greater than the
number one year old, and that the number four years old
is greater than the number two years old, owing to a ten-
dency to erroneously report a child at these ages as be-
ing older than it is. If we undertake to adjust or correct
these figures so as to truly represent the number living at
each year, we usually have to make some assumptions as
to the law governing the mortality, or as to what is some-
times called the law of life. ‘This expression, the law of
life, refers to the hypothesis that variations in mortality
at successive ayes take place in a regular succession which
may be geometrically represented by a curve, and that
therefore, if we know the mortality at certain ages in a
given community, we can, if we know this curve, and if
the number of observations were sufficient, deduce the
mortality at other ages. Numerous formulas have been
proposed for this purpose, from that of De Moivre in
1727, which is Y = 86 — x, x being the age, and Y the
corresponding number of the living, to the latest and most
generally accepted formula of Gompertz, as modified by
Mr. Makeham. This last is based on the assumption that
a person’s power of resisting death decreases as his years
increase, so that at the end of infinitely small periods of
time he loses infinitely small portions of his remaining
power to resist destruction, death being considered as the
consequence of two generally existing causes, the one a
progressive, necessary deterioration, the other chance. If,
for instance, there were a number of diseases to which
young and old were equally liable and which were equally
destructive at any age, the number of deaths among the
young and the old by such diseases would evidently be in the
proportion of the number of the young to that of the old.
If there were no other causes of death but these diseases,
the number of living and dying would decrease in a geo-
metrical progression as the age increases. But if the lia-
bility to death is constantly increasing in a given ratio as
the man grows older, then the number of the living will
decrease in a greater ratio than a geometncal progression
would indicate.
The diagram before you shows the diminution of vital
force with advancing age as shown by De Moivre’s hy-
pothesis, by the geometrical progression formula, and by
the English life-table.
This line of human life, which in some respects is not
unlike the line in the palm of the human hand which the
ancient teachers of chiroscopy afso called the line of life,
is that of the healthy and normal individual. Many per-
sons do not at any time possess the amount of vital force
which it represents ; many infants at birth have but the ca-
pacity for a few hours or a few days ot existence. Some
men begin to grow old at forty; the atheromatous de-
generation invades their arteries, the heart becomes fatty,
and at fifty they are in extreme old age as regards the
processes of retrograde metamorphosis, and the ability to
resist death. Calculations and corrections based on such
formule as these give interesting results, and are useful
to life-insurance work, but they are unnecessary to the
purposes of the sanitary statistician, Even the funda-
mental hypothesis upon which Gompertz’ law is based,
that the proportion of deaths at a given age is constant,
is always untrue for any given age, as the prevalence of
| infectious and contagious diseases of various kinds, and
[December 7, 1889
THE MEDICAL RECORD.
618
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of various lethality, varies with different years, and for this
reason it is desirable to have the records of deaths for a
considerable period of time—at least three years, and, better,
ten to twenty years, in order to correct these variations.
It is impossible to calculate a life-table for the United
States as a whole, since we have no accurate information
as to the total number of deaths occurring in any given
period of time in the United States, and still less as to the
number of deaths occurring at each group of ages. But
even if such table could be prepared, it would be of very
little interest or use, since the conditions of the various
sections of the country as to climate, occupations, pre-
vailing diseases, character of inhabitants, etc., are so wide-
ly diverse that the average or mean would scarcely be
applicable anywhere. ‘The most useful lite-t:bles for
sanitary purposes are those which relate to certain circum-
scribed localities, such as a single city, or even a single
ward of a city; but for scientific and medical purposes,
the most useful are those which relate to particular classes
of people, particular occupations, etc. There is a spe
cial difficulty in preparing an accurate life-table for a city,
- due to the effect of migration into and out of the city,
from and to the surrounding country, which disturbs very
much the rates of death at different ages. ‘The mortality
In a great city is almost always reported as less than that
which the actually existing causes of death and disease
tend to produce, because domestic servants, shop-girls,
and others, who have come from the country, go back to
their rural homes when their health begins to fail after a
year or two of city life, and there die. This is especially
the case in regard to deaths from consumption and dis-
eases of that class. ‘The groups of ages which are thus
specially affected are those between fifteen and twenty-
five years, and therefore the mortality at this group of ages
in the large cities, as calculated from the number of deaths,
is too small to properly represent the causes of death act-
ing on the population at those ages. On the other hand,
the mortality at the same ages in the rural districts near
the city will be correspondingly unduly increased.
The data necessary for the construction of life-tables
are comparatively rarely available for the purposes of the
sanitarian. Hence, while admitting that these furnish
the only true measure of public health, registrars of vital
statistics and sanitarians have sought for other standards
for such measurement, the data for which could be more
readily obtained and more easily applied. Especially has
the search been made for some means of measuring sani-
tary conditions and progress from the data furnished by
deaths alone without reference to population. One of
the most common of these is the use of the period of in-
fancy from o to 5 years, by comparing the number of
deaths at this period with the total number of deaths. It
is very certain that the period of infancy gives the most
sensitive test of sanitary conditions, but the comparison
must be made, not with the $al number of deaths at all
es, but with the number of the living population fur-
nishing such deaths.
In -Europe it is more common to confine the calcula-
tion to children under one year of age, and these are
much more valuable there than they would be in this coun
try because they have there a much more complete regis-
tration of births, and therefore the relation between the
number of infants horn and dying within the first year of
life can be ascertained with an exactness which is quite
out of the question in this country.
Another method, which we can only use for a census
year. is the use of the ratio which exists between the total
number of births during the year and the number dying
during the year out of this number of births. ‘This is not
the same as taking the total number of those dying under
one year of age. For example, in the city of Brooklyn,
during the last census year, there were 8,805 births, and
of these 1,408 died—leaving, on the date of the census,
7,397 living children under one year of age, putting aside
the effects of migration ; but the total number of deaths
of white male children under one year of age in Brooklyn
THE MEDICAL RECORD.
: Bull. de la Soc.
619
was 2,059-——hence 159.9 per 1,000 of those born within
the year died within the year, while the deaths of children
under one year were 278.4 per 1,000 living at the end of
the year, with a still higher rate for the year.
The test of sanitary condition which is most generally
employed in this country isthe proportion of the number
of deaths which occur in children under five years of age
to the whole number of deaths reported. This does fairly
well in comparing the rates of the same city, in which it
may be presumed that the general ratio of age-distribu-
tion is nearly uniform at different times} but it isa very
fallacious method of comparing rates of different cities or
locahties. For example, during the last census year the
ratio of deaths under five years per 1,000 of total deaths
was in Alabama 475.9 for males—in California, 250.0 ;
but in Alabama the proportion of male children under five
years to the total population is 17.5 per cent., while in
California it is only 9.1, or but little over half the Ala-
bama ratio, and hence the true rate is actually higher in
California than it is in Alabama, although the figures
would indicate the reverse.
Much the same may be said of comparison of deaths at
a given age-group to total number of deaths, which is apt
to give very misleading conclusions. For example, sup-
pose, in a given city, the total number of deaths of children
under five years of age were thirty per cent. of the total
deaths, while in a given class of people in the same city
they were only ten per cent. of the total deaths; it
would be by no means safe to infer that this special class
was in a better sanitary condition, because among the
poorer classes the proportion of children is always rel-
atively large, which implies a large population exposed to
these special diseases, and consequently a larger number
of deaths under five years of age, without reference to the
sanitary condition.
Another test which has been proposed is that of the
mean age at death, which is the quotient of the sum of
the ages of different individuals at death, divided by the
total number of deaths. This is only useful in comparing
the conditions of two populations when the age and sex
constitutions of these populations is the same. It is out
of the question to apply the test to different occupations ;
as, for example, to compare the mean age at death of
major-generals with that of second lieutenants. The
chief use of this test is in its application to different
causes of death, but even for this purpose the death-rate
in relation to population is much better.
A considerable part of the errors to which one is liable
in comparing the mean age of different occupations at
death may be avoided by excluding from the computation
all deaths of children under five years of age.
Although the expectation of life, or mean after-lifetime,
is the standard of comparison almost universally accepted
by statisticians, it is, in some respects, not a very satis-
factory one, since it is often misunderstood by the public,
which is apt to use the word “ mean” in the sense of
usual or ordinary, that which occurs most frequently.
But the ordinary lifetime, or, as Bertillon calls it, the vie
normale,‘ is a very different matter, as will be seen from
the diagram on next page.
This indicates that after the perils of childhood are
passed the greatest number of deaths cluster about the
age-period of seventy years, and the popular phrase here
would be that it was a premature deatii which occurred
in a man under sixty years of age.
The great majority of the mortality statistics prior to
the present century are necessarily incorrect and unrelia-
ble, because they are based, for the most part, on the
data of deaths alone. ‘The deaths can only be taken as
a measure of probable duration of life for any commu-
nity when the births and deaths are equal and there is no
migration, a state of matters which must very rarely hap-
pen and be of very brief existence.
Reap Rg SN eg RE at oo ES ee ee eg ee et
1 Bertillon, ae raat hi Sur la Vie moyenne et la Vie aormalc,
Anthropologie, Paris, 1879, 3° Scr., Pl. op. p. 470.
620
Among the many expedients which used to be em-
ployed for estimating population was that of multiplying
the number of living in which one death was supposed to
occur, by the number of deaths. That is to say, by guess-
ing at a factor which could only be ascertained by com-
paring the annual deaths with the number living. ‘Take,
for example, the estimates of the population in London
mace by Graunt in 1662 on the basis of one death occur-
ring out of every 32 living, which made the population to
be 403,000. In 1683 Petty, taking the mortality to be ır
to 30 persons living, made the population to be 669,930.
One peculiar thing about this method is, that it is lia-
ble to make the population seem the largest at those peri-
ods when it was in reality the smallest ; for when the
number of deaths was unusually large by reason of an
epidemic, which would actually lessen the number living,
it would show an apparent increase in the population for
the same period.
It may, perhaps, be asked why it is, if the nature of
the data which are required to make mortality statistics
reliable and satisfactory is so well known, that more of
them are not provided by the municipal and State Officers
charged with the registration of vital statistics. For ex-
ample, New York City has a very perfect system of regis-
tration of deaths, which is in competent hands and is well
executed. Why, then, has New York City published no
separate mortality report since 1883, and why, in the re-
ports which it has published, does it not give the data with
minuteness of grouping so that we might know the num-
ber of deaths at each age, of each sex, and of each race
and occupation in each ward from each cause of death,
instead of giving, as it gave in its last report, the number
of deaths from each of certain causes of death for each of
a few groups of ages, and separately for each sex, and
for natives of the United States, natives of foreign coun-
tries, and colored ; to which is added a statement of the
deaths from zymotic diseases in each ward ?
In order to understand the answer to this, it is neces-
sary to have a clear conception of the difference in cost of
tabulation and publication according to the mode of
grouping of the data. If, for example, the’ deaths are
given by twenty groups of ages and by sex and by color
for each of the 24 wards, and for the city as a whole. it
will require 49 columns to do this. If we make the dis-
tinction for, say, roo different causes of death, allowing
fifty lines to the page horizontally, and twenty columns
vertically, giving 1,000 places per page, we should get all
this information for the city on four pages; but if we
wish to show the number of cases of death from each
cause at each group of ages, of each sex and each color
in each ward, we shall have to have 2,000 columns, which
will make about 200 pages. If it be desired to estimate
the influence of seasons in connection with all these
things, we must have a similar table for each month, or
2,400 pages large octavo.
Again, let us suppose that we wish to have the data
fully presented in order to estimate the influence of occu-
pation upon health. We will only ask for details of one
hundred occupations in males. But we should like to
know the number of deaths in each of these occupations
for each of, say, ten groups of ages, in each of at least
THE MEDICAL RECORD.
[December 7, 1889-
five races, in the married and single, in each of twelve
months, for each of the twenty-four wards, for each of,
say, 100 different causes of death, giving 288,000,000 pos-
sible places, making 288,009 pages large octavo.
It is, of course, out of the question to present the data
in any such detail as this, and it is therefore necessary to
make a selection of combinations which will indicate the
most interesting relations of the several points under dis-
cussion. ,
It is, however, often very difficult, and even impossible,
to tell precisely what combinations it will be necessary to
make to get at the probable explanation of
an especially high or low death-rate in a given
group ; and hence we sometimes have to
make a very considerable numl e- of tenta-
tive combinations and tabulations, from
which we may select only a few as really
throwing light on the matter, and therefore
as worth publication.
When we have to tabulate data in such a
way that the individual items are to be dis-
tributed through a thousand columns or `
more, and each of these to be summed up
for different localities, a vast amount of
clerical labor is required. For distributing
in 1,000 spaces the various items as iigned
in each death-certificate, if it be done by the old-fashioned
system of tallying on a large sheet, an expert clerk will
not be able to tally off more than 1,000 records of death
per day ; so that for, say, 30,000 deaths, which is less than
the average number of annual deaths in New York City
for the last ten years, it would require the labor of a clerk
30 days to produce a single page table, about one per
cent. of what is needed.
By the use of cards or slips, tallying machines, adding
machines, and sorting boxes of various kinds, this labor
may be much reduced. One of the latest methods of
doing this is by the use of cards of a uniform size, in
which holes punched in certain parts of the card corre-
spond to the various divisions of locality, time of death,
sex, age, occupation, cause of death, marital condition,
etc. These cards may then be passed through a machine
which registers on a series of dials such combinations of
the data as the dials may be adjusted for, by means of
electrical connections established between a metal plate
below and a series of metal rods above, wherever there is
a hole in the card.
Death-rates, even when derived from complete and ac-
curate data and compiled in the most satisfactory man-
ner in the form of life-tables, necessanly give only an
imperfect view of the prevalence of disease in a commu-
nity, orof the relative amount of disability among the peo-
ple, requiring extra labor by the productive class due to
the recurrence of sickness. „Many forms of disease which
render life more or less of Wburden, and some of which
totally disable the individual from earning his subsistence,
seldom or never appear in the registers as a cause of
death ; while even of those diseases which are reported as
causes of a considerable proportion of deaths, we can
rarely at present indicate any definite or certain relation
between the number of cases of the disease and the num-
ber of deaths reported. For example, it is well known to
all practising physicians that the mortality varies greatly
in different epidemics of such diseases as scarlet fever,
measles, small-pox, whooping-cough, yellow fever, etc.,
the variations appearing to depend principally upon the
particular conditions of the environment as to tempera.
ture, moisture, winds, density of the population, etc., at
the time of the outbreak, and also upon particular condi-
tions of the specific virus or micro-organisms causing dis-
eases of this kind.
Take, for example, the spread of yellow fever in Texas
and along the Gulf Coast during the year 1867. Here
the specific cause of this disease appears to have entered
the United States by two distinct routes, one coming from
Vera Cruz, Mexico, and the other coming from the usual
December 7, 1889]
source, Havana. At that time the United States had a
comparatively large number of troops along the Southern
border of the country, and hence we have a series of
returns showing not merely the number of deaths, but also
the number of cases of sickness from this disease occur-
ring in a given population.
Now, in those places where the disease was of Mexican
origin the cases were more fatal than those of Cuban
Origin, “ two out of every five cases of the former dying,
while the mortality of the latter was only two out of
seven. ‘The ratio of deaths was 400 per 1,000 cases for
the first of these groups, 284 per 1,000 for the second.” !
For the great majority of diseases it is not possible to
obtain statistics as to their prevalence among a general
population. ‘The only sources to which we can look for
information of this kind are the records of the Army and
Navy, of the police force in certain cities, of the employés
of railroads, and of the members of certain societies hav-
Ing Insurance against sickness. ‘The records of the Army
and Navy are especially valuable in this point of view,
but they relate only to males of certain groups of ages and
of a carefully selected class of population.
In the last United States Census an attempt was made
to obtain on the schedules of the living population the
number of those who on the first day of June, 1880, were
so sick or disabled as to be unable to pursue their ordi-
nary occupations. This was the first attempt of the kind
which has been made in this country, but similar attempts
were made in two censuses in Ireland, in a census of the
„Australian Colonies, and in a census of Hungary. _
The first examination of the United States schedules
seemed to show that the returns of the sick were too imper-
fect and too inaccurate to permit of drawing any con-
clusions from them. But subsequently it turned out that
they were really more complete than had been supposed,
and a sufficient number were compiled for different parts
of the country to obtain a fair sample of the general
results. ‘This compilation showed that for the total pop-
ulation over fifteen years of age the number found sick
out of every 1,000 living varied from 7.17 to 22.7 for
males, and from 8.1 to 17 5 for females, or about 1} per
cent of males and 1} per cent of females. ‘These do not
include the blind, deaf and dumb, insane and idiots, and
it 1s probable that the figures do represent very fairly the
different proportions of sickness occurring in males and
females, and in certain groups of ages at the time that
the census was taken, which, it must be remembered,
was at a period when there is probably the least amount
of sickness and disability among adults.
From the results of data derived from mutual benefit
societies in England it has been estimated that for every
case of death in a community there are two persons con-
stantly sick ; that is to say, there is an average of two
years sickness to each deathg@r that if the annual death-
rate 1S 18 per 1,000 the average number constantly sick is
about 36 per 1,000.”
By the census reports the proportion of sick to 1,000
of population of different ages was as follows :
Age. Males. Females.
15 to 25......... EEEE TEET 6.9 6.8
25 WO J5 akuno rena ANE E 8.6 9.7
S510 46 E E T 12.2 11.5
BS OSG oii xa a eae atone E ET 16.8 14.4
§§ £066 E E E 25.5 20 4
05- and OVER osa reisa nnua 44.5 35-3
1 War Department, Surgeon-General's Office, Washington. 1886:
Circular No. 1., page xviii.
2Mr. T. R. Edwards (London Lancet, 1835-36, i., p. 855), from
the study of a series of returns from friendly assurance societies,
claimed that, for large numbers of people, there is a constant ratio of
sickness peculiar to each age, and that the duration of each case of
sickness at any age is in proportion to the mortality at that age. His
theory is that the mortality at any year of age exceeds that of the pre-
ceding year by 2.999 per cent., or that the mortality during any de-
cennial interval of aye exceeds that of the preceding decennial by
one-third part ; or that the mortality rate doubles in 23!f years. Ac-
cording to his theory, if a physician loses by death double the pro-
portion of patients at the age of forty-three that he does at the age
of twenty, the effect of his remedies in each case is the same.
THE.MEDICAL RECORD.
621
This corresponds, in a general way, to the conclusions
of Mr. A. G. Finlayson relative to the amount of sick-
ness in members of friendly societies, printed in 1854.’
He found that, taking the whole mass of male members
of friendly societies, from the age of 15 to that of 85,
about five years of sickness occurs to each man during
this 70 years; but during the period of labor, from the
commencement of the sixteenth year of age to the close
of the sixty-sixth, there are in this 51 years but 78 weeks
of sickness, or about one and a half week per annum ;
and the sickness occurring from 42 to 66 is almost double
that occurring in the first half from 15 to 41. Hence he
concludes that the sickness of the first 25 years of work-
ing life is almost exactly one-half of that of the second
25 years. In the class devoted to heavy labor the sick-
ness is almost a year more, or in the proportion of 11 to
g as compared with the sickness undergone in the class
engaged in light labor.
It is also to be observed that during the early years of
life, say from 21 to 41, the number of persons withdraw-
ing, or excluded from such societies, is very large, being
nearly five times the number of deaths. As the age of
the members increases the departures become fewer, be-
cause it becomes more of an object to remain connected
with the society, since the rate of annual payments is the
same for all ages, while the proportion of sickness steadily
increases, as we have seen, with advancing age.
Several attempts have been made to induce physicians
to keep a record of all the cases they treat, but with very
little result. In 1857 the Metropolitan Association of
Health Officers in Londor carried out a systematic regis-
tration of all cases of sickness which received attention at
the public expense, as in hospitals, dispensaries, alms-
houses, etc. About one-half of the hospitals and dis-
pensaries in the district contributed information, but the
enterprise broke down before the end of the second year,
and while results gave some interesting indications for the
time as to the prevalence and progress of certain forms
of epidemic disease, the records have very little statistical
value, as they have no definite relation to the numbers of
the population furnishing the cases of sickness. |
It is very improbable that anything like complete re-
turns of sickness will ever be obtained for any large body.
of the civil population. Such registration will always be
confined to infectious and spreading diseases; in other
words, those which are known or supposed to be prevent-
able. In order to make a registration of this kind of any
great practical value it must be continuous and com-
pulsory. The plan of endeavoring to get the medical
men of a locality to voluntarily contribute this informa-
tion, even when accompanied by the offer of the payment
of a fee, has produced partial and incomplete results,
which become more and more incomplete as time goes
on, and the first enthusiasm ın favor of the new plan dies
away.
‘The various systems of compulsory notification which
have been tried are, first, to require the medical attendant
only to furnish the returns to the Health Office ; second,
to require the householder, or head of the family, to make
such returns ; third, to require both the doctor and the
householder to make such returns ; and, fourth, to require
the doctor to certify to the householder, and the latter to
notify the health authorities.
The Infectious Disease Notification Bill, passed by the
English Parliament in 188g, is the latest attempt to solve
this difficult question.
It provides that where an inmate of any building used
for habitation is suffering from a disease to which the act
applies, then, unless such building is a hospital in which
persons suffering from infectious disease are received, the
following provisions shall have effect, that is to say :
“The head of the family to which such inmate (in this
act referred to as the patient) belongs, and in his default
the nearest relatives of the patient present in the build-
——
1 See Insurance Cyclopedia, vol. v., p. 83.
622
THE MEDICAL RECORD.
[December 7, 1889
ing or being in attendance on the patient,.and in default
of such relatives every person in charge of or in attend-
ance on the patient, and in default of any such person the
occupier of the building shall, as soon as he becomes
aware that the patient is suffering from an infectious dis-
ease to which this act applies, send notice thereof to the
medical officer of health of the district.
“ Every medical practitioner attending on, or called on
to visit the patient shall forthwith, on becoming aware
that the patient is suffering from an infectious disease to
which this act applies, send to the medical officer of
health for the district a certificate stating the name of
the patient, the situation of the building, the name of the
head of the family or other person who appears to him to
be primarily liable to give the notice under this act to
the medical officer, and the infectious disease from which,
in the opinion of such medical practitioner, the patient is
suffering.
“ Every person required by this section to give a notice
or certificate who fails to give the same, shall be liable on
summary conviction in manner provided by the Summary
Jurisdiction Acts to a fine not exceeding forty shillings. -
“ The local authority shall gratuitously supply forms of
certificate to any medical practitioner residing or prac-
tising in their district who applies for the same, and shall
pay to every medical practitioner for each certificate duly
sent by him in accordance with this act a fee of zwo
shillings and sixpence if the case occurs in his private
practice, and of one shilling if the case occurs in his prac-
tice as medical officer of any public body or institution.”
On the part of some members of the medical profes-
sion, both in Great Britain and in this country, strong ob-
jections are urged to compulsory notification of disease,
and especially to that form which requires the doctor to
furnish such notification direct to the sanitary authorities.
It is urged that such notification is a violation of profes-
sional secrecy ; that it leads to concealment of cases of
such disease and the refraining from calling in a medical
attendant, and that it tends to throw the treatment of such
cases into the hands of a lower class of practitioners, who
are willing to run the risks of violation of the law, or,
even, to make false returns for the sake of securing an in-
creased practice. ‘There is, however, little difficulty in
keeping the information furnished strictly confidential,
provided the health-officer is a man of tact and discre-
tion, and provided, also, that the press does not insist
oe being too inquisitive with regard to matters of this
Any system of compulsory notification, however, which
has to be continuously successful, involves two things.
First, that the health-officer shall not be in any way en-
gaged in, or connected with, private practice, so as to do
away with all reluctance on the part of general practition-
ers reporting their private cases.
The second is that, to obtain any benefit from notifica-
tion, special hospital accommodations for such forms of
diseases as are reported must be provided by the com-
munity, and there must be a power of compulsory re-
moval of patients to such hospitals in certain cases.
Undoubtedly, valuable statistical data might be ob-
tained by the simple notification alone ; but the desire to
obtain statistical information will never be accepted as a
sufficient ground for legislation requiring compulsory no-
tification.
We hear very much in recent years of the proportion of
deaths from zymotic diseases as a test of the salubrity or
sanitary condition of a place; but as there is no general
agreement as to what is and what is not a zymotic disease,
and as the term rests on a theory of causation of disease
which is now definitely abandoned, it should no longer
be made use of. It is much better to select the mortal-
ity from certain forms of disease, and specify these, in
order that we may know exactly what we are talking
about and be sure that the matters compared between
two localities are the same. English health-officers often
use the term “ seven principal zymotic diseases,” by which
they mean small-pox, measles, scarlet fever, diphtheria,
whooping-cough, typhus fever, and enteric fever. If this
is the selection it is not a good one, for it omits the diar-
rhoeal diseases. Forty years ago, near the commence-
ment of the speculations of Dr. Farrand Mr. Simon as to
the causation of disease, nearly all of the contagious dis-
eases were grouped together as zymotic diseases, and
were supposed to be more or less connected with filth.
At present we know that the cleanliness of the surround-
ings has little or nothing to do with the prevalence of
small-pox, measles, scarlet fever, or whooping-cough ; so
that these, which are typical zymotic diseases, are of very
little interest in connection with the question as to local
causes of disease in a place, connected with uncleanhi-
ness, and to be remedied by sanitary effort.
Their relative prevalence, and the mortality cue to them,
is of interest in a totally different connection, and their
separation involves an entirely different field of sanitary
work. Such diseases as phthisis, diphtheria, and the van-
ous forms of diarrhoeal disease, including cholera infantum
or the summer diarrhcea.of children, of England, are of
especial interest as regards the field of local sanitary work
in relation to sewerage, drainage, and cleanliness.
The influence of habitation upon death-rates, and on
the prevalence of certain forms of disease, is indicated by
statistics given by Dr. Korosi for the city of Budapest,
where the deaths are reported with the following classifica-
tion, viz. :
1. Persons in a habitation where, at most, two persons
dwell in one room.
2. Persons dwelling where from two to five persons
dwell in one room.
3. Where there are from five to ten in a room.
4. Where there are more than ten in a room.
The first class includes the rich and well to do. The
others present increasing grades of overcrowding. Of
each 10,000 deaths reported, 1,941 belong to the first,
5,759 to the second, 2,167 to the third, and 133 to the
fourth ; and these ratios may be used to compare with
the proportions of deaths from any disease or group of
diseases as occurring in the different classes.
Comparisons thus made indicate that contagious dis-
eases, with the exception of scarlatina and typhus, are
more frequent and more fatal in the crowded houses, and
that the same is true of congenital debility and diarrhoea,
while tuberculosis and pneumonia do not seem to be espe-
cially influenced by this cause. (?!). As the figures of
death in these categories are not comparable with those
of the living population, the results have not much value.’
Suppose, now, that we are studying the death-rates of a
city for a series of years in order to deterrsine whether its
sanitary condition is, upon the whole, improving ; whether
work which has been done in the way of introducing
sewerage, or improved water-supply, or special precau-
tions in dealing with contagious diseases, have had an
evident good effect, and have produced results which are,
on the whole, satisfactory in proportion to their cost. It
is very evident that we must have something more than
the mere gross death-rates for the whole population in
order to form an intelligent opinion on these points. A
gross death-rate may, it is true, give a correct answer to
the question as to whether the sanitary condition is im-
proving, but we can never be sure of the correctness of
this answer until we have made detailed comparisons of
the mortality by age and sex, and of that due to certain
great classes of disease.
What has been the influence of modern civilization upon
the average duration of human life? upon rate of increase
of population ? upon the average health and vitality of
the races which it has affected? ‘The present population
of the world is between one thousand five hundred and
one thousand six hundred millions, of which there are in
Europe over three hundred and fifty millions, and of
— — — ll d-
1 Korosi: Influence des habitations sur les causes des décès, etc.
Paris, 1877.
December 7, 1889]
European stock in other countries one hundred millions ;
in all, say, four hundred and fifty millions, as against
one hundred and fifty millions in 1788.’
Evidently the birth- and death-rates now prevailing in
Europe and the United States cannot have long continued,
for if we suppose a population to double itself only once
in a century, a million of people, living one thousand
two hundred years ago, would have developed into a
population of over four thousand millions by this time.
What, then, is the difference between the expectation
of life in New York at the present day and that in Euro-
pean cities one, three, five, ten, or twenty centuries ago?
This question has been asked in various shapes many
times, and many attempts have been made to answer it;
the general conclusion being that there has been a very
great increase in the average longevity of man in civilized
countries, not only within the last thousand years, but
within the last century. Notwithstanding, it must be con-
fessed that the statistical records bearing on this point are
very incomplete, vague, and unsatisfactory, and that it is
only for the last forty or fifty years that we can speak
with anything like scientific precision as to the amount ot
progress made.
So far as what is termed potential longevity, that is to
say, the maximum duration of life possible in an individ-
ual of the race, is concerned, there is no evidence that
this has changed for at least two thousand years, being
for man generally taken as one hundred years. You will
remember the scriptural declaration that the years of a
man are threescore years and ten, and though by reason
of strength they be fourscore years, yet is their strength
labor and sorrow; notwithstanding, there are sufficient
records to prove that even in those days the potential
longevity of man was as great as it is at present.
But when we come to the average longevity and expec-
tation of life at birth, there is sufficient evidence to indi-
cate that it has increased ; but whether this is due to the
preservation of more infant-lives for a few years, although
they may still die before the productive period is reached,
or to an increase of the number of those who live into
and share the working period of life, is still uncertain, for
this question can only be settled by comparative life-
tables, and I have already explained that we have no re-
liable life-tables that are much over fifty years old.
I have already referred to the average duration of life
among the better class of Roman citizens as fixed by Ul-
pian, being equal to thirty years. Among the oldest data
which we possess, from which we can attempt to compare
death-rates of past centuries with those of the present, are
the records of Geneva in Switzerland, which date from
1551. The average annual death-rate per 1,000 was as
follows : i
From 1551 to 1600........ccccccceecsc cc ceeceuees o
From 1601 to 1650.........2. Lanuon cee se ceceeues be
From 1651 to 1700......0. cc ccc cece ccecceceeees 35
From 1701 to 1750.......-2c0. cccccccccccssceces 33
From 1751 to 1800........0.0c ccc cc cece ceccceces 29
From 1801 to 1813 the mean duration of life was
thirty-six years and six months.
l From this, the probable duration of life is given as fol-
OWS : '
Probable duration of Proportionate
Periods. ife.
Years. Months. Days, ree beat
End of the sixteenth century ...... 8 7 26 100
End of the seventeenth century .... 13 3 16 153
1701 tO 1750 1... cece wee cence 27 9 13 321
1751 to 1800 6 oc ci cia eceseeececes 31 3 5 361
1801 to 1813.0... Cocca e cece 40 8 o 470
1814 tO 1833 occ siwerca saves wees 45 o 29 521
_ The figures are not sufficiently full or accurate to jus-
tify the conclusion that the probable duration of life in
this place has been increased five times in three centu-
nies, but they do indicate a very marked and progressive
increase.
ee ee eee
1 See Giffen, Jubilee Volume of Statistics, 1885, p. 99. l
3Mallet : Annales d'Hygiène, 1837, vol. xvii., p. 5.
THE MEDICAL RECORD.
623
In the sixteenth and seventeenth centuries Geneva had
a small population, frequently exposed to fatal pestilence,
and produced a comparatively large number of infants, of
whom but a very small proportion reached the age of pu-
berty.
In the early part of the eighteenth century the average
mortality of all European countries, taking towns and vil-
lages together, is estimated by Süssmilch as x in 36, or
27.778 per 1,000.
The most important contributions to our knowledge of
the increase in the duration of life in recent years is con-
tained in a paper on the decline in the English death-
rate, by Noel Humphreys, published in the Journal of
the Statistical Society, in 1883; and in a report by Dr.
William Ogle, in a supplement to the Forty-fifth Annual
Report of the Registrar-General of England, published in
1885.
The conclusions, as based upon English hfe-tables, com-
paring periods from 1838 to 1854, and from 1871 to
1880, are as follows :
The mean after-lifetime of a male at birth was for the
first period 35.91 years, for the second, 41.35, showing an
average gain of nearly a year and a half. The mean
after-lifetime continues longer in the second period than
in the first for each year of life until the nineteenth. At
the close of the nineteenth year the expectation of life
was exactly the same in each period, viz., 40.17 years.
From that time onward the after-lifetime is shorter in the
recent period than in the older one ; that is to say, the
individual male in England lives on an average a shorter
time afıer he is nineteen years old than he did forty years
ago ; but the number of males out of equal numbers at
the start who survive to live these shorter lives is very
much greater than it was formerly, so that the aggregate
life of the whole is considerably increased. The gain is
greater in females than in males. Thus in the first period
the expectation of life in females was 41.85, while in the
second period it was 44.62, being a gain of 2.77 years on
an average for each female. ‘The after-lifetime continues
longer in the new period down to the completion of the
forty fifth year, when the expectation of life becomes the
same, viz., 24.06.
Taking a million males and a million females, the fol-
lowing table shows the additional years gained at each
age-group, for each sex, during the recent period.
Age periods Males. Females.
OO TS eee cee eee eas 255,340 288,226
16 (O26 satdees Uae EET 281,872 339,933
BG 036 nia nas aaa tee cess 344.906 453.221
B50 4S casas wetwericereeaoete 310,746 499,471
AS 00 S 66 tisk cee sees ieawe ned 211,040 474,009
65 tO 05 46 sine cee deans ecco nees 86.920 385,257
O6:10°76 oiccidaccesnasdanewed ses 10,464 239.617
T5 tO-86 cco sas E esses tees 27,770 89,568
85 and upward ......6 ..sseeeee 13,451 8,282
Total years gained,........... 1,439,139 2,777,584
This table shows plainly how erroneous is the conclusion
sometimes drawn that, because the death-rates have fallen
only in the earlier age-periods, while they have risen in
the later age-periods, the aggregate gain to the community
from the changes is confined to the unproductive years of
life. We may fairly take the period which intervenes be-
tween twenty-five and sixty-five years of age to be the most
valuable part of life, and of the aggregate years saved,
66 per cent. in the case of males and 65 per cent. in the
case of females are lived in this period.
‘ The earliest attempt to give vital statistics for the
United States is probably a paper by Edward Wiggles-
worth, published in the “ Memoirs of the American Acad-
emy of Arts and’ Sciences,” 1793, vol. ii., page 131, en-
titled “ A ‘Table showing the Probability of the Duration,
the Decrement, and the Expectation of Life, in the States
of Massachusetts and New Hampshire, formed from
Sixty-two Bills of Mortality on the Files of the American
Academy of Arts and Sciences in the Year 1789.” The
whole number of deaths reported on these bills was 4,893.
624
THE MEDICAL RECORD.
[December 7, 1889
He had no data of population, but the reports indicated
that the births in the locality sending the bills were twice
as many as the deaths. As his calculations are based
solely on the deaths alone at certain ages, the conclusions
are evidently entirely unreliable; but, such as they are,
they are as follows :
The expectation of life at birth was 28.15 years; at
five years, 40.87; at ten, 39.23; at fifteen, 36.16; at
twenty, 34.21.
By another calculation he finds that the expectation at
birth was 35.47, and at five years of age 48.46. |
Another paper is by J. E. Worcester, printed in the
“ Memoirs of the American Academy of Arts and
Sciences,” Philadelphia, 1833, vol. i., New Series, page 1,
and entitled ‘“ Remarks on Longevity and the Expecta-
tion of Life in the United States, relating more particu-
larly to the State of New Hampshire.” ‘Taking the bills
of mortality of thirty-two townships in New Hampshire
for an average length of time of twenty-one years, he
found that the death-rate was 1 in 83, or 12.04.10 1,000.
He wisely remarks that the ratio is so small as to excite
suspicion concerning the accuracy of the bills.
With this may be contrasted the following table show-
ing the expectation of life in Massachusetts as computed
from the deaths occurring in the five years 1883-87, com-
pared with the living population in the middle of this period
as deduced from the Massachusetts census of 1885.
MASSACHUSETTS, 1883-87.
Expectation of Life.
Ciry or BALTIMORE, 1880.
and, therefore, that the increase of mankind may be con-
sidered as the chief source of misery, which misery, to-
gether with moral restraint to a limited extent, and vice,
check the superior growth of population, keeping it at a
level with the means of subsistence.
If this doctrine be applied to the lower animals or to
an extremely savage and ignorant set of men, it 1s very
nearly correct ; for, in this case, the term “ means of sub-
sistence” applies almost exclusively to the natural pro-
duce of the earth. As soon, however, as man applies his
intelligence to the increase of the means of subsistence
by improvements in agriculture, by manufactures, etc.,
it is no longer true that the means of subsistence increase
in an arithmetical proportion. ‘They may increase, and,
for the last fifty years have, throughout civilized regions
of the world, actually increased in a ratio more rapid than
geometrical proportion and more rapid than the increase
of population ; and it is, therefore, substantially true that
“ the character of every race of men is the real limit to
its numbers in the world, if allowance be made for acci-
dents of position and time.” ' ee
‘The uneducated and unskilled laboring classes who are
without capital, when gathered together in large masses,
tend constantly to illustrate the theory of Malthus by 1n-
creasing faster than they can provide means of subsistence
for themselves and their families.
But this tendency is opposed by the advance in knowl-
|
j| New York City, 1879-81.
Ages. White and Colored. White. Colored. : White and Colored.
le a i a ne AAR i RA i OEE EEEE E a a a i Sp ee —
| |
Persons. Male. Female. || Persons. | Male. Female Persons. Male. | Female. l Persons. Mate. Female.
== te | ES tee | i =
Ò da sinh ol eae 40.87 39.73 42.03 | 38.18 | 36.49 39.86 23.26 21.00 25.51 | 30.90
s ere 49.77 + 49.43 50.12 46.04 44.73 47.36 35 32 32.20 38.44 | 39.66
e itegats 52.67 52.36 52.98 49.80 48.42 51.18 41.9: 39.25 44.57 44.04
J epriesensrs: 53.02 52.73 53-31 51.05 49.77 52.33 43.66 41.19 46.13 45.39
ee 52.96 52.70 53 23 51.58 50.27 52.90 44.07 41.84 46 30 46
E AEA nara | 52.70 52.43 52 97 51.72 50.46 52. 44.32 41.84 46.79 46.28
IO fo do wen ae |j 49-61 49.27 49:95 49.66 | 48.50 50. 3 42.40 40.06 44-75 43.84
LE EETETEETERETT | 45.53 45.13 45.94 45.46 44.35 46.5 39.42 36.84 42.00 39.70
A E 41.93 41.41 42.45 41.50 40.36 42.65 36 62 33.76 39-47 35.84
BS saiekiniaoaus 38.76 38.24 39.28 38.06 36.86 39.27 33.68 31.02 36 34 32.56
BO cence. ssc eeee, 35.54 34-94 36.15 34-74 33.45 36.04 30.64 27.76 33-53 || 29.64
35 wees ee eens ‘ 32.33 31.65 33.02 31.42 i 30.04: 32.81 27.62 24.51 30.72 26.71
P. a ee | 28.98 28.26 29-71 28.05 | 26.70 29 40 24.68 21.71 | 27.64 23.89
ea | 25.64 24.88 26.41 24.67 | 23.35 25.99 21.74 18.91 {i 24.56 21.08
SO .....ceeeeee. i 22.29 21.55 23.04 21.27 19.96 22.58 18.92 16.26 21.58 18.26
SS EEEEEEETETTT | 18.95 18.23 19.68 17.86 16.56 19.16 16 10 13.62 18.59 15.44
OO: EE 15.98 15.32 16.64 15.01 14.06 15 96 13.42 31.29 15.54 |, 12.98
OS ssessseseroee 13.01 12.42 13.60 12.17 31.57 12.77 10.72 8.96 12.48 |! 10.52
JO wanes sccerecs 10 74 10.27 11.21 10.24 10.09 10.40 8.87 7.80 9:94 li 8.90
VE cere ee ccceee 847 | 8.12 8.83 8.32 8.61 8.03 7 02 6.65 7-39 7.29
BO 1... seeeeees 7.24 7.03 7.45 7.14 7.39 6.38 6.90 6.26 6.49 6.38
BS eeseesseoses 6.00 | 5 94 6.07 5.98 6.17 5.78 5.72 5.86 5.59 5.46
One of the most frequent fallacies in the use of statis-
tical data is to mistake an effect or a coincidence for a
cause. For example, it is common to speak of rapid
growth ìn population of a locality or country as if it were
in itself a good and desirable thing, a cause of prosperity
and well-being, and when this growth lessens or ceases we
find some philosophers trying to devise ways and means
to increase it. This, for example, has been the case in
France for a number of years, and various plans have been
proposed for increasing the birth-rate and diminishing the
death-rate, in order to produce prosperity and strength in
the country. The factis that rapid increase of population
in a country is an indication that things are going on well
there, that there is a demand for labor, and that men find
that they can increase their comfort by going, or staying,
there ; but it may, or may not, be a cause of prospenty
at a given time, and sometimes it may cause hardship,
weakness, and suffering.
You are all, no doubt, familiar with what is known as
the Malthusian theory, which is, essentially, that popula-
tion is limited by the means of subsistence available, that
population increases in a geometrical proportion, while
the means of subsistence do not increase in a faster ratio
than arithmetical progression ; that, therefore, the growth
of population is checked by want of means of subsistence,
edge, increase in energy, and improvement in inventions
in the educated classes, who, although it may be said that
they are acting only from selfish interests, are, neverthe-
less, led by those interests to expand the fields of agricult-
ure, manufactures, and commerce, and, thus, to both in-
crease the means of subsistence and to lessen the price
thereof. ‘
Under favorable conditions a population is capable of
doubling its number every twenty-five years. In the
United States, between the years 1790 and 1869 the
population doubled itself about once in 234 years. But
a proportion of this increase was due to immigration.
Whether in the future a systematic attempt to main-
tain an equilibrium between subsistence and population
will become a practical problem of national policy 1s, at
present, a purely theoretical speculation, for it 1s very
easy to show, as has been done by Mr. Atkinson, that the
means of subsistence at present at our command can
easily be quadrupled, as the increase of the populaton
occurs to both require and produce such increase.
NoTe.—In estimating the progress of the population
of the United States for the next century, if we assume a
rate of 33.3 per cent. of increase in ten years, which is a
1 Farr: Vital Statistics, London, 1885, p. 15.
December 7, 1889]
THE MEDICAL RECORD.
625
little less than the mean rate for the last century, we find
that the probable population in 1990 will be 1,206,562,-
248, giving a density of population of 399 to the square
mile, approaching the present density of China, which is
420, or of Belgium, which is 434 per square mile.
NoTE.—Maria Mitchell, in a recent number of the
Century, speaking of an interview with Sir John Her-
schel, says that, one morning at the breakfast-table, Her-
schel put the following question: Suppose that since
the time of Cheops, three thousand years ago, man had
only died from natural decay at about ninety years of age,
and that the population doubled itself every thirty years ;
starting with a single pair at the time above referred to,
would the present surface of the earth afford standing
room to the entire progeny if closely packed? The re-
plies to this conundrum were various; one saying that
they would occupy a layer three feet deep, another a
layer fifty feet high, and so on, extending the guesses as
he said, “ More, more,” to the distance of the moon, to
the sun, and finally to the planet Neptune, when his re-
ply was that they would have piled up upon the surface
of the earth to a distance equal to one hundred times the
distance of the earth from the planet Neptune.
One of the most interesting and important questions in
vital statistics in this country is that relating to the rela-
tive increase in the white and colored population in the
Southern States, and the influence which has been, and
will be, exerted upon this by the abolition of slavery. On
the one hand, it is claimed that the large increase in the
colored population between 1870 and 1880 indicates
that in fifty or, at most, a hundred years more it will
greatly predominate.’ On the other, it is affirmed that
the greater increase of the colored population is apparent
rather than real.
The following table will aid in forming an opinion on
this point; but we must wait until we know the results of
the next census before coming to any conclusion.
births, deaths, and marriages begin with the year 1853
and end with the year 1859. In neither State was the
registration of either births or deaths in any year suffi-
ciently complete to permit of accurate comparisons with
the number of living population, either for the whites or
blacks.
The conclusions drawn by the registrars may be summed
up in the statement that the birth-rate of the slaves was
much greater than that of the whites in South Carolina,
while the difference was not marked in Kentucky ; that
in both States the death-rate of the negro was decidedly
greater than that of the whites, especially in infancy, and
that the average age at death was decidedly higher in the
whites.
I have already shown the fallacies connected with tak-
ing the average age at death as a means of judging either
the healthfulness of a locality or the expectation of life.
Notwithstanding, this is practically the only ratio to which
we can refer in regard to the question under considera-
tion. In the last South Carolina report for 1859 the
proportions are as follows :
One birth in a population of ............ 48.27 whites,
eo ee ES ne Oe cag eee awit 26.05 slaves.
ae AE cee taba wae ees e 32.34 of both races.
One death in a population of ............ 136.82 whites.
e+ ee It es OO Sein E 59.20 slaves.
oo e as EET EEA 77.95 of both races.
Average age at death ....... 2... cc ees 28.42 years in whites.
es ee ee er EENE E 14.87 years in slaves.
One marriage in a population of ......... 169.90 whites,
In the last Kentucky report it is stated that the aver-
age age at death was, for the whites, 21.21 years, and for
the blacks, 18.27 years.
The records of the statistics of 1880 show that the
birth-rate for the year was greater in colored than in the
whites; since in the ten groups in which distinction of
color was nade for this purpose the birth-rate for the
whites was 32.0, and for the colored, 38.06, per 1,000 of
aggregate population; or for the whites, 127.1, and for
Table showing Percentage of Increase of White and Colorea Population in Certain Districts.
1840-50. | 1850—60. 1860-70. | | 3870-80. | | 1850-80. 1860-80.
District. ———_——_——__ |, —_—__ -- -. | —_—_——————_ | ee ee a
White. | Colored. || White. | Colored. White. | Colored. || White. | Colored. || White. | Colored. White. | Colored.
Liisisneeiiesoessaneitst 20.92 9-47 18.72 7.24 11.35 4-16 26.54 a7.57 || 67.28 l 42-42 0.90 32.88
o E 35-73 27.16 |! 33.85 14.50 | 29.4 3-92 || 24.77 23-74 | 115.60 47 23 1.54 28.58
III.. 23.30 29.17 |: 17.08 18.43 3 10.85 -19 34.56 |! 36.92 72.66 35-37 49-17
DV AE aut | 67.90 §9-32 14-79 9-43 -go 46.79 213.90 155.90 6.97 60.63
Total onn. 26.96 19-73 | 30.13 22.47 | 16.90 | 7.67 32.87 34.38 302.14 77.20 55.33 44.68
Kentucky, Tennessee, and
“uo «
se IV. ae
Mississippi, i
In examining these figures it must be remembered that
the census of 1870 was very imperfectly taken in many
of the Southern States, and that the apparent great in-
crease in the negro population is largely due to the in-
complete enumeration of the negroes in 1870. Hence I
prefer to compare the period 1840-60 with 1860-80, in-
stead of using the ten-year periods. It is also to be re-
membered that migrations have affected the whites more
than the negroes. Many more whites than negroes have
left Group III., and the increase of population in Texas
is largely due to white immigration.
We have little information of value relative to the vital
statistics of the colored population in the South previous
to the abolition of slavery. The only two Southern States
having registration laws which were to any extent en-
forced were Kentucky and South Carolina. The Ken-
tucky reports relating to the registry and returns of births,
marriages, and deaths are eight in number, commencing
January 1, 1852, and extending to December 31, 1859,
the last report being printed in the early part of 1861.
The South Carolina annual reports of registration of
1 See paper by E. W. Gilliam, Popular Science Monthly, xxii., 433.
tality was 17.28 per 1,000.
District I. includes Delaware, Maryland, peat of Columbia, Virginia, West Virginia, and North Carolina.
res ° issouri.
South Carolina, Florida, Alabama, and Georgia.
Louisiana, Arkansas, and Texas.
the colored, 163.8, per 1,000 of women between the ages
of 15 and 49. The birth-rate is always higher among the
poorer classes of a population, and it is doubtful whether
the birth-rate of the negro is higher than that of the labor-
ing classes among the whites. The mortality among the
colored infants in the earlier months of life is much heavier
than among the whites in the same localities. For ex-
ample, in the ten grand groups just referred to, out of
each 1,000 infants born the number which died under six
years of age was, for the whites, 66.7, and for the colored,
71.4. This fact tends to increase the birth-rate among
the colored, because with the loss of the infant, and con-
sequent cessation of nursing, the probabilities of a fresh
pregnancy increase. The marked difference between the
vital statistics of the white and colored in the South is
much greater in the cities than in the rural districts, as
will be seen from the following table.
The average mortality in a population of a little over
43,000,000 whites was recorded as 14.74 per 1,000 ; while
in a population of 6,752,000 colored the recorded mor-
It is known that each of these
recorded death-rates is much lower than the actual one,
owing to failure to record the whole number of deaths
626
THE MEDICAL RECORD.
[December 7, 1889
occurring during the census year ; but it is also known
that the proportion of failures to ‘record was decidedly
greater among the colored than among the whites, and
hence the difference between the death-rates of the two
races is even greater than that indicated by these figures.
two races under comparatively similar circumstances than
we now have.’
The data are insufficient to bear out any definite con-
clusions and the above can properly be put in the form
of questions only.
Birth-rate per #000 of Living Population.
i
rth-rate per 1,000 of |
Bi
Aggregate population. living population.
t
Colored. White. | Colored. ,
|
the South containing’
cities and large towns. „129 | 586, i
28.71
Fifty-one counties in deer
35.08
591,336
ie | Cored,
Twenty-three counties in! m i
|
a 34-31
39.46 |
How far is this excessive — in the colored popu-
lation due to race characteristics? Is it due to peculiar
susceptibility on the part of the negro to certain distinc-
tive forms of disease, or to his having less vital force and
capacity to resist disease and death? Undoubtedly the
great mass of the colored population is poor and ignorant,
lives in the dampest and dirtiest parts of cities, and in the
midst of unhealthy surroundings, and is in other respects
unusually exposed to well-recognized causes of disease.
The statistics of 1880 show that the colored race is
peculiarly liable to fatal results from certain forms of
disease, especially consumption, pneumonia, diarrhceal
diseases, affections of pregnancy, scrofula, and venereal
diseases ; and that, on the other hand, it is much less lia-
ble than the white race to fatal results from cancer,
diphtheria, diseases of the nervous system, scarlet fever,
and suicide.
Notwithstanding the interest and importance of the
question, we have at present no sufficient data to deter-
Increased
onlin oF of col-
6.37
5-35
- [Born and dying during Increased
er-
Increased per- | census year per 1,000 of propan Increased | pro-
' centage in ur-! births, apd b orn fan over rerai i or-
| ban over rural dd d
| counties. H a5 ying ur-
| White. | Colored, | P8 0casus year.
1.22 100.01 | 140.06 40.05 i 11.66
62.66 | 91.0 28.39 | A
In studying the causes of disease and death in com-
munities, a very important point to be considered is the
relative poverty, ease, or luxury in which different parts
of the population live—or the sickness and death-rates of
so-called social classes.
That extreme poverty, producing inability to obtain the
amount of food, clothing, and shelter requisite to preserve
health is a direct cause of high death-rates, especially in
Northern climates, is known to all; but the extent to
which this factor of -want influences the death-rates in dif.
ferent countries or communities is by no means easy to
determine, and thus far we have, for the most part, only
data bearing indirectly upon this subject. For the provi-
dent and presumably well-to-do classes we have the sta-
tistics of life-insurance companies ; but these are for sc-
lected lives, which fact tends to give a low death-rate
during the early years of the policy-holders, while, on the
other hand, the tendency to cease paying annual dues and
to give up the insurance Ìs greater in those who are well
Annual Rate of Mortality in Various Classes of the Population of Dublin at Different Age-periods during the
Four Years 1883-1886.
AGE.
Occupation or social position eames cane naa Gee
| All ages. o | 5 20 40 6o and upward
a a es, Se “= i fore ae - fae ee ak ae eee a Pee =
Years of life....... 1,406,124 151,853 / 40O,III 490,174 | 260,459 | 103,527
All persons 05.553 Sis debe Gas ceean ee Ges” Sees ie eens Deaths ........... 39,476 12,365 3,335 6,519 7,652 | 9:405
Rate per 1,000 28.07 8.143 8.84 13.30 29.38 f go.85
b
Years of life....... | 122,198 9113 28,950 37,832 26,987 19,316
Professional and independent class............ eese i Deaths ........... | 1,857 187 ec 237 350 l 998
& Svea Rate per 1,000 ..... 15.20 20.12 2.94 i 6.26 12.97 l 51.67
Years of life....... 230,212 25,097 73,439 84,535 36,077: 11,064
Middle class........reeso.sooeoeossesrseseseseeoe 1 Deaths... 6,034 1,462 we 587 1,171 1,073 1,741
Rate per 1,000 26.21 58.25 | 7-99 13.85 29.74 | 157.36
, Years of life 430,493 52,299 129,588 141,909 | 79%705 į 26,992
Artisan class and petty shopkeepers............... Deaths .........-. 9,902 3.602 1,123 i 1,621 1,883 1,664
Rate per 1,000 l 23-00 69.05 8.67 11.42 23-62 | 61 65
; ; Years of life....... | 623,221 65,344 168,134 ! 225,898 117,690 | 46155
General service class, including workhouse inmates. < Deaths ..... ...... 21,683 7,105 1,740 3:490 4:346 5,002
Rate per 1,000 .... | 34-79: | 108.73 10.35 | 36.93 |
mine whether the negro, under the same circumstances as
to poverty, etc., is, or is not, more prolific or short-lived
than the whites, and absolutely no data of any value
for determining the relative fecundity and mortality of
the mixed bloods, including mulattoes, quadroons, Oc-
toroons, etc. An effort will be made in the coming
census to supply this deficiency as far as possible. In
the enumeration of the population those of mixed blood
will be recorded separate from the pure blacks and the
pure whites, and an effort will be made to obtain corre-
sponding records of death in order to determine the death-
rates of these mixed bloods. An effort will also be made
to determine the birth- and death-rates of certain classes
of poor and ignorant whites, such as the tenement-house
population in our Northern cities, as distinguished from
those of the mass of the white population, which will give
us a better means of comparison of the mortality of the
and strong than in those who have reason to suspect that
they are diseased, so that the death-rates in the greater
ages are higher in the insured than in those not insured.
We can only draw some inferences from the vital statis-
tics of occupations, from tenement-house statistics, etc. ;
but it is very difficult to distinguish between effects of
density of population, occupation, race, intemperance,
' Dr. Berenger-Feraud, in a note on the fecundity of the mulattoes
of Senegal, published in Revue d’Anthropologie, ad Series, vol. ìi.,
1879, page 577, gives the details with regard to the offspring of 118
females of mixed blood, and concludes: 1st, That the union of a
white man with a negress in Senegal produces children appercony of
good health; ad, the offspring of these mulattoes between themselves,
when there is no further intrusion of pure black or white blood in the
descent, gives children who are usually sterile; 3d, when there is a
new addition of white blood after the first generation, the offspring
are less vigorous, the number of the girls becomes greater than that
e the boys, and the girls are often sterile with a strong tendency to
abortion.
December 7, 1889]
THE MEDICAL RECORD.
627
uncleanly habits, and actual want of the necessaries of
life.
One of the latest systematic attempts to enumerate the
population of a city by social classes, and to obtain cor-
responding reports of deaths so as to give death-rates, is
that made in Dublin by Dr. Gnmshaw, the results of
which are shown in the table opposite : `
In this connection may be mentioned the statistics col-
lected by insurance companies among the Quakers or So-
ciety of Friends, both in England and in this country.
In 1830 Mr. Robert Rankin published a table showing
the probability of life among the Society of Friends in the
city of Bnstol, England.
The superior expectation of life shown in this city led
to the establishment of a Friends’ Provident Insurance
Institution in the following year, due to the belief that the
members of this society had a superior longevity ; but oe
parties concerned, with their usual business sagacity, di
not invest money on a mere belief. ‘They set to work
and collected all the registers of Friends in different parts
of the kingdom, with births and deaths, from which a
table ° was prepared showing that at birth the expectation
of life was:
At iS yeaS sc. ong Suh an aw es enews ee te: eas 41.8
ACA? | to ccteh san eaueeutoeee nee awe arare 45-3
ACIS PS cate Scien scare ae sane dca taaieaer ete baw Grate ae oe eas 42.1
BOE 2g E E E E E ace eral AE EET 39.2
ALGO AE AET EENE AE EAS 33-3
BEG! A cara E E T 21.2
PE 00-288. urera aNu waa ha 14-7
The tendency now is to accumulate the best and the
worst of the race in the cities. They draw to them the
most enterprising, vigorous, and prudent, whose tendency
is to late marriages and few children, and thus tend after a
time to lower the standard of the race. “ Where the
tendency is to replace a feeble and lower race by a better
one there is progress, where the tendency is the reverse
there is decay. ‘Ihe hope that by increased knowledge,
charity, and co-operation, the feeble, the sickly, and
incompetent can be so cared for that they shall become
strong and vigorous, is that held by most men of the pres-
ent day, but there is nothing in the laws of heredity which
gives any foundation for this hope.” _
What is to be the outcome of this modern civilization ?
“ Its enemies are not without but within—not savage na-
tions on its borders, but dwellers in its own cities.” ‘The
general tone of modern European literature is pessimistic
as to the future, filled with doubts and fears as to what
the coming supreme democracy will do. In this country
it is more hopeful, and looks forward to progress in im-
provement in the physical conditions of the. race, though
admitting the dangers and difficulties which this very phys-
ical improvement tends to produce. But, whatever be the
views of individual thinkers and writers, on one point all
can agree, and that is as to the desirability of having at
our command definite, positive information as to the char-
acter, amount, and set of currents of this stream of hu-
man life in different countries and localities. An impor-
tant part of such knowledge is that which relates to the
composition of, and changes in, the population in differ-
ent countries, which is the special field of vital statistics.
(To be continued.)
SYNTHETIC CARBOLIC AcıD.—Carbolic acid is now pre-
pared synthetically by a German chemical house. It is
claimed that many of the unpleasant effects of the ordi-
nary carbolic acid are due to the impurities that it con-
tains, and that these are not produced when the synthetic
preparation is used, as the latter is chemically pure.
a —— — eee ee
1 From British Medical Journal, 1887, vol. ii., p. 343.
2 See Insurance Cyclopedia, vol, v., p. 144; also table on p. 147,
comparing expectation of life of F riends with those of the general
population, and showing a decidedly higher average for the former.
Compare with this, on p. 150, the mortality table for the Society of
Friends in Philadelphia, prepared by Chase, in 1875.
Original Articles,
maio MM
ONE OF THE CAUSES OF TYPHOID FEVER.
By WM. THORNTON PARKER, M.D.,
NEWPORT, R. 1.
Von GIETL, in his work’ “ Die Ursachen des Enter-
ischen Typhus in München,” defines typhoid fever as “a
specific, putrid, intoxication disease (Intoxications-krank-
heit), which is composed of a chain of diseased processes
which are dependent upon one another, but which do not
retain a regularity either in number or in succession. Its
local effect is a catarrh of the alimentary canal ; the
further and peculiar result a swelling of the glandular
apparatus as well of the mesentery as the mucous mem-
brane of the intestines. Exfoliation and ulceration gen-
erally follow, the final effects being mortification in all
degrees. The lower grades of typhoid infection agree
perfectly in their manifestations with the simple form of
putrid infection. ‘These last originate by inhaling and
swallowing air already vitiated with foul odors, and loaded
with poisonous materials. A most frequent cause of this
is to be found in little, narrow, over-filled sleeping-rooms,
with closed doors and windows, or when in these rooms
decaying materials are to be found, or the vapors pene-
trating the atmosphere of the room from outside. More-
over, the typhoid fever is also putrid infection, but with
specific character that manifests itself through the engender-
ing of a specific poisoning in the body sick, and thereby
affording immunity from a second attack ; therefore the
typhoid must have a certain individuality. Whether the
typhoid fever can originate by a collection of certain
favorable circumstances recognizable, or whether its germ
must be taken into the system, is at present unknown.
Observation has, up tothe present time, been unable to
solve the question, but it is beyond doubt that foulness
animates the typhoid poison and favors its development.
Observation proves further that fecal material finding its
way into drinking-water caused the severest form of ty-
phoid ; that the typhoid fever can remain resident and
persistent in a house for years; that now and then, in
hospitals, barracks, or tenement houses, fhe infection lo-
cates itself in certain rooms while those occupying the
neighboring rooms escape altogether.” ‘These are but a
few quotations from the admirable work of Von Gietl
already alluded to. No man has had greater opportuni-
ties to study and investigate typhoid fever, and no one has
more faithfully improved such opportunities than Von
Giet. ‘The teacher of Lindwurm, Liebermeister, Von
Ziemssen, and many other more or less distinguished in
researches concerning typhoid fever—how seldom we see
his name quoted! ‘The master-mind as professor of gen-
eral medicine at the University of Munich, and in charge
of the great wards of the General Hospital of that city,
where there is more typhoid fever to be studied than in
any other city in the world, Von Gietl’s opportunities cer-
tainly were extraordinary. Pepper, in his admirable ‘“‘ Sys-
tem of Medicine,” quotes Budd, the student, but not the
master. Fagg refers to Von Gietl as well as to Budd, his
student, and states that the Munich theories are now
widely adopted. I should like to quote more from Von
Gietl’s work, for it is worthy of more careful notice,
although many who believe in the bacillus typhosus would
consider Von Gietl’s conclusions altogether too old-fash-
ioned for them. And yet one at least of the old-fashioned
conclusions of Von Gietl has been brought very forcibly to
mind by the recent fatal outbreak of severe enteric fever
on the U. S. S. New Hampshire.
As a student of von Gietl in Munich, in 1872 and 1873,
! T well remember one of his theories concerning the origin
of this fearful disease. Those who have visited the large
houses of Munich, and of other German cities, still re-
1 Conclusions concerning the Causes of Wore Fever in Mu-
nich, by Professor Von Gietl, translated by Thornton Parker in
The Sanitarian.
628
THE MEDICAL RECORD.
[December 7, 1889
member that each house has a large privy vault, from the
main shaft of which smaller passages lead to the seat of
the privy. These passages are as large as a man’s body un-
til they connect with the main shaft, which is very large.
A simple wooden cover covers the seat when the privy is
not in use ; the instant it is removed a strong current of
foul air loaded with fecal matter rushes into the room.
For an American accustomed to our more cleanly privies
this stench is intolerable. On entering a German house
we notice the halls contain more or less of this fecal odor
—the rooms next to the privy, although not communicating
by a door except through the hall, are noticeably odorous
with fecal matter. This odor has actually penetrated
through the walls, windows, and doors. Now von Gietl,
upon examining a patient admitted into the General Hos-
pital in Munich, suffering from typhoid fever, would in-
variably ask the patient if his room were next to a privy-
room, and if he noticed a privy odor in the room. Very
often the answer would be—yes.
I mention this to show that von Gietl believed that ex-
posure to continued fecal odor, without other contagion,
would develop typhoid fever. Now, there are many other
old fashioned theories, pushed aside by those who are col-
lecting the various specimens of bacilli, which are well
worth remembering. It is difficult for some men, myself
included, to believe that we have one bacillus for typhoid
fever, another for cholera, another for diphtheria, another
for scarlet fever, another for phthisis, another for gonor-
rhoea, and so on ad infinitum, until our collection of these
interesting little creatures would rival in number the coins
of a numismatist. More easily believed and understood is
the paper of Dr. Griffith on the “ Unity of Poison” in
scarlet, typhoid, puerperal fevers, and diphtheria, erysipe-
las, sore throat ; certain forms of diarrhoea and allied ail-
ments, in pleurisy, pneumonia, and pleuro-pneumonia, and
many other affections heretofore usually considered to be
separate and entirely distinct diseases.
Would it not be fair to assume that the unsanitary con-
ditions surrounding the United States ship New Hamp-
shire were sufficient to propagate typhoid fever on board
that vessel—without the appearance of the bacillus typho-
sus to properly start the mischief, according to the scien-
tific theories of some of our modern investigators ?
The United States ship New Hampshire is an old-
fashioned “ man-of-war,” which, on clear blue water, might
have been a safe and healthy home for double the number
of men and boys who have lived on her during the past
five or six years ; but in an abnormal element, #.c., resting
in a mud hole, and surrounded by mud and all uncleanness,
and with tonsof fecal matter piled up around her bows, she
could hardly have been considered a safe resort for human
beings. The fecal element was certainly in the majority
here, and the atmosphere loaded with fecal matter en-
tered the ports on its death-dealing mission. Her brave
old sides of oak, which would have held her gallant crew
in safety in the good old days, gave no protection to this
new and treacherous foe, when she had been dragged from
her normal element into the unnatural and filthy place in
which so many of her crew received their death-wounds in
the shape of typhoid fever.
It is not my intention to magnify the fact that fecal odcr,
or the gases escaping from large quantities of decompos-
ing fecal matter, can produce typhoid fever, but merely to
protest against the claim that, given a case of typhoid
fever, the bacillus typhosus must have had some influence
in its causation. ‘That many different shaped bacilli can
be found in the discharge of patients suffering from vari-
ous disorders, there can be no doubt. Many admit that a
sufficient quantity of these same bacilli may, under favor-
able conditions, induce disease ; but it seems to me more
reasonable to suppose that decomposition of animal and
vegetable matter is more frequently the cause of prevent-
able disease, rather than that the emigration of particular
bacilli is to be the principal cause recognizable.
It is not the intention of this paper to bring forward
a theory of odor as the principal causation of typhoid, or
to deny the germ of disease which may go from one
person to another through the medium of air, water, or
food, but merely to call for a recognition of the theory of
von Gietl, that fecal odor alone—if continued and suffi-
ciently strong—can, and often does, develop typhoid fever,
and that this theory has had a very startling illustration in
the many deaths which have occurred from the infection
received on board the United States ship New Hampshire.
I believe that true science does not tend toward such
a complication of terms and theories that the average
mind stands appalled on contemplation, but that knowl-
edge simplifies and makes easy what before seemed incom-
prehensible ; and that, even as with machinery, the attain-
ment of the more perfect is the employment of the more
simple. So, as we advance in medical science, we will dis-
cover how much of truth there is to be found in the theory
of unity in disease. We have the foul conditions obtaining
which I have just referred to, and at one time an epidemic
of scarlet fever will result, at another diphtheria, at an-
other more or less severe diarrhoeas, and as in this instance,
at another typhoid fever. Filth and health are directly
antagonistic. Nature abhors filth, and strives in every
way possible to get rid of external or internal waste or
foul substance. Filth lowers the health, and if it be not -
destroyed is itself the destroyer of life; but in accomplish-
ing this work, it may do so in many different ways and
yet exhibit itself only in one exciting cause or in a com-
bination of causes—foul air, foul water, foul privy vaults,
decaying animal and vegetable matter. I believe the
time will come when the remarkable exploits of the many-
shaped and many-named bacilli will be one of the curiosi-
ties of medical literature. Dr. Griffith’s admirable illus-
tration of unity of poison is shown in this extract from his
writings concerning the series of evolutions—symptoms—
resulting from dissecting wounds received while operat
ing on the bodies of those who have died of peritonitis :
* One will die rapidly, say in twenty-four or forty-eight
hours, from acute blood-poisoning ; another will have mul-
tiple abscesses; another abscesses and pneumonia or
pleuru-pneumonia ; another the same, plus meningitis, or
even in addition kidney or liver mischief in more or less
acute stages; another all the preceding, plus pericardiac
and cardiac affection, leaving or not, if the patient recover,
permanent cardiac mischief ; another, in whom a tendency
to phthisis exists, will fall into true tubercular consump-
tion—the multiple abscess stage preceding it or not in
the course of evolution and development of the materies
morbi.”
Burdon Sanderson has shown that, starting with a
simple irritant inflammation, he can produce a virulent
specific poison reproducing its like and killing either by
pyæmia or more slowly by tubercular disease.
A CASE OF TUBAL PREGNANCY SUCCESS-
FULLY TREATED BY ELECTRICAL FCTI-
CIDE.
By GEORGE M. EDEBOHLS, A.M., M.D.,
GYNECOLOGIST TO ST. FRANCIS HOSPITAL, NEW YORK.,
Mrs. E——, aged thirty-three, native of the United
States, has always enjoyed most excellent health. She
is the mother of two children, aged five and a half and
three and a half years respectively. Last confinement,
December 2, 1885 ; no miscarriages. Menstruation began
when fourteen years of age, and has occurred with the
most invariable regularity ever since, except when inter-
rupted by gestation. Her last regular menstruation oc-
curred March 22, 1889. ‘The non-appearance of the
menses four weeks subsequently, and the occurrence of
slight morning sickness, led to the suspicion of pregnancy.
April 23 to 30, 1889.—Repeated severe colicky pains
in lower part of abdomen, especially on night side.
May ist.—Examination shows uterus of normal size,
ightly retroverted (first degree). External os somewhat
soft and slightly patulous. To right of fundus a small,
December 7, 1889]
tender mass, taken at the time for a partially prolapsed,
and probably inflamed, right ovary. Excessive tender-
ness prevented a thorough search for the right ovary in
its normal position.
May 5th to 13th.—Méetrorrhagia, more free than at
periods, accompanied by colicky pains, and the discharge
of a few small shreds.
May 13th.—Tubal pregnancy strongly suspected. Hem-
orrhage controlled by tamponing vagina with iodoform
gauze.
_ May 13th to 21st.—No further hemorrhage, but per-
sistent colicky pains, and pains down anterior parts of
right thigh. Daily examination showed mass to right of
uterus to be steadily and rapidly increasing in size. A
positive diagnosis of tubal pregnancy of the right side
was now made, based upon the following considerations :
1. The symptoms, above detailed, of an incipient gesta-
tion.
a tumor in the region of the right tube, where it was posi-
tively known that nothing abnormal had previously ex-
isted. 3. The accompanying of this development by
metrorrhagia, labor-like pains, and the passage of shreds.
On May 22d I accompanied Mrs. E—— to the office
of Professor T. Gaillard Thomas, to whom I stated my
diagnosis. Dr. Thomas was prevented by pressing en-
gagements from making an examination, an appointment
for which was made for the following day. On the way
home the patient was suddenly taken with the most excru-
ciating abdominal pains, fainting, vertigo, and symptoms
of collapse. Her pulse became rapid, small, and thready,
and her countenance blanched. Immediately upon reach-
ing her home, which was accomplished with the greatest
difficulty, I injected fifteen minims of Magendie’s solution
hypodermatically. Cessation of pain and improvement
of general symptoms followed. At my request Dr.
‘Thomas very kindly saw the patient with me in the even-
1ng, made a careful examination, and confirmed the diag-
nosis of tubal pregnancy. He considered that an im-
minent rupture had been prevented by the morphine.
Electrical foeticide was agreed upon as the treatment to
be pursued.
May 23d.—Electricity applied by Dr. E. L’H. Mc-
Ginnis, in the presence of Dr. Thomas and myself, with
every preparation made for an immediate laparotomy, in
case of the occurrence of untoward symptoms. A round
electrode was applied in the vagina against the mass, and
a flat electrode on the abdomen over the site of the tumor.
‘The slowly interrupted galvanic current, 75 milliampéres,
applied for ten minutes, gave no pain, although it pro-
duced violent spasmodic contractions of muscles of ab-
domen and of right lower extremity.
The electrical applications were repeated in the same
manner and with the same results on May 25th, 27th,
30th, June 3d and 6th—six applications in all. During
this time the patient suffered much from pains in the
lower part of the abdomen, more of a quiet and steady
than of the previous colicky nature, accompanied by a
slight rise of temperature (up to r00$° F.) and pains and
soreness in the abdominal muscles. The latter I attrib-
uted to the violent contractions produced by the electric-
ity. The pains on two occasions called for hypodermics
of morphine for their relief.
June 2d.—Patient seen by Drs. Thomas and W. R.
Gillette. ‘The latter concurred in the diagnosis and ap-
proved the treatment.
June 15th.—Menses reappeared, normal in duration
and amount, and painless.
Dr. Thomas examined Mrs. E—— toward the end of
June, and verified the cessation of growth of the tumor.
_ November 21st.—Patient has remained perfectly well
since June 6th. On two occasions excessive exertion
was followed by dull pain in the right groin, lasting for
one day. With this exception, there has been absolutely
nothing to remind her of her former trouble. Examina-
tions at intervals have enabled me to follow the gradual
diminution in size and final disappearance of the mass,
THE MEDICAL RECORD.
2. The development and rapid, steady growth of
629
without any further treatment. To-day nothing abnormal
can be found in the pelvis by bimanual examination.
I have thought it worth while to place the case on
record for the following reasons: 1st. Because the sub-
ject of uterine gestation and its treatment is one of lively
interest just at present. 2d. Because the diagnosis, care-
fully and deliberately arrived at, and confirmed by two
such eminent authorities as Drs. T. G. Thomas and W. R.
Gillette, cannot reasonably be questioned. 3d. Because
of the entirely satisfactory results of the treatment em-
ployed—the destruction of the foetus and its complete ab-
sorption within six months, without having exposed the
mother to the perils and possible sequelz of a laparotomy.
198 SECOND Avanus,
CATARRHAL NEURALGIA.'
By A. G. HOBBS, M.D.,
ATLANTA, GA.
I HAVE purposely not used the term catarrhal headache,
or catarrhal browache, because both are too restrictive to
cover the condition that I desire to discuss.
By catarrhal neuralgia I mean to include not only the
headaches and browaches that are caused by the pressure
from nasal hypertrophies or foreign growths, but all re-
flex pains that have for their origin pressure in the nasal
cavities, whether they be located in the forehead, the
temples, across the bridge of, the nose, or over the cheek-
bones. That such reflex pains do occur, and have for
their cause pressure in the nasal cavities, was known long
ago, and I might quote authorities, but I consider that to
do so, before the Fellows of this Association, would be an
unnecessary waste of time. When we consider the great
number of sensitive nerves, with their different sources,
that supply the nasal and adjacent mucous membranes,
reasoning from the abstract we might conclude that reflex
pains would be caused by any pressure upon these mu-
cous membranes and their underlying tissues, but I am
sure that I am warranted in saying that it 1s the expsrience
of everyone here that such pains not only exist, but have
their origin in nasal hypertrophies or neoplasms. If these
pains were only occasional, or of short duration, they
might not demand so much of our attention, but in many
cases the pains are more persistent than the neuralgias
from any other cause, and they, many times, produce a
more profound impression upon the general system, indi-
cated by a sense of lassitude, a haggard expression, a mal-
assimilation, and a decided loss of weight.
Much has been written recently on headaches and
browaches caused by uncorrected errors of refraction,
and it cannot be denied that such reflex pains, often
accompanied by nausea and dizziness, frequently have
their origin in asthenopia and astigmatism. Such symp
toms are reflex in character and have their origin in the
ciliary region of the eye, a part so abundantly supplied
with peculiarly sensitive nerves. While we should not
be hasty in diagnosing the origin of such reflex symptoms,
I do not consider it difficult to differentiate between the
eye and the nose, as the cause, when the two do not co-
exist. Ocular headaches are more intermittent, usually
following a prolonged use of the eyes; catarrhal neural-
gia persists longer at each attack and usually follows a
coryza. Ocular headaches, if severe, are often accom-
panied by nausea and dizziness ; catarrhal neuralgia rarely,
if ever, causes the latter symptom.
When the eye is the cause, the pain is situated in the
front part of the head and temples; when the nose is the
cause, the pain is not only in the head and temples, but
it may extend downward into the facial bones. Both
causes may coexist in the same case, when relief can be
effected only by both correcting the error of refraction
and reducing the nasal pressure. In such a case only a
partial relief would be reached if either of the causes
were neglected.
1 Read at the Seventh Annual Meeting of the American Rhino-
logical Association, Chicago, October 11, 1889.
630
THE MEDICAL RECORD.
[December 7, 1889
I have no statistics bearing upon the comparative fre- | them evinced some mild asthmatic symptoms, in addition
quency of catarrhal and ocular neuralgias other than my
own note-book of the Jast three years. Init I find 54
cases under the combined headings: Cafarrhal neuralgia,
ocular headache, and catarrhal and ocular neuralgia com-
bined. ‘Thirty-six cases occur under the first caption ;
14 cases under the second, and 4 cases under the third.
My recollection is that I have placed no one of these
cases under its respective heading except where the pa-
tient applied particularly for relief from some of the
above-mentioned neuralgic symptoms. In the great ma-
jority of these cases the patient had no clear idea of
the cause of his trouble, and, indeed, in many of them, he
had “gone the rounds,” and had taken all the anti-neu-
ralgic remedies mentioned in therapeutics, or, I might
say, mentioned in the current circulars of enterprising
drug-houses. It may be that the preponderance of ca-
tarrhal over ocular neuralgias, occurring in my note-book,
is due to the fact that I treat more nasal than eye cases ;
but it is my opinion that the nose, more frequently than
the eye, is the cause of the reflex neuralgias.
After recognizing the etiology of a case exhibiting these
reflex pains, on account of the severity of the pain, tem-
porary relief should be given the patient by the application
of cocaine sprays, or, in the case of complete stenosis,
the cotton probe saturated with cocaine first, then the
sprays. ‘The effect should then be to reduce the press-
ure permanently by the means that is most rapid.
If the pressure be due to a polypus, extract it; if to a
deflected septum, remove the deflection ; and if it be, as
is most likely the case, due to an hypertrophy, reduce it
with the galvano-cautery, the snare, glacial acetic acid, or
chromic acid. I find myself most frequently resorting to
the latter. After the removal of the pressure, pain ceases
to a great extent, if not entirely; then the more soothing
treatment of vaseline sprays, in combination with cocaine,
pinus canadensis, oil of terebene, or oil of eucalyptus, daily
or tri-weekly, will complete the resolution.
Many cases that are essentially acute, due to a recurrent
attack of an old hypertrophy, may be relieved by a few
well-applied cocaine sprays; but, if left in this condition,
the patient will be subject to a recurrent attack at the
next coryza.
I will amplify only a few cases from my note-book.
Mr. H—--, about thirty years of age, commercial trav-
eller, came to me with excruciating pains in his forehead,
temples, across the bridge of his nose, and over the cheek-
bones of the left side ; had been subject to these attacks
for three years, each time he caught cold ; had had no re-
lief from medication except, when insensible from mor-
phine ; attacks lasted from three to ten days. Upon ex-
amination, both nasal passages were found closed from
acute coryza. After opening the passages, by inserting
cocaine on a cotton probe, sufficiently to introduce a spray
of cocaine and vaseline, relief followed almost instantly.
He was th „a instructed to use cocaine in a vaseline spray
during the remainder of the afternoon and evening as of-
ten as was necessary to keep the passages open. He re-
turned the next morning, having had but slight recurrences
of pain during the interim. At this treatment, after thor-
oughly opening the passages with cocaine in a vaseline
spray, I touched the more prominent hypertrophies lightly
with glacial acetic acid and ordered the continuance of
his spray at less frequent intervals. At his return the
following day he reported himself entirely free from neu-
ralgia, and when I had thoroughly removed the acid
sloughs, the nasal passages were comparativelyopen. The
patient left town that day, without pursuing the treatment
as I advised. Three months afterward he felt an attack
coming on in a neighboring city, when he started at once to
me. After giving him relief as before, he consented to re-
main three weeks, during which time I treated him in the
conventional way for nasal hypertrophy. In writing to
me two weeks afterward, he said he had never had a re-
currence of his attacks. I find in my note-book fifteen
Other cases similar in most respects to this one; some of
to the facial and brow pains.
The same treatment was effectual in all of these cases,
without an exception.
I will now describe a case more chronic in its nature.
Mr. W—, aged thirty-two, gave me his history as fol-
lows : About six months previous to his first visit to me
he began having severe attacks of neuralgia in his face and
forehead, when shortly afterward the pains became almost
constant, and he had asthmatic symptoms at night; he
was oppressed by a feeling of malaise ; lost his appetite
and strength, and his weight decreased from two hundred
and ten to one hundred and thirty pounds in a few months.
After exhausting the skill of his family physrcian he went
for six months to a hydropathic institution, thence to an-
other sanatorium for two months more. In the meantime
he had taken many anti-neuralgic and tonic remedies.
When I first saw him the pains in the forehead, temples,
across the bridge of the nose, and over the left malar bone
were almost constant; he had nightly attacks of asthma
in a mild form, but sufficient to interfere with his rest ;
he had a haggard complexion, was weak, and weighed only
one hundred and thirty pounds. Upon examining his
nasal cavity I found a septum deflection on the left side
and a large turbinated hypertrophy just opposite. In ad-
dition to this, a posterior nasal examination revealed a
large polypus which completely occluded the left chonz ;
the right side was also in a hypertrophic condition. The
right nasal passage had been almost constantly occluded
for six or eight months. He said it had not been sus-
pected before, that his nose had anything to do with
his trouble. The polypus was removed with a Sajous
post-nasal snare at the first sitting, when a partial opening
was effected. I do not consider it wonderful when I say
that he had no severe pains after the first sitting. He was
instructed how to use cocaine in a vaseline spray, to pre-
vent the recurrence of the pains. My treatments were
continued at first daily, then tri-weekly, and weekly for
months, until he was entirely relieved of his nasal trouble.
He began to regain his strength and weight at once, and
he had, at no time, anything more than a trifling recur-
rence of neuralgia.
It is not eighteen months since I completed his treat-
ment ; he weighs two hundred pounds, and has had no
sign of neuralgia since the treatment ceased.
I find in my notes five cases similar in many respects
to this one, particularly in that they were of long stand-
ing before their etiology was i The nasal
features of these cases were not the same, except that
pressure existed in all. :
I will describe a case to show that both nasal pressure
and refractive error may he the combined cause of these
reflex neuralgias. Mrs. R——, aged thirty-six, came to
me with the symptoms described above, together with
nausea and dizziness after having made the slightest at-
tempt to read or to do any close work. I first thought I
had a case of refractive error plain and simple ; so I par-
alyzed the accommodation and corrected the astigma-
tism, which was moderate in degree. She was greatly
relieved, to the extent that she had no nausea and dizz1-
ness after reading, which act she performed better than
ever before. There seemed, however, to be but little, if
any, relief from her forehead and facial neuralgia, which
continued to nag her at intervals. After ten days I ex-
amined the nasal cavity, which I had failed to do before,
when I found a decided hypertrophy over the turbinated
bones of both sides. Not until this was removed, after a
treatment of six weeks, was she entirely relieved of all
her symptoms. While at a summer-resort during the
following summer she broke her glasses, and in trying to
do without them she had a slight return of browache, and
when she tried to read, a tendency to nausea and dizziness
followed. After receiving her new glasses there was no
return of any of her symptoms. I find in my notes three
other cases similar in many particulars to this one.
I know of no class of cases that apply to us tor relief
December 7, 1889]
in which treatment can give more prompt and satisfac-
tory results; indeed, when we make no mistake in the
etiology the result is absolutely sure, if we resort to means
that are effectual in removing the pressure upon the ter-
minal sensitive nerves that are distributed to the nasal
mucous membrane.
Clinical Depariment.
A CLINICAL NOTE ON CHLOROFORM
WATER.
By HARVEY B. BASHORE, M.D.,
WEST FAIRVIEW, PA.
CHLOROFORM water has lately proved to be of much value
to me in the treatment of false croup, and is in this af-
fection superior, I think, to chloral, in that it is not so
dangerous and is eliminated in part'by the lungs; of
course, its action is purely loca] and its value, too, prob-
ably due to the sedative effect upon the sensitive filaments
of the superior laryngeal nerve.
I use a solution consisting of five to ten minims of
chloroform to an ounce of water, to which is added a little
glycerine to aid the solubility of the chloroform. A tea-
spoonful of this is given every half-hour during an attack,
and if there is any dyspnoea the following day, a tea-
spoonful is given every two hours, increased in frequency
to every hour during the evening. |
This method of treatment—which is especially appli-
cable to those cases in which the dyspnoea and cough con-
tinue during the day—I have used very successfully.
CONGENITAL ABSENCE OF RIGHT TESTIS—
ECTOPIA OF LEFT—OPERATION FOR ECTO-
PIA—RECOVERY.
By HAMILTON WILLIAMS, M.D.,
BROOKLYN, N. Y.
Mr. ——-, of Brooklyn, aged twenty-three, consulted me
early in September last. He complained of a tumor in
the left groin, which, of recent years, had troubled him
very much, interfering, by reason of attendant pain, with
locomotion, and with the discharge of the sufficiently
laborious duties of his calling. The upper limit of the
tumor reached to within a few lines of the level of the
external abdominal ring, while its inner border was dis-
tant somewhat more than an inch from the line of de-
scent of the cord. The size was that of a pigeon’s egg.
Some pressure was necessary to elicit pain, and then it
was hardly of the sickening testicular type, though, indeed,
the latter had a rather awkward knack of “ materializing”
when the patient walked much or lifted weights. ‘There
was no moving of the tumor from its bed, but in it
there was a possibility of some slight axial rotation. ‘The
scrotum was empty on both sides, and of no more than
two-thirds normal size. The diagnosis was that of
ectopia of the left testis. No trace was to be found of
the nght. The patient attributed his condition to a fall
when about twelve years of age, but the absence of cicatri-
cial marks and the testimony of his mother attested its
congenital origin. He was otherwise well built, and might
have been deemed robust, were it not for extreme nervous
debility, hesitating, faltering manner, and unfixed gaze. He
was much depressed from a prolonged experience of
“ wet dreams,” “ spermatorrhoea,” want of “ courage” in
the society of women, and the dismal categories of the
advertising quacks. I operated on September 17th. An
incision was made over the tumor. ‘The coverings were
precisely those of the testicle within the scrotum, save
that the superticial fascia of the groin answered for the
dartos. On passing through the parietal layer of the
tunica vaginalis, the gland was easily lifted from its bed,
but extensive adhesions, some possibly inflammatory in
THE MEDICAL RECORD.
631
origin, stood in the way of its traction in the direction of
the scrotum. The adhesions were torn through without
avail, and I began to fear the cord would prove too short
for the journey. An upward and inward extension of the
incision revealed a looping of the cord between the
globus major and the external abdominal ring. Further
adhesions extending into the canal maintained this looped
condition. The cord, straightened out by the severance
of the adhesions, gained sufficiently in length, but with
none to spare. It was evident that others affected it
within the ring. An incision was now made from near
the lower extremity of the former downward and inward
to the scrotum and along its side, yet somewhat poste-
riorly. The inner side of the pocket formed by the parie-
tal layer of the tunica vaginalis was next freely torn
through. This had hitherto, after the manner of a parti-
tion wall, stood across the road to the scrotum. The re-
moval of the gland with an intact parietal covering would
have necessitated overmuch dissection to no useful pur-
pose. ‘The testicle was now placed on the scrotum, and
retained in position by sutures attaching its lower end to
the base near the septum. Having closed the wound, I
put a second line of sutures through the scrotum, so as to
confine closely the testicle between them’and the septum.
That I found to answer well. All was done under the
strictest antisepsis. ‘There was absolutely no suppura-
tion, and even the precaution was not taken of providing
for drainage in the dependent portion of the wound. He
made a perfect recovery, being out in ten days. Every
symptom and consequence of perverted functional activity
of the gland left ahead of the sutures. ‘The constraint of
the gland, in its iftegular site, brought about all the nerve
trouble with advancing manhood. Even from the artistic
stand-point of the nude and antique, he is a much more
available Apollo. He himself spoke of “ being a man at
last.” In conclusion, it may be noted that a firm band of
fibres, shooting from the extremity of the testis on to-
ward the perinzeum, and attached probably to some por-
tion of the pubic arch, perhaps as far back as the ischial
tuberosity, showed the anomaly to spring from an irregu-
lar origin of the gubernacular cord.
UR4AEMIC CONVULSIONS CONTROLLED BY
MORPHINE.
Dr. F. J. Bowes, of New York City, reports the follow-
ing case: “On October 7th, C. D——, aged thirteen,
gave the ordinary symptoms of malarial poisoning. When
seen on the 28th, for a cold, she had improved, although
headaches were still complained of. On the same day her
mother came with her and called my attention to an ab-
dominal distention and a slight puffiness about the eyes,
saying, as she did so, that she believed these conditions,
together with headaches and an irritability of disposition,
had been present for the past few months. Some of
these symptoms were thought to be the result of the bad
drainage, ventilation, etc., of the school house where she
was attending school.
“ Upon the addition of nitric acid to the urine, albumin
was precipitated to the extent of one-half the column. I
would mention in this connection, as having a possible
bearing on the cause, a habit our patient had acquired at
a very early age of retaining her urine, until obliged by
discomfort to void it. It was not an uncommon thing for
her to retain the urine after retiring at night, until her re-
turn from school, on the afternoon of the following day.
“ After discovering albumin on the 28th, I adopted
measures for increasing the activity of the skin, bowels,
and kidneys. In this I was partially successful, until the
night of October 7th, when there was total suppression,
with urzemic convulsions. Impressed with the gravity of
the case, I called in Dr. Sumner A. Mason, when further
efforts in the same direction were made. Between the
hours of twelve at midnight on the 7th, and four in the
afternoon of the 8th, she had twelve convulsions. At
#
632
THE MEDICAL RECORD.
[December 7, 1889
that hour I called and found her in the last of a series of
three. The pulse was uncountable, respiration shallow
and irregular, and the general condition such as to point
to a speedy dissolution.
“ Believing that the means employed to bring about an
action of the kidneys had been interfered with by the con-
vulsive seizures, it occurred to me that if I could procure
perfect relaxation an action might yet be secured. ‘To
this end I gave a hypodermic injection of morphia sul-
phate guarded by atropia sulphate. The effect was all
that could be looked for. The convulsions were arrested,
the pulse came down to ninety, respiration became uni-
form and tranquil, and a quiet sleep ensued. In a few
moments I was gratified to find there had been a copious
flow of urine. The recovery from that time to the pres-
ent has been uninterrupted. The albumin, which very
nearly filled the column, has totally disappeared under
appropnate treatment.
“ What impressed me as being of special interest in this
case, and which led me to report it, were the importance
of examining the urine of patients with headaches, and
the value of morphine given at the right time.”
Progress of Medical Science.
THE ACIDS OF THE STOMACH.—There is no doubt that
the chief acid found in the stomach during natural diges-
tion is free hydrochloric acid. ‘This has been abundantly
proved by Bidder and Schmidt, and numerous observers
succeeding them (Zhe British Medical Journal). ‘The
methods used are, however, too long and too complicated
to employ in clinical work. The physician wishes to
know what, in a particular case of disease, are the chemi-
cal changes going on in the stomach: whether, for exam-
ple, hydrochloric acid is present as well as pepsin and
organic acids. Now, in the examination of the contents
of a diseased stomach three forms of acid may be pres-
ent—hydrochloric acid, a mineral acid ; organic acids,
such as lactic acid, butyric, etc.; and thirdly, acid phos-
phates. It is chiefly of importance to determine the
presence of hydrochloric acid and of organic acids.
Many methods have been proposed for doing this; they
consist mainly in testing the effect of the stomach con-
tents on various colored solutions. ‘Thus a solution of
methyl-violet is decolorized by hydrochloric acid, so that
if this reaction is obtained the free acid is present in the
liquid tested. Lactic acid turns the violet a dirty yellow.
Tropzolin also is turned deep reddish-brown by free
hydrochloric acid. Unfortunately these tests, simple as
they appear, are not accurate, since the reactions are in-
terfered with by the presence of peptones and of some
neutral salts, and, as these are usually present in the
stomach contents, no reliable results can be obtained by
using methyl-violet and tropxolin. They have been
superseded by congo-red, which is turned blue by free
hydrochloric acid, and by a solution of vanillin and phlo-
roglucin in alcohol, which is turned a deep red by the
same acid. These simple clinical tests are, however, ren-
dered useless by the fact that they are interfered with by
the presence of peptone, ammonium salts, chlorides, and
phosphates. In the present state of our knowledge, there-
fore, there is no reliable indicator for the presence of free
hydrochloric acid in the stomach contents. Other meth-
ods which may be used are too complicated for clinical
use. Thus ether has the property of dissolving organic
acids from a liquid, leaving the mineral acids in solution.
It may thus be used for separating the lactic, butyric, and
other acids from the hydrochloric acid; and if, in a
liquid obtained from the stomach, it is found that ether
removes the whole of the acids present, it may be con-
cluded that no free hydrochloric acid is present. In
many cases this conclusion would be an important one as
a clear indication for a line of treatment. Dr. Leo has
lately published a new method for the indication of free
hydrochloric acid which may prove useful. Leo con-
siders the case where it is only a question of the presence
of free hydric chloride and of an acid phosphate. To a
few drops of the stomach contents a pinch of carbonate
of calcium is added ; if the acidity, as tested by litmus
paper, disappears, only a free acid is present, but if the
liquid is still acid after the addition of the chalk, an acid
salt is present. If, moreover, organic acids be present
they must be first removed by shaking with ether before
the chalk is added. It does not seem that Leo’s method
is one that can be applied at the bedside, because the de-
tection of free hydrochloric acid is chiefly requisite in
those cases in which organic acids are also present, as in
cases of dilated stomach. At present, indeed, a ready
method, suitable in clinical practice for the detection of
free hydrochloric acid in organic liquids, is a desideratum.
THE PsYCHO-MOTOR ORIGIN OF DELIRIUM.—M. Ritti, of
Charenton, read a paper recently on the psycho-motor
origin of delirium,,in the name of a colleague. As those
of language, the troubles of the intellect should be attri-
buted to sensorial and motor lesions ; there is no form of
mental disease in which these latter are more manifest
than that of mania (Zhe Medical Press). It is by de-
pression of the psycho-motor energy that the patient feels
himself isolated from the outside world, and by its ani-
mation in the state of excitability, irritability, that ideas
of greatness, strength, etc., seize the individual. In the
discussion which followed, M. Gamier said that, although
he agreed in part with what had been read, he could not
help remarking that in general paralysis or softening of
the brain, in second and third period, ideas of grandeur,
etc., attain their maximum, although the motor power is
diminished to its lowest ebb. M. Regis spoke on four
cases of hypocardriacal lypemania, and gave the distinct
signs of lypemania and softening of the brain, which he
enumerated as follows : The delirium of softening of the
brain presents a character of absurdity, stupidity, and in-
coherence. It appears suddenly, is mobile and inconsist-
ent, the patients speak without conviction and do not
contradict, and are slow to speak on their sufferings, while
the reverse obtains in lypemania. ‘The patient discourses
constantly on his affection, seeks to convince those around
him, and gets angry when contradicted. In softening of
the brain, the delirium takes sometimes the form of great-
ness, ambitidn, etc., but nothing of that sort is witnessed
in lypemania. The delirium of softening of the brain is
not benefited by morphia, as in the case of the other form.
The former comes on between the ages of thirty-five and
forty-five, while lypemania is observed at a more ad-
vanced age, and more frequently in women than men in
the ratio of eight to twelve; ideas of self-destruction,
voluntary mutilation, apprehension of not being able to
die, etc., are frequent, but for many years the intellect re-
mains intact and the mind lucid. ‘The examination of the
viscera gives generally a negative result, but a saburral
state of the tongue, inertia of the stomach, constipation,
a frequent pulse, and progressive wasting is often witnessed.
A cure is possible.
THE TREATMENT OF INGROWING NAIL WITH TIN FOIL.
—Dr. Theodore Clemens recommends the following treat-
ment: After thoroughly cleansing the diseased parts with
soap and water, and then drying, the edges of the nail are
covered with one or two layers of tin-foil. The strips of
tin-foil are held in position by a thin layer of yellow wax,
care being taken to place the strips on all places where the
nail is in contact with the flesh. This packing need only
be renewed two or three times during the first few weeks,
the procedure being simple, painless, and easily carried
out by the patient.—J/nternational Fournal of Surgery.
CHOLERA IN Persta.—A correspondent of the Bulletin
Medical, writing from Teheran, says that cholera in a
virulent form exists throughout the valley of the
Euphrates, and it is feared that it will become epidemic
in Persia. |
December 7, 1889]
THE MEDICAL RECORD:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., EDITOR.
PROPRIETORS AND PUBLISHERS
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
New York, December 7, 1889.
THE ABOLITION OF THE TITLE OF DOCTOR.
CounrTING the druggists, corn-doctors, horse-doctors, den-
tists, chemists, clergymen, and philosophers, the number
of persons not physicians who receive and are addressed
by the title of doctor (or “ doc”) must nearly or quite
equal that of the medical profession.
The title is therefore not a distinguishing one, nor does
it carry with it any especial respect, call forth any peculiar
- deference, or ddd ordinarily to one’s social advantages.
The number of “docs” and doctors in this country is
enormous and burdensome. he name is sounded in the
ear at every corner, and in every form or kind of gather-
ing. ‘The citizen goes to Dr. A for his preaching, to Dr.
B for his teeth, to Dr. C for his horse, and to Dr. D for
his corns, while his wife goes to Dr. E for her nails and
to Dr. F for her malaria ; and the result is that the aver-
age family of modern New York lives in a delirium of
“docs” and doctors, who are continually engaged in the
patchwork of the body or soul.
The question occasionally arises, and is seriously dis-
cussed, whether it is not time for self-respecting physi-
cians to consider the propriety of dropping the title of
“doctor” in their intercourse with their fellows alto-
gether, and leave it to the dentists, the veterinarians, and
philosophers. This title is not used by English surgeons,
and they seem to be not the worse in reputation or less
skilful and successful in practice.
There was a time when a special title, a peculiar cos-
tume, and an affected air and deportment were essential
to the physician. Without their “cassocks and mules,
they could not have duped the world,” said Pascal. Now
people are beginning to depend on physicians because
they have learning and experience and skill; not because
of their deportment or pretensions. We say they are be-
ginning to do so; and we are forced to confess that it is
only a beginning.
But the magic of the name of “ doctor ” has long gone;
it is as non-distinctive, weak, and effacive as that of a
“colonel” in Kentucky, or a “corporal” in Hayti. It
simply identifies a man in a crowd as being one of two
hundred thousand “docs” and doctors who are diffused
through the land.
The time will come, and is coming, when medical men
will be glad to stand on the same plane as other profes-
sions and classes, and be before the world plain “ Mr.,”
a title which is considered good enough for the President
of the United States.
THE MEDICAL RECORD.
633
Some day there will be founded, we trust, a Society for
the Abolition of the Title of Doctor, and of the slavery
of learned gentlemen to that most noxious of invocatives,
“ Doc.”
THE GARTER AND VARICOSE VEINS.
Just as the garter has begun again to become an objet
de luxe and to receive the thought and inspiration of
artistic minds, the sanitarian has put his foot down and
said that the gacter is a source of disease. By constrict-
ing the limb it impedes the flow of venous blood and >
leads to the production of varicose veins, oedematous
ankles, and other morbid conditions. Such has been the
view taken at a recent discussion of the subject by Eng-
lish physicians. We fancy that the garter, like many others
of the things of this life, may be a thing of beauty, or of
evil; it may adorn loveliness, circumscribe angelic out-
lines, and support comfortably and artistically and health-
fully the superior circumference of knit goods ; or it may
constrict, asphyxiate, and puff up sound and symmetrical
limbs into varicose and variegated ugliness. Those who
have seen dispensary service can recall the heavy Irish
ladies who sit down and laboriously untie the tght
string or dirty rag which holds up the stocking, and expose
the varicose ulcer} rich in excretions and blushing
pklegmonously over its state. This represents, no doubt,
the worst phase of the garter, and the class of cases in
which it may do harm.
But, as a rule, the garter is a source of no disease.
Varicose veins occur oftener in men than in women, and
proportionately oftener in athletes and men trained to
severe exertion. There are many things, indeed, which
cause them, and artificial constriction of the limbs seems
to be a very remote and rare factor. In England we are
told that the demand for “ anti-varicose” stockings is
chiefly made by full-fed men who lead sedentary lives and
drink more wine than is good for them. A wearer of the
anti-varicose stocking feels worse after a series of dinner-
parties, when the tempting varieties of the menu lead him
to indulge too freely in the pleasures of the palate.
_ Obviously, no very bad case can be made out against
the garter, provided it is a good garter, combining the
maximum of support with the minimun of constriction,
blending harmoniously with the hosiery and the circula-
tion. The garter has come to stay ; and the doctor had
better prescribe a proper kind than preach its abolition.
OUR STATE INSANE.
Ir is understood that at the next meeting of the State
Legislature another effort will be made to pass a law re-
quiring all county insane, except those of New York and
Kings, to be sent to State institutions.
The care of pauper insane by the counties, though much
better than it used to be, is still in many cases inhuman
and disgraceful.
In most of the poor-houses where the unfortunates are
kept the expense averages but twenty cents a day, while in
one county it has been reduced to eighteen cents.
The plan of transporting the insane to large and prop-
erly equipped hospitals, under the care of experienced
medical officers, is endorsed by all who have investigated
the subject impartially, and is only opposed by a clique of
634
politicians who use the county institutions as “spoils,”
and desire to make as much out of them as possible.
It would be more just and wise, an@ eventually more
economical, to erect such new State asylums as might be
needed, and have the pauper insane of the counties trans-
ferred to them.
The only objection to this plan that can be made is
that there would be waste and extravagance in putting up
these new buildings. ‘This is unfortunately a valid objec-
tion, but not by any means an insurmountable one.
AT IT AGAIN.
Our talented townsman, Dr. W. P. Northrup, appears
again in the rôle of contributor to Scribner's. In the
Christmas number just issued is an interesting and graph-
ically told story of the habits and religious customs of the
Bretons. The pardon of Ste. Anne d’Auray is the sug-
gestive title to the sketches, which are handled with rare
skill and judgment. The conception centred upon a sum-
mer vacation in Brittany and a psychological study of a
very curious people. It is well worth reading. It shows
how a medical man can spend his vacation with pleasure
to himself and profit to his readers.
SPECIAL HOSPITALS FOR PHTHISIS..
THE recognition of the contagiousness of phthisis, and
of the importance of prophylaxis in connection with this
disease, has given rise to an active discussion regarding
the advisability of having separate hospitals for phthisical
patients. ‘The matter is being agitated especially in Ber-
lin, and, no doubt, there will soon be some practical out-
come. It is desirable not to alarm unduly the public on
this matter ; for phthisis is not very contagious and is, in-
deed, practically non-transmissible to those who have not
the proper soil. But it would be advisable, for many rea-
sons outside the contagiousness of the disease, to have
these special hospitals. The treatment of phthisis, if |.
properly carried out, requires much attention and skill,
and the employment often of special apparatus.
Such special treatment could be much better given if
the cases were placed together, either in a single hospital
or separate wards. City hospitals, in particular, could
deal better with phthisis if they had country branches to
which curable cases could be sent.
HEIGHT AND WEIGHT IN THEIR RELATION TO
HEALTH.
THE body weight of adult men ranges from 60 to 70
kilogrammes, according to Quetelet. Krause gives a
mean of 64 kitos., Beneke, of 63.074, and Busch, of 65.1.
For women the range is 52 to 56; and the mean for men
according to Vierordt is 65, for women §5, kilos. ‘The
average height of young American students of the age of
twenty-three years, as determined by measurements of Dr.
H. Gihon, is 172 centimetres (68.-+ inches).
The weight at this age was 61.2 kilos. (140 lbs.),
while the weight at this age, as determined by Quetelet,
was 64.5 for men and 55.2 for women.
Bernhardt established the following formula: Assum-
ing H to equal the body height, C the circumference of
the chest at the mammary line, and W the body weight,
then for an average constitution W = $f.
THE MEDICAL RECORD.
When the
[December 7, 1889
denominator falls to 209.76, the individual has a feeble
constitution ; when it reaches 256.8, it indicates a very
robust constitution.
_ It has also been determined that there is a relation be-
tween body weight and height which undergoes certain
definite laws. ‘The weight reaches its greatest amount at
about the fortieth year, and then sinks as old age comes on.
The greatest height is reached at the age of about
thirty ; then there isa slight decrease, which in old age
may amount to 6 or 7 centimetres. >
The height and weight of man are, according to Que-
telet, l
At Height Weight.
o ara A E E E wes 172.2 | 68.90
40th t? NEET acct Wee eae 171.3 68.81
Dom. Se Sue eat atppecanewaetees 167.4 67.45
Goth: OE) ee ore acta ie sass 163.9 65.50
POU , obe Pe eeewtewe yy tee ust 162.3 63.03
We give the foregoing figures in connection with some
recent observations upon weight, height, and disease made
by Dr. J. Foster Bush, medical examiner for the Ameri-
can Legion of Honor. In his report for the years 1887
to 1889 he analyzes the mortality statistics of that period,
including 1,464 deaths. He gives tables showing the height,
weight, and cause of death. He finds that in phthisis,
cancer, apoplexy, and renal disease, there was a very large
proportion above or below the average of weight to
height, and that not more than two or three per cent. hit
the mean. In apoplexy, cãhcer, cardiac, and renal dis-
eases, the greater number were above the average of
weight to height; in phthisis the greater number were
below.
Gihon’s tables show that in a given number of healthy
young men about one-fourth are of mean height and
weight, while about five per cent. are above or below
what is taken as a normal range.
The figures given by Dr. Bush are not of very great
value, for he does not state how much above or below
the average his cases were, and it is admitted that there
is anormal range. They do call attention, however, to
the fact that a wide departure from a normal average in
the mean height and weight indicates, as a rule, a defect-
ive constitution. Physicians would do well, therefore,
to make themselves familiar with the physical measure-
ments of their patients. ) .
According to Gihon’s table, the height of students at
twenty-three is 172 ctm. (66 in.), the weight 63.5 kilos.
(140 Ibs.) | l -n
The mean height of 1,486,039 adults, mostly recruits
and soldiers, was 172.08 kilos. (67.75 in.); the average
weight of 32,584 adults was 64.55 kilos. (142.30 Ibs.); the
average chest-girth 87.68 ctm. (34.52 in.). This would
indicate for the American constitution, according to Bern-
hardt’s formula, the following :
64.55 = “esr
which places the male constitution of this country rather
below par average.
A Nurse Dies BY AN ETHER EXPLOSION.—At a pri-
vate hospital in this city, conducted by Dr. W. ‘Tod Hel-
muth, a nurse lost her life by an explosion of sulphuric
ether. She was in the act of pouring ether from one bot-
tle to another, and is supposed to have been too near to
a gas-light. Fatal burns were the result of the accident,
followed by death about forty-eight hours later.
December 7, 1889]
THE MEDICAL RECORD.
635
Mews of the Week.
Dr. FLORENCE O. DoNnoHvE, of Syracuse, N. Y., who
was recently appointed a member of the local Board of
Health by Mayor Kirk, received yesterday a commission
naming him a member of the State Board of Health.
TREPHINING FOR GENERAL PaRAtysis.—Dr. T. Claye
Shaw reports a case of advanced general paralysis, in
which all the mental symptoms disappeared after trephin-
ing and opening the dura mater.— British Medical Four-
nal,
ENGLAND CONTRIBUTES TO THE PASTEUR INSTITUTE.—
At a meeting of the Pasteur Institute Fund, held in Lon-
don recently, it was unanimously resolved to transmit to
M. Pasteur the sum of 40,000 frs., on behalf of the Insti-
tute, as a grateful acknowledgment of the services ren-
dered by him to English patients.
CINCINNATI has a hew hospital, called Christ’s Hos-
pital.
AN EPIDEMIC OF INFLUENZA IN Russia.—The daily
papers announce that St. Petersburg is suffering from
a curious epidemic of influenza. Practically everybody,
_ from palaces to the lowest hovels, catches this disease,
which lasts three or four days and causes great annoyance.
Over forty thousand cases have already been medically
reported in St. Petersburg alone, with the result that many
mills and factories have had to close, and it is difficult to
get cabs on the streets. The malady is now reported as
appearing in Moscow and in far Siberia, and everybody is
depressed over the unaccountable thing.
CREMATION IN Paris.—The cremation furnace in Père-
la-Chaise Cemetery, in Paris, is now complete, and the
Prefect of the Seine has approved the scale of charge to
be enforced thereat. The charge for the use of the crema-
tion furnace is to be 50 francs, which sum includes the
keeping in the columbarium of the funeral urn containing
the ashes for a period of five years.
SHOCKING DEATH OF A VIENNA PuHysICIAN.—Quite
a gloom has been cast over Vienna medical circles by the
death of a young pathologist in the General Hospital
here. Two months ago a patient died in the hospital of
glanders caught from a horse, and Drs. Rowalski and
Hoffmann subjected the body tu experimental observa-
tions.. The bacillus of glanders was readily discovered,
reared, and its behavior closely watched. The animals
injected with it died of the horrible malady. During
these observations Dr. Hoffmann caught cold and felt
acute pains in his side, to allay which he injected mor-
phia. He did this with the syringe he had used during
the glanders experiments. Although it had been disin-
fected, some particles of the poison must have still been
in it, for Dr. Hoffmann grew worse every day, and last
week he succumbed in horrible agony, his body being
covered with ulcers, which, when examined, proved to
be filled with the glanders poison.— Medical Press.
PROFESSIONAL CARDS IN NEWSPAPERS.—THE Southern
California Practitioner says: “ The convenience of hav-
ing one’s professional card im the daily paper cannot be
denied ; it enables the regular patients to tell when they
may find you at your office. It informs them of the num-
ber of your telephone, both at office and residence ; and
the column also furnishes an index of practising physi-
cians for the stranger. But a great deal of unfairness is
connected with the present system. In this city, at least,
the daily papers have no classification ; regulars, homceo-
paths, and quacks all come in the same list. It would
be a very easy matter, by referring to the official register,
to put the legal regular physicians under one heading, the
legal homoeopaths and legal eclectics either before or after
the regulars, and then illegal practitioners in a place by
themselves. As it is now it is a game in which only the
honest doctors lose ; the barnacles of all the ’pathies hope
to gain custom by sandwiching their cards in among those
of the legal physicians. We suggest as a cure that regu-
lar physicians cease to advertise in the daily press.”
THREATENED STRIKE AMONG MEDICAL MEN.—It is
not often we are troubled with a threatened “stnke” in
the medical profession, but from the feeling present
among the district medical officers of Moravia and Bo-
hemia such a phenomenon is imminent, as they consider
the fees and salaries, as well as the present stringency of
the sanitary laws, inadequate and intolerable. Petitions
signed by every medical officer have been forwarded to
the provincial diets praying for redress. The result is
awaited with much anxiety and suspense.—Medica/
Press.
ALBUMINOUS Foon IN BRIGHT’S DISEASE.—Senator and
Semmola have both agreed that albuminous food should
not be given to invalids suffering from Bright’s disease.
Dr. Schreiber has been devoting his attention to this sub-
ject experimentally, and now concludes that a rich diet
of white of egg, raw, mixed with other nitrogenous foed
stuffs, has no effect on the urine either in the healthy
subject or the one afflicted with Bright’s disease. On the
contrary, he finds that when the albumin is given in solid
form it checks the amount of albumin secreted in Bnght’s
disease. He quotes two cases of Leyden’s in support of
this view, as well as a case of Semmola’s, where album-
inous diet was prescribed and zo increase of the albumin-
ous secretion was observed.
PARISIAN PHYSICIANS ON SHOW.—An American sur-
geon, visiting the Parisian hospitals, writes: “ The fact
that hospitals have their clinics and shows at eight or nine
o'clock in the morning makes the effort to attend bad
for lazy people. Fortunately I am located near that
model of hospital structure, the new H6tel-Dieu, and
most of my sight-seeing has been there. R——, the
crack surgeon, is getting old, and shows much shining
pate. I never saw a man examine a case more thoroughly.
Jolly little K——-, him of speculum fame, I believe, han-
dles women in a way that would excite execration at home,
and which I can’t believe is proper anywhere. To expose
women from their feet to their breasts, without the com-
forting pretence of a sheet, and to punch their abdomens
as if he were going to dig the uteri out through the walls,
is not the way to make the examination chair a joy and
delight. I saw one young woman of some personal at-
tractions, and who seemed to have some modesty left,
although she was a low-class Frenchwoman, tremble as
if in ague during the ordeal, and shriek with pain when he
forced his very short forefinger up to the cervix as if he
intended to carry all before him.” .
636
THE MEDICAL RECORD.
[December 7, 1889
THE TWENTIETH ANNIVERSARY OF THE NORTHWEST-
ERN MEDICAL AND SurcicaL Soctety was celebrated by
a large reception of ladies and gentlemen, on Wednesday
evening, November 27th, at the house of Dr. T. H. Bur-
chard, No. 7 East Forty-eighth Street. About one hun-
dred guests accepted the invitation of the Society, among
whom were lawyers, clergymen, and physicians with their
wives. A fine musical programme was rendered by well-
known artists, and by members of the Society. The
guests were received by the officers and their wives. Such
social episodes vary the monotony of scientific work in
a medical society; and when properly managed these
gatherings bespeak a healthy life and tone to medical
bodies. ‘The officers of this Society are: President, Dr.
A. M. Jacobus; Vice-President, Dr. S. Baruch; Secre-
tary, Dr. E. S. Peck.
DIAGNOSTIC VALUE OF THE SALOL TEST IN MOTOR
INSUFFICIENCY OF THE STOMACH.—We recently referred
to this test as being one of value in determining the motor
activity of the stomach and the absorptive power of the
intestines. Dr. J. Decker, of Münich, now comes for-
ward (Berlin Klin. Woch.) and denies its value. From
his clinical tests he finds that in healthy stomachs the time
of reaction may be delayed as much as in disease.
THE KinG OF PoRTUGAL, who recently died at the age
of fifty-two, was an extremely interesting case. He had
suffered from diabetes for a long time. Two years ago he
developed a large lymphoma on the shoulder. Later he
had symptoms of myelitis, and finally a curious skin affec-
tion, diagnosticated by Professor Neumann as multiple
gangrene. Professor Neumann received a fee of $20,000
fot his diagnosis. ‘The King had eleven physicians in at-
tendance on him at thé time of his death.
THE First CONGRESS OF POLISH SURGEONS was held
at Cracow on October 16th and 17th, under the presi-
dency of Professor Rydygier.
THe EIGHTH CONGRESS OF RUSSIAN NATURALISTS
AND PHYSICIANS will be held at St. Petersburg from De-
cember 27, 1889, to January 7, 1890. It will consist of
eleven sections, two of which are devoted to “ scientific
medicine ” and “scientific hygiene,” respectively.
SACCHARIN.—The importation of saccharin has been
for some time forbidden by France, Spain, and Portugal ;
Italy and Hungary have now followed the example of
these countries. In Belgium a duty of 140 francs a
kilogramme is levied, not only on saccharin, but on all
products containing more than fifty per cent. of it. In
Holland a duty of 60 florins a kilogramme will probably
soon be imposed on saccharin.
“ Hyoiga’s ” HALF CENTURY.—Our esteemed contem-
porary Hygiea, of Stockholm, celebrates the completion of
its first half-century in a magnificent number of nearly
six hundred pages, containing eighteen papers in Swedish,
French, and German, many of them illustrated by fine
lithographic plates. The journal was founded in 1839,
the first number having appeared in April of that year.
The secret of our contemporary’s success and long life is
revealed in the frontispiece, wherein are presented the
portraits of the editors in chief of the journal since its
foundation. We congratulate /ygica,.and wish it many
more semi-centennials. l
Obituary.
PROFESSOR RICHARD VON VOLKMANN,
HALLE, GERMANY.
RICHARD VON VOLKMANN was born August 17, 1830,
at Leipsic, where his father, Alfred William Volkmann,
was Professor of Physiology. From Leipsic Professor
Volkmann went to Dorpat, but returned in 1843 to Ger-
many, and became Professor of Physiology at Halle. In
1850 Richard commenced the study of medicine at Halle,
went afterward to Giessen, and finished his studies at
Berlin under the celebrated surgeon von Langenbeck. In
1857 he settled at Halle and became an assistant in the
Surgical Clinic under Professor Blasius. After the death
of that surgeon, he became (1867) Professor of Surgery
and Director of the Surgical Klinik, which positions he
held at the time of his death.
In 1866 he served as surgeon in the Prussian Army, in
the war with Austria, and in 1870-71, in the war with
France, he was Surgeon-General of the Fourth Corps
d’Armée. During this campaign, in his leisure hours of
camp-life, he wrote his celebrated “ Reveries at French
Hearths,” under the nom de plume Richard Leander, and
these musings of the great surgeon will always occupy a
prominent place among the works of German poets.
Volkmann introduced Lister’s antisepsis in Germany,
and followed it in all its details with excellent results ; he
was an indefatigable worker with the knife and the pen,
and his name will always shine as a brilliant star among
the surgeons of all nations. His “ Beiträge zur
Chirurgie” belong to the classical medical literature.
Since 1870 he published “Sammlung Klinischer Vorträge.”
He is the author of numerous monographs on surgical sub-
jects,and was engaged at the time of his death writing a
monograph on carcinoma. His investigations of diseases of
joints have thrown new light on this subject, and there is
probably no better authority on “ tuberculosis” than he was.
On Langenbeck’s retirement the chair of surgery at Ber-
lin was offered to Volkmann, but he preferred to remain
at Halle, where he died on December rst.
In recognition of his eminent services, Emperor William
bestowed in 1885 the rank of a nobleman on Volkmann.
Although broken down in health for several years, his
death was rather unexpected.
WALTER DE FOREST DAY, M.D.,
NEW YORK.
Dr. WALTER De Forest Day, for many years Sanitary
Superintendent of the Board of Health, died at his resi-
dence, in this city, on November 27th. Although he had
been suffering from an incurable illness since May last,
his death was sudden. Dr. Day was born, in 18365, in
Catskill, N. Y. He was graduated from Williams Col-
lege in 1859, and soon after began the study of medicine
in this city, under the late Dr. Willard Parker. He was
uated in medicine from the College of Physicians and
urgeons in 1863, but two years earlier he entered the
military service of the United States as a medical cadet,
and immediately after the battle of Bull Run converted
the Methodist church in Alexandria, Va., into a hospital
for the treatment of the wounded.
The efficiency with which he did this work gained for
him the task of organizing the hospital service for the
Army of the Potomac. The proficiency he displayed in
this field attracted the attention of Professor Charles F.
Chandler, who, when he was made President of the Board
of Health of this city in 1873, selected Dr. Day as the
best-equipped man for Sanitary Superintendent, He filled
the Chair of Materia Medica and Botany in the College
of Pharmacy for twenty-one years, and was for ten years
clinical assistant to the Professor of the Practice of Medi-
cine of the College of Physicians and Surgeons. He was also
connected, from time to time, with various hospitals and
dispensaries, and a member of several medical societies.
December 7, 1889]
THE MEDICAL RECORD.
637
Society Reports,
SOUTHERN SURGICAL AND GYNECOLOGICAL
ASSOCIATION.
Secona Annual Meeting, held in Nashville, T. enn., Novem-
ber 12, 13, and 14, 18809.
(Continued from p. 613.)
SECOND Day, WEDNESDAY, NOVEMBER 13TH — AFTER-
NOON SESSION.
THE papers of Drs. Davis and Brockaw were discussed
by Drs. W. O. Roberts, Virgil O. Hardon, B. E. Hadra,
A. M. Owen, Hunter McGuire, W. W. Potter, R. S.
Cunningham, G. Frank Lydston, Richard Douglas,
George J. Engelmann, W. E. B. Davis, and discussion
closed by the essayists.
Dr. B. E. Hapra, of Galveston, Tenn., read a paper
entitled
THE OPEN ABDOMINAL TREATMENT,
in which he said that abdominal surgery, notwithstand-
ing its immense progress, has not as yet given even a
moderate degree of satisfaction in acute diffuse septic
peritonitis. Chronic infectious processes offer much bet-
ter prospects for surgical interference, such as tubercu-
losis, actinomycosis, and the recently described microbic
peritonitis, of as yet unknown origin.
The points making the diffuse septic peritonitis are :
1. The extensive area of peritoneal surface. with its enor-
mous power of resorption of the poisonous fluid. 2. The
active secretion into the sac, and thereby furnishing cul-
tivating fluids for the germs. 3. The ready absorption
by the lymphatics of the diaphragm. 4. General distribu-
tion of the poison by intestinal peristalsis. 5. ‘he infec-
tion of the intestinal walls from without, and the additional
infection of the peritoneal cavity by transudation and im-
migration of germs from the inside of the bowels. 6.
Distention of the bowels, increasing the pressure and re-
Sorption. 7. The impeding effect of this latter condition
upon respiration, defecation, and secretion of urine, lead-
Ing to systemic poisoning by retained products of oxidiza-
tion. 8. In perforative cases the contamination by fecal
matter ; in stab and gunshot wounds by other impurities,
bile, urine, etc., and, above all, contaminated blood.
The indications for treatment, besides supporting the
patient's strength, relieving suffering, giving proper action
to the bowels, kidneys—in short, besides the general medi-
cal treatment—are: 1. To remove the obnoxious material
—germs, fecal matter, and urine. 2. To prevent its new
formation or a repetition of its entrance. The sac should
be kept dry to deprive the germ of its soil.
have to be mended, so that the channels of contamination
may not lead to the outside. 3. To prevent the bowels
from distributing the poison throughout the whole cavity.
4. To counteract pressure and suction, in order to prevent
resorption of the poison. 5. To prevent infection of the
peritoneum and the bowel. 6. To relieve pressure, in
order to avoid disintegration and paralysis of the different
structures. 7. To free respiration, defecation, and urina-
tion with tympanites as developed.
Dr. L. S. McMurtry, of Danville, Ky., read a paper on
TWENTY CONSECUTIVE CASES OF ABDOMINAL SECTION.
‘The series of cases comprised the first twenty abdominal
sections performed by him, and illustrated a variety of
pathological conditions and diverse complications. All
the cases were in private practice, and, with two excep-
tions, all the operations were done at the homes of the
patients. Two cases were treated as private patients in a
well-appointed hospital. In many cases operative treat-
ment was only accepted after all ordinary and so-called
conservative measures had been exhausted ; and in sev-
eral cases the operation was only accepted when the pa-
tient's condition was regarded hopeless by physician and
The breaks.
family. In no case, however desperate or complicated,
was an operation refused. In the twenty cases there
were three deaths.
The difficulties attending the diagnosis of intra-abdom-
inal disease are well illustrated. One case of tubercular
peritonitis and encysted dropsy was diagnosed by four dif-
ferent surgeons, before he saw the patient, as ovarian cyst.
‘The history and physical signs were characteristic of that
condition. On opening the abdomen it was found to be
encysted dropsy, the result of tubercular peritonitis.
Evacuation and irrigation were followed by quick recov-
ery, and, though the peritoneum was studded everywhere
with miliary tubercles, and the patient now sixty-eight
years of age, she remains to-day in perfect health and
activity.
A case of uterine myoma (Case No. 15) was also be-
lieved to be an ovarian cyst. ‘The tumor was very soft;
it was, besides, heavily cedematous, and fluctuated dis-
tinctly. ‘The history and general condition of the patient
tallied with deceptive diagnosis. It was only when the
abdomen was opened that he had realized he was to do
a supravaginal hysterectomy instead of an ovariotomy.
Seven of the cases recorded were ovariotomies. The
cysts were in every instance large, and had, with two ex-
ceptions, been tapped several times. One was a suppu-
rating cyst. The only death he had to record is Case No.
16, an ovarian cyst. The operation was done in a remote
part of the State, and without the essentials for protection
from sepsis.
Dr. McMurtry said thorough work, irrigation, and drain-
age, all conjoined, give the only basis of success in the
cases reported. In anumber of his cases he had operated
in the midst of active peritonitis, with vomiting and tym-
panites. In this condition of affairs he had witnessed the
most gratifying results from persistent and oft-repeated
exhibition of calomel, dropping two or three grains on the
tongue every hour until the bowels were freely moved.
Increasing experience has impressed him more and more
with the difficulties of abdominal work, and makes him
less confident of meeting often with simple cases.
He closed his paper with a plea for earlier interference
in abdominal diseases. When operations are done in
good time, before emaciation and exhaustion come, and
before repeated attacks of peritonitis have complicated
the comparatively easy task for the surgeon, then will the
surgeon’s results excel even the brilliant records of the
present time.
Dr. RicHarp Douc.as, of Nashville, Tenn., read a
paper entitled
COMPLICATIONS OCCURRING IN THE CLINICAL HISTORY OF
OVARIAN TUMORS.
The papers of Drs. Hadra, McMurtry, and Douglas
were discussed at length by Drs. Potter, Roberts, Stone,
Wathen, Engelmann, Hardon, Haggard, Lydston, Cun-
ningham, Brownrigg, W. E. B. Davis, and discussion closed
by the essayists.
EVENING SESSION.
Dr. G. Frank Lypston, of Chicago, Ill., read a paper
on
TROPHO-NEUROSIS AS A FACTOR IN THE PHENOMENA OF
SYPHILIS,
in which he called attention to the relation of disturbances
of the trophic function of the sympathetic nervous system,
which the author claimed were the essence of all the phe-
nomena of syphilis. He said: The relations of certain
syphilitic phenomena to organic or functional disturbances
of the nervous system, and particularly the sympathetic
system, are manifested here and there along the whole line of
morbid phenomena developed in the course of the disease.
Syphilitic fever is undoubtedly dependent upon the action
of a special poison upon the sympathetic nervous system.
From what we know of the trophic functions of the
sympathetic, we are justified in inferring that the majonity
638
THE MEDICAL RECORD.
[December 7, 1889
of fevers are dependent upon the action of a specific poi-
son upon the sympathetic ganglia. The syphilitic poison
may produce disturbances of the sympathetic, with per-
version of tissue-metabolism and excessive production of
heat. The inconstancy of the syphilitic fever is explicable
upon the ground of idiosyncrasy. The syphilitic roseola
has been demonstrated to be an exception to the rule that
syphilitic lesions are due to a collection of proliferating
cells. It is due to vaso-motor disturbance, with resulting
dilatation of capillaries. This nervous disturbance is de-
pendent upon the impression of the syphilitic poison upon
the sympathetic ganglia. The accumulation of cells in
the more pronounced lesions of syphilis is simply an ex-
aggeration of the normal process of tissue-building. As
is well known, such tissue-building is presided over by the
filament of the sympathetic nerves.
The symmetry of the peripheral phenomena of syphilis is
suggestive of some casual condition affecting the central
nervous system. As an illustration of the manner in which
a nerve-lesion could produce disturbed nutrition, the au-
thor mentioned herpes zoster. Some of the lesions of
syphilis which are difficult of explanation upon mechanical
grounds, s.c., upon the theory of localized cell accumula-
tion, are readily explicable by central or local nervous
disturbance. For example, the alopecia of syphilis is
similar to that which occurs in other diseases as a con-
sequence of local and general malnutrition incidental to
disturbed nervous supply—as, for instance, alopecia
areata, the alopecia produced by fevers, and the alopecia
produced by neuralgic affections of the head. ‘That the
nutrition of the hair is profoundly affected by nervous’
disturbances, is shown by the result of fright in producing
blanching of the hair.
One of the principal arguments in favor of the theory
that tropho-neurosis is the foundation of syphilitic pro-
cesses is the peculiar action of the disease when it attacks
certain parts, syphilis seemingly possessing the power of
dissecting out definite portions of osseous tissue (appar-
ently by cutting off their nutritive supply) in a manner as
cleanly as it can be done by the knife. Thus the speaker
has in his possession specimens of the intermaxillary bone,
portions of the alveolar process of the maxilla, the palatal
and nasal processes of the superior maxilla, the malar
and ossz nasi which became necrosed and were removed
from cases of late syphilis. These fragments present as
natural a conformation as in their healthy condition.
The ordinary explanation of destruction by pressure of
syphilitic exudate will not suffice in these cases. If they
be observed carefully, it will be found that the first symp-
toms experienced by the patient are those identical to the
presence of a foreign body, #.¢., dead bone in the tissues.
If pressure were the cause of the necrosis, the death of
the bone would be preceded by more or less painful swell-
ing and inflammation. <
He claimed that all of the pathological processes inci-
dental to syphilis are due to disturbances of nutrition pro-
duced by the impression of the syphilitic poison upon the
sympathetic nervous system, and that it is immaterial to
the cogency of this theory whether the poison of syphilis
be a microbe, bacillus, degraded cell, or chemical poison.
If any attempt has been made to show that tropho-neu-
rosis 1s the basis of all syphilitic phenomena, the author
1s not aware of it.
THIRD Day, THURSDAY, NOVEMBER
SESSION.
14TH— MORNING
Dr. Joun Brownricc, of Columbus, Miss., read a
paper on
GUNSHOT FRACTURES OF THE FEMUR,
in which he discussed the class of cases requiring ampu-
tation, and those in which a more conservative course
should be pursued. He exhibited several appliances de-
vised by himself.
Dr. Hunter McGuire, of Richmond, Va., read a
paper on .
THE TREATMENT OF CYSTITIS IN WOMEN,
which was followed by a paper on
THE TREATMENT OF CONTRACTED BLADDER BY HOF-WA-
TER DILATATION,
by Dr. I. S. Stone, of Lincoln, Va.
During the past few years certain protracted cases of
cystitis, occurring chiefly in women, have been observed
by Dr. Stone, which have resisted all known forms of
medical treatment, and necessitatea some surgical or
mechanical measure of relief.
He describes the manner of dilatation as follows:
The patient is given morphia sulphas (gr. +), atropia sul.
(gr. Igły), hypodermically. She is placed on her hack
on a table for convenience (although it would answer to
arrange the bed with the patient thereon to suit the oper-
ator). A soft catheter is at once inserted into the blad-
der, and after the urine has escaped hot water (tempera-
ture 110, °F.) is thrown into the bladder, until the patient
will no longer bear it. ‘This is allowed to escape, and is
measured, giving the full size of the bladder in its present
condition. As the morphia gradually becomes absorbed,
the patient will bear still further distention— each time
perhaps one drachm may be added to the capacity of the
bladder. I prefer using a rubber ball-syringe, holding
two to four ounces. The pressure of the hand is safer
than that of the tube or funnel, or any instrumental gauge,
as the patient generally is unable to resist the tendency
to strain, owing to tenesmus produced by the expansion.
As each séance should continue thirty to sixty minutes,
the bladder may be filled and emptied many times, and
at first the operator must be well satisfied if the gain is
only one or two drachms, in a bladder whose capacity is
perhaps only two ounces. As the patient becomes fully
under the influence of the morphia, the water may be in-
creased in temperature to 120° or 125° F. The very
best effect follows its use when at this temperature.
‘These papers were discussed by Drs. Lydston, Davis,
Engelmann, Roberts, Brokaw, Hadra, and closed by the
essayists. |
Dr. BeEprorD Brown, of Alexandria, Va., read a paper
entitled
REMARKS ON OBSCURE AND MINOR FORMS OF PELVIC
CELLULITIS SIMULATING MALARIAL FEVER.
By referring to his note-books he found some twelve cases
of pelvic cellulitis, some of a grave and others of a minor
form, but all so very obscure in their manifestation of the
presence of local lesion as to be well calculated to mis-
lead, and to cause a mistaken or false diagnosis to be made
of malarial fever. ‘There was nothing in these cases to
call the attention to the pelvic organs. He has in a num-
ber of instances seen these cases run their course from
beginning to end without manifesting the first symptoms
of local disease in the pelvis, so that the resemblance to
malarial fever was very nearly complete.
Dr. JOSEPH TABER JOHNSON, of Washington, D. C.,
presented a paper entitled
OBSERVATIONS BASED UPON AN EXPERIENCE OF SEVENTY-
TWO MISCELLANEOUS ABDOMINAL SECTIONS.
Of this number 29 were for the removal of ovarian tu-
mors varying in size from one to sixty-four pounds, 26
recoveries, and 3 deaths; 29 cases of removal of the
uterine appendages, with 27 recoveries, and 2 deaths; 7
supravaginal hysterectomies for large uterine fibroids,
with 3 recoveries, and 4 deaths; 1 Ceesarean section, death
on the tenth day ; 1 cyst of the kidney, weighing seventy-
four pounds, died of exhaustion ; 1 fatal case of extra-
uterine pregnancy, operated on six weeks after rupture,
general peritonitis, with pulse 130, temperature 103° F.
for the week previous ; a fatal case of general abdominal
cancer ; 3 exploratory incisions, all recovered. Total, 72
laparotomies, with 59 recoveries, and 13 deaths. |
December 7, 1889]
THE MEDICAL RECORD.
639
Of the 53 ovarian operations, the first 3 deaths were
the second, third, and fifth of his series. In the last 52
Ovarian operations there have been only two deaths ; one
of these was from tetanus occurring on the fifteenth day
after operation, when everything indicated a perfect re-
covery. The other was an insane patient who had been
four years in an insane asylum on account of nympho-
mania. She could not be entirely controlled, and her ef-
forts to get out of bed set up inflammation about the ab-
dominal sutures, causing an abscess which burst inter-
nally and caused death.
Dr. JOHNSON emphasized the statement that experience
in Operating was nowhere so valuable as in the abdominal
cavity ; that the “ unexpected” was so often found, that
many cases would be lost if the operator was not prepared
for and equal to the emergencies as they “ unexpectedly ”
arose.
The following papers were read bytitle: 1. ‘ Puerperal
Eclampsia,” by John Herbert Claiborne, Petersburg, Va.
2. “ Laparotomy in Intestinal Obstruction,” by Cornelius
Kollock, A.M., M.D., Cheraw,S. C. 3. “ The Causes of
Frequent Failure of Relief of Reflex Symptoms after
‘Trachelorrhaphy,” by W. F. Hyer, M.D., Meridian, Miss.
The following officers were elected : President—Dr.
George J. Engelmann, of St. Louis, Mo. ; First Vice-Prest-
dent—Dr. B. E. Hadra, of Galveston, Tenn.; Second Vice-
Prestdent—Dr. Duncan Eve, of Nashville, Tenn. ; Secre-
tary—Dr. W. E. B. Davis, of Birmingham, Ala.; Zreas-
urer—Dr. Hardin P. Cochrane, of Birmingham, Ala.
On motion, the ‘Association adjourned to meet in At-
lanta, Ga., the second Tuesday in November, 1890.
NEW JERSEY SANITARY ASSOCIATION.
Fifteenth Annual Meeting, held at the State House, Tren-
ton, N. J., November 22 and 23, 1889.
FRIDAY, NOVEMBER 22D—FirstT Day.
AFTER an address of welcome by Dr. Wetherill, chair-
man of the local Association, C. PHILLIPS BASSETT, of
Newark, read a paper on the
EAST ORANGE SEWAGE-DISPOSAL WORKS
as compared with other methods. ‘The question of sew-
age-disposal occupied serious attention from 1883 to
1886, as no system of sewage-application had been con-
structed in this country at all applicable to the conditions
found in East Orange ; viz., small available area of land
in the midst of a dense suburban population, and a high
degree of chemical purity in the effluent from the works,
which had to be turned into a small stream tributary to
the Passaic, close to the Newark and Jersey City water-
supply intakes. No other works have been constructed
in this country at all competent to meet such conditions,
a claim which was confirmed in discussion by other mem-
bers.
G. W. HowELt presented a report on the
PASSAIC RIVER DRAINAGE.
The river drains am area of eight hundred and thirty-
three square miles, with thirteen thousand acres hable to
be overflowed for four or five days at a time, owing to
the smallness of the fall of the stream. Dr. George H.
Cook in his lifetime devised a system to remedy this,
which is now in process of application. The Association
adopted a memorial to the memory of Dr. Cook.
THE IMPROVEMENT OF SANITARY CONDITIONS IN THE
HEALTH AND PLEASURE RESORTS OF NEW JERSEY
was the theme discussed by Dr. HENRY MITCHELL, of As-
bury Park. Dr. Mitchell says the summer-resort business
of New Jersey has reached the dimensions of one of the
great industnes of that commonwealth, so that enlightened
regard for self-interest demands the adoption of the best
possible sanitary measures; yet in many cases they were
entirely disregarded, as in the case of a “sanitarium” now
building, with several beautiful cottages, and a hotel to
cost $100,000, but without sewers or a public water-sup-
ply. He recommended increased powers of the State
Board, and publication of local shortcomings, to arouse
neglectful communities.
The paper on
THE CLIMATIC TREATMENT OF GASTRO-INTESTINAL DIS-
EASES IN CHILDREN,
by Dr. BoaRDMAN REED, of Atlantic City, was readtby
Secretary English. The question why a change of air‘ef-
fects such striking remedial results has never been satis
factorily answered ; but it is proba’.'e that there are 1n-
gredients peculiar to the atmosphe.e of every locality
that have a tonic effect at first, but later, like too long a
course of quinine, they cease to stimulate. The best
treatment of graver forms of summer complaint is the
preventive one, and the best prevention is removal from
large cities before the hot season begins.
A paper on
THE NEED OF MEDICAL OFFICERS FOR SCHOOL-DISTRICTS
was read by Dr. G. F. WILBUR, of Asbury Park. Stress
was laid on purity of water-supply ; on the arrangement
of light for rooms; on attention to thorough personal
comfort of children in position, support of limbs, etc.;
on dryness of the site selected for school-buildings; on
heating and ventilation of buildings, and on direction of
the exercise of students. He recommended that schools
be under direct and constant medical supervision. ©
The annual address of the President, Dr. DOWLING
BENJAMIN, on Friday evening, was on
THE THERMOMETRY OF HYGIENE.
He said the tendency to frequent colds and the progress
of civilization is to render the human race more feeble ;
so that every nation which has attained a high summit of
civilization has fallen into decay, and we can hardly hope
to be an exception. The question, “ What is a cold?” is
hard to answer, but we can describe the conditions which
indicate it; namely, inflammation and congestion of mu-
cous membranes of mouth, nose, etc. He reviewed the
etiology of colds, which are oftenest taken in the house,
and made practical suggestions as to methods of ventila-
tion, which should never be allowed in winter from a
cold, open window. He condemned the ventilation of
the State House, where they were meeting, animadvert-
ing on the misplaced foul-air registers near the ceiling,
whereas they should be below. He concluded by con-
gratulating the Association on the beneficent result to the
community of their labors, notwithstanding that sanitary
science is not yet generally appreciated.
James M. GREEN, president of the State Normal School,
read a paper on
PHYSICAL CULTURE IN ITS HYGIENIC RELATIONS.
Mind is a function of brain; its strength therefore is
proportionate to development of the brain; and the sym-
metrical development of the brain depends on that of the
body.
SATURDAY, NOVEMBER 23D—SECOND Day.
A paper on
THE RELATION OF CONDUITS TO THE HEALTHFULNESS OF
WATER `
was read by Dr. W. K. NEWTON, of Paterson. Discussing
in detail the various materials ordinarily employed for con-
duits, he finds nothing to condemn except lead pipes,
which are always attended with a certain degree of danger,
as lead is a cumulative poison, or 1-100 grain per gallon
produces characteristic symptoms, paralysis, colic, etc.
He recommended abandoning the use of lead suction-
_ pipes to wells; and condemned, as unfit to drink, water
that has stood in lead-lined cisterns or in lead pipes.
640
THE MEDICAL RECORD.
[December 7, 1889
Papers by Proressor S. G. Dixon, of the University
of Pennsylvania, on
“ TUBERCULOSIS” AND ‘“ ‘TYPHOID FEVER IN MUNICH,”
were read by Dr. Egbert.
know of no other civilized nation that gives so little sup-
port and encouragement to sanitary matters as does this
great Republic.” ‘The example of the city of Munich, by
“its liberal support of its grand old sanitary professor,
Herr von Pettenkofer,” was presented for imitation.
From 1866 to 1880 the mortality from typhoid averaged
332 per 100,000 ; from 1881 to 1888, only 42. ‘This re-
sult he attributed to Von Pettenkofer, though the water-
supply had also been improved. It appeared, however,
‘that the ratio of mortality was no greater in the portion of
the city provided with the old water-supply than in that of
the new supply. He believes that typhoid bacillus cannot
live over four days in the average water supplied to cities,
basing his belief on experiments with bacilli exposed for
more than four days to Schuylkill water. _
A resolution was adopted testifying to the deep loss
T the Association in the death of ex-President J. L.
Bodine. i
ELECTION OF OFFICERS.
The Executive Council presented the report of the
nominations of officers for the ensuing year, which was
unanimously adopted, as follows:
_ President—George P. Olcott, C.E., East Orange ; First
Vice-President— Hon. E. O. Chapman, Trenton; Second
Vice-President—E. L. B. Godfrey, M.D., Camden; Ke-
cording Secretary— D. C. English, M.D., New Brunswick ;
Corresponding Secretary—Professor J. Madison Watson,
Elizabeth ; Zreasurer—Gecrge W. Howell, C.E., Morris-
town.
Correspondence.
MEDICAL EXAMINATIONS AND CIVIL SER-
VICE REFORM. CAN THESE THINGS BE?
To Tug Eviror or THe MenicaL RECORD.
SiR: In your issue for November 2d, I notice the follow-
ing editorial paragraph: “It is well known that the state
of civil service reform in New York is not what its friends
could wish it to be; and that it would be well if some
clear presentment of the facts were made by those who
have had occasion to know best, as to the details and as
to abuses—in the interests of better sanitation. It looks
as if the only answer to the question was, ‘ What are you
going to do about it ?’”
Having had personal experience in the ways of alleged
Civil Service Reform and its workings as applied to New
York City, Ihave determined, in the interest of the medi-
cal fraternity, to respond to your appeal, hoping that some
ultimate good may result therefrom.
It is evident to those who have had occasion to ap-
proach the machine that there is “ something rotten in
Denmark.” Possibly a permanent coryza may afflict the
members of the Civil Service Board, and they do nat
observe the stench. Possibly they are incompetent, or
perhaps so occupied by other and to them more impor-
tant cares and duties, that their subordinates have oppor-
tunities for disreputable acts which pass unobserved. _
No one, I think, questions the personal honesty of the
gentlemen who compose this board. But when a battle
is fought, the responsibility, on the defeated side, rests
with the general in charge; and he cannot shift the load
to other shoulders by complaining of a lack of efficiency
or discipline in his subordinate officers. The simile holds
good in the struggle between reform on the one hand,
and political “ pull” and “inflooence” on the other. The
people have reason to be thoroughly dissatisfied with the
commanding officers on the side of justice. ‘They have
been laggards in the fight, and should be replaced by men
In the latter paper he said: “I |,
who are Argus-eyed: men not alone who are conscien-
tious, but who also will put the same energy and deter-
mination into the cause of the right as are necessary to
compass and maintain the success of any great business
As to the politicians—we have.no just reason for com-
plaint. As found in New York they are “statesmen ” for
revenue only—for the money there is init. ‘l’o.a man
they hate the Civil Service laws, formulated to cut away
their patronage by removing appointments from their
hands. And as they find many a loophole of escape, they
also despise these laws and the weak supporters thereof.
We have herein no cause for complaint, as we cannot
expect assistance nor anything but keen antagonism from
“our friends the enemy.” He would be a fool or a
coward who laments because the enemy does not give him
aid. But we do have just cause for indignation when we
find indifference, or something worse, within our own
camp.
Let me speak only whereof I know. Concerning Civil
Service as applied to others than medical men, I know
nothing. But in respect to physicians I have had some
experience which I now propose to lay before the pro-
fession.
_ And here let me say that I have no axe to grind. My
own days of examinations are long past. Such personal
grievance as I have had has not been hastily thrust before
the public, either for sympathy or for any other reason.
This must be admitted without argument, since my own
experience dates back nearly five years; and yet not from
that day until now have I published a word regarding the
matter. Nor would I do so even now except for the hope
that your editorial, serving as a text and an incentive, may
lead others to do likewise ; and that together we may ac-
complish something more than one alone can do. i
The first Civil Service examination for permanent posi-
tions for medical men, ever held in New York, I believe,
was that of February 3 and 4, 1885. ‘There was a va-
cancy in the numberof Police Surgeons owing to the death
of a member of this corps. ‘The position is a desirable
one, being of certain tenure, and the salary being $1,500
at first, later, $2,250 per annum; with abundant time for
private practice, as the duties are generally light.
‘This examination was duly and properly advertised be-
forehand in THE MEpIcaL REcorp and Zhe Medical Foure
nal ; and thirty-nine phvsicians, of whom I was one, com-
peted for the appointment. We were examined for the
greater part of two days upon the seven main branches of
medicine, by three physicians selected by the board, as I
was told, each to represent one of the three great medical
colleges of this city.
In the event, I was so fortunate as to stand first, with
a rating of one hundred per cent. in each of the branches.
My friend Dr. Condict W. Cutler, then recently of
Bellevue Hospital, stood second, with ninety-eight per
cent.; and Dr. Charles S. Mack, then recently of Cham-
bers Street Hospital, was third, with ninety-three per cent.
According to the law, the Police Commissioners should
appoint one of the first three. In my innocence and
freshness I actually supposed that the heads of the mu-
nicipal police force would do as they should do—that
they would obey the law as a matter of course.
As I look back upon the affair, this belief—this child-
like trust on my part in official honesty of intention,
strikes me as most ludicrous and amusing. But at that
time I really supposed that the result of Civil Service
rules was to give the appointment to the candidate reach-
ing the highest rating.
Time passed, and no appointment was made. At last,
becoming worried, I took several letters of introduction
from eminent business men and called upon the Police
Commissioner—since retired from office—whose turn it
was to appoint (the four commissioners appoint in rota-
tion).
I bs him alone in his room at Police Headquarters.
He read my letters, also the paper announcing my stand-
December 7, 1889]
ing. ‘Then he said: “ Civil Service Reform be damned !
{ will not, as we say, Aang you up, but will tell you plainly
that neither yourself nor any doctor who passed that
examination will be appointed. I have promised that
place to a doctor who did not take that examination, and
after vour period of eligibility has expired there will be
another examination, and my man will go in.”
If the commissioner had knocked me down he could
not have surprised me more than he did by that speech.
In reflecting upon it, I can only account for his surprising
frankness by the remembrance that we were alone, and
any subsequent repetition on my part would probably be
met by a simple denial on his part, and there the matter
must rest. Though I felt bitter enough at the time, I am
now rather gratcful to this individual in one respect, for
he might have Aung me up (kept me in suspense by post-
ponements and false promises) indefinitely, instead of
giving me a prompt despatch, as he did.
I called next upon all the individual members of the
Civil Service Board, gave a brief statement of the facts
just narrated, offered to make affidavit thereunto, and
asked them to endeavor to prevent such a wilful and con-
temptuous infraction of the spirit of the law, by prolong-
ing the period of eligibility of successful candidates for
medical positions until at least some one member of a
given eligible list had received an appointment. ‘This
certainly was a reasonable request, and would, if carried
into effect, have blocked the Police Commissioners scheme.
to violate the law.
These gentlemen listened to me politely, seemed not to
care about the matter particularly, and nearly a month
later sent me-a note, through the secretary of the board,
stating that they would not take any action at present.
That ended the matter so far as my efforts were con-
cerned. I did not appeal for justice to the public, be-
cause the use of the daily papers for such a purpose is not
open to self-respecting physicians.
At length the time arrived—one year—when we who
had passed that examination were no longer eligible.
And, of a truth, none of that list were ever appointed.
Shortly thereafter I heard that there had been another
examination. Differing from the first, this examination
was not, as it should have been, advertised in the medical
journals, I am told that it was only advertised in the
City Record, the official and legal organ of New York
City appointments. Certain it is that not more than half
as many doctors appeared at this examination as at the
previous one, they being mainly those who had political
friends to notify them. Very few of the first list were
present, or had even heard of the second examination
until it had actually been held. °
Owing to the death of yet another Police Surgeon, dur-
ing my yeer of eligibility, and to the fact that the com-
missioners now retired a couple of surgeons who were
over sixty-two years of age, there were four vacancies.
These were filled from this second eligible list, by select-
ing four men, one of whom was the physician who, as I
have stated, had been promised the appointment more
than a year before. ‘This gentleman is the nephew of an
eminent statesman, to whom the commissioner aforesaid
was under obligations. (I would not have it supposed
that he was unworthy. I have reason to believe him an
excellent physician.) Another appointee was a close re-
lation by marriage to the leader of one of the city politi-
cal factions ; and this leader secured his appointment.
The remaining places went to two men who had served
in the army during the war. They were both near the
foot of the list, having shown a poor standing. But the
commissioners in this case had no choice, the law being
mandatory regarding veterans of the late war.
The two candidates who had stood highest upon this
eligible list, respectively, Drs. Charles E. Quimby and
Condict W. Cutler, not having enough “ pull,” were ig-
noreG, passed over, and never received an appointment.
Some little good to others came out of my own dis-
comfiture, in this wise: I wrote the Hon. John Jay,
THE MEDICAL RECORD.
641
Chairman of the State Civil Service Board, saying that it .
seemed to me only courteous that all the successful can-
didates of a given examination should be specially noti-
fied, when their eligibility has expired without appoint-
ment, of the time and place of the next examination.
Mr. Jay in his reply stated that he agreed with me, and
would endeavor to have this point carned into effect
throughout the State. This, I am told, has since been
done. ,
Between ‘the time of which I have been writing—1885
and thereabout—and the present date, I have heard from
various sources, authentic, I believe, occasional reports of
medical appointments to our city departments of which.
we cannot be proud. During these years I have had
quite a number of applicants for quizzing in preparation.
for the city Civil Service medical examinations ; and I
have always advised the gentlemen in question, as in con-
science bound, not to waste their time. If they have a
“ pull,” seventy per cent.—the under limit—will suffice.
If they have not a “ pull,” a higher per cent. will not
avail anything.
It may perhaps interest your readers to know of the
latest proof of the kind whereof I speak. I give it with
the brief preface, that it is only a fair assumption that it
is not the only case of itssort. ‘There are probably others
of which I do not happen to know.
Dr. A B C, a former student of mine, did not,
until after the fact, hear of the examination held this sum-
mer for the “Summer Corps” of physicians to assist the
regular corps of the Board of Health. He was but a day
or two late, and determined to try political influence. In
this he was successful, for a well-known city official, of his
own language and religious belief, procured for him a
copy of the questions, which he answered at his leisure,
at home, and doubtless to his own satisfaction. His
paper was then duly handed to his political friend, was
slipped in among the other papers, and in a short time he
received his appointment as a member of the “Summer
Corps,” in which he remained throughout the season.
I have reason to believe what the doctor said to me.
In the first place, he had no reason for deceiving me.
But, aside from this, I know that he was elsewhere when
the regular examination was held, and I know also that
he was, nevertheless, in the Summer Corps.
If it should be said that I owe it to the profession to
report, publicly, the names of such flagrant violators of
the law, I can only reply that I would gladly do so; but
that this and such other instances as have come to my
notice were told in confidence, which, although unsought
on my part, I cannot break.
I presume that the Civil Service Board will find it
` easier and simpler to disbelieve my statements than to
keep that sharp watch over the personnel of their depart-
ment and the purity of their “ reform ” which they devote
to their private finances.
The medical profession in this country seldom bestirs
itself in public matters even where its own weal is con-
cerned. More is the pity. We can hardly expect others
to show a greater interest in our own affairs than we our-
selves discover.
If such a large body of educated men as the physicians
of New York were really to take some concerted action,
and maintain it loyally, what could they not accomplish
in the way of abating political abuses? If a standing
committee, wisely selected, from the Academy of Medi-
cine, or the County Society, or both, should make earnest
and continued endeavor, perhaps the public at large
might come to understand—as an example—that their
lives might be better protected against plague and pesti-
lence than at present ; that the health-officer to a great
port should be one in fact, and not alone in name: one
who has demonstrated some ability in preventive medi-
cine, not one who is selected solely for political and par-
tisan reasons—his office being merely a source of revenue
to his party.
It may be, too, that such a fighting committee might
642
«succeed in wiping from our name the stain and reproach
which is conveyed in the exclusion of a physician and the
appointment always of some politician as the head of our
Board of Health. Even such serious matters as life and
death have their ludicrous side at times ; and what could
be more grotesque and worthy of comic opera than de-
barring a medical man from the head of a department
which absolutely demands for the protection of our citi-
zens a thorough medical training ?
It would be well for our standing committee to keep
an eye upon the Civil Service Commissioners with regard
to the various medical examinations, and the resulting ap-
pointments. Such scrutiny would not be pleasant for
these gentlemen, but, in view of the facts, who shall say
that it would be time ill spent?
I am told that the board have not always been wise in
their selection of physicians as medical examiners. ‘That
is a matter wherein, necessarily, their judgment cannot be
of the best. It would be a modest and becoming admis-
sion of fallibility on their part if they would request the
Academy—for instance—to name responsible and able
men, annually, for this purpose; and these examiners
should endeavor to give their examinations as practical a
cast as possible.
And finally, one—possibly two—further reforms are
needed in our vaunted Reform. First, the man who heads
the successful list should be the man appointed; and the
wording of the law should make this inevitable. Other-
wise, as now, the thing is a farce and a sham reform.
Regarding the second, I speak with much hesitation.
It has reference to the preferment of veterans over men
who may have been shown by the examination-test to be
the more able physicians.
I would not have it thought for a moment that I do not
feel hearty respect and admiration for these brave men,
as every true American must do. And I sympathize
with the public sentiment which shows them honor in
every proper way. But is this a proper way? I would
not be dogmatic. Perhaps my views herein are wrong
ones. But reflection would seem to show that this clause
is an excrescence in Civil Service laws. So far from
being a proper part of it, this provision seems to me to
antagonize directly the theory on which the whole fabric
of examinations rests ; which is, as I understand it, that
the man of greatest demonstrated fitness is the proper
man. Sympathy, gratitude, admiration of personal bravery,
or other emotion, is quite foreign to the matter. If it be
objected that the veteran should nevertheless be appointed
because examination is often a fallacious test of real
ability—which is, up to the present time, certainly the
truth—that is largely the fault of the examiner and the
kind of examination.
if sufficiently practical and not too brief and hurried.
It is probably expecting too much to hope for a change
for some years to come in the law regarding veterans.
And it is very probable that some of your readers would
support it, and disapprove any change in this regard. As
I have said, this may well be considered ground for ami-
cable difference of opinion. But in all other respects I
feel sure of the earnest concurrence of a united profession
in what I have indicated as a line of true reform.
Very respectfully,
Rosert H. M. Dawsarn, M.D.
345 WEST Firry-sixti Street, New YORK.
STATE EXAMINING BOARDS.
To THe Epitror or THe MenicaL Racorp.
SiR: If not intentional, it was certainly a happy coinci-
dence, that in THE Recorp for November gth, together
with a letter advocating “ A Medical Examining Board for
New York State,” there appeared, as it were in refutation
of it, an extract entitled “ The Trade of Medicine in Ger-
many.” From the latter one may form a slight idea of
some of the beautiful results which ensue whenever the
THE MEDICAL RECORD.
It could be made a very fair test,’
[December 7, 1889
state begins to “regulate ;” for it is an often observed
fact, that when legislative aid has once been involved, no
one can predict where its mischievous spirit of interfer-
ence will stop.
The history of the progress of medicine in the United
*States is—in spite of every shortcoming—that of a steady
and healthy upward movement, with either no legislative
“ regulation ” whatever to hamper it, or hardly any worth
mentioning. Year after year has witnessed a constantly
increasing demand, as well for a higher standard of gen-
eral education as for a wider range of special learning,
from him who essays to enter the ranks of medicine. And
to keep pace with these demands, a progress as uninter-
rupted has in general marked the policy of the medical
schools; witnessed everywhere by the addition of new de-
partments, and the eager adoption of every improvement
in the means of teaching. It isa matter of common re-
mark and congratulation how this spirit of advance, which
has been gradually evolving, has, in recent years, gone for-
ward with giant strides. Let him who graduated but ten
years ago contrast his opportunities for learning with those
now presented in the city of New York. Let him think
of the stately cullege buildings and the number of mag-
nificently equipped laboratories that have sprung into
existence in that short time ; let him remember the two
excellent schools devoted solely to the instruction of
post-graduates that have been founded ; and then let him
ask himself to what ‘these beneficent changes are due.
Will anyone be rash enough to assert that one jot or tittle
of all this improvement is due in any way to legislative
aid? ‘The benefits we now enjoy are whoily the outcome
of the enlightened demands of public opinion ; and it is
to public opinion alone, where democratic institutions
prevail, that every citizen must look for progress and re-
form. This it is,and not the paralyzing aid of legislation,
that we have to thank for every good we now possess ; and
may that shameful day be far distant when the medical
profession of the Empire State, hat in hand, shall knock
at the door of the Capitol at Albany—whose very ceilings
cry “ fraud !”—and beg “ protective regulation.”
Look again, and on the other side see the workings of
those medical departments in which politics now has a
hand. Observe what enlightened pathologists our coro-
ners are, what acute sanitarians usually grace the heads of
our boards of health, what eminent epidemiologists pre-
side at the entrance of our harbor.
But suppose we are to have a State Examining Board,
who is to compose this board? Regulars, homceopaths,
and eclectics, of course, since all being on an equal foot-
ing before the law, all are entitled to representation, and
all wil claim it. And does any man for a moment sup-
pose that a license issued by such a heterogeneous medley
will command more respect than that which is now granted
through a college diploma? Since it may justly be claimed
that the health of the soul 1s, if anything, more important
to the State than the health of the body, it would be just
as logical to advocate a State Examining Board in the-
ology, to be composed of Christians, Jews, Mormons, and
Buddhists.
All legislatures have granted in the past, and still con-
tinue to grant, charters to institutions which prove them-
selves of shady reputation. ‘This fact alone is in itself a
guarantee that in the formation of a State Board of Ex-
aminers every kind of “ inflooence” but the proper one
might be brought to bear.
But instead of pleading the baby act, and crying for
legislative “ protection,” be it ours to choose the nobler
part—be it ours to continue that manlier policy of rely-
ing upon ourselves for the command of public respect.
Let us persist upon this path, which, as heretofore, has
been trodden with honor and success, knowing that every
true advance can come only from within—never from
without.
And as my friend Dr. Wyeth has invoked the Academy
of Medicine, let me do so too.
Moved by the same spint of appreciation of the elevat-
December 7, 1889]
THE MEDICAL RECORD.
643
ing impetus that freedom gives, which led the Academy
a few years ago to abandon a worn-out ‘ code” to those
who still might feel the necessity for one, may it now and
always set its face against any reactionary movement
which, under the plausible guise of “ regulation,” opens
the door to the shackling of that free spirit which for its
perfect development asks no favors, craves no boon,
scorns every special privilege, demands naught save /2d-
erty. WALTER MENDELSON, M.D.
November 14, 1889.
HOW IS THIS?
To tue EDITOR oF THe MepicaL RECORD.
Sır : The last issue of THE MEDICAL RECORD contains a
report of the Seventh Annual Meeting of the American
Rhinological Association. In this report is mentioned a
paper on “ Ocular Reflex Symptoms in Nasal Diseases,”
presented by a Dr. C. H. Moore, of Indianapolis. ‘Ihe
substance of the paper and the criticisms derived there-
from are literally copied from an article entitled “ Reflex
Ocular Symptoms in Nasal Affections,” written by me in
1885, read before the New York Academy of Medicine,
and published in ‘THE MEpicaL REcorp of January 30,
1886. My conclusions and. those of Dr. C. H. Moore
placed in parallel columns will demonstrate the plagiarism :
GRUENING, 1886. MOORE, 1889,
The cases here presented have
the following features incommon:
I. Burning and smarting sensa-
tion of the lids or of the eyes, more
pronounced in the morning than
in daytime.
2. Inability to fix an object in
ordinary daylight
3. Increased vascularity of the
conjunctiva, and lachrymation up-
on slight provocation, such as a
mild current of air.
4. Sound condition of the eyes
and their appendages.
5. Inefficiency of the ocular and
the general treatment.
The cases reported had the fol-
lowing symptoms in common:
1. Burning and smarting sensa-
tion of the eyelids, especially in
the morning.
2. Difficulty in distinguishing
an object in ordinary daylight.
3. Increased vascularity of the
conjunctiva, and lachrymation on
exposure to the air.
4. The sound condition of the
eyes and their appendages.
S5. Failure of the ocular and the
general treatment.
6. Efficiency of the nasal treat-
ment in spite of the absence of
nasal symptoms.
By giving publicity to this card you will follow the tenet
of suum cuigue, under which ‘THE MepicaL RECORD has
grown and thriven. Truly yours,
E. GRUENING, M.D.
6. The efficiency of nasal treat-
ment,
New YORK.
THE OPPORTUNITIES OF RELIEF FOR THE
POOR OF NEW YORK SUFFERING FROM
DISEASES OF THE RECTUM.
To THe Epiror or THe MepicaL RECORD.
SiR: I am the recipient of a circular issued by a well-
known “ medical corporation ”—here in New York—that
advertises “a clinic for diseases of the rectum, to be
under the personal care of Dr. .” It begs reference
to this clinic of persons suffering from this class of dis-
eases, and adds: |
“ There has been, as you know, very little special care
of these very deserving cases, and we trust that the pro-
fession will aid the Hospital and Dispensary in giving
them special and proper care.”
This statement—as you are aware, sir—is absolutely
false, and its falsity is only equalled by its absurdity. You
and I know perfectly well, from personal knowledge and
attendance at the regularly organized general dispensaries
and hospitals of New York, that these “ very deserving
cases” do receive “ special and proper care”—more, that
there has never been any period in the history of the city
of New York, from the time the illustrious Bush prac-
tised general surgery in this community—over fifty years
ago—up to the présent moment, when such assistance—
of the best grade too—has not been afforded “ when
called for.”
I ask the insertion of this communication to attract the
attention of those who do not know of the good service
rendered in the general and well-organized dispensaries -
and hospitals of New York, and of those whose credulity
is imposed upon to maintain too many “ institutions,” at
a great cost, for many other than purely charitable pur-
ses.
The circular is signed by five members of “the hospi-
tal committee of this institution,” the majority of whom
have at least had opportunities of knowing that the ap-
peal is an improper one, and that my statements are
strictly correct. Morris H. Henry, M.D.
581 FIFTH Avenugz, New York,
November 18, 1889.
Aew instruments.
A NEW MASTOID RETRACTING SPECULUM,
RETRACTORS, AND LANCE-POINTED DIS-
CISSION KNIFE.
By FRANK ALLPORT, M.D.,
PROFESSOR OF CLINICAL OPHTHALMOLOGY AND OTOLOGY IN THE UNIVERSITY OF
MINNESOTA.
I DESIRE to ask the notice of the profession to an instru-
ment I have devised for the purpose of facilitating the op-
eration of opening the mastoid cells. In this operation
it is desirable that the two flaps made by the incision be
kept widely open, in order that the
work upon the bone may be kept well
under observation. I have been in
the habit of obtaining this result by
two tenaculums placed in both sides
of the opening, and held apart by an
assistant. ‘The instrument here shown
accomplishes the same result, and it
does away with the necessity of an
Assistant for this purpose.
I have called it a “ mastoid
retracting speculum.”
The arms of the speculum
can be closed or opened by
the screw-button, at the
base of the instrument. ‘The
hooks are made to interlock
nicely, so that they may be introduced into quite
a small aperture. ‘The hooks have sharp, but
not cutting, points, and the whole instrument is
made short and strong, in order that con-
siderable force may be used in opening
the blades—wlhich may become necessary
in case of great thickening or swelling of
the tissues over the mastoid process. The
instrument may be introduced into the in-
cision with its base either up or down.
When thus introduced and widely expand-
ed, and the parts wiped as dry as possible,
a fine view of the underlying bone may be
obtained, and the ease of the operation
much facilitated. ‘The wide expansion of
the blades also aids in the stopping of the
hemorrhage from the soft tissues, which also adds
to the ease of the operation by presenting a much
clearer view to theeyes of the operator. ‘This in-
strument, as well as others referred to in this article,
has been manufactured for me by Tiemann & Co.,
of New York, where they may be obtained. For the
same operation, I have also modified an already
existing instrument, by causing to be made a pair
of grippling hooks upon a small scale. |
These hooks have solid steel handles, and may
therefore be rendered perfectly aseptic. ‘They are f
to be introduced into the incision, and pulled apart
by an assistant. A pair of these instruments is ef-
ficient, but not more so than the speculum, and
necessitates an extra assistant, and consequently another
pair of hands around the field of operation. I have
called these hooks “ mastoid retractors.”
' 036019
644
THE MEDICAL RECORD.
[December 7, 1889
I wish, also, to present a modification of other discis-
sion needles. The blade is very thin and has a double
cutting edge, which extends almost down to the stop-
point. Just before reaching this point the edge is dulled,
so that, in working the needle around inside of the eye, it
will not cut the corneal tissue. The slanting shape of the
blade renders its introduction into the cornea extremely
easy, and the double cutting edge facilitates the breaking
up of the lens-substance.
This instrument I have called a “ lance-pointed discis-
sion knife.” ‘Ihe belly of the blade, as shown in the en-
graving, is wider than will be seen in the instrument.
Army and Havy Werws.
Official List of Changes in the Stations and Duties of CM-
cers serving in the Medical Department, United States
Army, from November 24 to November 30, 1889.
HAVARD, VALERY, Captain and Assistant Surgeon. By
direction of the Secretary of War the extension of leave
of absence, granted in S. O. 240, October 15, 1889, from
this office, is further extended one month. Par. 1, S. O.
272, A. G. O., November 21, 1889.
BALL, R. R., First Lieutenant and Assistant Surgeon,
Fort Riley, Kan., will proceed to Fort Sill, Ind. Ter.,
and report to the commanding officer for temporary duty
at that post. Par. 2, S. O. 173, Department of Missouri
November 21, 1880.
PILCHER, JAMES E., Captain and Assistant Surgeon.
By direction of the Secretary of War is relieved from
duty at Fort Wood, N. Y. H., and will report in person to
the commanding officer at Fort Clark, Tex., far duty at
that station, reporting also by letter to the commanding
general, Department of ‘Texas. Par. 3, S. O. 276, A. G.
O., November 26, 1889.
COCHRAN, JOHN J., Captain and Assistant Surgeon.
Leave of absence for fifteen days is granted, to commence
about December 1. 1889. Par. 8, S. O. 272, Division of
the Atlantic, November 27, 1889.
Official List of Changes in the Medical Corps of the United
States Navy for the week ending November 30, 1889.
GUNNELL. F. M., Medical Director. Placed on the Re-
tired List, November 27, 1889.
Garmes, J. H., Surgeon. Ordered to duty at Army and
Navy Hospital, Hot Springs, Ark.
Medical Items.,
ContTacious DISEASES—WEEKLY STATEMENT. — Re
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending November 30, 1889:
Cases. | Deaths,
PYPUUS lever oie cowie oni cous 64S ecw esse cen o o
Typhoid levéf acs reerurees ienesis an Raai 28 8
Scarlet LEVER os cute o ieran REEE EEVA ROENS 49 8
Cerebro-spinal meningitis.................e0eceee I 2
MRSC oii i chiccdee coe nsaecacs wands cues E 38 3
Diphtheria aie ores os aa iat be coda douareeeess 70 17
Small-pox 4b hice aed dces deo i ein view ss cate EN o o
aA eT. 6 od E E E ob AG OS ES E Sea aaa 6 o
Cholera oc eseesia snn e eeen da Era ea eis EE o o
TRIPLETS WITH BUT ONE PLACENTA.—Dr. C. Butler, of
Shepherdstown, W. Va., writes: ‘ Having noticed in THE
RECORD during the last few months several cases reported
of twins with one placenta, I thought perhaps the follow-
ing would be of interest to your readers. I was called on
July 12, 1889, to attend Mrs. A in labor, that being
her ninth confinement. Labor advanced rapidly, and in
less than one hour she was delivered of triplets, two girls
and one boy. The births followed each other so quickly
that I scarcely had time to ligate and sever the cords.
There were now three cords protruding, and in a few min-
utes the pain set in again and a placenta, to which all
three of the cords were attached, was expelled.” Dr. A.
E. Aultz, of Richmond, Ky., also reports a case of trip-
lets with three cords and but one placenta, as follows :
“ I would like to report a case of triplets with one pla.
centa and three cords, two of which were attached near
the periphery within one inch of each other, the other be-
irg inserted at a point about six inches from them. The
placenta was very firmly adherent. Upon being called to
see the patient, Mrs. Caroline B——, in labor, I made an
examination and gave the opinion that she would bear
twins. At four o’clock, two hours after I had been
called, the first child was born by first position ;°in three
minutes the second child was born by a feet-presentation,
and in twelve minutes a third child was born, also by the
feet. ‘Two of the children weighed seven pounds each,
and the third six pounds. ‘The placenta (and only one
placenta) was adherent, and was removed with difficulty.
The children and mother are doing well. Mrs. B——
is forty years of age and the mother of sixteen children.”
LOCAL ‘TREATMENT OF WarRTS.— Dr. Altschul (Cenfra/-
blatt für Chirurgie, No. 18, 1889) recommends mercu-
rial ointment, to which arsenic in the proportion of five or
ten per cent. has been added, as an application for the
cure of warts. This is spread upon muslin and bound
over the warts. When the latter become painful and ex-
coriated, the excoriations are cauterized with fuming
nitric acid. ‘Then tar-ointment is applied. ‘This treat
ment is certainly energetic enough and ought to destroy
warts if anything will.
BICARBONATE OF SODIUM IN MILK.—Hitherto it has
been deemed permissible to add soda bicarbonate to milk
to assist in its preservation, but now the Council of Hy-
giene of the Seine has condemned the practice as one of
danger. ‘The transformation of milk-sugar into lactic
acid, in milk so adulterated, gives mse to a lactate of
soda which is purgative, and frequently a source of al-
most uncontrollable diarrhoea in infants. Consequently,
the Council in its Bulletin decides that : “ Soda shall no
longer be permitted in milk, which is an aliment of the
first order, and very often prescribed tor invalids and
children.”—Meadical Age.
GREEN SoaP IN Caries.—Dr. Kollmann has obtained
excellent results, in cases of caries, from the use of green
soap, which he rubs in with a sponge, or the palm of the
hand, over the neck, back, and the posterior surface of
the thighs. ‘These applications are made two or three
times a week, and best at night, the quantity of soap used
varying from 25 to 40 grammes. The soap is left on for
halt an hour, and is then washed off with warm water,
and the patient sent to bed. Except in cases of chronic
periostitis, or caries of the pelvis, spine, or lower extrem-
ities, the patient is allowed to follow his occupation
during the day. Change of diet and cod-liver oil are not
essential during the time of treatment, although they may
hasten recovery. The results of this treatment were as-
tonishingly good, the average duration being four and one-
half months. The author thinks that in caries there is an
excessive quantity of lactic acid in the blood and tissues,
which is neutralized by the alkaline property of the soap.
— The Cincinnati Medical Fournal.
Dr. NICHOLAS I. Koztorr, a well-known physician. and
one holding a most important position in the Russian
public service, died recently in St. Petersburg of a cardiac
affection.
The Medical Record
A Weekly Fournal of Medicine and Surgery
ee | See £2 ee
Vol. 36, No. 24
Original Lectures.
ee
ON VITAL AND MEDICAL STATISTICS.' |
By JOHN S. BILLINGS, M.D.,
UNITED STATES ARMY.
Lecrures III. anp IV.
TxHosg of you who are familiar with the history of medi-
cine in the early part of this century will remember the
great anticipations which were formed and expressed by
prominent physicians as to the results which might be ex-
pected from what was called the system of statistical
medicine, introduced in the Paris School by Louis and
his contemporaries. This was not exactly a new system,
but rather an attempt to methodize an old one, z.¢., to
present the experience of different physicians in such a
way that comparisons might be accurately made, and the
results mathematically expressed. |
In this so-called numerical method, all the details of
each case observed are to be noted as far as possible,
without any special regard to whether these details may
appear to the observer to have any special connection
with the course of the case or its termination, or not.
When a number of such cases have been collected, they
are to be compared ia all their details, showing, ın round
numbers, how many present such and such particular cir-
cumstances, and how many do not.
In order to make a useful application of this method
it is, of course, necessary that the different observers
shall be describing substantially the same thing ; that is
to say, the disease to be observed must present a definite
series of symptoms so that a person properly qualified
will recognize its existence without any liability to error.
It should also be a disease which follows a tolerably
regular and definite course, having a commencement
which can be recognized. Such forms of disease include
the so-called specific diseases, and acute aff€ctions of par-
ticular organs. The method is most applicable to surgi-
cal cases of all kinds, including those which come under
the domain of the various specialties.
As regards details of pathological anatomy, it has been
pointed out by Dr. Flint that the statistical method can
apply only to those changes which can be appreciated by
the senses after death, and that there being but one con-
stant lesion found in typhoid fever, viz., the softening of
Peyer’s patches in the small intestine, the statistical
method gives us little assistance in the investigation of
the pathological condition of this disease.
We may note, however, that, if it be admitted that
typhoid fever is due to a specific bacillus, as seems now
to have been fairly demonstrated, and that this bacillus
has been discovered and verified mainly by the applica-
tion of experimental methods, it is, nevertheless, true
that the results thus obtained have met with a general and
prompt acceptance, mainly because the application of
statistical methods to the circumstances of outbreaks of
this disease in different communities are in perfect accord
with the bacillus theory of its causation.
This merely illustrates the general law that the experi-
mental] and the statistical’ methods must be used to-
SS
+ The Cartwright Lectures, delivered before the Alumni Association
of the College of Physicians of New York, November, 1889.
* An interesting discussion on the value of the statistical, or numer-
ical method, as applied to medicine, will be found in the Bulletin of the
New York, DECEMBER 14, 1889
Whole No. 997
gether, and their results must be in accord, to produce
full confidence in the results obtained by either alone. _
The sanguine advocates of the numerical system of
Louis supposed that all that was necessary to discover all
the laws with regard to the propagation of any disease,
and the true value of any or of all methods of treatment
proposed for that disease, was simply the collection by
different observers of all the data which could be obtained
from individual cases, and the tabulation of these ac-
cording to a certain fixed and almost mechanical system
of permutations and combinations, by means of which the
various symptoms are brought together in groups, in con-
nection with the results observed, and that thus should be
obtained a true scientific basis, or, as they commonly
phrased.it, “ the science of medicine.”
We can now see plainly enough that this is, from the
nature of the case, impossible ; that the data obtained by
different men can hardly ever be made fully comparable,
and that, however complete they may be, the number of
factors which combine to produce such a result as the
production of a particular form of disease in a healthy
organism is so great that, from mere statistics of observa-
tion, we can never obtain scientific knowledge as to the
relative part which each factor has taken in produc-
ing the result. ‘This can only be done by experimental
methods, in which the influence of one particular factor
can be applied and those of others eliminated as far as
possible ; and the great advances which have been made
toward obtaining a scientific basis for practical medicine
within the last twenty five years are, in the main, due to
the experimental method. So soon, however, as we
have, by the investigation of particular cases and by ex-
periments, obtained a more or less probable theory as to
the cause and mode of diffusion of a particular form of
disease, the outbreaks of that disease in a community af-
ford an invaluable means, in many cases, of testing the
truth or falsity of the theory. |
It must be admitted that the probabilities of error are
much greater in medical than in vital statistics, and this
for a number of reasons. The first is that no two ob-
servers examine, or interpret, a disease in precisely the
same way, and hence it is extremely difficult to collect a
mass of observations sufficiently large to form a basis for
Statistical reasoning. Those who wish to be scientifically
accurate in the use of such material are usually com-
pelled to deal witha very limited number of observations,
because they cannot obtain a large number upon which
they can fully rely.
The best data are, for the most part, those which lie in
the field of surgical observation, since here the symptoms
observed, the methods of relief applied, and the results
obtained, are tolerably definite, and there is not likely to
be much difference in the methods of recording them.
The methods of medical statistics differ fundamentally
from those used by the vital statistician in that they usu-
ally have no relation to the phenomena observed in the
normal, healthy, living population. The physician in-
quires, out of a thousand cases of children or of old per-
sons that have been treated, how many times has this
particular disease been met with ; or, in a given number
Royal Academy of Medicine for 1836, vol. i., p. 622 et seg. The
immediate cause of the discussion was a paper by d’Amador attack-
ing the value of the methods of Louis and criticising the results ob-
tained. Bouillaud, Chomel, Double, and others took part in this dis-
cussion, fro and con; and while no definite conclusion was reached,
it was very evident that the dispute was rather a matter of definition
than of anything else.
646
THE MEDICAL RECORD.
[December 14, 1889
of cases of this disease, what proportion have died?
This method is, in fact, practically the only one which is
available to the physician ; but the vital statistician, if deal-
ing with disease, will want to know what are the probabili-
ties that a male between twenty and thirty years of age will
contract a given disease, such as phthisis or typhoid
fever, and for this purpose he wishes to know the whole
number of cases observed in a given population, and the
number of the population furnishing those cases, in order
to establish the ratio.
Bertillon illustrates this in his comment that the small
number of deaths of old men attributed t#typhoid fever
might lead the physician, from his point of view, to say
that typhoid fever in old age is a rare disease ; “but the
vital statistician might conclude that the rarity of the dis-
ease in old age was simply due to the small number of
those living at that period.
Deaths from Cancer at Certain Groups of Ages in 1,000
Deaths Caused by this Disease.
CANCER.
<2 gt ttt em
eee 259 Raw ERENERE
B pew aE D T BFE
= memes ane ee SL! WHEE ti ty Lys De mun
E ee E EEL: Wie tj ts
es | | | ReKzxzzZZZZZ litt YUH Uys
m —_ ey Ys the Yys Le
) ho hF0re“o—ojr7rrrror>2"22 thie Gy
C A tli G CCAG GG GGG AAG GGA
es M A AAAA
<< B MN S MA E ME E G GGG A A Zi
95 1111). ) A AA LAN |
or pt PAE WHEEL
BE EE es ttt
This may also be illustrated from the statistics of the
13,000 deaths reported as due to cancer in the United
States during the census year 1879-80. ‘The first of the
two diagrams before you shows the proportion of deaths
from cancer at different ages in the manner in which it
would be calculated from the records of physicians or
hospitals ; namely, the ratio at each age to 1,000 deaths
caused by this disease. From this diagram it would ap-
pear that cancer is most fatal about the age of sixty. If,
however, we compare the deaths from cancer at each
age with the total living population at that age, after the
Deaths from Cancer of Persons Over Twenty Years of Age, with
Distinction of Age and éz in 100,000 of Population of Cor-
responding Ages. s..
CANCER.
_ HHTERRHHS
3 SORESENEN ae
St sew E eS S wee
ee H | {| |
methods of the vital statistician, we obtain the figure
shown in the second diagram, which indicates that the
mortality from cancer increases with advancing years to
the age of ninety, and that the reason why the number
ofjdeaths from this cause diminish after sixty is simply
because of the less number of living population after that
age.
In discussing the tabulation of the returns of cases of
acute rheumatism, in the “Collective Investigation Rec-
ord,” Dr. Whipham gives the number of cases in each oc-
cupation out of 655 cases recorded. Of these, 71 were
domestic servants; 16, agricultural laborers ; 13, farmers ;
10, grocers, etc. He comments that the number of domes.
tic servants, 71, is a remarkable occurrence, and proceeds
to account for it by the consumption of alcoholic drinks,
etc.
It is evident, however, that absolutely no conclusions
can be drawn from these figures, since there is no definite
proportion between the number of domestic servants at-
tended by the physicians who made the reports and the
number of domestic servants in existence, nor is there
any relation between any of these figures and the number
of domestic servants attacked by rheumatism. The only
way in which this factor could be brought in in such sta-
tistics would be with reference to frequency and charac-
ter of complication, or as to relative fatality of the attacks
in comparison with other occupations.
The fact that in each case of sickness there are many
different circumstances which combine to produce the re-
sult is not, as Louis remarks, a valid objection to the use
of statistical methods for the purpose of estimating the in-
fluence and relative importance of each of these influences ;
it is rather an argument in favor of their employment.
Counting is better than guessing, and when it gives con-
tradictory results as applied to two groups of cases, it in-
dicates that some circumstances have not been taken into
sufficient account, and that further inquiry is necessary.
In the body of the sick man, as in the test-tube, like
causes under like circumstances will produce like effects.
Admitting that the chances of error in medical statis-
tics are very much greater than in those relating to vital
statistics, it does not follow that they have no value. It
simply increases the desirability of collecting a large num-
ber of facts before proceeding to draw any definite deduc-
tions.
In statistics with regard to therapeutics, we have to
take account of the various influences which the condi-
tion of the organism exerts upon the results before we
can fairly estimate the action of the new and special in-
fluence which has been introduced in the shape of an ac-
tion of a drug, or a particular mode of treatment. In
any event, such statistics, even when derived from a small
number of cases, serve to indicate lines of investigation,
and to ask questions, if they do not answer them. As
Legoyt remarks, two pneumonias do not resemble two
dice, each haying the same number of faces and of num-
bers, but rather dice with an unequal number of faces and
different numbers.
The greater part of our pathology and thera-
peutics has not been derived from statistical ob-
servation. It is not by this means that the di-
agnosis of small-pox, or of scarlet fever, or of
rheumatism, has been worked out, or the fact
that the ulceration of the intestinal glands be
longs to typhoid fever, or the presence of gum-
my tumors to syphilis; nor has it been by this
means that the transmissibility of certain forms
of disease by contagion has been proved.
Whenever a necessary and logical connection
between a particular cause and the resulting
phenomena has been established, statistics are
of little or no value in demonstrating the con-
nection. In every case the result must follow the
cause, as it does in a chemical expenment, and a
few repetitions of such experiments give as great
a degree of céftainty as a thousand or more.
The’ chances of the occurrences of a certain event in
relation to cause can only be mathematically calculated
when the totality of the possible causes of the result re-
mains the same under the different circumstances investi-
gated. This is one of the chief reasons for the impossi-
bility of drawing positive conclusions from medical sta-
tistics properly so called.
December 14, 1889}
THE MEDICAL RECORD.
647
The consequent condition is one that I have already
mentioned, viz., the application of the law of large
numbers and the consideration of the limits of positive
error.
The services rendered by statistics to medical science
are by no means so great as was hoped by those who first
proposed the application of this method ; partly from the
nature of the case, partly from the wrong application of
statistical methods to groups of cases to which they are in
nowise applicable. What result, in fact, can we expect
from statistics applied, for example, to a number of cases
of fever before the distinction between typhus, enteric, and
relapsing fevers was understood ?
The results of medical statistics will not apply to the
treatment of any particular case. ‘They can never prove
that bloodletting should be employed in all cases of
pneumonia, or that it should never be employed in any
case of pneumonia. Even the results obtained from the
most satisfactory medical statistics will only be found use
ful to the physician in directing his treatment, in the ab-
sence of any special indications in the particular case
which he has before him.
The data upon which to base medica) statistics must
be obtained either from published records, from unpub-
lished memoranda collected by means of correspondence,
or by the so-called collective investigation methods, or
from personal experience. ‘The published data include
such records of private practice as are given in journals,
transactions, monographs, etc., records and statistics of
hospitals, statistics of public medical services and of med-
ical and life-insurance societies.
In many respects the crude data in the form of records
of individual cases are the most reliable ; but the labor of
collecting and combining them is great, and we desire,
therefore, to use the statistical tables prepared by pre-
vious workers, as far as they are available, for the partic-
ular inquiries which we have on hand.
Detailed reports of cases, such as are suitable for use
in statistical work, are not over-plentiful. In the major-
ity of cases the individual data are not given. We have
only summary statements of tables of results. This is the
case with regard to much the larger part of the great mass
of reports of results of hospital and asylum practice which
have been published during the last hundred years, either
in the form of separate annual reports or in summaries
for journals or societies. ‘These reports give some infor-
mation as to the prevalence of certain diseases in certain
places at certain periods of time, and in this way have
some historical value, but they do not show the propor-
tion of cases of disease or death to the living population
in which these occur, and very few of them give the data
by sex and age in the manner required by the statistician.
Some of these calculate death-rates with reference to the
total number admitted during the year, others to the total
number treated, which includes those remaining on hand
at the beginning and those admitted during the year, and
others to the total number disposed of during the year by
discharge, transfer, or death. A few of them give the
average daily number under treatment during the year
and the average number of days’ treatment for each case,
sometimes making a distinction of sex, but almost never
of race or age.
Comparisons of gross death-rates of different hospitals,
however calculated, are of little value for the purpose of
determining either the sanitary condition of the place, the
skill of the medical staff, or the merits of the particular
system of treatment, owing to the great variations in the
class of patients admitted. Of course, the statistics of
hospitals for special classes of diseases can only be com-
pared with those of the same kind, and, even for general
hospitals, the fact that the gross death-rate of one is
higher than that of another proves very little.
In a paper by Dr. Guy on the rate of mortality pre-
vailing in the general hospitals of London, he compares
the death-rates of King’s College Hospital, with which he
was connected, for the first five years of its existence, 1840
to 1844, with the five years from 1857 to 1861. ` During
the first period it was an old building, in a bad locality,
and greatly crowded, and without any reputation as a
hospital or as a medical school. During the last five
years it was in a new building, with excellent sanitary ar-
rangements and with an excellent reputation. He cal-
culated the death-rates on the number of admissions to
the hospital. The rate for the first five years was 8.4 ;
during the last five years it was 10.85. He concludes
that a higher rate of mortality may be due to causes very
different to sanitary defects in the building and want of
skill in the medical] staff, and that in a large city, in the
case of a hospital enjoying similar sanitary advantages,
the rate of mortality is mainly determined by the reputa-
tion of its hospital staff among the public at large and
among its own pupils, which reputation influences the
proportion of grave and dangerous cases which are sent
to it.
In comparing hospital death-rates it is now generally
agreed that it is best to make use of the death-rates in re-
lation to the total number of persons disposed of by dis-
charge, transfer, and death for a series of years, Com-
parison of the number of deaths with the admissions only,
is apt to give very misleading results. A better method
than this is that of Bertillon, who adds to the number at
the beginning of the year one-half the sum of those admitted
and of those going out. It is also desirable to know the
ratio of deaths and discharges to the mean population of
the hospital, which is obtained by dividing the number of
days of treatment by 365; but in this connection it is to
be remembered that when the mortality is calculated with
relation to the number of days’ sojourn in the hospital,
those physicians who keep their patients the longest will
show the lowest death-rates.
In this connection may be mentioned a curious error
contained in the hospital statistics of France for the years
1833 to 1852, inclusive. Here an attempt was made to
calculate the percentage of death on the total number
treated, but the way in which this was done was to add
the sum-total of those remaining at the end of each of
the twenty years to the number of those admitted during
the respective years, giving an average death-rate of 8.3,
the figures being: Number admitted during the twenty
years, 8,818,501 ; sum of those remaining at the end of
each of the twenty years, 2,204,676; making a total of
11,023,177.
Here it will be observed that a large number of patients
are counted twice over, for, instead of the total remain-
ing over at the end of each of the twenty years, there
should have been taken only the total remaining at the
beginning of the record, which was 99,262; so that
the number of patients has been improperly increased
by 2,105,414, with a corresponding improper lowering
io the deathrate, which should be 10.3 per cent. instead
of 8.3.
One of the earliest statements in relation to the mor-
tality of hospitals is that in Sir William Petty’s work on
“ Political Arithmetic,” to the effect that in the year 1685
the proportion of the deaths to the cures in St. Bartholo-
mew’s and St. Thomas’ Hospitals was about 1 to 7.
In the old Hôtel Dieu, in Paris, for the years 1770~80
the ratio of the number of deaths to number treated was
twenty-five per cent. |
In the hospitals in Paris in 1822, for over 40,000 cases
the mortality was 12.5.
In the Charité Hospital in Berlin, from 1796 to 1817,
twenty years, the death-rate was 16.66. In the Imperial
Hospital at St. Petersburg, from 1803 to 1817, fourteen
years, the deaths were 22.22 per cent. of the number
treated.
I have prepared an extensive series of tables of death-
rates in hospitals, from which these are merely selections ;
but my conclusion from a careful examination of them is
that they are worthless for any scientific purpose, and
that such statistics are useless unless they give the death-
rates by groups of ages.
648 | THE MEDICAL RECORD. -~ [December 14, 1889
3. Recovered or relieved during the year. a
4. Discharged incurable, unrelieved, for irregularities,
or at their own request.
The following table gives the means of comparing som
ancient and modern death-rates. m ,
| | §. Died during the year.
| Death- Death- | Average ? S 3 Á
Hospital. yp shened) i rare of ranc of diz) stay ig 6. Remaining in hospital on the last day of the year.
r | __|_ Seated. | Posed of | hospilal. | 7, Mean duration of cases in days and fractions of a
Ae « neat: TE da
Guy’s Hospital, London .......... fo | | | Gaye
SETH mas? Hospital, London heat | i i Tee | | In each of these genre the data are given for each
ran Nesp se gee age Gales 4 ; disease, for each sex, and for each of a number of groups
see ité Hospital Perin ea zor 1878-87 | 9.60 | 10.40 29.3 | of ages; the primary object being to ascertain the total
emeines Kranken ienna. ; 1.50 12.40 , 25. f : .
Italian hospitals ....... fe ee eee ace aaa 2 sick population, that is, the number of beds constantly
Panerus Hemel ae re nee er. a oe a ae occupied during the year for each disease, and each age
New York Hospital 02. sees. 1877-88 i foe | 7.86 18.0 and sex; 2, the number of cases of each disease, for
st. s Hospital... ...0....000- ' 1875-88 | ..... . l 9. i Š
City (Boston) Hospital sil ea a esis 1870-88 | beens | ions ge each age and sex submitted to treatment > 3 the average
Minshachuscite cco Hospital... 1874-88 ee are | 26.7 duration of each disease for each age and sex; 4, the |
ennsyivania ospital .......... rar 1074-00 |} asso . 20.1 . e
Cincinnati Hos ital . es oer hess 1874-88 eee 9.26 | 2.3 mortality of each disease for each age and sex; and, 5,
Rhode Island Hospital............ 1875-88 | ..... 8.91 37-4 the proportion of recoveries for the same."
eet eee E E From what has been said in these lectures it will be
In his prize-essay on “ Hospital Statistics” Dr. Steele | seen that no form of hospital statistics can be considered
substantially agrees with the remarks of Dr. Guy above | as satisfactory which does not give the distinctions of sex
referred to, and says that the hospital which confers the | and age, and this not only for the total of all the patients
greatest benefit upon the community is that having the | but for each of the several forms of disease treated.
highest death-rate, as it is the one which admits the most | The best form for hospital statistics is probably the fol-
critical and incurable affections. As the population of a ` lowing:
Form of Table for Hospital Statistics.
a a ee ee ee ee
| AGES.
Total, | n e ae | Ge ye ae E at Pa Ace
Under 5, 5-10 | 30-15 15-20 į 20-25 25-35 | 35-45 | 45-55 55-65 | 65-75 Over ys
fe i es z m ao: spares wees v= aa
ie Miorerorr reotas R N | a aaa a aS P ahis POTETE POE A ER er ce
Remaining at commencement..................... |
a ower eens ceo eeeeeor ew oseoees | sees osse CO PHF Ors CHRP woe ne FH HHH eOs | eee were se Ferrera ey PFO ssoe ae eevave at ani
TRE a ee ae Re A ey ER EET
Admitted during the year ..................-0000- ' | | |
ee nies eek. E EE E EE T Vase ana a mista. E E a S
1
Mecectis CER E E E E LE EE SE SE E E s.. s oe ea C E E 8 ee @ Fe sia! a@eeeeeere | eee t8teene vov eeweew + + Oe è oo è OC OC HO OB HHO | se eo ooo
Discharged ocorran aE a Ea 46 | | |
F, | Come caer cea wn Pete seen e nee Coes tees Cenvreene sos 8008 ' ee eesaes Le ee w eee r weecee ene came eeee cot teers | ewcccece
|
M. Bee 6. ever Oe. an eee ee Na 6. a pale aa a a i esas. eoso | Oo. sa oeseri raea eo teases jeccesooos
Transferred 2243socins ios ce deon cand oa onran enn | | | |
Bisse Geol uiaw sade, bos wee then edamame” Zo EEA Dette wane peak, eww a cen paises), Ta EEA
'
M re Gee ee ee Gd eh eps ees. Seah es eet ee Sins ek a E E e TEIA E
Diederen te ana A O a a aeaa eA | i
Eain aan oa a a a aeaa oela a a wes aN | EE E
a EEE TE E EE A eee, Fenua iee a a EPER A S
Remaining at end of year ........0000..... cee aee 1 |
We Sekai: ares aaah ah cada ded ee E E aa aaa A E au ber awe Fae Sea AES saeco
Ee ean et Oe nee tere nnn oe mee er eel ioe iceeea eee lasses
Total number of days’ treatment........... a tee be | | i
Be E E E EEEE ATTE EE TTET, e | eri tia ue eit cn Gea tes EO TE
, !
i M oeranGRS mi EE EE E ENET MAS EEE EAE SEIS Poe SERET | e
Veath-rate per total disposed of .................. 1 | | |
Biot este as E E ES AR EEA E S tasked BERS whe A not, nae AEE annie eee Traean
EREE a BE A A E T T NS
city increases, the demand for hospital accommodation Prior to the discovery and employment of antiseptic
also increases, and, unless more of this is provided, the | methods in obstetrics the records of lying-in hospitals were
tendency is to select the more serious cases for admission, | very unsatisfactory. It is true that we have no very def-
and thus to procure an increased mortality-rate. inite standard of death-rates in childbearing in private
_ I cannot assent to the proposition that a high mortal- | practice with which to compare them, but this rate is given
ity 1s any proof of the utility of a hospital, or of the skill | by the Registrar-General of England as being at thg rate
ofits staff—but it is certainly not a proof of the con- | of five per thousand children born alive for the twenty-
trary. eight years, 1847 to 1874.
The mortality of the non-accident cases averages from The summary of the returns of the extern maternities
four to five per cent. But the fame of the hospital, the | in connection with Guy's, St. Bartholomew’s, and St.
reputation of its staff, especially for difficult and hazardous | Thomas’ Hospitals for the twenty-one years, 1856 to 1876,
operations, may tend to increase the ordinary death-rate. | comprising an aggregate of 74,580 casés, gives a mortality
An increased mortality in the surgical ward may be | of 4.1 per thousand.
due to special provision for permanent residence of pa- The largest lying-in hospital, and the oldest, is that known
tients with incurable disease, such as the establishment | as the Rotunda, or Dublin Lying-in Hospital. In 198,481
of a ward for cancer-cases. cases of confinement in that hospital, the death rate was
There have been a number of reports and discussions | 13.9 per thousand.’ ‘The following table is of interest in
in statistical congresses and societies with regard to the | this connection :
best forms to be used in publishing hospital statistics. | — —.4...#_______ _
Ihe following are the desiderata for hospital statistics as 1 See paper on Hospital Statistics and Hospital Plans, by Florence
given by Miss Nightingale : Nightinga e, e ot the National Association for the Promo-
maini ; : tion of Social Science, 1861, p. 554.
r. Re ing in hospital on the first day of the yen: ? Summarized from Dublin Medical Journal, 1869, and from Dr.
2. Admitted during the year. Johnston's Annual Reports from 1868 to 1875.
December 14, 1889]
THE MEDICAL RECORD.
649
Neen ——————————_____ LL
Table showing, for Prussia, from 1816-86, the Number
of Deaths in Childbed, the Proportion per 100 to Labor
Cases, to Women between 15 and 45, to Total Deaths,
and the proportion per 1,000 of Population.*
i |
| EE Per cent. of Percent of | Per 1,000 1 death to
Period, | Number, women, of popula- each case
| labor cases, 15-45. all deaths. Ts af labor,
i |
ees 22,036 | 0.9454 18.82 ! 1.430 0.402 1 : 106.0
1821-30.! 44,826 0.8979 16.78 ! 1.300 0.360 1: 108.4
1831-40.' 48,291 | 0.7982 13.64 1.160 0.345 . 12 112.2
1841-50.) 47,506 ©.7779 12.45 1.030 0.294 1: 130.2
1851-60.) 53,341 Q. 7949 13.07 0.950 0.302 1: 127.5
1861-70. | 64,056 0.7716 13-99 1.070 | 0.304 | 1:129.8
1871-75.: 41,735 0.8398 34.82 1.130 ; 0.328 1: 122.2
1876-86. | 68,942 0.5830 10.89 0.902 ' 9.237 1: 167.7
t 4 l
* Ehlers Zeitschrift f. Geburtshülfe, etc., 1889, xvi, p. 455-
It is not an easy matter to determine what may be
called the normal or average mortality of women in child-
birth, in order to determine the probable utility of a par-
ticular mode of managing cases of labor, as, for example,
the so-called aseptic method. From the mortality statis-
tics of the last United States Census’ we find that in
155775173 births 5,646 deaths of the women are reported,
being in the proportion of 3.57 per thousand births. This
proportion was higher in the rural districts than in the
large cities, and in negroes than in whites, as will be seen
from the table :
| ! |
; Deaths from
| ‘Total births. | Deaths from — childbirth
| Em * per 1,000 births,
“The United States ......... | 1,5779173 5,646 3-57
tals occa ver vaccscevenis 1,348,563 5,283 3.91
Cities ....... enrera isses i 228,612 | 363 1.58
Whites in Southern States.. 723.884 ; 2,225 3.07
240,607 | 3,217 5.05
Colored in Southern States. |
ported, or to the surroundings, or to the method of mak-
ing reports and collecting data? Evidently the latter is
first to be considered. In the data furnished by the cen-
sus and the English registration reports, the cases attended
only by midwives and wise-women are included as well as
those attended by physicians, and it is among the negroes
and the Germans that the proportion of cases thus at-
tended is the greatest. Moreover, in the cities where
there is a regular registration of deaths upon physicians’
certificates there is less tendency to give the vague term’
childbirth as the cause of death than in the rural districts
where the cause of death is returned by non-professional
persons ; but this does not apply to England, and it is not
probable that it greatly influences the results in this coun-
try.
The deaths reported in the census as due to childbirth
are those which occur during or soon after labor, includ-
ing those due to hemorrhage, exhaustion, acute uræmia,
etc., while those which occur at a later period may be re-
ported as due to peritonitis, septiczemia, etc., although the
physician in reporting the results of his private practice
would include all these as deaths due to labor.
While the physician will usually consider only the rela-
tion between the number of cases of labor and the num-
ber of deaths in childbirth, the vital statistician will study
the relations of deaths in childbirth to the number of
women living between the ages of fifteen and fifty years,
or to the total number of deaths from all causes. ‘The
figures of the last United States Census show that of ev-
ery 100,000 women between the ages of fifteen and fifty
living in our large cities, 16.21 died in childbirth during
the year, while in the rural districts the corresponding fig-
ure is 51.58. The following table shows the ratios in re-
lation to deaths of women from all causes, with certain
distinctions of locality and race : |
Table showing, for Rural and Cities, for White and Colored Females, and for Females of Irish and German Parentage,
the Proportion of Deaths from Childbirth and Abortion in 1,000 Deaths of Females from Known Causes.
-_
eel —_— —— m — - S —
L l e nĖĖ——_————_——
p |
d RURAL. | C1TIES. | WHITE. COLORED. | P ete P an E.
| i
GRAND Groups. eg pS r ee aes a Vania
' Child- | Abor- i Child- ; Abor- |i Child- | Abor- Child- | Abor- jl Child- Abor- || Child- | Abor-
` birth. | tion. |. birth. | tion. |, birth. tion. birth. tion. i h. tion. birth. tion.
SIERA A ne A E E, = ee: TEN TREN SON. Ep | i oa
i ) :
». North Atlantic Coast region | 6 |
0 : 1. PPRTETETETETEETTETTT 9. 0.7 |; f 1.0 oe . e... .. 12.4 0.3 11.32 1.5
2. endl Atlantic Coast region..........0.eees00e ie ra | 49 1.8 7.3 0.7 17.8 30 © 7.2 0.6 || 6.4 rn
3. = + Atlantic Coast region..........c02--eree- 32.4 1.8 j xt e.. | 24.5 0.9 32.9 0.7 i !
+ No sata ON cee cer ceccccccccescecscsesses| 37.3 3.0 || 1.2 o.4 | 285.5 1.0 23.5 0.8 l '
5. Northeastern hills and plateaus AL bie ace 12.6 1.5 | 8.5 r2 | wank ‘ dite eee j| 10.8 0.3 | 10.2
6. ro achian region ...........eeeeeee- 23.0 1.3 6.7 3 ooe : nat ae gee ae j 6
4 Teen of the Great Northern Lakes ........... 23.6 2.7 | 6.7 | 1.2 |i ove i saie ous | 26.5 1.5 | 27.6 ) 1.0
. The Interior Plateau ...... TENANE eseeeasoo ae 17.2 | 1.2 3.5 | 0.2 || mex 0.3 22.6 1.0 17.6 0.4 17.0 0.4
9. Southern Central Appalachian region...........| 15.7 2.3 | 16.5 1.1 13.0 1.3 . . Poa
10. The Ohio River Belt . i j pa p | ; l : i | 38 (i aid f
South T Delt ....esesoceccsoeesosooeooe 12.9 2.0 1.7 0.5 10.0 0.7 12,0 1.3 9 10.7 0.4
ES uthern Interior Plateau..........ceeeseeeeees 25.9 2.7 | eee . (| 213 Z.I i| 29.3 s |i i
s2. South Mississippi River Belt...........00+--0- 3°.3 4.2 | oer oa 33-3 1.4 37-9 1 2.3 | 4 i
13. North Mississippi River Belt ..........+e0+see: 20.8 2.2 3.9 | 0.5 ates TA oe t eer, |i 36.3 0.8 ‘| 16.7 | 0.5
14. iirhs Central region...........- oe a S 26 5 A ae ae V eee 24.6 2.2 34.1 | 2.8 |
1%- ah z region, plains and prairics.......... eee] 14.4 2.4 || 28 | of 13.9 I.I 13.6 | t.4 | |
10. Mis raire FEQION. ... 02. ce ewer cence eee ercccece 18.8 2.0 | woes | E Saale ac SETZE ae. 19.9 o.5 | 3.6 | 0.8
ot spege ie Belt ....... suie'a od Wie era re We Mistere Secs 16.5 3-4 ;| 14.7 11.0 sale’ ! | 29.0 2.5 21.3 0.8
: ia ‘the Western Plains..........-.++seee 33-5 | 57 | 55 5.5 ft i j| 100.0 eee | 75.7 |
9- Heavily timbered region of the Northwest....... 19.6 0 3a fo wakes. beens n 28.1 1.9 52.2 1.0
20. pep aria TEQION 0... cece eee ce cere ceneenees 37.0 | 2.7 |! oe. is re, A 33.1 ave | 13.3 3-5
21. Pacific Coast region ....... ccc ccccc scene ccc nces | 29.8 j I7 i! 3-7 i 1.0 | ea yy Pan 33°7 15.4
i i E [! a ae | Í amas aeae aD
Total osos csesesrocsst sri ssssisee s snn sees | 19.5 2.3 |i 4.7 BA al 13-9 | o9 | 24.8 1.4 | 14.3 0.5 || 18.3 | 0.8
‘
For the same year (1880) the Registrar-General of Eng-
Jand reports the death-rate of women in relation to births
as 2.07 per thousand. If now we compare these figures
with those given by obstetricians and physicians, we shall
find that the latter give death-rates from two to four times
as great. ‘Thus, Duncan gives the death-rate in private
practice as from 8 to ro per 1,000 births, while LeFort
gives the figures from maternity hospitals as 30,594 deaths
in 888,312 births, or over 34 per thousand ; while Ehlers,
using the statistics of Prussia from 1816 to 1886, gives the
rate as from 5.8 to 9.4 per thousand. |
How are we to explain these differences? Is the re-
ported greater mortality in rural districts, in certain races,
or in physicians’ reports, due to peculiarity in the cases re-
a IIM ťi
1 Report on Mortality and Vital Statistics, Pt. II., Ixx.
If, then, we are to judge as to whether the death-rate in
childbed in the practice of a particular physician is to be
considered as high or low, we must first know whether
the figures relate to hospital or to private practice, and,
if the latter, whether it was in the city or in the rural
districts. To obtain some standards for comparison we
may use the numerous reports found in medical literature
in which physicians have given the statistics of their private
obstetrical practice, and compare the results with those
given in the statistics of maternity hospitals, for which pur-
pose the table on top of page 650 will be found of interest.
Suppose that for the sake of testing the relative effi-
ciency of two different modes of treatment, or of the
general progress made during a series of years in thera-
peutics, we take the statistics of a particular disease ;
which should be one having a tolerably definite train of
650
THE MEDICAL RECORD.
[December 14, 1889
Deaths in Childbed in City and Rural Practice, before and after 1876.*
| Cases.
Ameren i ety prace aee eaaa d sasn aeie riiai 9,468
Amenca, iN TUral pIACtCE osaten irese eceds pesehaots saneneasen 13,375
America, in maternity hospitals........... Lues ssessesocrssrssussors | 8,514
Great Britain, i in private PYACUCE, EMER: a n TIETEEN tise | 60, 487
(orent Britain, in Tural practice diss 626s ck aipesaslcstcestes. cevacens cess 23,170
Great Britain, in a T in in ooo n ea dkscewearetosewae verges aden 156,093
Great Britain, in hospitals 2) i.0isec osc isoe001082seseeeee PTAA TE 382
RE TE T ST 33:747
Petersburg, General and Maternity Hospital
Vienna, Imperial Lying-in Hospital
s.. boss tobb Oe poss sosooo
i eeeeeest—t—s n me a --— —
Barore 1876. | AFTER 1876.
7 - a ee ceser ja ; ste” sod aie ee
| Deaths. Per 1,000, Cases Deaths | Per 2,000
52 5.49 2,261 33 i 314.59
79 5.90 2,994 26 8.68
136 15.97 6,004 143 73.81
239 3-95 3,500 14 4.09
4 3.62 2,014 15 | 7.44
570 3.63 | 76,554 193 2.52
1,626 16.87 100,997 928 ? 9.38
1,423 42.16 l, |
skeins oo Daah | 15,070 106 3 7.23
* For prisons and asylums the death-rates should be given for the average daily population in the institution, and not for the number of idua or for the
number of cases disposed of ; but in these cases pou death-rates for the whole population are of very little use.
th-rates of the general population coming under the same groups.
and age in order to make cdmparisons with the
symptoms, so as to be easily recognized. A disease which
it is common to select for this purpose is acute lobar pneu-
monia. Suppose, now, that in a given group of cases of
pneumonia subjected to one method of treatment the mor-
tality is found to be greater than in another series of cases
subjected to a different treatment, are we thereby author-
ized to conclude that that mode of treatment connected
with the lowest mortality is really the cause of the low
mortality? By no means. Before we can do this, we
have to settle the character of the cases, the proportion
of those in each group occurring in advanced age, or in
intemperate persons, or in those affected with other dis-
eases, or in certain races, because all these circumstances
influence the death-rate. We have also to take into ac-
count the total number of cases in each group, in order
to make an allowance for the probable error due to small
numbers. If the two groups of cases have occurred in
different localities, or have been treated in different insti-
tutions, we have then to take into account the special in-
fluences of the locality or institution, as far as it is possible
to do so, and not until all these corrections have been made
can we fairly estimate the relative influerice of the treatment.
I have collected the statistics of 209,755 cases of pneu-
monia occurring in this country and in Europe within the
last fifty years, as shown by the following table, giving an
average death-rate of 21.11 per cent. The distinction of
sex is given in 33,904 of these cases, showing a death-rate
of 19.86 per cent. in males, and 24.68 per cent. in females.
| Rae | Percentage
| Cases. | Deaths, of mortality.
| | |
In Civi. HosPiracs. | |
German and Australian...........-.+++ 44,952 9,868 | 21.95
Prish. Secas o6eins vcpicn ss sees ee tiani | 3,467 770 22.20
COOKER occ cecee wiara onn iesenii 353 gt 25.77
AMONCOB AE peckmaderdeaeds cess »259 1,918 30.64
TSR 5 6-0:0:6'9460%-b05 ve kes oo we@ ors T | 133 | 41 30.82
BO A E T O A 55,164 12,688 23.00
In Mititary HOSPITALS. |
Austrian (1873-82)..........cceceeceees | 9,007 1,276 14.16
United States Army (1877-88).......... | 2,430 | 455 | 18.72
British Army (Crimea 1854-57) ........ 590 125 | 21.18
U mee States Army (1861-66), eee:
roops PUEDES DEP RR AEF 1,204 14,738 | 24.08
Unite States Army (1861-66), colsced!
HUODE s .cuscunssesuvaccacas PoeRenne 16,133 5,233 32.43
RO EE ETE curse | 89, 364 21,827 | 24.42
In THE NAVIEs. | |
United States Navy (1873-88).......... | 933 92 9.86
British Navy (1872-76) 1,670 194 11.49
United States Marine Hospital Service |
E I RET E N E sdenweas | 9,454 | 573 16.58
Total Naval and Marine service .. | 6,057 | 859 14.18
| |
Norway (1880-85), statistics for king- | |
COR ET O EN E Te | 59,170 8,907 | 15.05
Cen lssi rsr 003506805008 209,755 44,281 21,11
Cases with distinction of sex : ast
Civil hospitals, males .. s.s... sesssos 22,862 4,539 19.86
Civil hospitals, females .............. | 11,042 2,726 24.68
DORR EA S T ness yeuceenes | 332904 | 7,265 |
‘The distinction of deaths by ages for each sex is given
in 24,557 cases, and from these data I have calculated
LS i
fourteen per cent. were fatal ;
cases over fifty years of age who were intemperate or
It is necessary to have them with distinction of sex
the proportion of deaths to cases in each age-group, as
shown byjthe table and diagram on opposite page. The
immense importance of age as a factor in the death-rate
from this disease is at once apparent.
In the absence of statistics of cases and deaths by
ages, we can get very little information from statements
of death-rates from pneumonia. For example, the death-
rate in the United States Army hospitals from pneumonia
from 1877 to 1888 was 18.72 per cent. of the cases
treated. Was this a high or a low death-rate? We can
only say that it was probably rather below the average,
since the average death-rate for males between twenty
and fifty years of age is 19.9 per cent. on cases treated.
The need of such considerations is well illustrated in a
paper by Drs. C. W. Townsend and A. Coolidge, con-
tained in the Medical News, July 27, 1889, page 85.
This paper is a discussion of all the cases of acute
lobar pneumonia treated at the Massachusetts General
Hospital from 1822 to the present time, the figures being
divided into periods of ten years, making seven decades
in all. The following chart indicates the gross result in
hse72 |t v A sese
if fe sz y>- A4
E Sar | 78% stay ie
1,000 cases. ‘This would indicate a steady rise in fatal-
ity from 1822 to the present time. What are the circum-
stances which make the cases of pneumonia coming into
the hospital during the last few decades more fatal than
those which occurred during the first three or four dec-
ades? One of the first things investigated was the
average ages of the cases of pneumonia admitted in each
decade, and the results obtained showed that there was a
greater number of patients over fifty years of age in the lat-
ter decades, and that the average is steadily increasing.
In like manner, the proportion of cases occurring in persons
of intemperate habits, or complicated with other diseases,
was examined for each decade. ‘Ihe influence of race
was also estimated, with the result that in Americans nine
per cent., in Irish eleven per cent., and in other foreigners
a
AT
this was omitting all fatal
complicated. Now if we take the mortality and make
the necessary corrections for the influence of age, or
proportion of intemperate and complicated cases, we get
the above diagram.
ee eae : Oe
Hi #
December 14, 1889]
|
|
| CASES. DEATHS.
THE MEDICAL RECORD.
The Proportion of Deaths to Cases in Age-Groups.
651
DEATHS BY Aces TO || Cases BY AGEs TO ` | DEATHS BY AGES TO
CASES BY AGES PER 100. | ToTAL CASES PER 100. || TOTAL DEATHS PER 100,
if 1} į
1 | | | j
Male, Female. Total. || Male. Female.! Total. — Male. Female.! Total, Male. Female.| Total. Male. | Female.| Total.
‘ | == l i eal ae i — hin "
| | | | | |
9=10 445 | 285 730 42 27 69 9.43 9.47 | 9-45 2.620 | 3.75 | 2.970 1.19 1.31 1,23
SOME ink i: f.0 oe TE nates 3,730 | 98o 4:716 || 320 | 107 427 | 8.56 | 10.91 | 9.05 | 22.040 | 12.92 | 19.220 9.08 5.21 7.65
BBO cans od giwe ew wed oS bate 5,166 | 1,897 7,063 | 753 | 334 1,087 14.57 | 17.60 15.39 | 30.480 | 25.01 | 28.790 21.36 16.26 19.49
ae ae rere ee ree. 35143 1,327 | 4:470 | 685 275 | 960 21.79 | 20.72 21.47 | 18.540 | 17.49 | 18.220 19.43 13.39 17.21
Vl PR TT eee 2,228 1,036 | 3.264 | 665 316 g8t 29.84 | 30.50 30.05 13.140 | 13.66 | 13.300 18.87 15.39 17.59
S060 i sc scuacscsos aebes 1,294 954 | 2,248 || 539 353 | 892 41.65 | 37.00 39.68 7-630 | 12.58 9.160 15.20 | 17.19 | 15.99
60-70 .. | 726 02 1,528 | 387 432 | 819 53-30 | 53.86 53-65 4.280 | 10.57 6.220 10.98 | 21.04 14.68
70-80 . 190 | 268 | 458 | 119 183 | 302 | 62.63 | 68.28 | 65.93 s ‘ s
PIO week, S AT | 19 | 34 53 || 14 26 | 30 68.42 | 76.47 | 73.58
GOSI 5 ids Sob aagi z | z || I 1 100 00 | ..... | 100.00
UNKOWN aade SARASA | 18 | 8 26 a), 6 to 22.22 | 75.00 38.46 |
Volal t iiaii iniaiigo | 16,966 | 7,591 | 24,557 | se.. | | I| 20.79 | 27.12 | 22.75 f
I Í i
Diagram Showing by Sex and Groups of Ages for 24,557 Cases of Pneumonia.
O at
ri
Ya | o- Ta ra
AS
F E seatesdferferttoes
EE HEEE HEEE EEE HE
F enad A E E e E
re pee eee eee eee ee
E EHHE EHE EEE
H E A
HHHH EES ee
Ppa E EEHEEHE HEEE EEHEEHE
E E EE A EEEE E
HEHHEE EEEE EEEE EAA EEEE
e e eg
SHKREDARER Stee eo ELLELE] occeee
E EEE EEE EEC
E E tae ceet E E
JENE EEEE ae SSE 008 GHGS SRees oe. seeeees eee HHHH H H
a EEEE EE
E EEEE EEEE EEEE EH EE
E R Ea EEEE HEtttGE n
e E E EAEE HERE H
FRP E A RE Seseeeeees seseeeseesteCeseseTa TSScszzs
EAE A E E
3 4 ae aa HE zs HH]
FFY- F e H
aeei rena ESEESE SeS sepeceeostastaatit
iri EE EE FERET
í i CLES aaa
HEHHEE =
— — — The ratio, per 100, of deaths, at each group of ages, to cases at same age.
329%. 2508 The ratio, per 100, of cases, at each group
of ages, to total cases. ——- —- The ratio, per 100, of deaths, at each group of ages, to total deaths,
Here, then, when we set apart the influence of the
causes of death which are entirely independent of treat-
ment, we find that there is but little variation of mortal-
ity from decade to decade, and if the influence of race
were brought in, we could not infer that, upon the whole, -
there had been any material change in the mortality of
pneumonia for the last sixty-eight years, although there
have been very great variations in the treatment during
that time. ` ‘
The conclusions arrived at by the authors are as fol-
OWS : |
1. In the 1,000 cases of acute lobar pneumonia treated
at the Massachusetts General Hospital from 1822 to
1889 there was a mortality of twenty-five per cent.
2. The mortality has gradually increased from ten per
cent. in the first decade to twenty-eight per cent. in the
present decade.
3. This increase is deceptive, for the following reasons,
all of which were shown to be a cause of a large mortal-
ity :
ie The average age of the patients has been increasing
from the first to the last decade.
652
THE MEDICAL RECORD.
[December 14, 1889
6. The relative number of complicated and delicate | to put this record into the form of a classified return pri-
cases has increased.
¢. The relative number of intemperate cases has in-
creased.
d. The relative number of foreigners has increased.
4. These causes are sufficient to explain the entire rise
in the mortality.
5. Treatment, which was heroic before 1850, transi-
tional between 1850 and 1860, and expectant and sus-
taining since 1860, has not, therefore, influenced the
mortality rate.
6. Treatment has not influenced the duration of the
disease or of its convalescence.
Suppose we try to estimate the relative value of a par-
ticular treatment of rheumatism—-say, by salicylates. We
find several tables in medical hterature giving the results,
treated by this and other methods. As a type, take the
analysis of 1,200 cases treated at Guy’s Hospital given by
Dr. Hood,’ in which he gives the average duration of ill-
ness, number of relapses, and number of cases of cardiac
complications in 350 cases treated with salicylates and in
350 cases treated without them, and concludes that re-
lapses and cardiac complications were more frequent un-
der the salicylate treatment, but that the pain ceased
sooner and the average length of stay in hospital was less.
But the cases are not tabulated by sex, age, race, etc., so
as to enable us to estimate the bearings of these circum-
stances on the results, nor in any tables are these results
thus classified.
In the fourth volume of the “ Collective Investigation
Record ” of the British Medical Association there is a
table of 655 cases of acute rheumatism in which the de-
tails of each case ate given under twenty-seven heads.
Dr. Whipham analyzes these, showing how many cases there
were in each sex, how many there were in each group of
ages, how many in each occupation, etc., but he does not
systematically attempt to group these circumstances ex-
cept as regards teetotallers, temperate and intemperate
persons; in other words, he does not tabulate them as a
vital statistician would do so as to show how many of
each sex in the first attack, in each age-group, recovered,
died, had sequelz, etc., when treated by salicylates, and
how many when not treated. In attempting to treat the
data by formal statistical methods it will soon be seen
that they are totally insufficient in number to give definite
results. For example, in temperate males having their
first attack and treated with salicylic acid, of 25 between
five and fifteen years of age 1 died, of 77 between fifteen
and twenty-five 1 died, of 35 between twenty-five and
thirty-five none died, and of 17 between thirty-five and
forty-five 2 died. Of the intemperate males under the
same conditions—16 in all—none died. Are we to con-
clude that intemperate males with acute rheumatism
should be treated with salicylic acid? Not at all—it
would require something like 60,000 cases instead of 600
to demonstrate anything of this kind. :
_ Evidently the statistical data which are of the most
importance differ for different diseases. If, for example,
we are comparing the mortality from pneumonia under
different systems of treatment, it is clear that we must
have the data with subdivisions by age; and the same
would hold good for Bright’s disease, and, in fact, for al-
most all diseases, if the law of decline of vital energy
with advancing years holds good. But for cancer the
data of sex and race are quite as important as those for
e.
An important point in medical and vital statistics is to
keep the current record, or what may be called the day-
book account, entirely separate and distinct from the clas-
sification or modes of tabulation. The current record must
be made complete at the time, for if any items are left out
they can never be replaced. But this record, once made,
may be used in various systems of classification and com-
parison for many years afterward. If an attempt be made
' British Medical Journal, December 31, 1881, p. 1119.
marily, it is certain to be defective and will not be appli-
cable to researches of another kind.
Nore.—In attempting a collective investigation for the
purpose of securing medical statistics everything depends
upon the questions asked, and there are exceedingly few
men who are competent to prepare them. As an ex-.
ample of how not to do it, take a set of questions adopted
by a certain medical society for investigation (Middle-
sex East (Mass.) District Medical Society. See Boston
Medical and Surgical Fournal, vol. ixviii., 1863, p. 345).
For example, “ Bromide of ammonium in atheromatous
affections and obesity. Dose, five grains thrice daily.”
‘“‘ Iodide of ammonium as a substitute for iodide of po-
tassium; said to have a more absorbent power,” etc.
“ Galium aparine. In epilepsy. Dose, one fluidrachm
thrice daily,” etc.
In the reviews ot the progress of medicine, of which we
already have a large supply in the shape of annual ad-
dresses and centennial literature, and to which extensive
additions will no doubt be made at the close of the
present century, ten years hence, you will find more or less
elaborate statements of the advances which have been
made in diagnosis, pathology, preventive medicine, and
surgical therapeutics in all its branches. Also, it is easy
to show that we have made great advances in the art of
relieving pain. But when we seek by statistical methods
to determine what advances we have made in the preven-
tion of death by. the internal use of drugs, it must be con-
fessed that the data are, for the most part, wanting, and
that the optimist and the pessimist can propound their
theories and beliefs upon nearly an equal footing, #c.,
that of ignorance of the real facts in the case.
It is easy to see that the statistics of fevers collected in
the last century, before typhus, enteric, and relapsing
fevers were distinguished from each other, are of little
use now, and that modern bacteriology has destroyed, to a
great extent, the value of the old statistics of tubercular
diseases, typhoid fever, cholera, etc., and of the statistics
of surgical operations. They have rendered some service
in their day, but their value is now chiefly historical.
There is, however, in existence in medical literature a
very considerable number of cases which have been re-
corded with sufficient detail to be available for statistical
treatment which they have not yet received. Death-rates
in relation to number of cases of special forms of disease
showing relations of mortality to sex, age, and race, are
yet to be calculated, and there is material for some good
and useful work in this direction.
Within the last twenty-five or fifty years, in civilized
communities, the gross mortality has diminished, there
has been a prolongation in the average expectation of
life, and the mortality of the years of infancy has greatly
diminished. But how much of this is due to preventive
medicine, how much to improved conditions of habita-
tion and to the lowering of the price of food, and how
much to improved methods of treatment? Dr. Sweifel
endeavored to answer this question in a lecture on “The
Influence of Medical Knowledge on the Life of the Peo-
ple,” delivered in Leipsic in 1887 (“ Der Einfluss der
ärztlichen Thatigkeit auf die Bevélkerungsbewegung ”).
Taking, as a basis for his calculations, the figures of
Bavaria for ten years, and those of Saxony for thirteen
years, he found that for 100,000 living population the
average number of deaths from tuberculosis increased
from 250 to 258 ; from inflammation of the lungs, from
222 to 270; from croup and diphtheria, from 98 to 123.
He remarks that these are saddening figures. In spite of
the sanitarians and health-resorts, in spite of ventilation,
new methods of treatment by inhalation, compressed air,
fic., the number of men who die from diseases of the
respiratory organs is steadily increasing, and he queries
whether Séssmilch was not right in his phrase “ göttliche
Absterbeordnung,” divine law of death.
On the other hand, he shows that the mortality from
— Amma tea —
i December 14, 1889]
THE MEDICAL RECORD.
653
typhus has fallen from 62 to 34. But the question is,
whether this is due to diminished prevalence of the dis-
ease or to a diminished mortality in the same number of
cases of the disease due to improved medical treatment.
It may be noted in this connection that the chief effect
of improved sanitation appears in the lessened mortality
in children under five years of age, and that it is chiefly in
-the mortality occurring after these ages that we are to
look for the influence of improved medical treatment. In
examining this, however, it is to be remembered that im-
proved sanitary conditions affecting chiefly infants, by
preserving a number of feeble and sickly children, tend to
produce a higher rate of mortality in succeeding years.
In cases admitting of surgical treatment, and in childbirth,
there can be no doubt as to the diminished mortality in
the practice of those who use the best accepted modern
methods ; but these methods are not yet used scientifically
by half of the profession, and the results are not percep-
tible in the general death-rates thus far collected.
It must be admitted that the greater part of the in-
creased expectation of life is probably due to better food,
purer water, greater cleanliness, and improved methods of
preventing the spread of contagious diseases. If we look
at the curves representing the loss of life in large masses
made in the line of prevention, and for which we have
the best reason to hope for improved methods of cure
after they are once established.
Total Deaths from Known Causes over Twenty Years of
Age = 346,280 (Census of 1880).
f
. k ta
$: ; a. os E
Se a coh
i aage ogia FFE
as shy = 33 | ass
igSens vD | saD
Eog agos | ERES
S$. 5 2 w| Os wo Su. > be
Qexaa| qian |A ia
}
CORMIMP BOS 80.6.5:3 2555 beers SR aE NN NS eee a Sa | 217.64 75:367 28.94
FCUMIONIE sess aeaaaee 5 te dine wcua a aas i 706.35 36,827 14.14.
Dropsy and heart diseases ..........--..+545: | 97.27 33,683 12.93
Apoplexy and paralysis.........-++....0-00+ 63.43 21,965 8.43
Accidents and 1Bjuries «sic cicaccecesesvacee 58.60 20,295 7.79
Debility and old age........ vscecssseceacsns 57.88 20,045 7.69
Other diseases of the nervous system... ...... | 41.30 14,302 5-49
Cancer and MMOL soo cns ceccs cesses seers seus | 40.42 14,000 5-37
Enteric fever... cccovcscccce ATT 36.99 12,811 4-92
ETIR MOVER EE E ns be Ses E hia ee | 26.30 9,110 3-49
Puerperal septicemia and childbirth .......... | 25.29 8,759 3-36
Other diseases of the digestive system...,.... | 24.44 8,464 3-25
Diarrhoea and dysentery.........++.seeeeeees 19.27 6,674 2.56
Diseases of the liver ionic cis coc cccscstvescoes | «15.97 5,531 2.12
Diseases of the stomach. .....esssssossssress | 10.64 3,686 1.41
iseases of the kidney ......: ccccsccescsesccs| 8.65 2,998 1.15
Diagram showing Proportion of Deaths from Specified Diseases to 1,000 of Total Deaths from Known Causes of Adults,
Twenty Years of Age and over (Census of 1880).
| S
l3 | ~ ~ N w a ts
3 K ? Š © Is D 3 A <
è a lla z È RFA
op hdegeter ttn et ,
- oe pt snans Consumption.
BEE EEE eee H sni
seuccaae 1 BARRASRRREENNA Pooutiquje,
SS cca E H EEEH EEHEHE HECEETHH Proper and heart diseases.
EAT pene earns? ST HH BEE Apoplexy and paralysis.
m FE EHEH HHH
ater ee
5a HHHH
HH
Accidents and injuries.
HH H+}
Jebility and old age.
Sense cuEETetsee Debility and old ag
PIPOTEN
es HHH rte Hatt ttt tt | Re HH a HHH F HHHH HHH Other diseases of the nervous
Saw) Sraeraa im H system.
ee EEE 3 an ser a
I ETETE a HH HE HHHH Cancer and tumor.
D HEH BCC CEE eeueu HEH eric fev
n H T =a A HHHH- a HHHH iT |] Enteric fever. ,
ee tebe a Sanus BRAE EEE EEE EEE EEE falaki Saver,
w ua HHH WNRYSZUDAR FHH Sa sesneennas —_
tag HHHH a : EEE ALE H HH +4 Puerpera septicemial an
GE jnana wae YAW HH as aan saz HEH Bang CELE i childbirth
TIECT TITI CETEL] HH FHH PEE E AN A E ED i system.
EH sau HHE garama HHHH — HHH PEP MAAA
DE TTriTititititiitii REECE HH CERET a AE E .
- usana Saanecne SRNSENSEURSNRENUNEERE uuasE ma aan TEEPEE H RE A A E
ae ed || PEE FE EEEE EEE BERANE SEER eaka e
Biss EPEE] H an SJAAL CORLEA] iseases of the stomach.
Het HE EEE EE EE EEE EEE EE EEE EEE
of people at different times and places, we see that the
laws of life and death have but a narrow range of varia-
tion after the age of infancy has passed, and that improve-
ments in therapeutics have lifted the lines but very little.
They have lessened suffering greatly, but they have not
. greatly deferred death.
In our present state of knowledge there are certain
forms of disease and derangement of organs whose ten-
dency is to recover without any treatment, or in spite of
bad treatment. ‘There are also certain diseases and de-
rangements which are incapable of cure by any known
method of treatment. Otherwise, man would not be mor-
tal. Between these two classes is a small number of
cases of disease the result of which depends on the treat-
ment. In order that medical statistics may give us any
information in regard to this last class we have got to
have some idea as to the proportion of each of the two
other classes.
Out of the 756,803 deaths reported in the United
States in the last census year, 355,575 were of persons
of twenty years of age and upward. The above table
shows the proportion of these deaths which were due to
sixteen groups of causes, which produced in all eighty-
five per cent. of them, and the proportions due to each-
of these is indicated by the diagram before you. -
I leave it to you to say for which of these diseases, or
classes of disease, it is most likely that progress is to be
EEE EE EE EE HHN
Diseases of the kidney.
A very good illustration of some of the ways in; ‘which
lies can be told with statistics may be found in the various
books and papers which have been produced in connec-
tion with the anti-vaccination controversy.
In order to understand the relations between vaccina-
tion and small-pox, it is necessary to have the death-rates
from small-pox given for different periods of life—that is,
by age. In this country and in Great Britain we have
no data as to the deaths by small-pox by different ages
prior to the introduction of vaccination, because the reg-
istration of deaths by ages has only been carried on for
a little over fifty Years. We can, however, for Great
Britain, compare the statistics of vaccination for three
different periods—the first from 1847 to 1853, in which
gratuitous vaccination was provided for the people, but
it was purely an optional matter with them whether they
should make use of it or not; from 1854 to 1871, vac-
cination was obligatory by law, but this was mainly theo-
retical, since the law was practically not enforced ; from
1872 to 1880, when the vaccination was rigidly enforced.
The table on top of page 654 shows the results of this
difference.
Before the introduction of vaccination there were but
few persons who did not have the disease at some time
in their lives. It appeared in epidemic waves over Eu-
rope, usually at intervals of from five to seven years, be-
ing about the period of time required to accumulate, by
654
THE MEDICAL RECORD.
[December 14, 1889
Mean Annual Deaths from Small-pox at Successive Life Periods, per 1,000,000 living at each Sub life Period.
AGE.
SUB-PERIOD.
All ages. o— | 5— 10— 15— 25— hs nee
= >, ==] ——— —————
E Veccuation A aat bel ne cet eked Ue et ae | ae | ae 83 Wr aes |
3. Vaccination obligatory, and more efficiently enforced by vaccination officers (1872-80).| 156 323 | 186 98 173 var } 58
rer | 198 633 | 222 92 167 135 | 55
Entire period of obligatory vaccination (1854-80) .......0.00 sss eececeeeeenees tos
births, a sufficient amount of susceptible persons to enable
an epidemic to make headway. Of course, then, the great
majority of persons had the disease in infancy, or in early
childhood, and a large proportion of these died. So that
in those days the small-pox mortality, in the ‘early years
of life, was high, while those who survived were either
protected from future attacks or presented a certain
amount of immunity to the poison of the disease, so that
the small-pox death-rate of the higher ages was then low.
When vaccination came to be general, the young were
protected, but were not protected as permanently and com-
pletely as would have been effected by an attack of small-
pox. The result of this was that the death-rate from
small-pox under five years of age fell eighty per cent.,
while from five to ten years of age it fell forty-five per
cent., and in the older ages it may even have increased
where revaccination was not systematically and thoroughly
carried out. ‘Taking the English records for 1872 to
1874, and 1877 to 1880, it is found that the proportion
of deaths under and over fifteen years of age, per thou-
sand deaths from small-pox, differs according to whether
the persons were vaccinated or unvaccinated, as follows :
Of a thousand unvaccinated persons dying from small-
pox 672 were under fifteen years of age and 328 over
fifteen. Of a thousand vaccinated persons dying from
small-pox 334 were under fifteen and 666 over fifteen,
the proportions being, as will be seen, almost precisely
reversed under the two conditions.
The annual fluctuations of mortality from small-pox in
Sweden from 1749 to 1883 are shown in the following
diagrams made from figures furnished by the Swedish
Board of Health.
Whether the data be taken from a State, a large city,
or a small town, the results are the same. ‘Take, for ex-
ample, the records of the town of Kilmarnock, in Scot-
— e
land. For thirty six years, from 1728 to 1764, this place
had an average population of 4,200, and a very accurate
register of the births and deaths was kept. During these
thirty-six years there were nine epidemics of small-pox,
succeeding each other at regular intervals of about four
years—just the time required to raise a fresh crop of un-
protected victims sufficiently numerous to spread the con-
tagion. ‘The following table will give an idea of the se-
| £ Deaths i in chil- Deaths i in c Apera —
Date és nterval since, § dren born dren who had had
aee | height of former © | since height, passed safely, cna tome
e '| epidemic. % | offormerepi-| through one; than one epi-
| £ demic. | epidemic. esa g
Yee eet |
1728-29... Unknown. | 66 ; ee oe
a eer | 4yrs 5months. | 45 44 | I °
Pe x eae | 3yrs 5 months. | 66 58 | 7 1
6 OTTS 3yrs 7 months. | 66 60 5 1
1744-45... 4y'rs 8 months. | 74 67 6 I
tis r 5 years. | 84 79 | 4 I
1754... 4 y’rs 6 months. | 95 84 11 o
1757-58.. 3 yrs 2 months. | 45 39 6 o
3702.60; |4 yrs 8 months, | 66 53 II 2
Cases occurring between
epidemics .......sssooses 14 8 5 I
ORIG tasceus cance | 555 492 56 |
| Or 87 per cent. ' Or «1 percent. Or x per cent.
verity of some of these epidemics. Of every thousand
deaths during these thirty-six years 161 were due to small-
pox ; in the twenty-six years ending 1879, only 9.9 per
thousand were due to it, or one-sixteenth of the old pro-
portion. In the old days one epidemic left very few
unmarked victims for the next one. ‘Those who recov-
ered were pitted for life, and there were very few except
young children who were unscarred.
By the modern English life-table, of every 1,000 chil-
dren born alive 2.3 may be expected to die of small-pox
Diagram showing for Different Countries, etc., the A [pproximate Average Annual Death-rate from Small-pox per
1,000,000 of Living Population Before and After the Introduction of Vaccination.
Silesia (Austrian) .......
Derin Retr ere Peers ge
Prussia (East Province).
Copenhagen..:........ ;
Austria (Lower) ........
Prussia (West Province).
Bohemia .. ... uaua.
SWOKM sarc iicssntaress
Pomerania ... ...... u.. — |
Austria... .... SSS — joo
Gallicia .. .... EET ass EAVAAAQIs —-_ |
Saxony (Prussian)...... SS alll
GEE ~Refore vaccination.
O AE EDAN ee eS ees ey es, eee N O
Bakowind .6..0.si00 000 I EEN SESE GEE aE Mey ae ree
O PE Seay SOR Dei Selec Pees epee
O URD ar eS Eo are EEEIEE
FAAN STOS ESEE O
i ERR Se eS noe ON ier
a
After vaccination.
' -December 14, 1889]
. THE MEDICAL RECORD,
655
After Vaccination.
Before Vaccination.
TITT
FERE Har
Praak
thtt EEEREN TUBSERA AHHH
Dae RAGA RSSRRREREPABRHRERR SSR
HERZERZEASEAMRPABHAECTR EMRE Bie
FHE
*
j ae EEEE ES
2
N
Ssestestatetars Eat i
HHHH SERSSSRSERNER
BARRSNERARRRRE BRRRVORNARE SAS
ase BEE EERE
PET Sead Rin Runan
EEEE CLECE ELE ETIEE]
= oe EE E HHH DEEVT
ZEL EEREEEREEELCEF LEEI ttrt
PEE EEE AsSSeanes
SHRM OYUESRO AEE E
aan BSR BARASRRRS
BRORCRTEROUEaNS REE
BSERMAFEHBERRORRAOHARH E
REREGBSSRS EEEL] ADERS ES h gE
a SURSRRARRRE DA
pe tn pp te pt he
SESEREUERSR PARES PE Saanana
FE
eepe A
EEEE
FPT ENE EHE
HEE
H H
sescssezaecetiersezosss tal
pees ene HEES
AH
HEEE FERETE REGDE
TARANA HF
= fe pay ts
TEE
HEE ttt
REE FALARNANEA el
Cen -i GL
SARINE
r AANRSNANNRAONRNNNNARANNRRARRENEN
RAN EEE ASA A a
E,
es € RENA Va
URERESK e
before reaching five years of age. In the old Kilmarnock
table the proportion was 116 to every 1,000.
If you compare the death-rate per thousand of living
population in an epidemic of small-pox occurring in a
city in the United States in recent times with that of an
epidemic occurring in a city in the last century, you will
probably find that the death-rate was greater in the mod-
ern city than in the ancient one. Perhaps two-thirds of
the people in the modern city were properly vaccinated—
in the ancient city none were vaccinated. Are we to
conclude that partial vaccination increases the death-rate
from small-pox? Yes, for a single epidemic year ; but if
you take a period of twenty years or more for your com-
parison, you find the death-rate much lower in the vacci-
nation than in the ante-vaccination period. Why is this ?
Because in the ante-vaccination period the adults had
been through several epidemics of small-pox, and had
either had the disease and survived, or had proved insus-
ceptible to the virus, being, in either case, protected.
The only class of the population in much danger from
small-pox in those days were the young children born
since the last epidemic, less than ten years before. But
in the modern community, partially protected by vaccina-
tion, there has accumulated a considerable number of
unprotected adults during the long periods which now
elapse without an outbreak, and these increase the fuel
for flame, and consequently the death-rate. Comparisons
of small-pox statistics for single years are therefore almost
worthless.
The results of vaccination may be indicated in another
way : At the commencement of its organization, in 1761,
the Equitable Society for Insurance of Lives, the oldest
and most important of life-insurance companies, charged
124 per cent. extra for all persons who had not had the
small-pox. In 1781 this was reduced to eleven per cent.
extra.
In 1802 it was resolved “ that the directors be empow-
ered to grant policies of assurance upon the same terms
to persons who aver in their declaration that they have
had the cow-pox, as to those who aver in their declara-
tion that they have had the small-pox. But if such per-
son shall die afterwards of the smad/-pox, then such policy
shall be void.” In 1823 the words, “ but if such person
shall die afterwards of the small-pox, then such policy
shall be void,” was stricken out.
Percentage of Deaths from Scarlet Fever, Providence,
< R. I, in Total Deaths for Forty-nine Years
Rcd at |b
Sunil
mle! || ||
my y
This somewhat irregular periodicity in the appearance
of these contagious diseases, of which one attack affords
more or less protection against a subsequent attack, is
shown not only in these diagrams of the prevalence of
small-pox, but also from other similar diseases ; as, for
instance, in scarlet fever, as shown by the diagram before
you, which indicates the percentage of deaths from this
cause to the total deaths occurring in Providence, R. I.,
for each of forty-nine years. -You will see that the epi-
demics occur irregularly at intervals of about five or six
years, with somewhat greater mortality at intervals of
about ten years.
In vital statistics, as in other branches of social science,
656
THE MEDICAL RECORD.
[December 14, 1889
it is not true that the effects of causes acting in combi-
nation are equal to the sum of the effects of each of the
causes acting separately. Different causes of death hav-
ing no relation to each other do not have a joint effect
which is equal to the sum of the effects of each cause
taken'separately, and it is therefore difficult to bring the
phenomena of vital statistics within the boundaries of
mathematical formule. In the doctrine of this kind of
averages time and number are not convertible terms.
Statistics apply to masses of men, to communities—not
to individuals. We find a mass of matter moving in a
certain direction with a certain velocity, and endeavor to
calculate the direction and amount of the forces which
have produced this result. In like manner we may con-
sider the tendency to death in a community as a result-
ant of several forces as indicated in the diagram, and
endeavor to estimate the influence of each of these forces
in producing the result.
\ 4
It is evident that we can know little of the influence
which hygiene or therapeutics have had in shortening the
line A B, if we know nothing of the length and direction
of the ether lines of force, and hence we must have the
conclusions of vital statistics to make proper use of
medical statistics.
In studying medical and vital statistics one is somewhat
in the position of a man on the deck of a large Atlantic
steamer out of sight of land and gazing on the troubled
ocean. He sees many waves, large and small, apparently
moving in very different directions ; and it is not until he
has, by careful examination and repeated comparison,
learned to distinguish the ripples due to the wind now
blowing, the larger cross-seas resulting from forces which
were acting a few hours before, and the long, rolling
swells which indicate to some extent the direction and
force of the tempest of yesterday, that he can begin to
understand the roll of the ship on which we stands;
while to appreciate the force and direction of the great
current which is sweeping with it all the troubled water
and the ship itself, requires skilled observation with spe-
cial instruments, and the use of charts which embody the
experience of hundreds of voyages. So also in viewing
the records of human life, disease, and death, the varia-
tions which are at first most perceptible are often those
which are most superficial, and which give little or no in-
dication of the magnitude and direction of the movement
of the great, masses beneath.
Appendix.
The most valuable sources for data relating to vital
Statistics, and in many respects to medical statistics also,
are those contained in the “ Reports of the Registrar-
General of- England” for the last forty years, and espe-
cially in the supplement volumes which have been issued
every ten years during that period. Next to these, for
matters relating to this country, come the statistics of the
State of Massachusetts for the last forty years, the statis-
tics of New Jersey for the last ten years, the mortahty
and vital statistics of the Tenth Census, and the statistics
of Boston, Philadelphia, New York City, and of the Dis-
trict of Columbia. Especially valuable, also, are the vital
. statistics of Sweden, of Belgium, of Italy, as published for
the last six or seven years ; of Norway, of Switzerland, of
Prussia, and of many of the. large cities of Western Eu-
rope.
‘The following works will also be found useful for ref-
erence :
Siissmilch, J. P. : Die göttliche Ordnung in den Verän-
derungen des menschlichen Geschlechts, aus der Geburt,
dem Tode und der Fortpflanzung desselben erwiesen, 2
Theile. Vierte verbesserte Ausgabe, genau durchgesehen
und näher berichtigt von Christian Jacob Baumann. _ 8vo.
Berlin, 1775.
Niles, N., Jr., and Russ, J. D.: Medical Statistics ; or,
A Comparative View of the Mortality in New York, Phila-
delphia, Baltimore, and Boston, for a Series of Years :
Including Comparisons of the Mortality of Whites and
Blacks in the two former Cities; and of Whites, Free
Blacks, and Slaves in Baltimore. 8vo. New York, 1827.
Neison, F. G. P.: Contributions to Vital Statistics, be-
ing a Development of the Rate of Mortality and the Laws
of Sickness, from Original and Extensive Data; with an
Inquiry into the Influence of Locality, Occupations, and
Habits of Life on Health; an Analytical View of Rail-
way Accidents; and an Investigation into the Progress of
Crime in England and Wales. ‘Third edition, 4to. Lon-
don, 1857.
D’Espine, M.: Essai analytique et critique de Statis-
tique mortuaire comparée, renfermant les Monographies
étiologiques des Accidents et de la plupart des Maladies
mortelles, et expliquant les Lois générales de la Morta-
lité des Peuples par les Influences combinées des diverses
Caus2s de Mort. 8vo. Genève, 1858.
Ansell, C., Jr.: On the Rate of Mortality at Early Pe-
riods of Life, the Age at Marriage, the Number of Chil-
dren at a Marriage, the Length of a Generation, and
other Statistics of Families in the Upper and Professional
Classes. 8vo. London, 1874.
Bertillon : La Démographie ée de la France, ou
Etude statistique de la Population frangaise, avec Ta-
bleaux graphiques traduisant les principales. Conclusions.
Mortalité selon l’Age, le Sexe, |’Etat-civil, etc., en chaque
Département, et pour la France entière, comparée aux
Pays étrangers. Folio. Paris, 1874.
Ollendorff, A. : Die periodischen SterblickeitsSchwan-
kungen in ihrer Bedeutung fiir die Medicin, Arch. f.
path. Anat., etc. Berlin, 1886, cv., 110-128, 1 pl.
Bertillon, Jacques: Article “ Démographie ” in Ency-
clopédie d’Hygiéne et de Médecine publique. 8vo, tome
I, p. 119. Paris, 1889.
In addition to the census and registration records we
have another important source of information in vital
statistics, namely, the records of life and health insurance
' companies. These are not as well known to physicians
generally as they should be, and I wish, therefore, to call
special attention to the two most valuable compilations
of them now in existence, namely, the “ Insurance Cyclo-
pzdia,” commenced by Cornelius Walford, of which five
volumes have now been published ; and the “ System and
Tables of Life Insurance based on the Experience of
thirty American Life Offices,” by Levi W. Meech, pub-
lished in 1881.
SEVEN Cases OF Leprosy have been found in Minne-
sota.
An EPILEPTIC MEDICAL STUDENT in this city was de-
tected eating a piece of human flesh in the dissecting-
room, while suffering from temporary mental aberration.
December 14, 1889]
Original Articles,
TUBERCULOSIS OF AN ARTERY, ILLUSTRAT-
ING ONE OF THE MODES OF DISSEMINA
TION OF TUBERCLE BACILLI IN THE BODY.
BEING A SPECIMEN PRESENTED AT A MEETING OF THE
New YORK PATHOLOGICAL SOCIETY, JUNE 12, 1889.
By JOHN S. ELY, M.D.,
NEW YORK,
Even before. the discovery of the tubercle bacillus, in
1882, considerable attention had been directed to en-
deavors to explain the mode of dissemination of the sup-
posed poison of tuberculosis throughout the body. Be-
lief in organized specific virus as the probable cause of
infectious disease had been steadily growing since the
study by Davaine of the bacillus of anthrax, and in 1878
this belief received most substantial support from the in-
vestigation of Koch into the nature of the infectious
diseases of wounds. It is therefore quite natural that
many investigators should have been at work upon the
various problems connected with the etiology of tuber-
culosis, most of them imbued with belief in the existence
of some specific organism as its exciting cause. As has
been said, one of these problems had to do with the mode
of dissemination of the virus in the body, more espe-
cially in cases of acute miliary tuberculosis. ‘The fact
that, even before the discovery of the specific virus, a ra-
tional and accurate description of at least one way in
which this may occur had been offered, is striking dem-
onstration of the usefulness of careful study of the lesions
of the infectious diseases, even though for a time all at-
tempts to discover their specific micro-organisms may be
vain. Let us hastily glance at some of the more impor-
tant steps in the proof that, in most cases of acute miliary
tuberculosis, it is through the medium of the circulation
that the infectious material finds dissemination.
In 1879 it was shown by Miigge ' that in acute miliary
tuberculosis of the lungs it was not uncommon to find
miliary tubercles on the intima of small veins in the lung.
In nine out of ten cases examined, he succeeded in de-
monstrating their presence. During the same year Weig-
ert* published reports of three cases of acute miliary
tuberculosis, in which old foci of tubercular inflammation
which had undergone cheesy degeneration were found to
have extended to large veins at the roct of the lungs, set-
ting up in them tubercular phlebitis. He drew attention
to the ease with which large quantities of cheesy matter
might, in such cases, find entrance into the circulation.
The next year, in the study of a case of tubercular men-
ingitis, Cornil * observed small tubercles in the intima of
many of the meningeal vessels ; and a little later, Kiener ‘
repeated this observation in the case of other serous mem-
branes. In 1882, only a short time before the publica-
tion of Koch’s discovery, Weigert * added a series of most
instructive cases to those published in 1879, in which he
found abundant substantiation of the conclusions then
drawn. In six of the cases acute miliary tuberculosis
was shown to have resulted from infection of the blood
from large vein tubercles, and in two cases the thoracic
duct was found to have been the point of entrance of the
virus into the circulation. In both of these Weigert was
able to discover small tubercles on the intima of veins in
various parts of the Jungs. The next year he ° reported
1 Miagge, F.: Ueber das Verhalten der Blutgefasse der Lunge bei
disseminirter Tuberculose. Virchow’s Archiv, lxxvi. (1879), 243.
2 Weigert, C.: Zur Lehre von der Tuberculose und verwandten
Erkrankungen. Virchow’'s Archiv, lxxvii. (1879), 269.
3 Cornil, V.: Contributions a l'étude de la tuberculose.
l'anat. et de la physiol., xvi. (1880), 313.
4 Kiener: De la Tuberculose dans les séreuses chez homme et
chez les Animaux inocules. Archiv. de Physiol. norm. et path., 2me
Série, vii., 790 and 894.
ô Weigert, C.: Ueber Venentuberkel und ihre Beziehungen zur
tuberculdsen Blutinfection. Virchow’s Archiv, Ixxxviii. (1882), 307.
6 Weigert, C.: Die Wege des Tuberkelgiftes zu den serdsen Hau-
ten. Deutsche med. Woch., 1883, No. 24, p. 453.
Journal de
THE MEDICAL RECORD.
31
657
the finding of tubercle bacilli in the lesions of all these
cases.
In 1883 we begin to have accounts of the finding
of tubercle bacilli in the blood. ‘The first of these we
owe, I believe, to Babes and Cornil.’ In 1884 similar
observations were made by Weichselbaum * in three cases
of acute miliary tuberculosis. ‘The same year Lustig’
applied the knowledge gained from these investigations
to diagnostic uses, finding tubercle bacilli during life in
the blood of a patient in whom the diagnosis of acute
miliary tuberculosis had been suspected, but could not
otherwise be proved. In 1885 these observations were
confirmed by Ulacacis,* Sticker,’ Riitimeyer,° and Dou-
trelepont.’
Up to the time of which we are speaking, it was as the
result of involvement of veins, more especially, that in-
fection of the blood was supposed to occur. In 1886
Weigert * showed that this is by no means always the
f°.
-,
*
b Uf y vig »
Fic. 1.—Tubercular Arteritis, the Result of the Encroachment of an Arca of
Tubercular Inflammation upon an Artery in the Lung. (From Delafield and
Prudden’s * Handbook of Pathological Anatomy.” )
case ; that arteries are often seriously compromised by
surrounding tubercular masses. He reported at the same
time the case of a child, four years of age, in whom this
had led to the production of acute miliary tuberculosis.
He was almost immediately confirmed in this by Nasse °
and Durand-Fardel,’* both of whom found, in addition,
1 Babes et Cornil: Note sur les Bacilles de la Tuberculose et sur
leur Topographie dans les Tissus altérés par cette maladie. Arch. de
physiol. norm. et path., 1883, p. 456. Babes: Der erste Nachweis
der Tuberkelbacillen in Gefassen und deren Anwendung. Deutsche
med. Woch., 1883, p. 514.
2 Weichselbaum : Ueber Tuberkelbacillen im Blute bei allge-
cea Miliartuberculose. Anzeiger d. Ges. Wiener Aerzte, 1884,
O, 19.
3 Lustig, A.: Ueber Tuberkelbacillen im Blute bei an allgemeiner
acuter Miliartuberculose Erkrankten. Wiener med. Woch , 1884,
No. 48.
4 Ulacacis, G. : Sulla presenza del bacillo tubercolare nel sangue.
Gaz. degli ospidali, 1885, No. 25; Centralbl. f. klin. Med., 1885, No.
, P. 517.
A Sticker, G.: Ueber das Vorkommen von Tuberkelbacillen im
Blute bei der acuten Miliartuberculose. Centralbl. f. klin. Med.,
1885, No. 26, p. 441.
ê Rutimeyer, L. : Ueber das Vorkommen von Tuberkelbacillen im
Blute und Milzsaft bei allgemeiner acuter Miliartuberculose. Cen-
tralbl. f. klin. Med., 1885, No. 21, p. 353
7 Doutrelepont: Fall von Meningitis tuberculosa nach Lupus.
Tuberkelbacillen im Blute. Deutsche med. Woch., 1885, No. 7, p.
8.
8 Weigert, C.: Ausgedehnte umschriebene Miliartuberculose in
grossen offenen Lungenarteriendsten. Virchow’s Archiv, civ. (1886),
® Nasse, D.: Beiträge zur Kenntniss der Arterientuberculose.
Virchow's Archiv, cv. (1886), 173.
10 Durand-Fardel, R.: Les Bacilles dans la Tuberculose miliaire.
Tuberculose glomérulaire du Rein. Arch. de Physiol. norm. et path.,
1886, No. 4, p. 393.
658
THE MEDICAL
miliary tubercles on the intima of small arteries in the
kidneys. |
Tubercular endocarditis was described during the same
year by Heller,’ in a paper read before the Congress of
German Naturalists and Physicians at Berlin.
This, then, completes the proof, for these observations
have been repeatedly confirmed. We have seen that
veins, arteries, and thoracic duct have been observed to
be involved in masses of tubercular tissue ; that miliary
tubercles have been found in the intima of veins and ar-
teries throughout the body, and in the endocardium ; that
these lesions have all been found to contain tubercle ba-
cilli; and, lastly, that tubercle bacilli have been found in
the blood in cases of acute miliary tuberculosis, both
during life and after death.
The specimen which I present to-night illustrates one
of the modes in which infection of the blood may occur.
It is a section of the upper lobe of the left lung of a
child who died of acute miliary tuberculosis. Autopsy
revealed very large and cheesy bronchial glands, and
scattered through both lungs were many miliary and sub-
miliary tubercles. At the apices and in the vicinity of
the bronchial glands cheesy masses of conglomerate tu-
bercle were found. But what is of especial interest is the
encroachment of many of the tubercles upon the walls
Fic. 2.—Dr. Northrup’s Specimen illustrating Vein Tubercle.
of blood-vessels. In places the walls of veins are affected ;
in others those of arteries. The most beautiful of these,
and the one to which I desire to direct attention more
especially, is a small artery near the base of the upper lobe,
which is encroached upon by a miliary tubercle immedi-
ately adjoining it, and in which a tubercular arteritis is
seen. The wall of this vessel is infiltrated with small round
cells, and, projecting into its lumen, and partially occlud-
ing it, is a mass of small round cells, in the centre of
which cheesy matter is distinctly visible. It will readily
be appreciated how slight a variation in arterial pressure
might be sufficient to cause this degenerating mass to be
thrown into the circulation, and carried by it to any part
of the body. The accompanying drawing (Fig. 1), made
from the specimen by Dr. Prudden, represents the condi-
tion which I have endeavored to describe.
Tubercle bacilli have been found in these lesions in
other sections from the same lung.
In conjunction with the specimen of tubercles in a
vein just presented by Dr. Northrup, these specimens are
an interesting corroboration of the theory whose develop-
ment I have endeavored to trace; the first (Dr. North-
rup’s, Fig. 2) showing the effect produced by the lodgement
of tubercle bacilli on the intima of a vein, one of the ways
in which they may have entered the blood-current being
exemplified by the second.
‘THE ARCHIVES OF SURGERY.—Mr. Jonathan Hutchin-
son has started a quarterly surgical journal under the
above title, to which he will be the sole contributor. Mr.
Hutchinson expects to continue his publication for about
three years.
1 Heller: Ueber tuberculése Endocarditis. Tagebl. d. 59 Ver-
samml. deutscher Naturforscher und Aerzte zu Berlin, 1886, p. 420.
RECORD. [December 14, 1889
SLOW PULSE.
By NATHAN MAYER, M.D.,
HARTFORD, CONN.
Tuis sketch describes, in its main features, a case of very
slow pulse, and hazards some diagnostic opinions in regard
to it. The subject is not one of wide practical applica-
bility, but it is one of exceeding interest as far as the
causation and prognosis are concerned.
A man, aged sixty-five, who has not been sick for fifteen
years of aught save the chance minor disturbances of an
every-day life, complained one day of oedema of the right
foot with some pain, and was ordered a saline cathartic.
Next day, in conversing with a fnend, he suddenly became
unconscious and fell to the ground. Recovery of con-
sciousness and strength took place in ten minutes, with
ordinary restoratives. ‘Then the pulse was found to be
heavy, full, and twenty-four beats to the minute. The re-
covery of sight, speech, hearing, and intelligence was per-
fect ; the skin sensibility, normal. No loss of sensation
anywhere, to impairment of power, no dulling of the sen
sorium, were to be detected. In short, the nervous symp-
toms were ni/. Nor did gastric symptoms develop. No
womiting, pain, flatalence, were at all present ; at least at
first. And in the next following days, with the pulse
remaining as at first, the general improvement was so
marked that the patient demanded to be let up to
attend to his business, and to be fed as usual, which,
however, was denied him.
At this period it became desirable to determine
what had caused this slowing of the pulse, which
yy varied from twenty-four to thirty, but usually held
twenty-eight beats per minute.
A slow pulse, even quite slow, has been found in
sharp attacks of jaundice, when the blood was acutely
vitiated by admixture with the foreign excretion. It
has been found as a result of pressure on the brain, no
matter from what cause—displaced bone or effused
blood. A slow pulse is also thought to be the likely
result of an abnormal excitation of the pneumogastric
nerve, the inhibitory nerve of the heart, the nerve which re-
gulates, slows, and governs its movements. When the nerve
is cut the heart-beats increase rapidly, beyond counting, and,
in fact, the organ works without control. When the nerve
is unduly irritated the hold-back force is increased, and the
heart slows up in the same measure. When the pneumo-
gastric is subjected to a faradic current the heart will stop
altogether. I may remark here that this quality of the
pneumogastric is by some physiologists attributed to the
nerve-fibres it receives from the spinal accessary, and that
a detachment of the latter nerve from its ongin near the
medulla oblongata seems to have the same effect as a
cutting of the pneumogastric. On the other hand, the
branches of the sympathetic, with their ganglia, are re-
garded as the main acceleratory nerves, and a degeneration
of those might have an effect similar to an irritation of the
par vagum, the inhibitory nerve.
Finally, a very slow pulse may result from states of great
debility—though it is more likely to be very fast and
small—or it may result from weakness of the heart-walls
and inability to respond readily to the impression of the
entering blood. ‘This weakness may be a simple dilatation
with thinning of the muscular walls, or it may be a fibrous
or a fatty degeneration of these walls, or it may be a
thinning and anzmia of the walls without dilatation or
degeneration.
In the consideration of these points in reference to my
patient I was able at once to exclude icterus ; next, to
close out any brain-pressure ; for the perfect normality
of the mental power and of the reflex actions, of the func-
tions of mobility and of sensation, showed that there was
no pathological condition of the nervous centres. A press-
ure upon, or an excitation of, the pneumogastric nerve
was, after some reflection, declared against on the basis
that 18 to 20 regular respirations per minute, and no gas-
December 14, 1889]
tric or laryngeal disturbances cleared of suspicion that
nerve which supplies lungs, stomach, liver, and larynx
equally with the heart. Being thus especially referred to
the latter organ, the heart, a very careful examination was
made. The results demonstrated no notable extension of
area, that is to say, nearly normal proportions: No dis-
placement ; a slight mitral murmur covering the begin-
ning of the systole, and best heard over the left auricle;
a faint and muffled beat, and no perpetuation of the
murmur into the aorta.
The diagnostic deductions derived from this were : No
dilatation and no enlargement of the organ; no peri-
cardiac effusion; no valvular disease—for the slight
murmur was attributed to another cause—and a thinned
and degenerated condition of the walls of the heart.
When the muscle of this organ undergoes a degenerative
process of a fatty nature, it is either in sympathy with a
general adiposity of the system or in consequence of in-
terference with its special nutrition. In this case there
was no pronounced fattiness, although the patient was in
good flesh, and it was left to the judgment to attribute
the disturbance to an embolus or to an atheromatous
condition of the arteries supplying the heart. If there
had been a great development of fat in the system gener-
ally, that condition known as fatty infiltration, and which
consists of a ponderous deposit of fat around the heart,
and interpenetration of fat between the bundles of mus-
cular fibre, might have been credited with weighing down
and impeding the organ. If there had been a weak
pulse, unsteady or irregular, the Ciagnosis of degeneration
of the muscle-fibre into adipose tissue would have been
warranted. But, with a muffled impulse, there was a full,
massive pulse—yet a very slow pulse. Under these cir-
cumstances I found it impossible to determine the exact
status of the case, and only hazarded the following
theory: An embolus stopping one of the coronary ar-
teries, or an atheromatous condition impairing both cor-
onary arteries, may so have diminished the nutrition of the
organ that the walls have begun to atrophy. But be-
yond this, that the ganglia of the sympathetic plexus
which supply the heart are dulled in sensitiveness and
react but slowly to fhe stimulus of the entering blood.
Thus a large beat, but an infrequent one, could be caused,
and this condition corresponds to that of my patient. As
the muscle thins or deteriorates I should expect the beat
to lose its force.
_ As for the patient, he had many previous conditions to
make a fatty heart probable. He was nota very active
man, a hearty eater, a constant, but moderate, consumer
of spirits, and had had some slight rheumatic attacks long
ago. Itis about four years since he applied for insur-
ance, and was remanded for repeated examinations on
account of a pulse between go and 100. He consulted
me, and I advised to stop smoking—he being an inveter-
ate smoker. He did so, and on re-presentation was found
admissible. His heart was examined then, and no ex-
ception taken to it ; so it was likely in fair condition and
in good working order.
The idea of an embolus of the coronary artery is, then,
not only evolved from his present condition but from the
suddenness of its occurrence. ‘There is no evidence that
his heart beat out of the usual rhythm up to the time of the
seizure I have described.
The course of the difficulty is interesting. Three
months after this' primary attack the beats had ranged up
to 30, but subsided gradually to 22, 20, and, at times, to
18. At first the most trifling exertion caused cyanosis of
the face and a convulsive rigidity of the muscles—in
fact, an appearance of strangulation. The ordinary
strain of urination, and the least effort in voiding fæces,
brought on this state. . In an instance of dietetic impru-
dence, attended with eructations, the symptoms became
alarming. And on the surreptitious employment of a
laxative, attended by four or five movements of the bow-
els, they held out for such lengths that death was expected
during their continuance. The face became blue, the
THE MEDICAL RECORD.
659
eyes protruded, the respiration was gasping, with labored
puffing forth of the cheeks at each breath, the muscles
were rigid, and—it was subsequently claimed—sight „and
hearing were lost. ‘The pulse—well, the pulse leaped up
to 120 to 130 in the minute—became very small and al-
most imperceptible. With the rally of forces the pulse
relapsed into full beats of 24.
In the main this patient was without inconvenience,
and his system seemed to accommodate itself to the new
condition. He urinated and defecated without disturb-
ance, ate even heartily, smoked, read, sat up for hours,
took little walks, and sustained animated conversations.
From a state of utter quiet and recumbency he gradually
and very gently was emancipated to this status, and seemed
to bear unconcernedly what at first seriously threatened his
life. But the rate of pulse-beats indubitably grew less.
The literature on this subject is exceedingly meagre
which must be my excuse for this full account.
I add
sphygmographic tracings, taken with the assistance of Dr.
Arthur J. Wolff, of this city, who kindly photographed
them, and who was my consultant in the case. The time
of taking each was seven seconds. ‘They represent the
pulse at 18 beats and at 22. Occasionally there came a
fainter but immediate repetition of the beat, which is
shown in two tracings. l
Let me attempt an explanation of the pulse-rise during
the convulsions. To begin with, the heart beats slower
and slower ; less oxygen is admitted to the blood ; the
tissues become saturated with carbonic acid—in other
words, the patient becomes asphyxiated. This makes it-
self felt first in the brain. As a consequence, the nerves
of special sense become inert first; next, the adjoining
nerves. Presently the pneumogastric loses its power,
and with it, its grip’on the heart. Ina moment the pulse
leaps up, we have 120 to 130 beats per minute, and oxidi-
zation is restored. ‘The pulse regains its former quality.
Death ensued in the fifth month, after a few convulsive
attacks, and in one of them. All were attended by ap-
pearances of cyanosis and suffocation. The intervals
were clear, and not burdened with-discomfort.
The autopsy, made twelve days after death, demon-
strated a heart weighing seventeen and one-quarter
ounces. ‘The orifices of the coronary arteries were di-
lated, the arteries themselves patent, the coats normal.
The aortic valves held water. The mitral orifice ad-
mitted three fingers; the tricuspid, four fingers. ‘The
muscular tissue was red and of firm consistence; the
outer coat, of brownish tinge. The ventricles were di-
lated, the right especially ; the walls of both hypertrophied.
Microscopic examination of the muscular tissue demon
strated fatty degeneration.
A CASE OF SPONTANEOUS Cow-Pox has been discovered
in the herd of a gentleman living in Newton, N. J. We
are informed that this is the third case of original cow-pox
that has appeared in the United States. We adopt the
expression “spontaneous” cow-pox, without admitting
that this or other specific disease arises de novo.
660
THE MEDICAL RECORD.
[December 14, 1889
Clinical Department.
REMARKABLE HEMORRHAGE IN TYPHOID
FEVER.
By O. H. MERRILL, M.D.,
CORINNA, ME.
F. B—— was taken sick with typhoid fever September
15, 1884. The temperature was noted to be 105° F. in
the evening, unless quinine had been administered in anti-
pyretic doses. - There was no diarrhoea, and very little
abdominal tenderness. In fact the bowel symptoms were
“ conspicuous by their absence.” ‘The case ran along in
a common sort of way till September 23d. At that time,
without any warning whatever, there was a perfectly over-
whelming discharge of blood per rectum. Three large
evacuations occurred before I could reach him. On my
visit I found the pulse so rapid and so weak that I could
not count it. The temperature was 96° F. He could
barely whisper, and by that means indicated that he felt
like having another evacuation, but he did not have any
more.
A hypodermic injection of morphine was administered,
and two fluid drachms of the fluid extract of ergot were
also injected into his arms and legs. Ice was applied to
the abdomen, and absolute rest enjoined. The first evacu-
ation which was normal occurred ten days later. ‘It was
five days after the hemorrhage, before the temperature
reached 104° F. From that point the case ran an ordin-
ary course, and on October 21st the patient was dis-
charged. Nothing further was seen of him till November
5th, some two weeks afterward. He then had an attack
of bronchitis, in which the temperature was 101° F. On
November 12th I was called to see him on account of an
alarming epistaxis. Syringing with strong astringent solu-
tions, applications of ice, and plugging the anterior nares
were tried one after another, with no good result; the
blood simply passing backward, and being either swallowed
or spit up. Finally, as the patient was now in extreme
danger, the nostrils were cleared of coagula, and the pos-
terior nares very firmly plugged. Then a tampon was in-
serted into the anterior nares, and it was supposed that
the case was under control. Nevertheless, in a short time,
blood began to drop from one eye at the rate of thirty
drops per minute. Nothing further was done except to
give large doses of ergot, and the bleeding from the eye
became less and finally stopped. The plugs were removed
on the third day, and no further hemorrhage took place.
During the epistaxis it was noted that the urine was
heavily loaded with blood. Blood was also vomited at
this time, but it was supposed that it had been swallowed.
The patient, then, to recapitulate, discharged blood
from rectum, nose, penis, eyes, and mouth in very large
quantities—so large indeed that on two different occasions
he was believed to be in extreme danger. Nevertheless
he recovered perfectly, but ever afterward evinced a
deeply religious tendency, and is even now engaged in
preaching the gospel with more or less success.
HIGH TEMPERATURE IN TYPHOID FEVER.
By JOSEPH N. STUDY, M.D.,
CAMBRIDGE CITY, IND.
In looking over a number of text-books as to what is said
regarding high temperature in typhoid fever, I find that
there is a unity of opinion that the prognosis in this dis-
ease is exceedingly grave in proportion to the height
which the temperature reaches for any prolonged period
of time.
This opinion is abundantly supported by the statistics
of our best-regulated hospitals.
That the prognosis in this affection cannot always be
judged by the height of the temperature, I believe medi-
cal men frequently have opportunity to observe. That
many persons die from this disease with a very moderate
increase of temperature, is a well-known fact, and it can-
not be denied that there are individuals who possess an
idiosyncrasy to resist high temperature and diseases.
In giving an opinion as to a probable prognosis in
typhoid fever, these facts should not be entirely over-
looked.
Within the past few years I have had the opportunity
of treating a few such cases where the temperature
reached an alarmingly high point, and continued high for
a prolonged period of time. And at the same time my
patients presented no alarming symptoms further than the
high temperature, and made a good recovery.
Permit me to relate two such cases.
I attended the family of Mr. X——, American, in July.
The family consists of Mr. X and wife; daughter,
aged nineteen ; son, aged twelve ; infant, agec eight weeks,
and Mr. D—, aged seventy-two.
All became affected excepting Mr. D——-. In the
cases of Mr. X—— and son the fever pursued an ordin-
ary course, convalescence being established after the
usual length of time.
In the cases of Mrs. X——— and daughter the fever
pursued an unusual long course before convalescence was
established. The temperature of these two was taken
daily between four and six o’clock in the afternoon. Mrs.
X——’s temperature for twenty-six days registered from
103%° to 1054° F., average 104}° F. The daughters
temperature for thirty-two consecutive days registered
from 1034° to 106§° F. in the axilla, the average afternoon
temperature being 1049° F. On one day only was her
temperature taken in the forenoon, and it then registered
105° F. in the axilla. Both patients became greatly
emaciated.
‘The mother nursed her infant for some days, until her
milk failed. The child during this time lost flesh and was
‘exceedingly fretful; its temperature was occasionally
taken, and showed an increase of from one to three de-
grees.
The mother took little medicine, indulged in the most
imprudent diet, and remained up and about the room all
the time. The daughter remained @& bed forty days, par-
taking freely of milk and liquid food.
Antifebrin was given a few times to the daughter, and
would promptly reduce the fever about three degrees, but
the depression was so great it was discontinued. ‘The
source of infection was an open well, which contained a
large quantity of stinking mud, rusted tin cans, and other
refuse matter. For accuracy, four different thermome-
ters were compared in recording the temperature.
A CHINESE PareETIC.—Dr. Matthew D. Field, of this
city, writes : “ Chow Hays, a native of China, aged forty-
two, married(?), and by occupation “ washee washee,”
was committed by a police magistrate for examination as
to his sanity. He presented well-marked physical and
mental symptoms of general paresis of the insane. His
case was quite typical, with grandiose ideas; was about
to establish a thousand laundries, and wanted ten thous-
and wives. Insane Chinamen are no novelty at the pavil-
ion for the insane, but I believe this is the first case of
general paresis in a celestial in New York City. Dr. W.
H. Mays, late superintendent of the Insane Asylum of the
State of California, at Stockton, in his biennial report for
1885 and six writes: ‘ There are seventy Chinese under
our care, sixty-seven males and three females. In the
Napa Asylum about as many more may be found. In
proportion to the number of Chinese in the State, I con-
sider mental disease particularly rife among them. In
China, insanity partakes somewhat of the nature of a
penal offence. Hence travellers in that country, seeing
little of it, proclaim its non-existence, and base thereon
deductions unfavorable to our civilization. But in Japan,
where enlightened and progressive views are making rapid
headway, institutions for the care of the insane are begin-
ning to dot the land.”
December 14, 1889]
THE MEDICAL RECORD:
A Weekly Fournal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., EDITOR.
PROPRIETORS AND PUBLISHERS
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
meaane
New York, December 14, 1889.
EPIDEMIC INFLUENZA.
‘THE epidemic of influenza which we have already referred
to as occurring in Russia has spread into Finland and
Eastern Prussia, and is not unlikely to spread throughout
Europe, and even reach this country. The disease travels
rapidly, and has been known to make all Europe sneeze
within six weeks, so that we may expect an arrival here
before our winter months are over. It used to be thought
that this epidemic moved in definite cycles of one hundred
years. Although such an idea has been long abandoned,
it is a curious fact that the influenza prevailed in America
one hundred years ago, and Dr. John Warren, in a letter
to Dr. Lettsom, says that “ our beloved President Wash-
ington is but now recovering from a severe and dangerous
attack of it.”
In 1830 an epidemic started in Chine, it reached Russia
_ in January, 1831, and by May it had spread to Western
Europe ; but it only reached this country in January, 1832,
and then prevailed but slightly.
Another and severer epidemic started in Russia in
December, 1836; within a month it appeared in Lon-
don, and rapidly spread over Europe. This time, again,
America was not affected. An epidemic of considerable
extent prevailed in the United States about ten years ago,
and there have been various mild manifestations of the
disease. On the whole, however, North America does
not seem to be very favorable to the development
of epidemic influenza in its worst forms, and it is unlikely
that we shall have a severe visitation, if we have any at all.
- The disease is not dangerous, except sometimes to chil-
dren or the aged, while the former often show a decided
exemption.
There is no doubt that this new epidemic will prove a
boon to bacteriology, for Seifert’s micrococcus has not
quite satisfied pathologists, and we anxiously await the
announcement of the discovery of the influenza bacillus,
only regretting for the sake of American science that the
miasm always begins in the East and travels West. The
bacteriological laboratories of Europe will therefore have
the first chance.
The disease is undoubtedly due to some micro-organism
which floats in the air, and which infects the human sys-
tem, but is generally killed in so doing. For influenza is
but slightly if at all contagious.
We observe that some feeling of alarm prevails lest
this epidemic be a precursor to cholera, as was the case
in 1831 and 1847.
THE MEDICAL RECORD.
661
a
There have been, however, plenty of cholera epidemics
without a preceding influenza, and a great many influenza
epidemics without any associate cholera. The micro-
organisms of the two diseases are as essentially different
as are the diseases themselves. The cholera germ lives in
water and soil, the influenza germ in the air. The rela-
tion between the two diseases has been, we believe, purely
accidental.
COMPULSORY NOTIFICATION OF
EASE.
Ir is time that the medical profession take some decided
stand with regard to the subject of compulsory notification
INFECTIOUS DIS-
of infectious diseases. At present we are sued by the pa-
tient if we send a notice, and sued by the Board of Health
if we do not.
Illustrations of both these contingencies of modern
medicine have occurred in or near this city, and must be
fresh in the minds of the profession. A doctor was re-
cently imprisoned by the stupid action of the Brooklyn
Board of Health because he did not send in a notification
of a case of yellow fever, which was not yellow fever after
all. Recently a Boston physician was fined $1roo and
costs for nut reporting promptly a case of small-pox. The
physician claimed that he did make the report as soon as
he was convinced of the nature of the disease. He is
known to be an intelligent and experienced man ; yet, de-
spite his protests, he was fined. The doctor is a poor
map, in poor health, and with a family to support. He
can ill afford to pay the sum exacted, nor should he be
compelled to do so.
It is well known that chicken-pox sometimes takes a
- severe form and for a time closely resembles small-pox.
We can recall a case in which, after a notification of pos-
sible small-pox, the City Board of Health physicians paid
visits for three days before they could decide as to the
nature of the disease.
A young man is now suing the city of Philadelphia for
$50,000 because he was sent to a small-pox hospital when
he had only the measles. He subsequently caught the
small-pox in the hospital, and barely escaped with his
life. The Brooklyn Board of Health is now being sued
for having insisted that a case of remittent fever was one
of yellow fever. Officers of hospitals for infectious dis-
eases constantly find mistakes in diagnoses made, and
sometimes make them themselves. Some illustrations of
this are given in a recent issue of the British Medical
Fournal, |
“ Dr. R. D. R. Sweeting, in his ‘ Report on the Western
Hospital of the Metropolitan Asylums Board for 1887,’
states that 21 cases of measles (and rétheln) had been
admitted during the year, 13 certified as scarlet fever
and 8 as enteric fever ; again, Dr. R. A. Birdwood, in his
‘Report on the Small-pox Hospital Ships for 1888,’ states
that four patients, not suffering from small-pox, had been
admitted on mistaken diagnoses ; the diseases they were
actually suffering from were scarlatina, syphilis, eczema,
and ecthyma.”’
From all this it is evident that physicians should not be
made responsible for not prcmptly notifying authorities
of the nature of an infectious disease, even if they accept
the duty, unconstitutionally forced upon them, of sides
the State without remuneration.
662
THE MEDICAL RECORD.
[December 14, 1889
MEDICAL EXAMINING BOARDS AND “LIBERTY.”
Our correspondent, Dr. Mendelsohn, contributed a very
eloquent letter to our columns last week, regarding the
subject of the regulation of medicine, and of medicine in
its relation to the State generally. Much that was said
about the debasing influence of the spoils system upon
public medical officers is, unfortunately, true.
Upon the subject of the regulation of medicine by the
State, however, our correspondent betrays a profound ig-
norance. ‘The purpose of this regulation is not to protect
the medical profession alone, but to give to the people a
reasonable assurance that a class ef persons upon whom
life, health, and the prevention of epidemic disease often
depends, should have some educational qualifications.
The danger of the State going too far in its interfer-
ence with medical affairs exists, but is very slight, and not
now imminent. It is not safe or logical to infer from
certain results in an absolute monarchy that similar re-
sults will occur here in a free republic. This is a country
where laws are made by the people and for the people.
If a law is bad it can be remedied without petitioning an
imperial chancellor.
The statement that laws regulating medical education
and practice have done no good, and had no part in se-
curing our present progress, is quite erroneous, and shows
much ignorance of the history of medical education in
this country. We commend our correspondent to some
impartial historic studies.
It is not claimed that State aid is a specific for bad
educational methods or low professional standards. It is
one means, however, and a decidedly helpful one in has-
tening on the time when higher standards will be demanded
by universal public opinion.
A State Examining Board will not secure a ameda
millennium, but it may prevent the development of bogus
and purely business medical colleges, which turn out dis-
honest and ignorant men, who fail, or do not seek, to pass
at reputable institutions.
Itis quite possible that in a few thousands of years matters
medical will have naturally and spontaneously reached
perfection, as some apostles of personal liberty seem to-
think. But it is not the part of wise men to trust en-
tirely. to such general optimistic conceptions of the uni-
verse. Itis better to start things on so as to taste a little
of the beatitude in our own day.
IODIDE OF POTASH IN HEART DISEASE.
THE potassium salts, including the iodide, have long ago
been shown to have a paralyzing effect upon the heart in
large doses. M. Germain Sée now tells us, however, that
in medicinal doses potassium iodide is a cardiac and vaso-
motor tonic. We must doubt the value or thoroughness
of Sée’s experimental studies, for they seem to ignore as
well as contradict all previous work. But the clinical
conclusions may be true enough. M. Sée asserts that
the cardiac affections which are mostly benefited by this
treatment are adiposis, fatty degeneration, weakened heart,
cardialgia, nervous or organic irregularity of the organ
(arythme), especially in the aged. As to aneurism of the
aorta, iodide of potassium was the only remedy that gave
real satisfaction. In all heart disorders, far from being a
depressor, it was particularly useful in lesions with debil-
ity. It raises the energy of the heart and the vascular
pressure. ‘Then, in dilating later on all the arteries, the
flow of blood is facilitated and the organ recovers its con-
tractile powers.
Hews of the Weck.
THE EPIDEMIC INFLUENZA is said to have appeared al-
ready in Paris, though not in Berlin or London.
THE SOUTHERN MEDICAL REcorD has passed into the
hands of Dr. D. H. Howell, of Atlanta, Ga.
DARTMOUTH MEDICAL COLLEGE held its annual com-
mencement November 26th, and graduated twenty-one
students.
Cooper MEDICAL COLLEGE oF SAN FRANCISCO held its
twenty-sixth annual commencement November 21, 1889,
and graduated a class of 41, out of 64-matriculates.
A HOSPITAL FOR INCURABLES IN PITTSBURG.—The
sum of $800,000 has been bequeathed by the will of the
late Mr. J. H. Schoenberger, to found a hospital for in-
curables at Pittsburg, Pa.
Dr. Jonn S. Bruincs has, with the approval of the
Secretary of War and of the Surgeon-General, accepted
the position of Medical Director of the University Hos-
pital in Philadelphia, to which he was recently elected.
Dr. Hans Vircuow, Privatdocent in the University of
Berlin, and Prosector in the Anatomical Institute, has
been raised to the rank of Professor Extraordinanus. Dr.
Hans Virchow is a son of the celebrated pathologist.
Dr. BRAMANN, first assistant in Professor von Berg-
mann’s clinic at Berlin, who performed tracheotomy on
the late Emperor Frederick the Third, has declined to
accept a “call” to Greifswald as Extraordinary Professor
of Surgery.
QUACKERY IN BRazıL.—On October roth the late Brazil-
ian Minister of Justice sent a circular to all presidents of
provinces, directing them to institute criminal proceed-
ings (proceder criminalmente) against all persons practising
medicine without legal title. Itis to be hoped that in this
point the new Republic will show itself as enlightened as
the Imperial Government which it has supplanted.
WEIGHT AND FEEDING.—Drs. A. V. Meigs and J. A.
Scott wish us to believe that if a person weighs just 100
Ibs. and then takes into his stomach just one pound, he
will not weigh ror lbs., but only 100.8 or 100.9 lbs. In
other words, weighing just before and just after eating
will not give exactly the amount eaten. These observa-
tions of our Philadelphia contemporaries throw a dark
and depressing shadow upon the historic researches of
the great Sanctorius, who passed his life in eating, excret-
ing, and weighing. But perhaps Philadelphia scales are
wrong.
AT THE OPHTHALMOLOGICAL CONGRESS recently held
at Heidelberg, the Graefe prize was awarded to Professor
Deutschmann, of Hamburg, for his essay on “ Ophthalmia
Migratoria.” Dr. Uhthoff, Privatdocent in the University
of Berlin, received an honorable mention for his work on
the ‘‘ Influence of Chronic Alcoholism on the Visual Or-
gans of Man.”
December 14, 1889]
THE MEDICAL RECORD.
663
A New GYNECOLOGICAL OPERATION, termed Salpingos-
tomy, has been devised by Dr. Skutsch. Its object is to
save the tubes instead of removing them when they are
diseased. In the patient on whom the operation was
done, there was obstruction and dilatation of tubes. <A
Pravaz syringe was employed in order to puncture each
tube and ascertain its contents. As clear yellow serum
was drawn. away, the operator determined to save the
tubes. An oval piece, about one square centimetre in
size, was cut out of the outer end of each tube, and the
mucous and serous coats united by fine silk sutures around
the border of the hole thus formed. A sound was then
easily passed from the tube into the uterine cavity on both
sides. The patient made a good recovery, and was re-
lieved of her pains, but a long after-history is not given.
In some cases of pyosalpinx it would be advisable, he
thinks, to sew the ends of the tubes to the abdominal
wound, to open them, and allow them to discharge pus ex-
ternally. When the discharge ceased to be purulent the
tubes might be freed from their artificia] attachments and
replaced in the pelvis.— British Medical Journal.
A MEDICAL ASSOCIATION OF IRREGULARS has been or-
ganized in Massachusetts, under the name of the Massa-
chusetts Constitutional Liberty League. It recently met,
and after a series of lurid “ whereases,”
Resolved, That all organized so-called irregulars be and
are hereby invited to co-operate with the Massachusetts
Constitutional Liberty League and the National Consti-
tutional Liberty League, in resisting restrictive legislation,
or any legislation suggested and supported by regulars.
Resolved, That all unorganized so-called irregulars be
especially and earnestly urged to immediately identify
themselves with the State and National League.
Resolved, That all patrons of so-called irregular prac-
tice owe it to those who have served and saved them, es-
pecially. after the regulars had utterly failed to cure or
even benefit them, to sustain them in their struggle for
constitutional liberty with their sympathy and substance.
THE Next PHARMACOPaIA.—Attention is being called
to the fact that the next revision of the Pharmacopceia will
be one of the most important in the history of the work.
Medical societies are asked to bear this fact in mind.
DISPOSITION OF STABLE REFUSE.—At a meeting of the
Section on Public Medicine of the New York Academy
of Medicine, Dr. Jos. D. Bryant said that there are sixty
thousand horses in the city below One hundred and Thir-
ty-fifth Street, and the refuse amounted to about nine
hundred thousand pounds daily. About three hundred
thousand dollars is invested in the business of removing
this refuse. He urged that there would be great benefit
to the public in compelling all this refuse to be baled be-
fore it 1s carried through the streets. Commissioners
Bryant and Smith had agreed on a report recommending
that after May 1, 1890, baling be made compulsory. ‘The
meeting voted its approval of the report.
ASSOCIATION OF LIFE INSURANCE MEDICAL DIREC-
TORS.—About twenty-five medical directors of various life
insurance companies of this country met in this city last
week, and organized the “ Association of Life Insurance
Medical Directors of America,” with the following offi-
cers: Prestdent—Dr. J. M. Keating, of the Pennsylvania
Mutual ; Vice-Presidents—Dr. G. W. Russell, of the Ætna,
and Dr. Lewis McKnight, of the Northwestern Mutual ;
Secretary—Dr. Frank Wells, of the John Hancock ; Treas-
urer—Dr. J. W. Brannan, of the Washington ; Executive
Commiuttee—Dr. J. M. Keating, of the Pennsylvania Mu-
tual, Dr. Frank Wells, Dr. J. W. Brannan, Dr. Henry
Tuck, Dr. G. S. Winston, Dr. E. W. Lambert, and Dr.
Edgar Holden. The object of the Association is “ the
promotion of medical science as applied to life insurance
by the personal intercourse of the members, presentation
of papers, discussions, and such other methods as may be
found desirable ; and also the encouragement of social and
personal relations between its members, and the advance-
ment of the general interests of life insurance.” The
next meeting of the Association will be held in May, 1890,
and it will meet annually thereafter during the same
month.
RosertT GARRETT’S MEDICAL BıLL.— The suit of Dr.
Nathan R. Gorter against Robert Garrett, for $25,000 for
professional service, has been settled. Dr. Gorter of-
fered to compromise for $18,000 ; the proposition was
accepted and the money paid.
HORSE-MEAT SAUSAGES.—Some alarm has been created
by the discovery that a Long Island establishment has been
making sausages out of horse-meat. There is, however,
nothing poisonous or unnutritious in horse-meat. ‘The
only objection that can be made to this kind of food is
that sound and healthy horses are too expensive to be
eaten, hence it is to be assumed that the horse-meat of
butchers’ shops does not represent the noblest type of a
noble animal.
THE ISABELLA HEIMATH RETREAT, TENTH AVENUE
AND I90TH STREET, NEW YORK.—There are two conva-
lescent wards at the Isabella Heimath, each containing
fourteen beds. ‘They are intended for convalescents who
have no home in which they could find rest and care. The
trustees are ready to admit, for a term not exceeding
four weeks, convalescents of both sexes needing care and
rest after acute internal diseases or surgical operations ;
and no distinction shall be made on account of creed or
‘nationality. Applications, bearing the indorsement or
recommendation of the attending physicians or surgeons,
should be addressed to August Caillé, M.D., 185 Second
Avenue; A. G. Gerster, M.D., 56 East Twenty-fifth —
Street; A. Jacobi, M.D., r10 West Thirty-fourth Street ;
H. G. Klotz, M.D., 222 East Nineteenth Street, consult-
ing physicians.
Topacco HYSTERIA.—At a recent meeting of the Paris
Hospital Medical Society, M. Gilbert showed the mem-
bers a patient, aged sixty-two, who had worked in a to-
bacco factory forty years, and smoked excessively. About
a year ago he exhibited symptoms of motor and sensory
disturbance in the lower limbs. ‘These were apparently
cured by the influence of a magnet, but soon afterward
reappeared in the form of motor hemiplegia, with sensory
anesthesia. ‘These cases often occur in tobacco factories.
MM. Gilbert and Letulle diagnosed the case as toxic hys-
teria. M. Hayem objected to the constant misapplication
of the term hysteria.— British Medical Journal.
“ Toxic” NoT “ Tonic.”—On page 606 of THE MEDICAL
RECORD, in the notice of “ Nothnagel on Heart Disease,”
in the second line of second paragraph, zonic should have
been printed oxic effect.
664
THE MEDICAL RECORD.
[December 14, 1889
SOCIETY OF THE ALUMNI OF CHARITY HosPITAL.—The
following officers have been elected for the ensuing year :
Prestdeni—Dr. D. Bryson Delavan ; Vice President—Dr.
Ramon Guitéras ; Secrefary—Dr. W. L. Baner ; 7reasurer
—Dr. A. T. Muzzy.
THE LATE Dr. GEORGE WILLIAMSON, who died in this
city on December 8th, was well known to the younger
members of the medical profession as an earnest worker
and a true Christian physician. He graduated trom the
“University of New York in 1875, and served as interne in
the Epileptic Hospital and Orthopcedic Hospital. For
many years he was one of the assistants at the Manhattan
Eye and Ear Hospital. He leaves a widow but no chil-
dren.
A Cuicaco HospiTaL Criricisep.—The Cook Coun-
ty Hospital, says Zhe Medical Standard, has for years,
with some honorable exceptions, been a collection of ser-
vile tools of the vilest political ringsters. In place of
upholding the dignity of the profession, the County Hos-
pital staff has made the name of hospital physician a by-
word and areproach. The performances of several of the
members of the Board of 1888 were so unprofessional as
to merit the censure of the Chicago Medical Society.
A New METHOD OF ANTIRABIC INOCULATION.—In-
spired by the belief of M. Pasteur, that the desiccation of
spinal cords obtained from animals having died of rabies
diminishes the quantity and not the virulence of the rabic
poison, M. Hoegyes, of Buda-Pesth, was led to try the
effect of simple dilution, and he has successfully carried
out seventy vaccinations on this plan without the produc-
tion of any untoward syinptoms. He soaks one part of
diseased cord in a sterilized solution of sea salt (7 grammes
to the litre), the proportion varying from 1 in 10 to 1 in
10,000.—Medical Press.
A Nursinc HErRoineE.—-The spirit of Florence Nightin-
gale lives in the person of Sister Thérèse, Superior of the
Sisters of Charity now serving in Tonguin, who has
recently been decorated by the General in command.
When she was barely twenty-five she was wounded at’
Balaclava. At Magenta she again received a wound.
She accompanied French soldiers to Syria, China, and
- Mexico. In the Franco-German war she was grievously
wounded at Reichshofen while attending the cuirassiers
who fell in that memorable charge. At a later stage of
the same campaign she distinguished herself by seizing a
bomb which fell into an ambulance, and carrying it away `
eighty yards, when it burst, seriously injuring her alone.
She was scarcely recovered from the effects of this injury
when she volunteered for service in Tonquin.-—British
Medical Fournal.
A New TEST FOR ALBUMIN IN THE URINE.—Trichlor.
acetic acid is stated by M. Boymand in the Répertoire de
Pharmacie for the present month to be the best reagent
for the detection of albumin in urine. It is more re-
liable and possesses none of the disadvantages of the or-
dinary tests, such as nitric acid and metaphosphoric acid.
It has also the power of precipitating that peculiar form
of albumin which is thrown down by heat but redissolved
on the addition of acetic acid. ‘Trichloracetic acid is ob-
tained by the action of chlorine gas upon acetic acid,
three atoms of the hydrogen of the radical acetyl being
replaced by chlorine. The compound is represented by
the formula CC1,CO.OH. It is a crystalline solid body,
very soluble in water, and it forms salts analogous to the
acetates. Acetic acid may be regenerated from it by the
action of nascent hydrogen. The test may be used in a
solid form or in solution. If the solid be employed, a
small fragment is placed in a test-tube containing the
urine ; it sinks to the bottom and is dissolved, producing
a cloudiness, or, with very clear liquids, a zone of cloud.
The solution can be used either saturated or fairly con-
centrated. When poured upon the urine to be examined
it forms a characteristic ring, like that obtained by means
of nitric acid, but without producing any coloration.
When the urine is rich in urate of soda it is better to
dilute with distilled water, and thus avoid a cause of
error which is common to all reagents. We have not
been able to obtain a specimen of trichloracetic acid for
the purpose of verifying the statements made respecting
it as a precipitant of albumin in urine under all condi-
tions, but we hope tu do so in a short time, and to report
the result of our experiments.— British Medical Fournal.
HyYPoH£MATOSIS.—Dr. Maurel has read a paper before
the Paris Academy of Medicine, on “ Hypohzmatosis,”
which may be summarized as follows: The height,
weight, and measurement of the thoracic region have a
definite proportion one to the other. ‘This proportion is
variable according to age, but is definite for any given
age. When what may be called the normal proportion
does not exist, a series of abnormal conditions exist which
M. Maurel classes under the name of hypohzmatosis.
Sometimes these several conditions collectively produce a
special condition—anzemia resulting from imperfect oxi-
dation of the tissue, or, in other words, non combustion
owing to imperfect thoracic development. Gymnastic
exercises frequently remedy this evil, and thus act as an
antidote to hypohematosis-— British Medical Journal.
AS THE WorLp Gets ItT.—Under the ttle “Seven
M.D.’s Beautifully Trapped,” a sheet called Zhe Micro-
cosm says: “ This interesting feat was adroitly accom-
plished in last Sunday’s New York World, by the intrepid
lady reporter and detective employed on that paper. She
played sick and visited the seven prominent doctors, prob-
ably with a made-up sallow complexion, and thus obtained
from each a critical diagnosis of her case. Now comes the
funny, and at the same time serious, part of this exposure.
Each of the seven learned physicians solemnly attnbuted to
her a different ailment, and then each as gravely prescribed
a different class of medicines. A more humiliating ex-
posure of the humbug and empiricism of this professional
business of dealing out poisons to the sick at $5 for two
dozen words of Latin quail-tracks on a slip of paper, has
never before been placed on record. If that single ex-
posure does not lose the doctors of New York, in prescrip-
tion receipts alone, a cool million dollars, then we sadly
miss our guess.” Upon all this our esteemed and valiant
contemporary Zhe Zexas Health Journal makes serious
comment and reply. First, the editor of Zhe Microcosm
is shown up as a “notorious and nefarious humbug,” and
then it is added : ‘‘ We have not seen the article referred
to in the New York World, but do not for once doubt the
hysterical article written by Miss Bly, who doubtless con-
sulted a lot of quacks and blatherskite advertisers, such
as: Hall of Zhe Microcosm.”
December 14, 1889]
Society Reports,
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, November 7, 1889.
ALFRED L. Loomis, M.D., PRESIDENT, IN THE CHAIR.
THE Presipent appointed Dr. M. Allen Starr editor of
the volume of “ Transactions.” |
Dr. Simon Barkucu read a paper entitled
A PLEA FOR THE PRACTICAL UTILIZATION OF HYDRO-
THERAPY.
The fact that water in the treatment of disease had been
chiefly employed by empirics seemed to have prevented
in some degree general recognition of its virtues by the
medical profession. The author justified his appeal for
its more general utilization by physiological laws and clin-
ical results, both ancient and modern. ‘The literature
showing the value of hydro-therapeutics was very extensive,
yet modern text-books dismissed the subject with a few
words. ‘There were at present but three cities in which it
was much used in the general hospitals. Vienna taking the
lead. In spite of professional and lay prejudice, the
remedy had stood the test of. time better than any other.
A review of the experience of those whose names had be-
come prominently associated with hydrotherapy was given,
and brief quotations were made from such modern thera-
peutists as Niemeyer, Dujardin-Beaumetz, Hoffman, etc.,
testifying to the value of the method.
But proof of Het did not rest alone on clinical ex-
perience ; ıt was fully supported by ascertained iolog-
ical laws. What other agent Ma water aE produe
such a variety of results, according to its mode of applica-
tion? ` Its stimulating or depressing effects could be made
to manifest themselves either directly upon the skin where
` applied, or upon internal or remote organs, through reflex
influence. One example of reflex influence was seen in
the response of the blood-vessels of the pia mater to a
stream applied to the surface; if the stream were cold,
they become dilated ; if warm, they become contracted.
The hand immersed in cold water increased in size, show-
ing that by the use of water the blood could be driven
from one part of the body to another. Water applied to
the feet exerted an influence upon the cranial circulation ;
applied to the back, it influenced the circulation in mu-
cous surfaces, etc. The heart also responded to tempera-
ture Impressions upon the periphery. A low temperature
briefly applied accelerated the heart's action; prolongation
of it diminished the action. Evanescent application of a
high temperature to the skin caused a decrease of the
pulse-rate, quickly followed by an increase. By cooling
the blood in fevers, the heart’s action could be slowed,
and an invigorating effect thus brought about. Having
stated that the vascular tension could be modified by hy-
dropathic procedures, he said that this influence upon the
circulation was so decided, indeed, that hydrotherapy be-
came 1n reality a hydraulic problem. It was a most per-
fect means of influencing the vascular system. He said it
was to be remembered also, in discussing the value of hy-
drotherapy, that the vital process by which the system
sought to protect itself against thermic changes had also
been ascertained. Vascular spasm protected the internal
organs against too rapid cooling of the surface, while the
secondary effect was reaction and vigorous dilatation of
the cutaneous vessels. It had been shown that by hydro-
pathic treatment the blood-cells could be increased in
number, and also improved in quality. ‘This, and the in-
fluence upon the nervous system, produced a healthy
change irf the functions of nutrition, secretion, and excre-
tion. In this country, Dr. Putnam-Jacobi was one quoted
as having added to our knowledge of the physiological
and therapeutic action of water.
In discussing the clinical aspect of the subject, he said
THE MEDICAL RECORD.
665
he agreed with Dr. F. A. Hoffman in the statement that
he did not deal with the disease, but with the sick man.
He approved of Hoffman’s classification of the treatment
as direct (removing the cause) and indirect, but he would
add a third method, that by which he could so impress
the various functions of the body, chiefly innervation, as to
enhance the resisting powers of the patient, and thus en-
able him to pass over danger-points. He claimed for hy-
drotherapy only the position of being a valuable but in-
dispensable auxiliary to other treatment. By hydrotherapy
he meant water at any temperature, in any form, used
internally or externally in the treatment of disease. Of
the three therapeutic methods mentioned, the removal of
the cause of the disease directly was not always practical
because of our ignorance of the etiology. In the case
of gastric and intestina] diseases, we seemed to be on
the threshold of discovering the cause through bac-
teriology. In the removal of this and restoring gastric
function, water had been used with great success. In-
testinal irrigation, by means of the fountain syringe and
Nélaton catheter, was the most efficient method of treat-
ing several types of summer diarrhoea. ‘The value of
sipping hot water in gastric troubles had been demon-
strated. Other cases in which he had found the method
of marked benefit were those of neurasthenia and
other nervous diseases, rheumatism, gout, scrofula, etc.
The neurasthenic cases were treated differently according
to whether they were of an erethitic or an asthenic nature.
Two cases were cited to show that much depended in the
treatment upon the temperature of the water, and the
uniformity and frequency of its repetition. He said that
hysteria was among the affections which would almost
certainly yield to the water treatment when aided by other
measures. They had discharged three cases from the
Montefiore Home as cured, notwithstanding they had been
sent there as incurables. No patients of any kind were
admitted to this institution, except those who had been
considered incurable ; yet by hydropathic measures they -
had sent out a number as cured, who had had gout, rheue
matism, sciatica, hysteria, etc. (Chorea often yielded to
this treatment; the active impact of very cold water by
the douche was necessary here. Many cases of neuralgia
were connected with anæmia and chlorosis, and were
cured by hydropathic treatment ; indeed, he said that if
there was any condition in which the tonic effects of hy-
dropathy were pronounced, it was functional anzmia.
During the winter it was often sufficient for the patient to
stand with the feet in warm water, and splash cold water
on the body, the duration being only until the entire body
had been wet. The result of hydropathy in the treatment
of phthisis had been also satisfactory at the Montefiore
Home, and one pronounced case of the morphine habit
was cured. Statistics had demonstrated that the mortality
of typhoid fever could be reduced from twenty-five per
cent. to two per cent. by this treatment. The fact should
not be overlooked that the object was not to reduce the
temperature, but to refresh the nervous system, that the
body might be enabled to withstand the disease, The
bath should be adapted to each particular case.
Dr. GEORGE L. PEaBopy, having been asked to open
the discussion, said he would speak only of the applica-
tion of water to the treatment of a form of acute disease
which was of common occurrence here, and in the treat-
ment of which our results had been almost uniformly dis-
creditable to medical practice. He referred to typhoid
fever. It was a matter of surprise that in this city, where
physicians sought to introduce into their practice all that
was good and new from all parts of the world, it was
necessary for one to urge the desirability of trying this
procedure. He thought that the sooner we rid our minds
of the fallacy that it was likely to do patients with a high
temperature harm t> expose them to a considerably lower
temperature, the sooner would we get at the rational treat-
ment of this grave malady. It was almost impossible to
give a patient cold who had a temperature much above
the normal ; it was not likely that a patient with a tem-
666
perature of 104° F. would take cold, even if he kicked
the bedclothes off and lay entirely exposed. He thought
the mortality from typhoid fever in cur hospitals was quite
unjustifiable ; it ranged anywhere from twenty-five to
thirty per cent., and, here and there, it rose to fifty per
cent. In the German army, where this treatment had
been earned out in a large number of cases, the mortality
had been reduced to below four per cent. Perhaps one
reason why it had not been applied, except in a few in-
stances, in our hospitals, was that it required two attend-
ants and a portable bath-tub.
Regarding the method of applying it, he thought there
could be no question but what the full bath, of a tempera-
ture of between 65° and 80° F., was best; the patient
should be put into the bath at as frequent intervals as the
temperature indicated. ‘The temperature should be kept
at or below 102° F., throughout the entire course of the
disease. How much more rational was this treatment
than that which he had often observed, of administering
antipyretic drugs, bringing the temperature down from
105° or 106° F., to normal or below, allowing it to rise
again equally high, and again bringing it down with the
drug. A good many patients wére brought to the hospital
in a very unfavorable state, and in that case, instead of
plunging them into a cold bath, he would apply the wet
pack. Personally, he did not like the graduated bath; it
was far more troublesome, and was less comfortable to
the patient. Cold affusions on the Kibbee cot produced
rather too much shock. He thought it was folly to apply
cold to the surface of the body when it was already cool.
We often found profound depression in typhoid fever in
which the surface was cool, and the internal temperature
-high. It was certain that no routine habit of applying
cold to the surface would apply in these cases. He could
conceive of no other direct object in applying cold than to
increase surface radiation, and if the heart was too feeble
and could not be stimulated to pump the blood to the
‘surface, there was no reasor in cooling the surface
further.
Dr. A. A. SmitH hardly knew where to begin to dis-
cuss so extensive a subject. In Bellevue Hospital he had
continued the treatment of four cases of typhoid fever,
begun during the service of Dr. Flint, and all recovered ;
since then he had had five cases, in none of which the use
of the cold bath seemed to be justified, since the temper-
ature did not nse above. 103.6° F. ‘They all recovered
without such treatment. This, he supposed, would be the
experience of others. Unless the bath was used in a large
number of cases, it would be difficult to draw any con-
clusions regarding its superiority over other methods of
treatment. He was, however, a warm advocate of hydro-
therapeutics. He said that if there was any class of cases
which made him very unhappy, and which he failed to
make very happy, it was that of the neurasthenics. If
Dr. Baruch could teach us how to cure these patients by
hydrotherapy, he would put us under great obligations.
Regarding the cure of hysteria by this method, he must
admit to some scepticism, yet he hoped others would try
it and have equal success. Patients with hysteria de-
served our earnest attention, for he believed that under-
lying almost every case there was some cause in irritation,
or disturbance, which should not be ignored. He wasa
great believer in the wet pack, and he thought that its
only benefit did not consist in reducing the temperature ;
he had felt that the soothing of the nervous system was as
great an object to attain as the reduction of the tempera-
ture. Warm water had been of great service in reducing
the temperature. He had known the temperature in
scarlatina to fall a degree and a half from no other treat-
ment than wrapping the patient in a sheet wrung out of
warm water, repeated several times during the twenty-
four hours. It often banished delirium and muscular dis-
turbance, caused sleep, and reduced the temperature.
Dr. M. PuTNaM-JAcosBI gave the details of a case of
typhoid fever treated in the New York Infirmary by water-
baths. She differed from Dr. Peabody in the view that
THE MEDICAL RECORD.
-bony trabeculz.
[December 14, 1889
the benefit was alone from the reduction of the tempera-
ture. She saw no reason for pushing it further than to
produce the desired reduction of the temperature and
beneficial influence on the circulation and nervous sys-
tem. She did not think, therefore, that hard and fixed
rules for its use in typhoid fever should be necessary.
Dr. G. B. Fow.er thought the physical properties of
water commended its use in the treatment of disease to
all physicians, and he was rather surprised to hear that
the bath was as little used as Dr. Baruch had stated. He
certainly had used it ever since he began practice, in all
cases of hyperpyrexia. In the angina of scarlet fever,
diphtheria, etc., he kept the throat almost frozen, using
ice, and certainly with very good results. He expected
it to do more than reduce the temperature. Its results
were less violent than those of the therapeutic measures
usually employed. ‘The author had only hinted at one
method of using water, namely, by drinki Dr. Fow-
ler regarded this as important in the treatment of fever
as the external use of water. He gave his patients an
excess to drink, and in the sickness of children gave it to
them in the nursing-bottle. He saw a great many cases
sometimes called neurasthenia ; women with constipation,
loss of appetite, catarrh of the alimentary tract, etc., the
blood-corpuscles on the glass sticking to one another,
crumpled, the urine scanty, want of free perspiration.
Here the clinical facts pointed to a deficiency of water
in the system. One might as well try to raise a crop
without rain as to nourish an individual properly without
water.
Dr. Barucu closed the discussion.
NEW YORK PATHOLOGICAL SOCIETY.
| Stated Meeting, Fune 12, 1889.
WILLiAM P. NortTHRuP, M.D., PRESIDENT, DY THE
CHAIR.
REPORT OF’ THE COMMITTEE ON MICROSCOPY.
Drs. Henry P. Loomis and Ira J. Van Greson, the
Committee on Microscopy, reported that the microscopi
cal section referred to them at the last meeting of the So-
ciety, which was obtained from the bone presented by Dr.
Lewis H. Sayre, was found to be filled with dilated and
irregularly shaped medullary spaces encroaching upon the
In the semicircular depressions at the
margin of the trabeculz were seen granular-looking, mul-
ti-nucleated cells (osteoclasts). In some places these cells
were almost surrounded by bone. The committee di-
agnosed the lesion as that of rarefying ostitis.
Dr. WitiiaM P. NoRTHRUP presented specimens illus-
trating
GENERAL TUBERCULOSIS— THROMBOSIS OF THE LEFT
MIDDLE CEREBRAL ARTERY—CHEESY MASSES IN THE
MEDULLA.
A male child aged five months was, when first seen by
the house physician, lying in bed in the attitude of a
boxer. ‘The head was markedly retracted and turned to
the left, the left elbow was raised to the level of the
shoulder, the forearm flexed on the arm and held in a
plane on a level with the elbow, the nand clinched with
the thumb in the palm. ‘The right arm was extended on
the level of the shoulder and its fingers clinched over
the thumb, The knees were moderately drawn up. Noth-
ing pictures the position better than to imagine the child
on its feet in the attitude of a boxer. The abdomen
was distended but not tense. Sensations were normal.
Respiration was of the Cheyne-Stokes character ; pulse
rapid and weak ; temperature, 99.5°; lungs normal ; tache
cérébrale marked ; cry not meningeal ; pupils dilated but
not reacting. ‘rhe child died three days afte? the first
recorded observations.
Autopsy.—Body emaciated. Attitude the same as de-
scribed above. rain: ‘lubercles sprinkled over whole
cerebrum, thickest along the course of the vessels. About
December 14, 1889]
THE MEDICAL RECORD.
667
the left middle cerebral artery, in its first inch and a half,
was a mass made up of tubercle tissue and inflammatory
exudation. The artery was blocked by a thrombus and
the brain-tissue to which it was distributed was diffluent,
while the remaining and surrounding substance was firm.
The diffluent mass left an opening into the left ventricle.
‘The ventricles seemed not to be dilated, or only moder-
ately. In the wall of the fourth ventricle, at the junction
of the medulla and pons, was a yellowish, spherical cheesy
mass, about four millimetres in diameter. A similar
mass, though smaller, was found lower down in the op-
posite wall. The spinal cord was normal. Zungs : ‘Tu-
bercles large, opaque, and abundant; cavity of capacity
of 3ss. Bronchial lymph-nodes enlarged and cheesy ; no
pneumonia. iver enlarged, tubercles numerous. Gall-
ducts thickened and tubercular. Heart normal. Mes-
enteric glands large and cheesy. Peyer's plaques swollen,
but no ulcers.
Dr. Northrup presented a second specimen, illustrating
ABSCESS OF THE SCALP FOLLOWED BY THROMBOSIS OF
THE LONGITUDINAL SINUS, AND PYÆMIC ABSCESSES IN
THE BRAIN AND LUNGS IN AN INFANT.
The patient was a male child, two months and six days of
age, who was brought to notice with an abscess of the scalp,
over the vertex ; no history of injury. Three days later,
and two weeks before death, he became restless, fontanelles
depressed, temperature gradually increasing to 103° F., with
twitching of the left arm and jaw, and rolling of the head.
He gradually failed, developing in the last days of life an
ulcer on the tip of the tongue ; fine rales over both chests,
and became pale, stupid, and aphonic.
Autopsy —Extremely emaciated ; abscess over vertex
nearly healed ; beneath the site of the abscess the bone
was reddened ; the longitudinal sinus contained a firm old
clot two and a half inches long, having its middle just be-
low the centre of the abscess. Slight redness of the dura
mater ; no exudation upon its surface. The wall of the
sinus seemed normal; across its cavity stretched a fine
bifurcated filament. This was located in the middle of
the clot; its tissue was normal. Brain: The right lat-
eral surface contained six or eight small abscesses varying
in size up to a diameter of from three to four milli-
metres. These extended inward from the pia mater and
were fusiform in shape; the contents, fluid creamy pus.
There was no meningitis. Post-mortem softening was
advanced. Jungs: Scattered broncho pneumonia with
marked infiltration of the small bronchial walls. On the
surface of the right lung, just under the pleura, was a
small abscess similar to those of the brain. There were
no other abscesses found. ‘The thrombus of the longi-
tudinal sinus, the small abscesses of the brain, and the ab-
scess of the lung showed abundant colonies of streptococci.
Numerous colonies were distributed in the lungs with evi-
dent beginning of abscesses.
Dr. H. P. Loomis said that he had recently seen a case
` somewhat similar to the one reported by Dr. Ely. In-
oculation of a rabbit with the cheesy material from the
bronchial glands showed that it was tuberculous.
Dr. NoRTHRUP presented a card-specimen of
VEIN TUBERCLE,
from a case of discrete miliary tuberculosis of the lung in
a child (see p. 657). The specimen was of unusual inter-
est from the fact that a fortunate cut across one vein had
passed through two tubercles growing from the inner sur-
face of the same vessel. A second microscope slide
showed the two tubercles stained for tubercle bacilli, in
which the micro-organisms were distinctly demonstrated.
The tubercles were of typical structure, containing granu-
lar giant-cells and tubercle bacilli.
The Society then went into executive session.
CREOSOTE IN D1aBETES.—In doses of from four to ten
drops a day creosote is said by Dr. P. Valentine to have
yielded excellent results in several cases of diabetes
mellitus.
Correspondence.
PREPARING FOR THE INEVITABLE.
To tHe Eprror or THe Mepicar RECORD.
Str: Your able editorial on life insurance for physicians,
in Tue Recorp of November 23d, abounds in good
suggestions. But will it go far enough? That is, will
enough physicians join a mutual benefit association to
pay our widows a sum that, at five per cent. interest,
would keep those we leave behind in anything like the
circumstances they had been accustomed to? I think it
exceedingly doubtful. Making allowances for “bad
risks” that would or should be rejected, with two or
three exceptions, how many centres are there that could
muster enough physicians that on the death of a member
could pay the widow even $2,000 or $3,000, granting
the assessment would be $1 or $1.50 for each death ?
Mutual Life Assessment Companies have been formed
time and again, and nearly as often have they led a pre-
carious existence, finally dying of inanition. What fs the
remedy? At present there is hardly a town of any size
but what has those boons for all mankind—physicians as
well as mechanics—building associations. Let a mem-
ber buy two shares of an association that has $1,000
shares—imany are only $500. He deposits his $2 a week,
commencing, say, the rst of January or July. After pay-
ing in twenty-six weeks, and he has had his dividend
added to his deposits for the six months—declared on the
1st of January or July—let him draw out $50, which will
about pay a semi-annual premium on $5,000, assuming
the insured is anywhere from thirty to thirty-five years of
age. I have reference now to what, in insurance language,
is known as “old-line insurance,” non-forfeitable, pay-
able at death. Take, for instance, a company like the
Manhattan of your city—with abundant assets, well se-
cured, and time-tried—and for every $1,000 insurance he
carries, his premiums will be about $12 to $14 every six
months. I speak of this company as I am somewhat
familiar with their figures, having carried policies with
them for several years, making my payments on the plan
I herewith suggest. Surely there is hardly anyone in the
profession but what can put that much, or double, away
every week, and scarcely feel it.
There are many doctors, I: am happy to say, who do
put $2 a week in building associations, allowing it to ac-
cumulate year after year, and when they “ buy out” how
much have they? At the outside $1,000 or $2,000, ac-
cording to the amount of the shares, which amount,
should he decide to die about that time, can be attached
for any indebtedness he may have, before his executors
can touch it.
Again, let him die at any time during his building-as-
sociation membership, he has to his credit only that
amount paid in at $2 a week—in one year $104 and in-
terest, same as in a savings bank, only more secure. Let
him die at any time during the same period, withdrawing
every six months (or twelve if so desired), and he leaves
an estate that, for every $2 a week, as suggested, is worth
$5,000 that cannot be molested by law.
The practice of medicine to-day, with its many spe-
cialties and the numerous free dispensaries and hospitals,
cuts deeply into the annual income, of which, after taking
out the “family expenses,” schooling, horse-keep, etc.,
there is little left to put away. Hence it behooves us,
while in health, to make preparations for our loved ones,
and there is nothing more comforting than to know that,
with a secure policy for a good round sum, we are ready
to meet the summons, come when it may. Very truly
yours, WILitaM Jupkins, M.D.
216 Race STREET, CINCINNATI, O.
A New Remepy ror Diaseres is phosphorus in
doses of about gr. yy, three times daily.
THE MEDICAL RECORD. [December 14, 1889
668
deformity has been corrected enough to allow the patient
to walk on the bottom of the foot, the boot is put on,
laced, and the straps Æ and Æ tightly drawn over the
ends å and ¢ of the spring 4 (Fig. 4).
Hew instruments.
| A NEW CLUB-FKOOT APPARATUS.
By GEORGE H. EARL, M.D.,
WAREHAM, MASS,
THE apparatus consists essentially of a bent spring, ap-
plied to the foot by means of bandages, or to the boot by
means of straps, in such a way as to make traction in two
directions upon the deformed foot. It does what the
hands do in the method known as “ hand working.”
4
A c
' Fic. 1.
FaFig. xis a view of the spring. Fig. 2 shows the
spring applied to the deformed foot. Fig. 3 shows a plan
of the spring as fitted to the boot. Fig. 4 is a perspective
of the boot with spring and straps applied.
Fic. 2. .
The spring is applied by bandaging the short arm 4 to
the inside of the foot, just under the malleolus (Fig. 2),
the bandage Z passing over the dislocated bones on the
outside of the foot. Then the long arm ¢ is bent down
A b
Fic. 3.
along the outside of the foot, and secured by the bandage
D passing over the end of the first metatarsal bone.
Traction is thus made in the direction of the arrows 1.
and 2. The arrow 3. represents the fulcrum. After the
$: j
IIRA, Wi)
ea Se ay Ly
ae
á
AJ
Oa m
ae
4
FIG. 4.
The short arm 4, through the strap Æ, is making con-
stant traction on the dislocated bones on the outside of
the foot ; and at the same time the long arm ¢, through
its strap /, is drawing the forward part of the foot around
toward a straight line.
FIG. 5
The splint prevents the foot from turning over while
walking, during which the weight of the patient’s body is
forcing the forward part of the foot up. This latter is
J}
f
|
if
Jij j
4 N Vi
T
Olly #
will WHA
FA te AA
SN A ig
ey |e
Fic. 6.
the work which “ Scarpa’s shoe ” is especially designed to
do, but while on it inflicts severe pain, and prevents the
foot from being used.
Figs. 5 and 6 represent two casts, made “ before and
after.” The case is one of congenital club-foot»; patient,
December 14, 1889] THE
twenty-one years of age. Of course, the usual tenotomies
were made.
I have neglected to say that the variety was equino-
varus, and that the spring is particularly adapted to that
form.
The spring inflicts no pain, can be worn night and day,
and be applied by the patient.
A CONVENIENT ANASSTHETIC INHALER.
By FRANK DUDLEY BEANE, A.M., M.D.,
NEW YORK CITY.
HEREWITH is presented to the profession a convenient,
simple, and effective anesthetic inhaler, a device evolved
from my search for a handy but efficient substitute for the
ordinary “ cone” or “ bag,” and one which I have used
with uniform satisfaction for several months. Years of
experience, including trials of many of the inhalers in the
market, convincéd me that the bag or cone alone se-
cured rapid, safe, and thorough anesthesia ; that it alone
supplied the two requisites, a large supply of the agent
and easy regulation of the air-supply. All the inhalers I
have thus far tested have proven defective in one or the
other or both of these particulars. The inhaler here of-
fered and illustrated consists of a short elliptical copper
cylinder, with a rubber hood (mouth-piece) riveted to a
metal cap, the latter being removable for convenience in
cleansing. The hood-end of the cylinder is encircled by
a narrow metal collar to prevent overflow of the anzs-
thetic in case the cotton becomes supersaturated. The
distal end of the cylinder has an adjustable ventilator,
surrounded by a dozen small perforations on either side,
for regulating the admission of air. A vent in the upper
surface of the cylinder, surmounted by a collar and cap,
allows of the introduction of the agent used without re-
moving the inhaler from the face. I have found that a
packing of absorbent cotton in the cylinder is admirable for
holding the anzesthetic ; but soft muslin, linen, or other
absorbent material, may be substituted.
The advantages claimed for this instrument are :
1. Simplicity. No so-called automatic valves (usually
failing to operate) or other complications. 2. A free sup-
ply of the anzsthetic, insured by the large size (1$ x 14
inch) of the hood-cap opening. 3. Easy regulation of
the admixed air. 4. Economy of the anesthetic, as the
surface evaporation is very limited. 5. Convenience. It
is always ready, being easily cleaned, and occupies but lit-
tle space in the surgeon’s bag.
The instrument, well nickel-plated, is accurately and
neatly made by Messrs. Meyrowitz Bros., 295-297 Fourth
Avenue, this city.
A NEw OPERATION IN FRANCE.—On July 13th last Dr.
Terrier performed an operation which had not been be-
fore attempted in France. He established a.permanent
fistula between the gall-bladder and the duodenum in a
woman whose ductus communis choledochus was obliter-
ated, and who, being afflicted with extreme jaundice, pre-
sented very grave symptoms. Dr. Terrier had lately seen
the patient since the operation. The jaundice had dis-
appeared, the bile passed into the intestine, and the health
was excellent.— Lancet.
MEDICAL RECORD.
669
Army and Havy Hews,
Official List of Changes in the Stations and Duties of Ci-
cers serving in the Medical Department, United States
Army, from December 1 to December 7, 1889.
WOLVERTON, WILLIAM D., Major and Surgeon, Fort
Douglas, Utah. Leave of absence for one month, to
take effect on or about December 18, 1889, 1s hereby
granted, with permission to apply at Headquarters Divi-
sion of the Missouri for an extension of seven days. Par.
2, S. O. 114, Department of the Platte, November 30,
1889.
GARDINER, JOHN DE B. W., Captain and Assistant Sur-
geon. By direction of the Secretary of War will be re-
lieved from duty at Fort Reno, Ind. Ter., upon the
arrival at that post of Captain James C. Merrill, Assistant
Surgeon, and will report in person to the commanding
officer, Fort Supply, Ind. ‘Ter., for duty at that post. Par.
8, S. O. 279, A. G. O., November 30, 1889.
McCaw, WALTER D., Captain and Assistant Surgeon,
Fort McPherson, Ga.. Leave of absence for fifteen days
is hereby granted. Par. 3, S. O. 276, Division of the
Atlantic, December 3, 1889.
Official List of Changes in the Medical Corps of the United
States Navy for the week ending December 7, 1889.
NEILsON, J. L., Surgeon. Detached from the New
Hampshire, and ordered to the Portsmouth.
BEYER, H. G., Passed Assistant Surgeon. Detached
from the Portsmouth, and placed on waiting orders.
SIEGFRIED, C. A., Surgeon. Detached from the Naval
Station, New London, Conn., and ordered to the New
Hampshire.
HALL, Jonn H., Passed Assistant Surgeon.
to the Naval Station, New London, Conn.
Kire, I. W., Assistant Surgeon. Detached from the
Naval Hospital, Philadelphia, Pa., and ordered to the
Naval Hospital, Pensacola, Fla.
Ross, J. W., Surgeon. Detached from the Naval
Hospital, Pensacola, Fla., and placed on waiting orders.
Ordered
Medical Items,
CONTAGIOUS DIsEASES—WEEKLY STATEMENT. — Re-
port of cases and deaths frọm contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending December 7, 1889:
Typhus fever
PPO SAUCE ao caaaaebhsuseh a cdcsmedias: E 16
SCRTIOL IANO L AEE E TE E TTO N E 64
Cerebro-spinal meningitis
Measles .
(°)
o'
etalk pox
eeeeet eee eeeneee eee eeeeeeeeeeeeseoeeeeeneeeneee
wn
N m
m oounoan
Haos
bet
os
THE PATHOLOGY OF PAINLESS WHITLOW.—Dr. Thiriar,
of Brussels, publishes some notes of a case of painless
whitlow, or the so-called Morvan’s disease, which he thinks
tend to prove that the central nervous system must be
affected in this somewhat rare and ill-understood condition.
Only one post-mortem examination seems to have been
at all fully reported of a case of this character, and that
was of one of Dr. Morvan’s own patients (Gazette des Hépi-
taux, April 30, 1889). Here there were both peripheral
670
and central nervous lesions, the cervical enlargement of
the cord and the nerves of the upper extremities being af-
fected. In the nerves there was a hyperplasia of connec-
tive tissue, and in the cord an abnormal development of
interstitial tissue occupying the posterior column, the pos-
terior cornua, and probably the central gray matter. It
was unfortunately not possible to ascertain whether there
existed morbid tubular cavities near the central portions
of the chord—the form of lesion styled syringo-myelia—
which Dr. Thiriar believes to be the condition to which
painless whitlow is due. His patient was a woman aged
sixty-six, who six years previously had had a severe bruise
on the left thumb, which caused a great deal of swelling,
which swelling had never entirely disappeared. Fourteen
months before her admission the first two phalanges of the
ring-finger of the right hand became swollen and painful,
ultimately opening and giving exit to some pus. A year
later the left thumb again became painful and increased
m size, and after a time broke and gave vent to some pus.
Since that time there had been very little pain from either
of the whitlows. On examination the lymphatic glands
on both sides of the neck and in both axillz were found
to be inflamed, and the upper arms were both consider-
ably atrophied and wanting in sensibility. There was no
pain or tenderness in the neighborhood of either of the
whitlows. The theory proposed by Dr. Thiriar to account
for the second whitlow, which came on without any ap-
parent cause, is that the old injury to the left thumb,
which was never cured, set up an ascending neuritis which
was followed by syringo-myelia, and probably then by de-
scending neuritis on the right side.— Zhe Lancet.
PROMOTING THE SPREAD OF SCARLATINA.—At the Hy-
gienic Congress in Paris, Dr. de Valcour related that a
death having taken place from scarlet fever at an hotel in
\ionaco, the room was relet to another tenant the next
day, and he likewise died of the same fever. It was not
till a third case of scarlet fever occurred in this room that
the hotel was closed and disinfected.
‘THE PATHOGENY OF HEMORRHOIDAL DISEASE.—In
course of a paper on hemorrhoidal disease Dr. Boden-
hamer (Zhe Mew York Medical Journal, January 12, 1889)
says that the chief predisposing cause of hemorrhoids in
the human subject, according to some authorities, is an
anatomical one; and, in order to fully estimate the im-
portance of the subject, this cause must be explained ana-
tomically, which is the more necessary inasmuch as just
the reverse of it obtains in quadrupeds; and in this ex-
planation regarding the large vascular supply to the
rectum, it will be perceived that hydraulics plays the most
important part.
Anatomists know that in the inferior portion of the
rectum in the human subject a large number of hemor-
rhoidal veins exist ; these veins are comparatively of large
size; they occupy a peculiar depending position ; and
they receive but little support from the loose cellular
tissue which surrounds them. ‘Together with the fore-
going facts we must consider the entire absence of valves
in the depending plexus of the vena porte. ‘These
several conditions of the veins of this part consequently
tend to a retarded or sluggish circulation, the blood being
more or less detained in them and favoring stasis. When-
ever the body is erect, the blood therefore accumulates in
these veins, so that under the most favorable circumstances
they are subjected to more strain and pressure than any
others of the body, and, in consequence of the want of
valves in the portal system, the whole weight of the col-
umn of blood in them reaches from the liver or the heart
without any interruption downward. These several cir-
cumstances act no inconsiderable part in the pathogeny of
hemorrhoids. They necessarily give rise either to hem-
orrhage, vascular turgescence, hyperzemia, congestion, or
hemorrhoidal tumors. Indeed, any mechanism whatever
which opposes the free circulation of the blood in that
hybrid blood-vessel of the liver, the vena portæ, may prove
a predisposing or an efficient cause. of the hemorrhoidal
THE MEDICAL RECORD.
[December 14, 1889
disease. According to authority, therefore, the depend-
ing situation of the veins of the portal system must always
be a predisposing cause of hemorrhoids in man so long as
he maintains the erect posture. ‘The absence of this cause
in quadrupeds because of the horizontal position of their
bodies is not, in the opinion of the writer, sufficient alone
to prove that they are on this account entirely exempt
from hemorrhoids, as some authors maintain ; but this
cause may be a real one, so far as it goes, and have some
bearing on the fact that animals are not subject to hem-
orrhoids.
EFFECTS OF HEAT ON THE SYSTEM.—A series of articles
on tropical and subtropical climates has been published
by Dr. Cullimore in the Medical Press. Regarding the
effects of heat on the human system the author says that
they differ materially according to the duration of resi-
dence, and, therefore, also, as regards travellers and per-
manent residents. At first, and particularly in the hot
season, the functions of respiration and circulation are
considerably increased, as is also the vital capacity of the
lungs. ‘The circulation, as shown by the greater power
and frequency of the pulse, is excited to a febrile or semi-
febrile condition, the temperature of the body being in
some instances heightened, at least fora time. The ap-
petite and spirits are good, and the capacity for enjoy-
ment and travel as a rule remain unimpaired. After a
certain sojourn or period of residence, ranging from six
months to a couple of years, this state of exhilaration and
excitement ceases, and the new-comer begins to approach
somewhat the condition of the indigenized white man,
and if he remains, say for nearly a hfetime, without dis-
ease, that of the native himself. He has seen some few
Europeans in India who could with impunity set the sun
at defiance, and one, at least, who was not a teetotaler,
who could do so without the aid of umbrella or hat. The
vital capacity and respiratory movements become lowered,
the pulse, though perhaps more frequent, loses its tension,
the heat of the body assumes the normal condition, the
plumpness and rotundity, the weight, the firmness of the
body diminish, and the excretions, as the urea and car-
bonic acid, decrease. ‘The action of the skin is increased.
That of the liver and bowels at first are increased,
though there are many exceptions, constipation being
not uncommon among new arrivals, particularly on the
_ West Coast of Africa. The amount of urine is lessened,
' the process of digestion endeavors to adapt itself to the
novel surroundings, the appetite gradually becoming
languid and in need of stimulation. There are, however,
here also many exceptions. ‘There is prostration of nervous
energy and lack of mental activity, not, however, due so
much to the influence of heat, unless severe and continuous
(above 84° F.), as to heat and excessive moisture. In sub-
tropical and tropical Australia, though the heat 1s consid-
erable, it is dry, and the go-aheadism and mental capacity
of the colonists are proverbial. In damp, low-lying coun-
tries the reverse is the case, for not only are the natives
degraded and apathetic, but horses and sheep languish
and die. As regards active disease, while we recognize
great and continuous heat, particularly when associated
with extreme moisture, as its main predisposing cause in
the tropics, it is to the chilling effect of variations and
oscillations of temperature, generally accidental, relatively
greater in tropical than in temperate climates, of heavy
rains, inundations, extensive marshes, and uncultivated
jungles, and, according to some authonities, emanations,
therefrom, that is to be attributed the main exciting cause
of disease. Sudden falls and high diurnal ranges of tem-
perature, cold winds blowing, and perhaps rain falling,
on a sleeping and perspiring body, rapid alternations of
heat and cold, are more favorable to disease than a cli-
mate with a steadily high thermometer. Suitable clothing
and careful attention to the erection and site of the dwell-
ing, to sanitary and individual precautions and manage-
ment, will, however, in great measure enable us to prevail
against the former, while with the latter we are almost
December 14, 1889]
powerless to contend. We may alleviate its attendant dis-
comforts, and even by exercise and attention to diet, etc.,
stave off its ultimate results, but eventually tropical
anzmia, with or without a certain amount of acclimatiza-
tion, with attendant racial deterioration, lays hold of the
system, and the healthy European, or, at all events, his
children, assumes many of the mental, moral, and physi-
cal traits of the half-caste, and even of the native himself.
MONKS AS PHYSICIANS IN THE MIDDLE AGES.—Fechin,
who figures as the first presbyter named in the Third Or-
der of Irish Saints, according to the famous catalogue
given in Archbishop Ussher’s “ Britannicarum Ecclesiarum
Antiquitates,” is an interesting example of the circum-
stance, brought out into strong relief by Montalembert,
that the early medizval monks were the depositories and
practitioners of the best medical knowledge of the time.
His sphere of activity was mainly in the West of Ireland,
and according to Archdeacon O’Rorke, the historian of the
County Sligo, leprosy was the disease the saint was most
frequently called in to cure. At Fore he was one day
begged by a loathsome leper to take him in charge, and
Fechin, having carried him on his back to the monastery,
left him in the hospital and consigned him to the care of
Themania, wife of King Domnald, who, being promised a
heavenly crown in recompense, undertook the unpleasant
task. ‘The Queen tended the patient devotedly, and she
had her reward ; for, so the chronicle runs, “next day,
when the saint was going to the hospital, he saw a globe
of fire ascend toward heaven from the roof of the building,
and on entering the sick-room found that the man they
had been nursing, and who had departed in the form of
fire, was no other than our Lord Himself—the whole oc-
currence illustrating the truth of the words, ‘ Inasmuch as
ye did it unto one of these the least of my brethren, ye
did it unto me.’ In going away the leper left behind a
staff and a lump of the purest gold, with directions to
the Queen to give them to Fechin, which she did, and the
staff became the famous Bachal Fechin, with which the
saint is supposed to have performed many miracles
through life, and which was held in great reverence after
his death ; but the gold he employed in building hospitals
and in other works of charity.” Skilfully disentangling
this and such-like legends from their mythopzic drapery,
Archdeacon O’Rorke accumulates a mass of evidence,
corroborated from other sources, which makes it clear
not only that the chief, if not the sole, practitioners of
Ireland in the seventh century were monks, but that the
disease they were most commonly confronted with was
leprosy, wrongly supposed to have been first brought into
Europe by the Crusaders.— Zhe Lancet.
FRAULINA SCORBILIS IN DYSENTERY.—A correspondent,
referring to a paragraph on this subject taken from the
Avisos Sanitarios, suggests that there was an error in the
original notice, and that the writer probably meant Paul-
linia sorbilis or guarana, the use of which in the treatment
of dysentery is by no means a novelty.
SALICYLIC ACID IN THE ‘TREATMENT OF MALIGNANT
SCARLATINA.— Dr. Shakowaki writes that he has adminis-
tered salicylic acid with the greatest success in one hun-
dred and twenty-five cases of grave scarlatina occurring in
children, the mortality being reduced to three and one-
half per cent. Ordinarily his method of administration
was in the form of a mixture consisting of one part of
salicylic acid to 75 parts of water, and 30 parts of sirup
of orange-peel, a teaspoonful of this being given every
hour during the day and every two hours during the night.
He writes that under the influence of this remedy the
temperature is rapidly reduced, in certain cases even at
the end of forty-eight hours, the temperature falling
four degrees. Habitually all traces of fever disappear
after the tenth day of the disease. Nevertheless, the au-
thor advises to prolong the treatment for some time
longer than this in progressively decreasing doses, so as to
avoid any danger of relapse. ‘Through the use of this
THE MEDICAL RECORD.
671
remedy the author believes that he has avoided the most
serious complications of scarlatina, such as urzemia, ana-
sarca, and diphtheria. He claims that this medication
will only be ineffectual when given too late—that is, after
_the fourth day of the disease, or when there exists some
grave chronic complication.— Therapeutic Gusette.
THE DISINFECTION OF Booxs.—The Boston Health
Board has ordered that the public library ticket, held by
any person in whose family a case of contagious disease
has occurred, be stamped so as to show the presence of
such disease. All books returned with a card so stamped
are to be disinfected, and no other books can be taken
out on this card until an official notification is received
that the danger of contagion no longer exists.
GLYCERINE SOAP SUPPOSITORIES.—Dr. Schaffer recom-
mends the use of suppositories cut from a cake of glyce-
rine soap as a substitute for glycerine enemata.. The
soap is said to contain thirty per cent. or more of glyce-
rine, and the remedy is as effectual in this form, he
claims, as it is when used pure.
THE IDEAL ORTHOPEDIC SURGEON.—Orthopedists have
been in the past very prone to run in ruts, and have made
very slow progress. They have many times degenerated
into mere mechanics and have deprived themselves of the
right to be called surgeons. While I believe the ortho-
pedist should be eminently conservative, I do not believe
that conservatism consists in refusing to operate. The
greatest obstacle to the rapid advancement of orthopedic
surgery to-day is the tendency of the general surgeon to
operate upon every orthopedic case that comes in his
way, while the orthopedist too often refuses to operate,
applying an apparatus to every case. Between the man
who operates upon everything and the man who operates
upon nothing the poor cripple has a hard time of it, and
orthopedic surgery is brought into disrepute. To my
mind the ideal orthopedic surgeon is he who exercises
the greatest judgment in drawing the line between the
cases that require operation and those that do not, who is
equally skilful on the one hand in applying the knife and
on the other in applying proper apparatus, and who is
without prejudice in either direction.—Dr. J. E. Moor,
in the Northwestern Lancet.
INTRAPLEURAL INJECTIONS IN PLEURISY.—Dr. Juhel-
_ Renoy recommends the use of intrapleural injections of a
“one per cent. solution of zinc chloride in the treatment
of pleurisy. After evacuation of the serum he injects
very slowly a small quantity of this solution, withdrawing
it at the end of ten or fifteen minutes. Before the injec.
tion the fluid is boiled and then cooled to a temperature
of about 95° or 100° F. He claims that by this method
the duration of the disease is materially shortened.
~ He HAD QUITE A BILL AT THE Drucoist’s.—The Zoc-
sin gives the following particulars relating to the physick-
ing of a patient in the olden times, the good old times,
when people took physic and plenty of it, firmly believing
that it did them good. ‘The individual in question, Mr.
Samuel Jessup, died, May 17, 1817, at Heckington. He
was defendant in a trial for the amount of an apothecary’s
bill at the Lincoln Assizes. ‘The evidence at the trial
gives the following details: In twenty-one years (from
1794 to 1816), he took 226,934 pills, supplied by a re-
spectable apothecary in Bottlesford, which gives an aver
age of 10,806 pills a year, or 29 each day. In the last
five years preceding 1816 he took the pills at the rate of
78 a day,‘and in the year 1814 swallowed not less than
51,590. “ Notwithstanding this,” says the Zocsin, “and
the addition of 40,000 bottles of mixture, besides juleps
and electuaries, set out in fifty-five closely written columns
of the apothecary’s bill, he lived to the age of sixty-five
years.”— Zhe Hospital Gazette.
A New OPERATION ON THE URETHRA.—Dr. R. Ger-
suny, of Vienna, who some time ago transplanted a rab-
bit’s nerve into Professor von Fleischl’s arm, has recently
672
devised a new operation for incontinence of urine. Ina
case of epispadias in a girl, the urethra admitted the little
finger, and had the form of a funnel, one centimetre long ;
the clitoris was cleft ; there was complete incontinence
of the urine.
membrane corresponding to the cleft was excised from
the anterior commissure of the labia up to the neck of
the bladder, and the edges of the cleft were sutured.
The girl was then operated on by Professor Pawlik, ac-
cording to his own method, but the patient could hold
her water only for an hour when sitting; on walking or
standing, she could not do so at all. Five years later Dr.
Gersuny operated on the patient, who was then nineteen
years of age, by laying bare the urethra as far as the arcus
pudendi, twisting the external orifice of the urethra to the
extent of a semicircle (180°), and suturing it in this posi-
tion. The success was incomplete, and this was also the
case after a second operation, in which the urethra was
further twisted to the extent of go°. Four weeks later a
further twisting, to the extent. of 180°, was effected.
This proved completely successful. The external orifice
of the urethra was turned round to the extent of one cir-
cle and a quarter (450°), and the urethra was twisted in
its longitudinal axis in the form of a screw. After the
last operation there was retention of urine (ischuria) for
three days, so that the patient had to be catheterized.
From that time she could micturate spontaneously, and
the urine never passed involuntarily. ‘The capacity of
the bladder was at first from roo to 200 cubic centi-
metres. Evacuation took place under strong pressure,
and lasted for ten minutes. This condition improved
rapidly, and after five months the patient could hold her
water for five hours in any position; then she was at-
tacked with strong tenesmus, and evacuated, without ef-
fort, half a litre of urine; the act, however, still required
about four minutes. The progressive improvement was
the result of the gradual dilatation of the bladder and the
strengthening of the detrusor urine. The operation of
Dr. Gersuny is indicated in those cases in which the
sphincter of the bladder is quite powerless and the detru-
sor intact.— British Medical Journal.
A PRECURSOR OF M. Brown-SEQUARD.—M. Megnin
publishes, in the Journal des Connaissances Médicales of
August .15, 1889, a note in which he announces that he
has discovered, in a book entitled “ La Chasse au Chien
Courant ” (p. 202), published in 1838 by Elzear Blaze, a
passage couched in the following terms: “ When you
have the fortune to kill a wild boar, do not throw away
the testes (les suites), they will prove very useful to you
later. If perchance the desire to marry seizes you at an
advanced age, when only vague hopes of becoming a
father remain to you, vous savez ? There are moments when
one has confidence in himself, then everything vanishes
like a phantom. ÆA bien! the testes of your wild boar,
dried and powdered, diluted with broth of an old cock,
and swallowed fasting, by you and your spouse, will have
a marvellous effect ; children will be born to you every
nine months, and you will be obliged to come to me ask-
ing for another recipe which will bring about the former
condition of affairs.” I give this recipe to you just as
I have found it in the works of a learned physician.
‘‘ Magna est uxoraus inquietudo et animi perturbatio prole
sterilis existere : propterea, ut tanto infortunis liberentur
prolemque habeant, per aliquot dies jejuno stomacho vir
et uxor cum jure galli veteris testiculorum apri in umbra
exsiccatorum pulverem capiant ; profecto brevi tempore
optatum adispicentur, ut in multis sterilibus ex quacum-
que causa non semel expertum est.” (JuL CÆSARIS
BARICELLI, à Sancto Masio, doctoris medici Hortulus
Genialis. Genovæ, 1620.) Répertoire de Pharmacie.
[This seems to be a coq-à-l'åne.—ED.]
THERMO-PALPATION.—It has been known for some time
that there is a difference in the surface temperature of
the body corresponding to the organs underneath—that
is to say, the temperature is higher over the lungs than
THE MEDICAL RECORD.
At fourteen years of age, the mucous.
[December 14, 1889
over the liver or the heart. From a communication pub-
lished in the Orvosi Hetilap, one of the chief medical
journals in Hungary, by Herr Jonás and Dr. Benczúr, it
appears that this fact is available as a basis for a novel
method of physical examination which may be styled
“ thermo-palpation.” These observers say that it does
not require any peculiar sensitiveness of touch or any
special education to appreciate the difference of temper-
ature on passing the fingers over the surface of the body
from the situation of the lungs to that of the liver, and
that patients themselves, and students who had not yet
learned percussion, were quite able accurately to detect
the height of a pleuritic effusion by the difference of
temperature. Diseased and healthy organs can be map-
ped out in this way by going over the surface, first, say,
downward an@ then upward, when the line of demarca-
tion will be distinctly felt. ‘The general principle appears
to be that organs containing air, such as the lungs and
intestines, permit of greater surface warmth over them
than more solid organs, such as the heart, liver, spleen,
etc. Of course, instead of using the fingers, a differen-
tial thermometer may be employed, and much slighter
differences may be recognized than is possible by the
touch alone.— Zhe Lancet.
CONTAMINATION OF WELL-WATER.—A writer in the
Annals of Hygiene for October, 1889, relates a curious
fact which may tend to shake the confidence of many
country residents in the purity of their water-supply. It
is generally supposed that there is no danger of contami-
nation if the cesspool is at a lower level than the well
and at some distance from it. But in the case to which
the writer refers there were two wells on the place, sepa-
rated a distance of two hundred and seventy-three feet
from each other, and one being fourteen feet lower than
the other. Yet when water was pumped from the upper
well the water in the other was very decidedly lowered,
showing that there was quite free communication between
the two. If the lower one had been a cesspool, the wa-
ter in the upper well would doubtless have been contam-
inated.
THE BRAIN AND Mora. CuLTuRE.—Under the title
of “ Gehirn und Gesittung,” Professor Mynert, of Vienna,
read a paper before the last meeting of the German As-
sociation of Naturalists and Physicians, in which he con-
sidered the brain as an inhibitory apparatus against the
lower and more instinctive natural impulses. The higher
its development the greater is the tendency to subordi-
nate the particular to the general, and even in the lower
animals we see a high state of social growth, as in the
communities of bees and ants. In the development of
the human individual, we see in the infant, a being en-
tirely wrapped in its instincts of self-preservation, the
‘primary ego ” is predominant, and the child is an egois-
tic parasite. As development goes ont his stand-point is
passed, conscience assumes its priority, the brain acts as a
check on the purely vegetative functions, and the “ sec-
ondary ego” takes precedence over the primary one ; and
this is the general order of society we designate as civiliza-
tion or social order (Gesittung). If this inhibition becomes
weakened, as in progressive paralysis, then we see the dis-
ordered predominance of the natural instincts or impulses,
and when it is totally lost the individual is in the position
of a criminal, who opposes the ethical order of society—a
parasite, and one of the worst kind, one who not only
lives upon his host, but destroys him in so doing.—
American Fournal of Insanity.
New REMEDIES FOR WHOOPING-COUGH.—Dr. Andeer
(Centralblatt f. Med. Wissensch.) gives resorcin in one-half
to two per cent. solution, according to age. Half a wine-
glass is administered several times daily. Dr. Stepp
(Deut. Med. Woch.) gives one to seven drops of bromo-
form in water three to four times daily. ‘The bromoform
should not have any red color, as it then contains free bro-
mine and is irritating.
The Medical Record
A Weekly Journal of Medicine and Surgery
——e --- ——
Vol. 36, No. 25
New YORK, DECEMBER 21, 1889
Whole No. 998
—— NE o o MM
Original Articles,
RELATION OF MEDICINE TO THE PROBLEM
OF SOCIALISM.'
By WILLIAM MECKLINBURG POLK, M.D,
PROPESSOK OF OBSTETRICS, GYNECOLOGY, ETC., IN THE MEDICAL DEPARTMENT
i OF THE UNIVERSITY OF THE CITY OF NEW YORK.
MR. PRESIDENT, LADIES, AND GENTLEMEN: When I re-
ceived the notice of my appointment as your orator upon
this occasion, my impulse was to write at once and decline
the honor. I could not see that my life or my opportu-
nities had been such as to enable me to reach the high
standard which should be obtained upon the occasion.
If such was my first impulse, you can easily comprehend
how greatly it was intensified when I fully understood what
had been said here in these halls by those whom you had
honored in the past. Were I to mention but one name, and
that the name of John W. Draper, no one within the sound
of my voice could question the fitness of the sentiment.
Because he was a “ Doctor of Medicine,” who impressed
himself not only upon the very foundations of our science,
but in his work upon “ Intellectual Development” did so
much to impress layman, physician, and priest with the
deur of medicine, grand not only in its relation to
individual man but in the influence exerted by its disciples
in the preservation and revival of learning, a preservation
and a revival about which clusters all that is worth having
in the life of to-day.
The ripe scholarship involved in his productions was
fittingly offered here, and such is my estimate of your
position, your influence, your mission, that nothing short
of such products is deemed sufficient by me for such an
occasion as this. You can excuse me, then, when I repeat
that the realization of my task oppressed me. But I trust
to your leniency, and will pass on to the fulfilment of my
office as best I can.
The selection of a subject of discourse is by no means
an easy task where the audience is as heterogeneous as
prevails upon the occasions of your annual meetings. A
physician can always speak to a company of physicians,
but when the laity enter he feels the restraint of his tech-
nical training.
Your orators have met the difficulty in many ways, so
that few questions of general yet professional interest have
been left untouched. Medical education has received the
most distinguished consideration, the advances in medical
knowledge have been ably presented, our history, ancient
and modern, has been unfolded, and the gifted Roosa,
casting the horoscope, has supplemented Lord Lytton by
differentiating for us our position with the “coming man.”
What, then, is left for me to-night? ‘The Preacher has
said, “ There is nothing new under the sun.” ‘The man
with an absolutely novel idea is a phenomenon not often
seen in history or literature. All of us are borrowers,
and it has been justly said that if ideas were refused recogni-
tion because something similar had been propounded be-
fore, there would be a pretty outlook for civilization.
Certainly there would be a depressing outlook for most
speakers were they not permitted to seize upon some topic
of general interest, and endeavor, by rearrangement, per-
haps by developing some fresh association, to offer some-
thing in return for your patient presence before him.
t Being the Anniversary Address before the New York Academy of
Medicine.
It is in the rôle, then, of one who presents a familiar
subject in a new association that I appear to-night.
I have stated that I would speak upon the relation of
our profession to some of the questions of the day. I
shall modify this and say “the question of the day.” No
less an authority than Professor Seelye has but recently
said, ‘‘ There is one question of our time toward which all
other questions, whether of nature, of man, or of God,
steadily tend. No one will be likely to dispute the affirma-
tion that the social question is, and is to be, the question
of our time.” In my own case the impression created
by this remark was fixed and intensified by the perusal of
a small volume called “ Our Country: Its Possible Future
and its Present Crisis.” The broader bearings of social |
questions had been too far removed from the busy routine
of my daily life for me to give more than a passing notice
to it, and had it not been that I saw certain phases of the
question which were touched somewhat nearly by us my
interest in it would have remained general.
- Believing, then, that we have something more than a
general interest, I propose to ask your indulgence while I
endeavor to trace the relation of medicine to this social
question.
We should be encouraged to this inquiry by the wide-
spread interest which it is evoking. One of the surest
evidences of the truth of this assertion is to be found in
the frequent and able discussions and dissertations upon
it in the current literature of the day. Politics is making
of it a factor in government, and the Church, conscious
of the moral aspects of the question, is fast awaking to
the necessity of an active censorial position on its part.
The social question may be defined as an inquiry into
the status of the orders of civilized people, and their
relations one to the other in the economic arrangements
of the social system. The recent growth of the inquiry is
due to the conviction that the relations are becoming
dangerously abnormal through the action of preventable
causes. ‘These causes are being gradually defined and
remedies are being sought for by many of the best minds
of the day.
As is to be expected in such a question, there exist
wide differences of opinion. But upon one point all appear
to agree, namely, that discontent with the present arrange-
ment and relation is wide-spread, and that this discontent
is assuming the nature and proportion of a defined class.
question upon which the two great orders of present
society are arraying themselves, the one in opposition to
the other.
The question assumes phases which differ somewhat in
different countries according to the kind of government
which prevails, and, as enunciated by the class in whose
interest it was first raised, is called “Socialism.” Itis the
belief of many, and history seems to confirm it, that in
Sociaiism we but witness a continuance of that process by
which man as a whole is being ever lifted upward. Provi-
dence, ever careful of its products, seems to will it that
the classes into which man arrays himself shall never be
too far separated, and when this interval reaches certain
dimensions forces are set at work by which its component
parts are made to approach one to the other, always with
the result of lifting the mass upon a higher plane, the
most striking change being developed always in the con-
dition of the lower order, which is continually being level-
led upward. Examples of the process stand out in every
e :
To go back no further than nineteen hundred years, we
674
find a movement beginning in an obscure village of Palestine
which, extending itself over the lower classes, dominated
the Roman empire, and subdued every conqueror who suc-
cessfully overran the realm. ‘The underlying principle
was betterment of the lower order, and in that far-reach-
ing agitation it is not difficult to discover the greatest
step in social evolution recorded in history. |
We see it again in the Reformation, and its latest im-
print stands before us in the tragedy of the French Revo-
lution.
“Socialism,” however, was scarcely a formulated creed
until about the beginning of this century. The stimulus
derived from the French Revolution initiated it, and this,
together with the growth of the democratic idea of
government as witnessed in this country, may be said to
have developed it. Realizing that little could be accom-
plished save through political power, its first aim has been
toward securing the ballot. Its history so far has been
largely made up of successful efforts to that end, so that
to-day in most civilized countries political power in great-
er or less extent is practically conceded it. In this coun-
try we see the highest development of its political effort,
and there can be no question that, conscious of its
power, it is making ready to advance toward the end and
` aim of its existence. To-day it practically stands organ-
ized for self-protection ; its next step will be one of ag-
gression.
“Socialism,” then, is the expression of the lower orders
of their discontent with the conditions of their life, and is
the formulation of its ideas and purposes as to the rem-
edy. It draws the line with sufficient clearness between
itself and its opponent, so that no one need be ignorant
of its purposes.
The question at issue is being gradually narrowed to
that of property rights, the term property being made to
cover everything out of which the man meets his daily
wants, whether it be his money accumulations, his hands,
or his brain. It is interesting to note that while the suc-
cessful working of republican government in our country
stimulated toa tremendous degree the growth of Socialism
in Europe, yet Socialism has never until the present day
been able to assume a definite shape in our midst. Our
peculiar position has undoubtedly been responsible for
this immunity. The first aim of Socialism, political power,
was conceded by us at the outset, and as for the question
of “ property rights,” it could have no hearing.
In fact in this, a new country, such was the breadth of
resource, such the beneficent influence of soil and climate
and of government, that all the conditions securing con-
tent so far outstripped those of an opposite tendency, that
anything like general dissatisfaction in any one class of the
population was an impossibility. Profit and prosperity
being so easily in reach of all, the complaints of the mal-
contents were safely set down to laziness or viciousness.
A most curious condition of affairs has been evolved,
however, from what was apparently the most fortuitous
combination of human circumstances. ‘The fundamental
principle of our system was declared to be the freedom
and equality of man in the pursuit of any of the just pur-
poses of life. Our domain being large, and population
relatively sparse, immigration was successfully encouraged.
Ignorance being recognized as a threat to the State, educa-
tion was amply provided for and carefully fostered. Out
of these sprang that marvellous manifestation of human
force seen in American energy. Now the doctrine of
equality can mean but one thing, namely, the freedom of
all to compete for the prizes of life ; and certainly, here
with us, it has produced an amount of material advance-
ment such as the world never before witnessed. ‘The
pace at which we have moved has been indeed tremén-
dous, but while demonstrating some of the advantages of
freedom, it has come to develop a well-recognized law
of nature, the survival of the fittest. It begins to show
that to the strong literally belongs the victory. It is in-
teresting to note, too, that this seems to be the case in
both of the orders into which our society has been divided.
THE MEDICAL RECORD.
[December 21, 1889
Already combinations for the purpose of destroying free-
dom in competition are assuming shape in each. It is
only necessary to point to the restrictions upon imported
contract labor and those upon apprenticeship sought for
in one class, and the combinations to check production
and expenditure in the other. It would appear, then, that
the doctrine of human equality was being worked out
among us to a point which will demonstrate that it has
inevitable natural restrictions.
The suddenness with which this apparent failure of the
practical application of the doctrine has come upon us
is mainly due to.the abnormally rapid increase in our
population through immigration. For this increase has
been mainly in the order which has the least in the shape
of worldly possessions, and therefore feels most the press-
ure incident to its acquirement. |
Instead, therefore, of a limited discontent, which could
safely be put down to laziness and viciousness, we find
ourselves possessed of a rapidly spreading dissatisfaction
with the present state of our economic conditions, which
can be traced to the strain put upon man’s resources by
the free and active competition for what there is to be
had of profit and prosperity in a rapidly increasing popu-
lation. And this is not all. When you educate a man
you encourage him to institute comparisons ; he institutes
them, and when applied to himself content is not always
the result. One would suppose that the same education
which enables a man to institute and apply comparisons
would take him higher than mere discontent suggests.
This is true only so long as he feels that his natural
powers are equal to the demands of his situation. And
no matter under what conditions he lives, the moment
that his powers of comparison prove to him the in-
sufficiency of his natural forces in the struggle which
society lays upon him he will begin to agitate for a change
which will neutralize his disability, one, in fact, that will
admit of a wider applicatign of the doctrine of equality
than is contained in the laws of the system under which he
may live.
Here in America there is a fear that education may
not enable him to reconcile the incongruities which his
observation tells him exist between the facts of his daily
life and the assertion upon the equality of man contained
in that comer-stone of his Government, the “ Declaration
of Independence.” Such an one is apt to see in the
doctrine of the equality of man a panacea for economic
inequalities which he sees about him. And if they touch
him sorely a selfish interest will lend zest to his desire to
apply it to his betterment. But the essential point for
our purpose is that he is being continually told by those
who seek his vote that his Government was initiated and
constructed upon that idea, so that, whether there be wis-
dom in it or not, whenever the inequalities of his situa-
tion in the social or economic order press heavily upon
him he will contend for its application, the result of the
contention depending, of course, upon the strength and
the efficiency of his combinations. We have seen that
Socialism is a question of property right: the term prop-
erty being used to cover all that a man possesses with
which to meet the wants of his daily life, whether this be
his hands, his brain, or his surplus (that is, his invested or
hoarded money). ‘There are two ways fora man to better
his property condition. One is to get it from those who
have an excess above their necessities, by taking it by
force, either directly or else through law enacted to that
end. The other is to get it from those possessed of the
excess, by the exercise of superior mental or bodily skill
in untrammelled competition. But it must be remembered
that the holder of the surplus is possessed of three of the
elements of property as defined. And such is the prepon-
derating weight of surplus that it turns the scale in favor
of its possessor. It will be recalled by all of us that a war
but recently swept over this country which, in the aboli-
tion of slavery, emphasized the inalienable right of man to
the absolute and untrammelled possession of his own
hands and his own brain.
December 21, 1889]
These elements of property may then be put outside
the field of contention. ‘There remains but one other,
“ Surplus.” The Socialist, however, virtually argues that
the only property right inherent to man is his hands and
his brain, that surplus is a tyrant to be controlled, to be
directed to the general rather than to the individual good.
No one can say how he will do this, but that he will
attempt it is self evident.
Now surplus was never so clearly defined, so definitely
accentuated as the controlling force in man’s affairs as it
is today, the mass of men lying almost in grovelling
attitude before the golden calf. It would appear, then,
that the destiny of surplus was in its own hands.
Resolving surplus into its equivalent, namely, its posses-
sor and controller, the upper order, we see at once be-
tween what forces the issue is being formed. It is quite
evident that Socialism has no intention, for the present, of
permitting the question in open politics ; it looks rather as
if its purpose was to work parties toward its position by
using its combined vote in one or the other as it sees its
interest. Practically this constitutes with us, so far, its
political organization for its economic ends. It is fair to
assume that the question will ultimately reach a just
solution, but it is evident that there will be much friction
in the solution of its various phases. With us so far it
has been free in the main from the violent acts which
have attended its development in other countries, and many
think that, because of the nature of our institutions, this
freedom from disorder will be maintained. Others, on the
contrary, feel because of our very freedom from govern-
mental restraint that the question is almost as full of
explosives as was that which culminated in the French
Revolution ; for, like that, it is a class question entering
every household in the land. It may be nonsense to
compare the lower orders of this country with those of
France one hundred years ago, but it is as well to
remember that human aspiration was the life of that
movement, and human aspiration is certainly at the bot-
tom of its continuance in Socialism. Someone has said
that there is a popular faith among us that God takes
care of children, fools, and the United States. It begins
to look as if we might be thrown upon our own re-
sources. Fortunately we have been liberally supplied ; it
is only necessary to look to the proper employment of
our means.
It goes without saying that this question is nimani
one of statecraft.
the statesman.
But so was Christianity, so was Mohammedanism, and
if I mistake not there are excellent proofs of the influence
of medicine in propagating the one and in civilizing the
other. If you will turn to the delightful pages of Draper’s
“ Intellectual Development of Europe” some suggestive
facts will be found concerning the influence of the schools
of medicine in turning the Arab conqueror to ways of
peace and intellectual culture, and in another chapter will
be found statements full of food for our thought con-
cerning the propagation of Christian ideas through the
action of a certain Perabolani.
Your orator, John Watson, in his sketch of the “ History
of Medicine,” delivered here some years ago, told you of
the attitude of medicine in those days. How in the per-
son of the Perabolani it worked as an engine of Christian
propagation, and how in the person of its temples of
learning it stood upon the side of the pagan. How in
the contes: that finally witnessed the triumph of Christian-
ity we were rent in twain, our culture deposed, and our
ignorance installed as directing influence in our affairs.
For us, then, there is both warning and encouragement in
turning the pages of history. ‘he state must rest upon
the intelligence of its people for the wise solution of the
questions which vex it, especially upon the intelligence of
the leading orders of its society. Are we not one of them
and do we not stand out more prominently than ever
before as a recognized force in the social system of the
day? As we have borne no small part in great questions
It is grand politics, the province of
THE MEDICAL RECORD.
675
of the past, let us see that we be not blind to our mission
of the present.
In viewing this mission, let me again remind you that
the honest believer in “ Socialism” looks upon the fulfil-
ment of its essential principles as not only possible but
unavoidable ; for he regards it merely as a phase of that
evolution process through which man in his entirety is
being carried ever onward to the more perfect state of
existence. And yet we cannot shut our eyes to the fact
that this is far from the position assigned it by the in-
terest against which “ Socialism” must operate, if it act
at all; and it is easily seen, whether it prevail or not,
that from this difference dangerous friction must result.
Certainly, it becomes us to inquire if this friction may not
be lessened at some points through our efforts.
The content of a people is dependent upon their physi-
cal well-being, the first essential being a healthful life.
The conditions n are at the command of the one
order, so that they have but themselves to blame if it is
not allowed. But how is it with that other which is forc-
ing the social question to the front? Is there another
element in any civilized land, but especially in this, which
is better placed than ours to properly answer this ques-
tion? As I look over this audience I venture to say my
eye falls upon a body which, through its members, touches
every class. Yes, every person in this community. And
this community, what is it? Is it not the exponent, do
we not find in it the very essence of that question of so-
cialism which is beginning to press so hard upon us? In
this seething mass of humanity, with its pleasures on the
one hand, its sufferings on the other, its aspirations here,
its lost hopes there, we have a very epitome of the whole
human race. And as we pass from home to home, from
tenement to tenement, do we find the conditions of health-
ful life present or even possible with the majority of our
population? It has been said that our profession is the
buffer between the colliding forces of society ; and we are
so because as individuals we hold more of their confidence
than any other class. Are we doing our duty in this posi-
tion ? if not, in what are we failing? Gentlemen, there is
a woful ignorance, perhaps a woful blindness on the
part of the mass of the high order to the physical condi-
tion of the lower, and it comes from the fact that they
are too busy with their own affairs to trouble themselves
about the matter. They will give their money lavishly,
provided they are not called upon to give their time.
But this problem requires attention as well as money,
thought as well as prayer. I take it that in this matter
our mission is from the higher order to the lower, from
the lower to the higher. How many people in this town
really know what are the conditions of healthful life ?
They have a general idea, but genera] ideas are not work-
ing formulz. We need working formule. ‘The public,
both orders, must be taught that much of the discontent
lies in the absence of the conditions of healthful life.
And then they must be taught to know those conditions,
to study those conditions with a view to their introduction
and their acceptance. I say acceptance, because it is well
to remember that it is as difficult to get the ignorant to
apply to himself the laws of physiological science as it is
the laws of theological science. In all this it is recog-
nized that theories must vanish, and what is done must be
done in accordance with the accepted rules of economy
in business pursuits, simply staring with a just interpreta-
tion of that law of healthful existence which applies to
the condition to be corrected. ‘This isas far in the direc-
tion of specification as my time will permit to-night. But,
after all, we are here this evening to inquire more as to
the relation of medicine to a general question, than its
specific application to any one part of it.’ This is the
harder task, but the first step toward it is to ask about it.
But will the public heed us? That, gentlemen, depends
upon our attitude in the matter. We must drop our ex-
'Dr. H. D. Chapin: * Preventable Causes of Poverty,”
June, 1889. Alfred H. Peters: ‘‘ The Extinction of Leisure,”
August, 1889.
Forum,
foid.,
676
ee | er ie eee ner ee ae i Á
clusiveness, and nasi once for all that. we only
need speak in plain terms, that plain people can compre-
hend, upon the practical application of our facts, not our
theories. Our facts are plentiful enough, as you well
know. In the present social order we appear as teacher,
as practitioner. As practitioner, as minister to his ail-
ments, man has always accepted us, but as teacher he has
been less receptive. Man always exacted of usmore than
we could give, namely, eternal life. And failing to get
this, he easily became sceptical as to whether we could
tell him anything at all about life. Having but a surface
knowledge of nature, supernaturalism became his main-
stay, remaining his prop until within the days of our own
knowledge. And yet while he asked of us the elixir of
eternal life, he fatled to furnish us the educational condi-
tions essential to a knowledge of the Jaws which govern
even the short life nature assigned him. ‘This perhaps
was natural, recognizing as he did that he was to be the
material out of which we were to carve our science.
Seeking our material as best we could, as nature’s dis-
ciples, we were often brought to antagonize some of man’s
most sacred instincts, bringing upon us his suspicions and
his wrath. ‘Thus a habit of reticence concerning what we
did know has grown upon us, which perhaps may not be
misnamed exclusiveness. But the necessity for reticence
which so long hampered us is fast disappearing, the con-
ditions essential to our progress are more generally recog-
nized and conceded, and this, together with the decline
in the faulty application of supernaturalism, is rapidly
changing for the better the situation heretofore existing
between our body and the public. We owe our emancipa-
tion to the strides made by the collateral sciences, but
more particularly to biological and anthropological re-
search ; for, after all, ours is but a subdivision of the science
of anthropology. Man’s curiosity concerning the laws of
other life has at last fully possessed him with the desire to
know something, yes, all of those that pertain to himself.
Quick to avail himself of everything that nature’s law
could contribute to his pecuniary profit, he is awaking to
the fact that that profit can be easiest gained and fullest
enjoyed by him who best fulfils in himself the law which
nature gave him to live by. And with the dropping of
the scales he now begins to see that as the spiritual per-
fection can only be reached by seeking for, by finding, and
by following God’s moral law, so physical perfection can
only be had by seeking for, by finding, and by following
that law which his God has given him to live by when he
enters into the land to possess it.
If ever there was an age in which knowledge of the
laws of life, of health, and of death were more universally
sought for than is this history fails to record it ; for ed-
ucation and competitive life have brought the civilized
world to our door, so that it may truthfully be said we
stand upon the threshold of the golden age of medicine.
It is indeed our opportunity, and if we fail to grasp the
occasion it will be the fault of just such representative
bodies as I have the honor to address to-night. It is as
the teacher, then, that I will speak to you. You meet to-
gether here from time to time to consider many questions,
but there is a wonderful sameness about them all. ‘They
relate to the peculiarities of this or that disease, the use-
fulness of this or that remedy ; occasionally a question of
ethics frets you, and now and then you vex yourselves
about the question of education for medical men. Do
you ever much trouble yourselves about the medical edu-
cation of the great public? Perhaps you think you do
this through the medium of your members, and that pro-
viding for their equipment your duty ends. Ah! be-
lieve me, Academicians, when I say that useful as this office
is, it falls far short of a fulfilment of your mission.
Let us take a broader view of our mission than is in
volved in these processes of mere self-instruction. Let us
shaké off the exclusiveness of our teachings, and, taking
the public more into our confidence, speak directly to it
of those laws of hfe and health which are each day be-
coming so necessary to it in its present emergency, and
THE MEDICAL RECORD.
[December 21, 1889
—_
which they are eager to receive from us as its recognized
expounders.
Drive home to him whose property right is represented
by his brain, by his muscle, that his body is his capital
out of which his profit must come, and if he consume all
of profit he gets from year to year, it is the more impor-
tant in the economics of his life that he keep his body in
the best working order. He hears of chance, of luck ; bring
it home to him that the luck he loses 1s lost because of
physical defects engendered in his heredity, in the hygienic
defects of his daily habits; and put it hard upon him
that in the failure of to-day he but sees the paralyzing in-
fluence of some infraction of the laws of health yesterday,
and that in the conduct of his life to meet his daily wants
—in health as in morals—he must accept the dictum, “ As
we sow so must we reap.”
The moralist teaches that retribution follows the in-
fraction of God’s law. We cgn demonstrate it; he cannot,
save through us. Go then to Surplus, present it your
facts and show it how to turn its thought, its action, to ’
the correction of those evils which in its system press so
hard upon the physical condition of those outside itself.
Show that with a large part of the brain and muscle of
this land, especially of this city, such is its poverty it is
almost impossible to secure to itself many of the common-
est essentials of healthful life.
Show it, prove it, as you surely can, that from this con-
dition springs that inefficiency, that mental and physical
deterioration, that lazines:, that viciousness which con-
stitute the blight upon its social system. Lay plainly be-
fore it the inevitable reaction of such states of human ex-
istence, and in doing it, do it wisely, to the end that we
may say, We have met to the fullest the duty which, in the
process of social evolution, was laid upon our shoulders,
for in answer to the mandate of that first law of nature,
we have taught you the way to “ self-preservation.”
Thus, starting from the basis of those laws for which we
stand, let us unfold to man not only his duty toward his
neighbor, his duty toward his God, but his duty toward
that temple of God which was created when he was born
into this world.
CONSERVATISM IN GYNECOLOGY AND OB
° STETRICS.’
By MALCOLM MCcLEAN, M.D.,
VISITING GYNECOLOGIST, RANDALL'S ISLAND HOSPITAL ; SURGFON-IN-CRARGE OF
ST. ANDRKW’S INFIKMARY FOR WOMEN, NEW YORK.
In the midst of the enthusiasm incident to an unprece-
dented progress made in our profession it is no easy mat-
ter to maintain an attitude which shall shield us from the
imputation of being on the one hand too radical and on
the other too conservative.
Recognizing this difficulty, it is , with considerable hesi-
tation that your reader has essayed to set down any sug-
gestions which are intended to define between extreme
and active interference and cowardly or dangerous inac-
tivity.
Practitioners in obstetrics and gynecology seem to be
divided into three classes: First, those who are ever active
to interfere surgically, mechanically, apparently assum-
ing that the ws medicatrix nature exists only in the minds
of a few unenlightened individuals who are too slow to
appreciate the necessity of bold surgical procedures,
and who are not capable of grasping the problems of ad-
vancing science. Second, those who, having learned to be
passive, depend alone, almost, upon natural changes to
effect a cure, who are obstructive to every innovation,
who only see virtue in the ways they first walked in—these
constitute a large class who would have their profession
at a stand-still from decade to decade.
‘There must be recognized, however, a third class, who
calmly weigh the merits of each advanced theory or achieve-
raent, putting eagerly into practice that which seems to be
1 Read at the meeting of the Medical Society of the County of New
York, November 25, 1885.
December 21, 1889]
good and condemning that which proves to be worthless ;
who are ready to recognize the true worth of any method
of treatment which brings with it more light and more re-
lief, but who resist temptation to follow blindly in the cur-
rent of anew excitement simply because great numbers are
swayed by conspicuous examples of great surgical achieve-
ments. ‘These are they who must act as balance-wheels to
the profession, who must limit the enthusiasm of the zealots
whose ambitious desires lead them into a fever for “ rec-
ords” rather than to a firm determination to succeed by
a careful, conscientious discrimination in favor of the
confiding patients. I fear that too few of us, alas! belong
to this third class. |
On the one hand we see the records of countless ex-
ploits with the laparotomist’s knife, and we are easily
persuaded that, to be modern, we must be bold and dex-
terous. We must not fall behind in records, if we do in
the aggregate number of our cases. A little reading, a
little breathing of the laparotomist’s atmosphere, whether
it be in the operating-room or in the halls of scientific soci-
eties, and we are converts to the new faith and boldly enter
in. A few short months roll on and we are ready with our
“ years record in laparotomy.” With pride we point
to our scores of successful cases, and we feel convinced
that we have at last struck the panacea for most of
woman’s ills. We become more and more impatient with
treatment which entails slow-and tedious measures, and
too often we forget that cases have been cured by other
means than the knife, and that our patients have a right
to the benefit of the every doubt.
But another danger confronts us in our experience,
which must by no means be overlooked. ‘Trusting to the
good fortune of many cases working out their own salva-
tion, we allure ourselves into paths of inaction, of half-
hearted belief, of trifling and superficial estimation of
the duties before us, and in the falsely assumed guise of
conservatism we fail to act when everything declares that
delay is dangerous. ‘Those of us who fall into such ways
are as full of danger to our patients as are those who
plunge recklessly into more active measures.
Such practitioners crowd our ranks with incompetency
and stupidity, and see no good in the advances of a
newer generation. It iş not necessary to portray more
minutely that pitiable company—they are to be found
everywhere, in city as well as in country, and if they can-
not be converted they are to be avoided.
But I feel that special attention and consideration
should be given to the new generation of extremists who
are filling our profession with their doctrines of radical
operative interference in the majority of severe cases
which come under the eye of the gynecologist.
_ When Mr. Tait had his first followers in this country
It was at once suggested that this new path of surgery
would be, perhaps, crowded tc a hurtful extent. One of
the first, if not the first in this part of the world, to test
the operation known as Tait’s, while showing his specimens
of extirpated tubes, remarked: “I am not yet prepared
to give the operation the broad application given to it by
Mr. Tait, but that it has a future I feel assured.”
Possessed of rare skill and unsurpassed courage, that
distinguished operator has, I believe, still the conviction
that a too general application is being made of a radical
operation which should only be called for when.all other
treatment is known to be of no avail. But the mass of the
younger gynecologists—impetuous, ambitious, ‘‘ one-
ideaed ”"—seem bent on bringing great numbers beneath
the laparotomist’s knife, without anything more than a
rudimentary experience, at most, in the use of treatment
which does not necessarily involve a mutilating operation.
Men whose opportunities, on account of age, location,
or other environment, have been necessarily limited so far
as practical experience in medicine is concerned, are will-
Ing to believe themselves capable of judging fairly of the
conditions demanding an operation which not only ex-
poses life to great peril but, at best, mutilates and
deprives woman of an essential part of her organism.
THE MEDICAL RECORD.
677
The best surgery, whether it be abdominal or general, is
more likely to be done by one whose mature judgment
has calmly weighed a% the evidence in a given case than
by one whose predilections stand in the place of knowl-
edge and experience, and impel him to fit the case to his
treatment, instead of adapting his treatment to the require-
ments of his case.
It would appear as though there are various influences
which lead so many, in this day, to drift into the fascina-
tions of radical operations, some of which I have already
hinted at. Two special influences of different moral tone
certainly play an important part in the determination even
of the more skilled and experienced operators.
First, the influence upon the mu of seeing path-
ological conditions of the internal organs. Specimens of
“ cystic ovaries,” of enlarged tubes, etc., appeal to the
senses in such a vivid manner that we are easily—too
easily, I fear—convinced that nothing but extirpation of
such tissues can ever effect a cure. And right here we
doubtless make serious error. Because we can extirpate
an ovary with more or less macroscopical change appar-
ent, or a tube with fluid in it,®it is not necessarily . true
that such appearances, even though they be pathological
(which is not always the fact), are evidences of hope-
less structural change, and hence demand their extirpa-
tion. 7
This point I wish to insist upon sufficiently to make it
emphatic, as I am well convinced that the frequent
handling of and seeing these organs in the conditions
described has much, far too much, to do with the decis-
ions of surgeons in these matters. Imagine, if you please,
the appearance of an inflamed pulmonic lobe—or other
organ removed and presented as a “specimen” at our
surgical societies. If the same logic were used in refer-
ence to these other organs as we find proposed in connec-
tion with the disease of the tubes and ovaries we should
have to consider it. necessary for a cure to perform a
surgical operation for their removal. Moreover, ovaries
that are “ cystic” or “slightly cystic ” are frequently con-
demned because they have unfortunately been caught in
the act of ovulation, a physiological process be it observed.
Who ever saw a properly developed ovary without cysts or
vesicles in it? What has become of the Graafian vesicle ?
By what new route is it discovered that nature extrudes an
ovule? Yet, if one will take the pains to look over vast
numbers of histories, given in the operator’s own words, he
will observe that the ovary removed was “ slightly cystic”
and hence had to perish.
It is only a fraction of a century past since tonsils were,
almost without consideration, condemned to instant ex-
tirpation. Yet after a while it occurred to some thinking
men that it was probably carried too far, and then the
operation of tonsillotomy took its proper place in surgical
practice.
The testicle and its essential adnexa are not infre-
quently the seat of violent organic changes, and I doubt
not, if we could muster up courage enough to procure
such an organ by extirpation for a pathological specimen
at our scientific assemblies, we might convince many that
such a frightful condition of things demanded nothing
less than their removal for a cure. Such a specimen, with
its quadrupled size, its muco-purulent infiltration, its
enlarged tubes with blood or pus, would, we must grant,
create as vivid a picture to the average mind as do those
formidable cystic ovaries with catarrhal, serum, or pus-
containing tubes of the feebler sex. Would the man be
ridiculed or accounted behind the march of his peers
who should venture the suggestion that that testis and its
vessels would regain its integrity if treated conservatively,
if allowed to stay in the body subject to nature’s restora-
tive forces ?
The other special influence which damages the operator
and his patients is the rage for “ statistics.” When a sur-
geon once gets the “ record ” fever his brain is excited by
something less than science and much less than wisdom.
Take for example a given case. An operator is rapidly
+
678
THE MEDICAL RECORD.
[December 21, 1889
swelling his list of “ successful cases of laparotomy ”—his
first fifty or his first hundred may be almost but not quite
complete. A case of violent dysmenorrheea, “ ovarian neu-
ralgia,” or other neurosis presents itself. Think you he—
or, indeed, the expert of the gentler sex—will risk the un-
certainties and tediousness of general or conservative local
treatment ? Not fora week! ‘The historical verdict reads:
“ An operation was immediately proposed and consented
to. Operation performed May, 188-. Right tube ca-
tarrhal, both ovaries slightly cystic. Removed. ‘Iem-
perature never rose above 99° F. Recovery uninter-
rupted.” Behold! the fifty, the hundred cases are now on
record, and “a year’s record in laparotomy ” is brilliantly
completed ! `
Are we drawing the picture too coarsely—are we
weakening our argument by erratic hyperbole or by ex-
aggeration? We ask you to read in the public medicine
journals for yourself and see if such records may not
be found.
This latter element I consider a most dangerous one to
enter into the judgment of a surgeon’s duty. It is to ex-
pect too much of human‘hature to suppose that we will
not be biassed in our judgment by a desire to enlarge our
list of brilliant deeds when numbers of operations become
an incentive to emulation.
We have had so many reports, both verbal and in print,
of these cases of late that it is only necessary to refer to
one or two which represent fairly the work which this
paper is in part intended to criticise. Within the past
year we nave been regaled by the report of one hundred
and forty-four successful cases of abdominal section in
a small West Virginia town within less than two years.
Unless the operator had already become a veritable
celebrity throughout that section of the country it would
need no comment further than to denuunce a course
which must have been radical to a dangerous degree to
have enabled him to have found it necessary to mutilate
so vast a proportion of his unfortunate patients. But for
fear that injustice may be done, and that this operator may
have so vast a field as to make the proportion of abdom-
inal sections to his gynecological practice much less than
it seems to be, let us take a sample or two from his pub-
lished records and consider their merits.
Case XI.—“ Mrs. M. D—, married ten years ; aged
thirty-nine. Aborted two years after marriage, and states
she was never well after this accident. Menses always
lasted eight or nine days, and were so profuse that she was
compelled to remain in bed for a week at least, after their
cessation, to recuperate from the resulting exhaustion.
Operation November 7, 1887, assisted by Drs. ‘Thomas
and Zerkle. Found both tubes occluded and adherent.
Ovanies cystic.”
“Case XVI.—Mrs. F. W. C——, aged thirty-six. Moth-
er of two children. Two years since birth of last child,
from which time illness dates. Severe menstrual pain.
Locomotion difficult. Functional disturbances of the
nervous system very prominent. Bilateral laceration of
the cervix uteri. Both ovaries tender to the touch. Dif-
fused pain and soreness over lower portion of abdomen.
Operated on cervix April 14th, and on May 8, 1888, re-
moved both ovaries and tubes. Left ovary contained
half ounce of serum. Right ovary filled with blood and
serum. Patient made rapid recovery.”
“Case XIX.—Mrs. R. A. U , aged twenty. Mar-
ried nine months. Always suffered from more or less
dysmenorrhcea and leucorrhoea. Constant uneasiness over
the ovarian regions. Operation July 3, 1888, assisted by
Dr. ‘Thomas. Ovaries cystic and considerably enlarged.
‘Tubes in a catarrhal condition.”
“Case XX.—Mrs. M. A. L——, aged thirty-two.
Always suffered more or less from dysmenorrhcea. Moth-
er of two children. Dates her illness from an abortion
two years ago. Pain of a ‘dragging’ character, nearly
constant, over both ovaries. Uterus found to be immov-
ably fixed in a retroverted position. Tubes enlarged and
ovaries prolapsed. Operation July 3, 1888. Ovaries
and tubes removed. Ovaries cystic and tubes distended
with serum and slightly adherent.”
“ Case XXII.—Mrs. Julia M——, aged thirty; mother
of three children. Suffers from severe pains in both ihac
regions. Nutrition badly impaired. Uterus displaced
backward and fixed. Operation July 7, 1888. Both
ovaries cystic and tubes distended by serum.”
“ Case XXIII.—Mrs. C. E. W——, aged twenty-seven ;
mother of two children. Has been an invalid for two
years. Great suffering from dysmenorrhea. Found
both ovaries enlarged and very sensitive to touch. Oper-
ation July 10, 1888.” l
“Case XXV.—Miss A. O—, aged twenty-three.
Has been an invalid for several years. Severe dysmenor-
rhoea, and intense pain in back. Operation September 4,
1888. Both ovaries enlarged and cystic.”
“Case XXVII. .Miss D.R. T—, aged twenty-three.
Menstrual period lasts ten days. Has never suffered any
pain, but the flow is profuse and the resulting exhaustion
so great that she is ob}iged to remain in bed the greater
part of every month. Operation September 6, 1388.
Found both ovaries greatly enlarged, very soft and
spongy.”
These cases are sufficient to show that in one portion of
our country, at least, abdominal section is resorted to with
reckless frequency. What man is able to say that one of
these cases would have resisted all other faithful treat-
ment? If such cases require laparotomy, then at least
four-fifths of our female patients are fit subjects for castra-
tion. But these instances only stand to represent the
work of great numbers of operators, in city and country,
who are endeavoring. apparently, to simplify their rules
of practice by condemning the majority of troublesome
cases to abdominal section.
Our scientific discussions are rendered tediously monot-
onous, if not ridiculous, by the rapid drift of debate into
the delectable field of laparotomy and “tube” lore. But
some man will say, all of this, or most of this moralizing
is superfluous, for we believe all of this, or most of it, but
it is a picture drawn from an extreme view of the practice
of gynecologists. It does not fairly represent the facts as
they concern the truly skilful man, but applies rather to
those untempered imitators of men who are more fully
qualified to judge when these operations to which we have
referred should be performed. To this let us say, this
paper ventures to remind the teachers in this department
that to their one sided radical way of dealing with a great
proportion of pelvic diseases we may point as the guiding
principle in the minds of the lesser hghts of the profes-
sion. We will go further and aver that the teachers—the
leaders themselves—so frequently assert their extreme
dogmas that at length they believe thoroughly in them
themselves, and put into practice theories which were in
their minds once only theories, and doubtful ones at that.
In obstetrics, perhaps to a less degree, there exists the
same spirit of non-conservatism. Many obstetricians seem
more absorbed in the questions of the relative value of a
Porro operation and a Cesarean section than they do in
the consideration of the best means to avoid the necessity
for any such procedure.
It is safe to say that there are hundreds of women
marred and many killed every year because of the lack
of a reasonable amount of skill being shown to detect a
malposition of the foetal head. ‘Thousands of dangerous
forceps operations are done by men incapable of making
approximate diagnoses.
Version is only resorted to after tissues have been lacer-
ated and bruised by long forceps in the hands of several
equally dangerous men. And then, if perchance it is dis-
covered that a uterus is ruptured and two lives have been
lost, version is ignorantly accused of having done the
frightful deed. I have known at least two cases of
craniotomy and one of Cesarean section in multipare
who had previously borne large children normally, and
these formidable operations were done because a true
conservative treatment had been ignored.
December 21, 1889]
In our obstetric societies in this day how much discus-
sior do we hear of the numerous forms of dystocia out-
side of those cases in which abdominal section may play
apart? Are we not drifting away from good doctrines
in our enthusiasm for surgical feats of uncommon skill ?
Having thus in a somewhat cursory manner found fault
with a strong indication of recklessness in our ranks, let
us simply assert that a vast number of cases of pelvic dis-
ease would be conducted to a safe termination in cure,
by a patient application of reasonable conservative treat-
sar which are being given up to the laparotomist’s
nife.
Enlarged tubes, if not enlarged ovaries, zs// resolve and
empty themselves of serum, blood, and even pus. “ Cys-
tic ovaries ” which contain cysts only of the Graafian fol-
licular variety zg:/7 continue to perform a healthy function
if allowed to live. Š
Pelvic inflammations will disappear in a large number
of cases without the knife applied through the peritoneum..
Tender ovaries, adherent uteri, will regain their physio-
logical functions in many instances; and childbearing will
be possible in cases that are all too commonly condemned
to mutilation. These and many other most important
facts should be so firmly impressed upon our minds that
we may be able not only to give our patients a fair oppor-
tunity to escape a dreadful mutilation, but also to discuss
with candor the value of other modes of treatment which
may suggest themselves.
To the inexperienced it is our bounden duty to sound a
note of warning—to first learn to diagnose and treat the
conditions of disease in the pelvis of woman in a thorough,
scientific, and patient manner before he presumes to
pass judgment on organs with which he has so slight ac-
quaintance.
To show by a single example the baneful force of a one-
sided view of surgical matters of vital importance, we
have only to refer to a recent meeting of eminent obste-
triclans and gynecologists from various nations assembled
in this hall. The subject of extra-uterine pregnancy was
under discussion, and Professor, Martin, of Berlin, whose
opinions are justly held in high estimation, asserted that
it was his universal practice to perform laparotomy in
every case ; and notwithstanding the unparalleled records
of the American method of treatment by electricity, not
a voice of dissent was raised, I believe, in all that assem-
bly. Certainly no adequate ‘rebuke to such a wholesale
dismissal of our claims for electricity was offered. And
who can tell the far-reaching influence of such teaching ?
Shortly after, a ‘‘ primary operation ” case of extra-uterine
pregnancy was presented by one of our number, and with
loud denunciations he spurned as tnflers and ignoramuses
‘those who presumed to claim that electricity ought to
have even a trial on its merits.
A few cases may be of service in illustrating the changes .
that may occur in some of the cunditions we have touched
upon, and they have been selected’ from a long list ex-
tending over a period of ten years.
Case I. Cystic Ovary.—Mrs. V——, aged twenty-six,
nullipara, had been married two years, never pregnant.
Suffered several years with severe dysmenorrhcea, sacral-
gia, headaches, etc., with fixed pains occasionally in left
groin. Was treated by a female gynecologist for several
months ; and at a consultation with an eminent practi-
tioner in that department it was decided that a displaced,
enlarged, and tender left ovary should be removed by
laparotomy. There was also a retroflexed uterus without
adhesions. The patient refused to submit to operation
and was subsequently examined by me. I found the con-
ditions above described, and put her through a course of
tamponing with boric glycerine for six months, the appli-
cations being made once or twice a week in the inter-
menstrual periods. Afterward a good-sized Albert Smith
pessary was tolerated and the patient became pregnant,
went to full term, and was delivered of a healthy child.
Three months afterward I examined her, and found the
- Ovary as large as ever, not so tender, but in the same
THE MEDICAL RECORD.
679
low posterior position. She has never had any symptoms
of discomfort, even, since.
Case II. Pyosalpinx.—Mrs. R——, aged twenty-five,
I-para, no miscarriage. Had excellent health until after
birth of her child, which was seven months old. She had
slow convalescence from a tedious labor, being unable to
get about without great pain for four or five weeks after
confinement. She is said to have had continuous fever
during that time. When she did get up she had great
pain in the back, severe dragging pains in the groins, and
a purulent vaginal discharge.
When she came to me the uterus was still enlarged and
sharply retroflexed, and exceedingly tender. On each side
of the uterus could be felt the outlines, distinctly marked,
of sausage-shaped fluctuating tumors which were very ten-
der. These were continuous with bands of adhesion bind-
ing the uterus in its vicious position in the hollow of the
sacrum.
Notifying the patient that she should hold herself in
readiness to submit to a serious operation if symptoms in-
creased, I very cautiously instituted a very mild course of
galvanism, followed by the glycerine and iodine tampons.
From the cervix there flowed a stream of pus. After six
weeks of patient work the tubes emptied themselves, the
adhesions became less tender, and allowed the uterus to
be partly reposited. At this time, seven months after the
suspension of treatment, the patient reports herself as
“ perfectly well,” and her appearance justifies the state-
ment.
Case III. Pyosalpinx.—Mrs. H. S——, aged twenty-
eight, 2-para, no miscarriage. Last child five months
old. Delivered with instruments. Perinzum hadly lac
erated. Had bad getting up after both confinements, the
last leaving her extremely weak and unable to walk with-
out agony. Did not nurse the child. She.wassent to me
from a distant city and I placed her in my private hos-
pital for treatment. She was just finishing a painless or
almost painless menstruation when she was seized with
rigors, rapid elevation of temperature—104.5° F.—and
great pain in the right groin and hypogastric region.
Examination showed a perinzum torn to the rectal
sphincter and with jagged, suppurating edges, the vaginal
wounds being deep and pouring out pus. The cervix was
torn slightly, but a stream of greenish-brown pus poured
from the cavity of the uterus, which was fixed by adhe-
sions in a retroflexed position. ‘The whole vaginal vault
was exquisitely sensitive, and the region of the right broad
ligament, and posteriorly to the nght of the uterus, was a
large distinct mass which was exceedingly painful. For
some days the patient’s life was despaired of, so severely
prostrated was she. I was urged by eminent counsel to
operate later on for the removal of the tubes and ovaries,
but owing to the patient’s dread and my own doubts as to
the absolute necessity of the operation the case was sim-
ply treated with iodine, hot douching later, and general
tonic regimen. Within two months—a normal menstrual
period having passed without disaster, and the pelvic roof
showing improvement—she was etherized and the pern-
num repaired. Her recovery was good, and at my re-
quest she has presented herself for examination within a
few days past.
In reply to my questions she states that her health is
“ better than it has been in five years,” that she has posi-
tively no pain nor tenderness. On examining the pelvic
organs I find the uterus partly retroflexed and partly fixed,
the tubal swelling and other evidences of exudation are
entirely obliterated, except a suspicion of a tense cord in
the position of the pyosalpinx diagnosticated six months -
ago.
Cage IV. Ruptured Uterus.—Tifs was a case. of rupt-
ure of the uterus, occurring during the second stage of
normal labor, and has been reported in full in a previous
paper. I only allude to it here to show that the treatment
was rationally conservative, and saved the patient, whereas
laparotomy is recommended in such cases without ques-
tion. This woman had a rupture of the uterus at its right
680
THE MEDICAL RECORD.
[December 21, 1889
anterior upper segment, which allowed the body, legs, and
one arm of the child to escape from the cavity of the
uterus. All of the symptoms of the catastrophe were
present. I introduced a clean hand, and drew the escap-
ing child into the uterine cavity again, and turning it, de-
livered rapidly. The placenta and membranes being care-
fully removed, I examined the foetal envelopes and found
but one opening—that through which the child was deliv
ered—namely, the vaginal portion. At once recognizing
the evidence that the membranes above had formed a
hernial sac ahead of the child as it had been thrust through
the rent in the uterine muscle, I felt sure the peritoneum
had no amniotic nor other foetal substances poured into it,
and determined to give the case to nature to absorb the
clean blood which had escaped into the broad ligament
and elsewhere, to the amount of a pint. The patient re-
covered entirely, and I delivered her by version within
two years after the above related accident.
Case V. Pelvic Peritonitis ; Ovaritis ; Pyosalpinx (?) ;
Subsequent Pregnancy.—This case may be related in a few
words which will carry a forcible lesson. Mrs. L——, aged
twenty-four, nullipara ; good history. Shortly after mar-
riage she was taken sick with what she called “ inflamma-
tion of the bowels,” and after weeks of suffering in bed
she so far recovered as to apply for relief of her pelvic
pains and soreness at the office of a distinguished gynecol-
ogist of this city. He found her in a bad state, suffering
from a recent attack of pelvic peritonitis, with an enlarged
and exquisitely sensitive right Fallopian tube; and for
some reason—I believe because she refused to permit
laparotomy—he referred the case tome. On examining
her I found the pelvis filled with exudation, the uterus
fixed firmly in a retroflexed position, and the right ovary
and tube enlarged and very tender. I could not detect
any fluctuation. ‘This case had been repeatedly inflamed
until everything seemed massed together in one great cica-
trix.
Guided by an experience with such cases, I put her
through a most thorough course of douching with hot salt
water, iodine and glycerine tampons, etc. In one year
she became pregnant, and she was delivered, at term, by
my assistant, Dr. Tracy, after an unusually easy labor.
A good convalescence followed, and to-day the pelvis is
free from evidences of exudate.
These, with a variety of other cases of every degree of
severity, which I might weary you with, will serve to point
the moral that there is something else to be done for the
salvation of our cases than the grave operations which
open the abdominal cavity. But I would feel that this
paper had sadly miscarried should it be interpreted to
teach that active interference is to be put aside in all
cases. Let no man impute to the reader any uncertain
sound, any cowardly inaction. There is a time to act,
and then to act promptly and thoroughly. There is a
time to stand by and guard the patient against mischiev-
ous meddling, to wait patiently for results which will
come to the rescue ; and in so doing it is as much to our
credit as is the most intricate surgical achievement. A
general surgeon may display uncommon skill in the use of
the amputating-knife, but he is a better surgeon who
sri when to withold the knife and save the mangled
imb. :
He who is gifted with a skill to invade the great cavity
of the body, with dexterous fingers to detach and remove
offending tissues, is to be looked upon with reverence if
he abuse not his art. But on him rests a fearful respon-
sibility which he must ever bear—a responsibility to his
patients, and to those, in less degree perhaps, of every
practitioner who sees his skill or who reads of it in the
journals of our profeSgion. Let him see to it, then, that
no sordid motive urge him to advocate or put into prac-
tice an operation which is not demanded by the best in-
terests of his patient. And on the other hand, let no man
stand, through bigotry or ignorance, in the way of prompt
and efficient measures, no matter what they be, so long as
they be nght and just, and in demand. Conservatism is
not cowardice, is not clumsy inaction, any more than it is
reckless impetuosity. |
Would it not be better for our post-graduate schools,
our scientific societies, and our representative gynecolo-
gists, to lay greater stress on the skilled use of the instru-
ments demanded in minor surgical gynecology; on the
proper observation of the general rules of treatment, of
antiseptic details, and of careful diagnosis, than to fill the
minds of the growing brethren in the profession with ideas
which tend to a strong bias in favor of a dangerous and
often harmful operation.
How many men are expert in the details of a thorough
pelvic examination? How many are there who are
strictly guarded as regards septic infection of their pa-
tients? If it can be shown that the vast majonty are
well-trained, conscientious workers in these commonplace
details, then will we admit that they are ready to receive
their first lessons in abdominal surgery. But the expe-
rience of men who are brought in contact with these spe-
cial cases frequently goes to show that there are men
who will rise up in our societies and argue for the inevi-
table demands of laparotomy, etc., whose awkwardness
in the use of the Sims speculum even would be apparent
to all of us.
As a sign of the times I would like to relate the expe-
rience of a gynecologist to one of our hospitals within the
past year. He had succeeded, in the rotation of service,
a gentleman of growing reputation as a laparotomnst,
and found the service pretty well given up to cases of ab-
dominal section. His attempt to awaken the interest of
the House Staff in the minor operations, perineorrhaphy,
trachelorrhaphy, in cystic inflammations and the like, was
a signal failure, the staff to a man being utterly indiffer-
ent to anything less than an extirpated ovary or tube.
And yet there was not a man on that staff possessed of the
requisite amount ot skill to introduce, without pain to the
patient, an ordinary speculum! Further comment is un-
necessary.
The rational use of antiseptics in all departments of
surgery have brought improvements which mark an era in
our art ; but this extension of our work has also brought
its evils.
Depending upon the protection given by clean surgery
we are emboldened to invade tissues with too much reck-
‘Jessness, and without sufficient warrant or deliberation.
Furthermore, it is well to bear in mind that a cure, or
even the improvement of a symptom, does not always
follow what is often designated as a successful operation.
A patient may, indeed, escape the immediate dangers
of the operation, but very often—more often than oper-
ators are willing to make note of—she is left in a state
which is worse than the first.
If the cases of abdominal section were fairly reported
upon one or two years after the successful operation we
might be less sanguine in following the example of the
great surgeon of Birniingham.
Ventral herniz, extensive and painful peritoneal adhe-
sions, fistula, and a suspicious increase of melancholia,
these are some of the fruits of laparotomies which have
been previously reported among the hundreds of success-
ful cases. But is there no field for this important surgi-
cal exploit? Is laparotomy only the hobby of enthusi-
asts? Certainly there is a field for this very successful
branch of surgery, but we wish it distinctly to be under-
stood that its field of real usefulness is /smted, and within
its proper limitation it is the only proper course to pur-
sue.
To push its application outside that limitation is to
abuse it, and to distort the clear judgment necessary for
a just consideration for the patient’s welfare.
Dr. Prince A. Morrow, of this city, is engaged in col
lecting statistics of all cases of leprosy in this city, and
asks medical] men to send him reports of any case or cases
under their observation.
December 21, 1889]
BASILAR KYPHOSIS: ITS RELATIONS TO
CERTAIN CEREBRAL DEFORMITIES.
By SARAH E. POST, M.D.,
NEW YORK.
By basilar kyphosis is meant a deformity of the skull ho-
mologous with kyphosis in the spine. l
Spinal kyphosis consists in an altered position of the
vertebræ, producing a dorsad angle in the place of a curve.
The angle of spinal kyphosis is formed by the spinous
process of the vertebra most prominent in its outline.
If, however, we should strip the offending vertebræ of
all their processes, if we should even remove the neural
arches altogether, we would still find the angle repre-
sented by the bodies of the vertebrz ; we would, in fact,
have it borne in upon our minds that the angle was
primarily induced by malposition of these bodies,
being merely accentuated by the neural arch and
the prucess carried upon it.
Such a resolution of the grosser appearances of
kyphosis is provided by nature in the configuration
of the skull. Here we have three primitive verte-
bree (Virchow), the bodies of which are represent-
ed by the base of the skull or os tribasilaire, com-
posed of the basilar process of the occipital bone,
the post-sphenoid, and the pre-sphenoid bones,
the neural arches being represented by the cranial
vault. Here there is no prominent spinous pro-
cess to attract attention to the deformity. ‘The
laminz, too, fail to follow the displacement and
to indicate its presence in any as yet significant
way. We say, as yet, because it is probable that
upon further study the vault of the cranium will
be found highly significant in these cases.
In basilar kyphosis, then, we have a dorsad or posterior
angle, which is to be found in the bodies of the constitu-
ent vertebrz, or the base of the skull. Ossification between
the two sphenoid bones is well advanced at birth, so that
the two already form one compact mass known as the body
of the sphenoid. Ossification between the occipital and
sphenoid bones is, on the contrary, not completed normally
until the eighteenth or twentieth year. Following the prin-
ciple that the part last developed is that most apt to be mal-
formed, the angle of basilar kyphosis will be found pn-
marily to include the occipito-sphenoidal articulation, the
post-sphensoid bone representing the malformed vertebra,
the clavicular process being its most prominent point.
In addition to the essential angle of basilar kyphosis, we
find two contiguous angles which are important in assist-
ing to describe the topography of the inner surface of the
skuil. Cephalad, or at its upper border, we find the angle
which the body of the sphenoid makes with the deepest
level of the anterior cerebral fossa ; and caudad, or at*its
lower border, the angle which the basilar process makes
with the level of the occipital foramen. ‘The latter angle
is determined by the articulation between the primitive
pedicles and laminz of the occipital bone, the line of
which passes through the occipital condyles and the con-
dyloid foramina. ‘This angle is normally diminished in
the foetal state, giving rise to the steeply inclined basis
cranii and the globular skull of the foetus, in which ab-
sence of depth in the anterior and posterior cerebral fossz
are apparently more characteristic than occipito-sphen-
oidal kyphosis, or infringement upon its median vertical
diameter.
Basilar kyphosis is not simply a persistent foetal trait, it
is a distinctly abnormal] or pathological condition.
The angle of basilar kyphosis is an exaggeration of the
normal angle made by the basilar process of the occipital
bone with the body of the sphenoid, its projection being
into the cavity of the skull. It is apparent that basilar
kyphosis markedly diminishes the intra-cranial capacity,
it is apparent that the angle of basilar kyphosis encroaches
upon the cavity of the skull, first by shortening its ceph-
-alo-caudad or antero-posterior diameter, and second, by
direct infringement upon its dorso-ventrad or vertical
THE MEDICAL RECORD.
681
diameter. ‘The distance between the base of the skull
and its roof is diminished in basilar kyphosis beyond the
proportion necessitated by its contracted antero-posterior
limits. ‘The importance of the deformity in its effects
upon the brain may be readily appreciated.
Th. Ackermann * has found basilar kyphosis in a num-
ber of cases of encephalocele, the result being fairly uni-
form whether there were anterior or posterior cranial de-
fect. Ackermann considers the kyphosis a result of
diminished intra-cranial pressure consequent upon the de-
fect.
Now, this is an interesting point. From the earliest
historic times encephalocele has been well recognized, yet
up to the present day the question of priority continues to
be propounded. Did the cranial defect exist first, and
did the brain take its erratic growth asa result of the loss
FIG. 1.
of its enveloping wall ; or did the hyperplasia or the hydro-
cephalus exist first, compelling non-union or loss of sub-
stance in.the yielding cranial bones? If, as Ackermann
surmises, hydrocephalic processes leave their impression
upon the base of the skull, we may interrogate this part in
the investigation of a number of doubtful conditions. If
basilar kyphosis is inconsistent with increased intra-cran-
ial pressure, the loss of cranial substance was not produced
by pressure in these cases of encephalocele, but was what,
for want of a more intelligent term, we designate as a
primitive defect. ‘The experiments of Dareste, Lebedev’s
study of the chick’s embryo, and William Koch’s exhaus-
tive study of spina bifida, also sustain the opinion that
bony defects at least do not depend necessarily upon hy-
drocephaloid conditions. Koch, quoting Ranke’s theory,
considers the bony defect in both myetocele and enceph-
alocele alike due to failure of separation between the cu-
taneous and medullary layers after the formation of the
medullary canal. On account of this failure a septum con-
tinues to unite the neural tube with the skin, and effectu-
ally prevents union between the osseous and muscular lay-
ers. These finally, by increasing in thickness on all sides
1Th. Ackermann: Die Schadeldifformitat bei der Encephalocele
Congenita. Halle, 1882. Ackermann's method of measuring basilar
kyphosis is to make first a median vertical section of the skull, and
upon this section to construct lines, the first to pass antero-posteriorly
through the centre of the section of the basilar process, and the second
antero-posteriorly through the centre of the compound body of the
sphenoid, the inequalities of the surfaces being disregarded in the
measurements. The resulting angle is termed the occipito-sphe-
noidal angle, or the angle of the saddle, found to consist normally of
one hundred and fifty-seven degrees. The angle may be easily con-
structed in a normal skull, but in a kyphotic skull instruments of pre-
cision would be required, and even ‘hen the surface inequalities with
which alone the brain has to do would not be adequately represented.
We have therefore preferred a surface measurement such as may be
made by anyone without trouble.
Ot the four lines used to represent the base of the skullin this paper,
all occupy the median vertical plane: AA passes through the level
of the occipital foramen; C, from the inner ventrad margin of the
occipital foramen to the apex of the clavicular process or most pro-
minent point of the post-sphenoid bone; CJD, from the apex of the
clavicular process to the apex of the olivary process or most promi-
nent point of the prewsphenoid bone ; and DÆ, from the apex of the
olivary process to the level of the cribriform plate, this being ap-
proximately a measure of the depth of the anterior fossa. The lines
BCand CD represent the occipito-sphenoidal angle or the angle of
basilar kyphosis.
682 THE MEDICAL RECORD. [December 21, 1889
of the septum, exert traction upon the neural organ and | Sutton ascribes the tumor of occipital meningocele to
elevate it from its bed in the canal. Increase in weight, | closure of the canals connecting the lateral recesses of
gravity, and subsequent meningeal effusion, complete the | the fourth ventricle with the subarachnoid space. The
work thus begun. It is well known that encephalocele | tumor is the dilated fourth ventricle. It is associated
and myelocele are apt to be umbilicated or furrowed. | with a rudimentary or absent cerebellum, if developed at
: an early stage of intra-uterine life. ‘The theory
of Sutton would produce hydrencephalocele by
distention of the central canal and the mechani-
| ‘ cal withdrawal of cerebral tissue, the agent be-
P ..---- ing the traction exerted by the growing tumor
{ upon the adjacent cerebral mass. ‘This is the
old theory of hydrocephalus, pressure and de-
r fect, opposed to which we have the theories of
E Ackermann and Koch, to which we have already
referred. The evidence afforded by the skull in
Dr. McNutt’s case is before you.
Fig. 2 is a drawing made from a photograph
of a normal skull, taken from a child of one
; year. Itis presented simply for purposes of
SCHNITZER A i comparison.
dies Fig. 3 is a drawing made from the photograph
The place of umbilication or furrowing is supposed to lo- | of a skull of a foetus of about four months. It is also
cate the primitive defect. Koch considers the shortening | given for comparison only. The angles made by the inner
of the spinal column, the absence of certain vertebra, and | surface of the base of the skull in these three cases are
the dwarfing of others in pronounced cases of rachischisis, | compared in Fig. 4. Bearing in mind that the lines used
also the existence of rachischisis without neural involve- | to represent this schematic diagram are of precisely the
ment, as all opposed to the theory of hydrocephaloid ori- | same length in the three cases, the infringement of the
gin. Koch considers that encephalocele may become | cavity in both the foetal and kyphotic skull will be found
hydrencephalocele by loosening of the band of connection
between the neural tube and the skin, and the partial sink-
ing back of the hernia into the canal.
We are fortunately able to present in this connection a
typical skull illustrating Ackermann’s cases. ‘The drawing
shown in Fig. 1 has been made from a photogragh of |
this skull, and is in all respects quite accurate. The case
was one of hydrencephalocele, reported by Dr. McNutt
before the Clinical Society of the Postgraduate -Medical
School, April 16, 1887.’ ‘The patient was a male child,
born at term; the delivery was normal. The parents
were young, healthy people, but emigrants, and the mother
had, during her pregnancy, suffered many hardships, in-
cluding deprivation of proper food. ‘The tumor was pres- | there graphically represented. It will be readily seen that
ent at birth. It was located in the occipital region, was | the occipito-sphenoidal angle is very nearly the same in
translucent, and toward the base covered with hair. The | the foetal and in the post-natal normal skull; but, that
bony defect occupied the median line of the occipital | the capacity of the foetal skull is proportionately dimin-
bone, the bones of the skull were soft, the fontanelles | ished by the tilting of the whole base upward on the axis
9 | furnished by the articulation in the lateral masses of the
ve occipital bone ; and still further encroached upon by the
4 upward inclination of the anterior cerebral fossa. ‘The
result of these two forces is to shorten the base and dimin-
ish the capacity of the skull. In the kyphotic skull this
hii Te E-o ooo result is exaggerated by sharpening of the occipito-sphe-
A ae Ce noiðal angle. ‘The base of the skull is here comparatively
~S a ( ---- | still shorter and the cavity more contracted than in the
foetal condition. In the kyphotic skull we have persist-
ence of the foetal peculiarities, and, added to these, occip-
ito-sphenoidal kyphosis.
Basilar kyphosis has been associated in cretins with
premature synostosis (Virchow) of the base of the skull,
and it has been in some treatises ascribed to persistence
of a normal foetal condition made permanent by this
means. So far as isolated examples can carry weight,
these specimens would appear to negative such a pro-
position. In the first place the foetal skull here repre-
sented does not show basilar kyphosis, and in the second
place the kyphotic skull does not present synostosis. We
have noted that the bones were soft, the foramina large,
and the sutures open. Even the intersphenoidal articula-
tion is still cartilaginous. ‘The same was true of all of
Ackermann’s cases.
A second point of interest connected with basilar
kyphosis has to do with the symmetric bilateral atrophy of
the brain found in cases of infantile spastic biplegia. By
post-mortem examination Richter’ has found basilar
FIG. 4
large, and the sutures open. ‘There
was left facial paralysis, luxation of the SSK
shoulders, talipes, and the hands and Na
wrists were deformed. The child lived six weeks. Upo
autopsy the sack of the tumor was found to consist of the
dilated fourth ventricle, the cerebellum was absent, the
occipital convolutions interlocked, and the pedicle of the
tumor contained degenerated cerebral tissue.
1The Postgraduate, January, 1888, p. 55.
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1 Richter: Virchow’s Archives, No. 106, p. 390.
December 21, 1889]
kyphosis in a number of cases of this kind. His observa- i : +
tions were made by dividing the head vertically in the
median line while the brain was 7” situ, and he graphically
describes his finding. He viewed the brain curved around
and carried up by thé kyphotic prominence. As a result
he saw collision of the falx with the corpus callosum in
the median line, producing atrophy of the callosum, the
degeneration proceeding centrifugally to the cortex upon
both sides.
This explanation must be eminently satisfactory to any-
one who has puzzled over the various theories offered for
these symmetric cases of corticalatrophy. It is not, how-
ever, quite unobjectionable. The corpus callosum does
not in the adult undergo secondary degeneration. ‘The
cortex atrophied by embolus will be represented by
secondary degeneration in the tracts to the periphery, but
no line of secondary degeneration crosses from it to the
opposite side of the brain, as in infantile biplegia, where,
as in Dr. McNutt’s case,’ an atrophied band in the cal-
losum connects the atrophied convolutions.
Again, we know that the corpus callosum is not nii
to the building of convolutions.*
An Englishman has recently col-
lected thirty-three cases of absent
corpus callosurn in otherwise fairly
formed brains. His own case lived
to manhood and was reasonably
intelligent, attending to his busi-
ness, and only considered a little
stubborn and queer by his friends.
- Why cutting the callosum during
foetal life should inhibit the growth
of convolutions is yet undetermined.
A further point of interest is
Inti maxillary
Jugular vein
Ascend
THE MEDICAL RECORD.
683
been made, the ordinary signs of rachitis were very evident.
| Rachitis as a basis for biplegia may not impossibly repay
Temporal art: — 4 mt
AN
fostlauricuiar +
Pr arpa arc. `~
“~
investigation.
In concluding, I beg to express my indebtedness to Dr.
Sarah McNutt for the opportunity of studying her speci-
mens, also for many other kindnesses which have greatly
forwarded my work.
AN ANOMALOUS RIGHT EXTERNAL CAROTID.
By J. HARTLEY ANDERSON, M.D.,
PITTSBURG, PA.
In a recent dissection I found at the bifurcation of the
common carotid, which took place opposite the greater
cornu of the hyoid bone, and immediately below the
posterior belly of the digastric, an axis of five vessels,
corresponding to the branches of the external carotid.
The first branch was the superior thyroid, which ran
down to the thyroid cartilage, giving off its usual branches.
The second branch corresponded to the lingual, which
STYLO-nvo/0
found in a case of biplegia in which O. A VT, M Aa n 16 2°24 are.
Richter demonstrated basilar ky- sical bsg NJ V H f l f )
phosis, but in which the, paralytic Superior thyrotd art. | i Wi, A M
seizure dated from the sixth year. i iis: MN Lingual are,
Of sixteen cases of biplegia re-
ported by Osler, ten only were con-
genital. Must basilar kyphosis be
foetal in origin, or may it, like spinal
kyphosis, have its inception later
in life? Richter’s explanation of
this post-natal case is that the de-
formity had previously existed, but
had not interfered with the brain
until its later development.
k o enumerate :
The essential feature of basi-
tak: kyphosis i is sharpening of the
occipito-sphenoidal angle. It is
associated with a steeply inclined
basilar process and superficiality of
the anterior cerebral fossee—characteristic foetal conditions.
2. The direct effect of basilar kyphosis is to shorten
the base and to diminish all of the diameters of the skull.
3. Basilar kyphosis is not necessarily associated with
premature synostosis of the base of the skull. |
4. Basilar kyphosis has been found in cases of congenital
cerebral hernia. In this connection it is supposed to ex-
clude intra-cranial pressure as the cause of the cranial
defect.
5. Basilar kyphosis has been associated with the sym-
metric cortical atrophy of infantile biplegia. It is sup-
posed to cause this condition by bringing the corpus
callosum into collision with the falx cerebri and induc-
ing inhibition or atrophy proceeding centrifugally to the
cortex upon both sides.
The mother’s deprivation of food during her pregnancy,
together with the delayed ossification, may not inappropri-
ately suggest intra-uterine rachitis as a cause of this de-
formity. In the case of biplegia to which reference has
eae McNutt : American Journal of the Medical Sciences, January,
I
2 Brain, July, 1889, p. 171.
7 Hyota bone
| Thyroid cartilage
Vhs A;
4 ‘4
f; TAN j
gave off the facial about a third of an inch from the axis.
The third branch was the inferior maxillary, giving off the
posterior auricular and the temporal, both of which were
small. ‘The fourth branch was the occipital. ‘The fifth,
the ascending pharyngeal, arising from the underneath
part of the axis. The branches of all the arteries, except
the cervical branches of the facial, were normal in posi-
tion. ‘The internal maxillary was small in size, as also was
the occipital. In ligating on this artery the operator may
expect to find all kinds of anomalies. The origin of the ex-
ternal carotid may usually be found opposite the superior
border of the thyroid cartilage, but very often it is found
as high up as the hyoid bone, and as low as the cricoid
cartilage. Morgagni cites a case in which the origin was
an inch and a half above the subclavian. ‘There are on
record two cases in which the origin was on the arch of
the aorta. In one case this anomaly was on both sides,
and on one side in the other. As I have nowhere seen a
description of this axial arrangement, I thought it might
be of some use to bring it to notice. Dr. Quain mentions
an arrangement of the vessels in close proximity, on the
external carotid, from which [ infer that it was not axial.
684
THE MEDICAL RECORD.
[December 21, 1889
THE MEDICAL RECORD:
A Weekly Fournal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., EDITOR.
PROPRIETORS AND PUBLISHERS
WM. WOOD & Co., Nos. 56 and 58 Lafayette Place.
New York, December 21, 1889.
EPILEPSY, CHOREA, AND THE EYE MUS-
CLES.
THE commission appointed by the New York Neurologi-
cal Society to investigate the relation of insufficiency of
the ocular muscles to chorea and epilepsy made its re-
port in November last, and after an animated discussion,
which was continued at the December meeting, this re-
port was adopted. ‘The details of the work of the com-
mission will be published soon, and it will be a document
of much interest. Meanwhile, we shall give our readers
some account of this work from the records of the So-
ciety’s sessions that have been furnished us. The Com-
mission consisted of Drs. E. C. Seguin, William R. Bird-
sal, F. P. Foster, Charles L. Dana, M. A. Starr, D.
Webster, and W. O. Moore. These gentlemen worked in
co-operation with Dr. George T. Stevens for the purpose
of testing the validity of the latter gentleman’s statements
that treatment of insufficiencies of the ocular muscles
would cure a large percentage of cases of epilepsy and
chorea. In a paper by Dr. Stevens, published a few years
ago, it had been asserted that about fifty per cent. of
epileptics were relieved of their attacks by the special
form of treatment referred to. Dr. Stevens has since
then obtained some confident and aggressive followers in
this city, and, consequently, considerable attention has
been attracted to his method. |
The Neurological Society’s Commission, according to
the statement in its plan of work, having found a suitable
case of idiopathic epilepsy or chronic chorea, had the pa-
tient examined separately by two of its neurological mem-
bers and a full history taken. The patient was then sent
` to Dr. Stevens and examined by that gentleman. If ac-
ceptable, further eye examinations were made again by
one of the ophthalmologists of the commission. Each
patient, therefore, went through four separate examina-
tions before treatment was begun. Records were then
kept of operations performed and of the progress of
the case.
Twenty-eight patients were thus examined and put un-
der treatment, but for various reasons fourteen were with-
drawn, or not counted. In some cases the patient could
not follow up treatment; in others, no relief being ob-
tained, they refused to attend ; in others, some evidence
of organic disease developed. Several attended less than
the minimum limit of time adopted as a test of treatment,
viz., four months. Fourteen cases, however, were treated
continuously for over four months, and in some instances
over two years. Nine of these cases were of epilepsy ; five
of chronic chorea. Three of the cases of epilepsy and
three of the cases of chorea were improved. None were
entirely and completely cured, although two of the cases of
chorea seem to have become practically well. None of
the cases of epilepsy were cured or even very strikingly
improved, though as to this latter point there seems to be
some difference of opinion.
The commission, in their conclusions, state that they
cannot recommend a treatment of insufficiencies of the
ocular muscles in cases of epilepsy and chorea as the sole
therapeutic measure or as a curative measure. This con-
clusion does not deny to oculo-muscular treatment all
value, but it is evident, from a perusal of the discussion,
that the members do not attach very much importance to
it. At the best, it seems that ocular irritation from mus-
cular insufficiency may exaggerate or keep up a convul-
sive disorder; just as a tight prepuce or disordered
stomach may do it.
The importance of peripheral irritation, however, as a
cause of the severe neuroses, is no doubt vastly exag-
gerated ; perhaps no more by oculists than by other spe-
cialists. There will continue to be a diversity of opinion
as to the exact value of Stevens’ oculo-muscular treat-
ment. It will be impossible, however, for any candid
person to read the commission’s report and thereafter
believe that this method is a specific for epilepsy, or thac
it is really a curative measure. In chronic chorea the
results allow a wider divergence of opinion. But, al-
though several cases were very greatly improved or even
cured, this occurred only after a long time, and it might
be attributed to the natural course of the disease.
Although the extravagance of Dr. Stevens’ claims is
abundantly shown by the commission’s report, some
words of justice are due him. It was certainly a coura-
geous act on his part to undertake the somewhat thank-
less task of allowing his views to be put to so exacting a
test, and it argues an honest conviction in the truth of his
own views.
By his persistence and ingenuity in following up his
special line of work attention has been drawn to a class
of functional eye disturbances which had been very gen-
erally overlooked. The exact importance of these in the
production of morbid symptoms and the pathogeny of
disease time will determine definitely. It is already
shown that their importance has been greatly overrated.
VITAL AND MEDICAL STATISTICS.
THE lectures of Dr. Billings upon vital and medical sta-
tistics have proved to be of much more interest than
their title promised, and they will doubtless serve a use-
ful purpose in showing the proper methods of carrying
out a statistical inquiry as well as the limitations of this
method. The familiar observation to the effect that
“one can prove anything by statistics is false,” unless it is
amended so as to say “by statistics ignorantly used.” `
Whatever may be the shortcomings of the statistical
method it is the one which practically has to be largely
used by the physician in order to draw conclusions as to
the course of disease ; and it is most desirable, therefore,
that he should have an intelligent understanding of the
tools which he has to employ.
December 21, 1889]
THE MEDICAL RECORD.
685
Dr. Billings’ lectures dealt not alone with statistical
methods, but also with the application of them in many
directions. He presents us, it must be confessed, a rather
discouraging picture of the result of man’s battle with dis-
ease. Although the expectation of life is greater, yet
this is only true of the earlier ages. After a man reaches
twenty his-expectation of life is less than it was fifty years
ago, for the reason that more persons of feeble constitu-
tion are now nursed to manhood.
The decrease in the general mortality is due to better
care of infants and the prevention of contagious. disease.
_ So far as statistics show, it does not appear that there
is any difference in the mortality-rate of most infectious
diseases from what it used to be. Pneumonia, diphtheria,
scarlet fever, measles, small-pox are just as fatal as they
used to be. Or if there is any difference, it is one which
may be attributed to the special character of the epi-
demic, or the age and constitution of the people. Deaths
from child-bed and surgical operations, it is true, are-
shown to have been greatly reduced.
We regret that the statistics of typhoid fever were not
dealt with by Dr. Billings, because there is asserted to be
a great reduction in the mortality from that disease by
modern treatment.
When one comes to study death-rates and sick-rates of
hospitals and among poorer classes he is confronted with
a peculiar problem. ‘Therapeutic measures efficient else-
where do not apply here. A case of phthisis in the early
Stage dies or gets well exactly in accordance with modern
treatment. ‘This is a fact which physicians know, yet
Statistics would probably show just as great a mortality-
rate from this disease as ever.
Every physician meets cases in which, by timely treat-
ment, he has saved victims of scarlet fever, diphtheria, and
pneumonia, etc., yet statistics do not show it, while, of
course, mortality statistics Co not tell of what 1s done in
non-fatal disease or of the cured cases. So that, alto-
gether, modern medicine no doubt accomplishes more
than is apparent by figures and tables. |
WHOLESALE OFFICIAL PRESCRIBING,
WE notice with considerable surprise the publication in
the daily papers of a prescription for the threatened epi-
demic of influenza, which is said to be by the sanction of
the Board of Health. We trust we have been misin-
formed on this subject, as the so-called remedy is not only
of no good whatever, but its use as directed is liable to be
attended with great danger. Here is the prescription in
question :
“ For Russian influenza or ‘ gnp’—spray the affected
membrane with a ten per cent. solution of quinine freely
and frequently, and take four or five times a day a pill
made as follows : Quinine, 3 grains ; camphor, 4 grain ;
extract of belladonna, } grain.”
Very many of the pharmacists about town have very
properly refused to make up the prescription, and very
many patients who believe in wholesale cheap prescribing
may follow the directions to their sorrow. We cannot
believe that the publication of this prescription is made
by the authority of the Health Board: If it is, the Board
owes an explanation and apology to the profession and
the public.
THE HOMCEOPATHIC HOSPITAL AFFAIR.
Duric the past few days a very interesting quarrel
has been agitating homceopathic circles regarding the real
articles of faith upon which the Hahnemannian creed shall
rest. The questions at issue have been precipitated by a
protest, on the part of the Homceopathic Society of this
county, against certain gentlemen who are not members
of said society being retained upon the Medical Board of
the Homecopathiz Hospital at Ward’s Island.
It will be recollected that fifteen years ago the Com-
missioners of Charities and Correction set apart the
Ward’s Island Hospital exclusively for homceopathic
practice upon the patients, and appointed acknowledged
homceopaths upon the Medical Board. It now appears
that five of the twenty-four physicians constituting the
board are not members of this society ; are consequently
not declared homeeopaths, and that the society has passed
a resolution petitioning the commissioners to dissolve
the board and appoint a new set, who shall all be mem-
bers of the society.
The following queries were also laid before the com-
missioners :
“t, Do the commissioners intend that the Medical
Board of the hospital should be composed exclusively of
homceopathic physicians ? 2. What is their criterion of
judging if a physician is homeeopathic? 3. Is member-
ship in the Homceopathic Medical Society of the coun-
ty that criterion? 4. Is a physician who does not
comply with the law of the State eligible? And, 5.
Do the commissioners intend that a physician who has
left the Homceopathic Medical Society shall continue
a member of the board ?”
These questions were referred to the President of the
Medical Board, and he replied that he believed there
was no exclusively homceopathic physician in New York ;
that the law requiring physicians to belong to a county
society was a dead letter, and that the reasons why two
members had left the County Society were more credita-
ble to them than to the society.
It is claimed by the other side that the intention to
follow homceopathic principles can only be made manifest
by a membership in their Homeeopathic county society.
During the discussion of the question fro and con many
curious facts have been brought to public notice, which
show a very uncertain state of conviction on the part of
those who are within the circle. It is admitted by sev-
eral, if not all, the parties in the quarrel that homeopathy
is not faith in infinitesimals, or in so-called potentization
by trituration, but is the “like cures like” principle.
Even this latter, we are told, is not a universal truth or ab-
solute guide. Consequently a modern homeeopathist uses
the latter principle as the best general guide in selecting
remedies. ‘This appears to be the minimum modern test
for a homeopathist, since the members of the society can
claim no more.
Whether the members are right or wrong in their be-
lef does not concern us. Each one is free to believe as he
pleases and practise such a belief according to his con-
science and the faith of those who place their lives in his
hands. It is eminently proper for such as have a creed to
stick to it.
Happily for the regular profession, it can view the situ-
ation with absolute impartiality, as from the nature of
686
THE MEDICAL RECORD.
[December 21, 1889
things no quarrel upon the points involved could ever
occur among us. In the absence of any other authority
for homoeopathy than that assumed by the society, we
do not see how the said society can do other than en-
deavor to purge the Homeopathic Hospital of those
men who do not even follow this “ like cures like ” rule.
As a matter of principle, if the Homeopathic Hospi-
tal has been set apart exclusively for homceopathic prac-
titioners by the county society, the medical staff of the
hospital should be composed of men concerning whose
belief in the original dogma there should be no question.
There does not seem to be any way of avoiding the is-
sue. ‘There has always been acknowledged intimacy be-
tween faith and works, and they cannot be consistently
separated in this instance, despite the apparent ambition
of the society to secure patronage. We sympathize with
the gentlemen who are bold enough to be independent in
their conviction, but it is this very independence which
should invite their resignation as men who cannot prac-
tise what they do not believe. Hence it must be con-
ceded that the decided vote by the Society, at its meeting
on Wednesday night, to petition the commissioners to
reconstruct the board, was perfectly proper and emi-
nently sound.
ews of the Week.
For Sick Basies.— Many well-known ladies attended
the house-warming in the babies’ ward at the New York
Post-Graduate Hospital, Nos. 222 to 230 East Twentieth
Street, Wednesday afternoon. Among the many charities
of New York there has been almost no provision made
for the care of sick infants. The general hospitals de-
cline to receive them, and many babies die because their
mothers are unable to give them suitable nourishment
and medical treatment. Recognizing this fact, the di-
rectors of the Post-Graduate Hospital, assisted by several
charitable ladies, established a babies’ ward. ‘The work
grew so rapidly that it was found necessary to occupy an
entire building, next to the hospital proper. During the
past summer more than one hundred babies were treated.
No cases except contagious diseases were refused. ‘The
babies’ ward is under the medical care of Dr. Henry D.
Chapin. Addresses were delivered by Dr. D. B. St. John
Roosa, Dr. Chapin, and the Rev. Dr. Satterlee.
FATAL SUPERINCUMBRANCE.—The deaths of fourteen
infants in London, in one week, were attributed to “ over-
laying.” The cause of one death in this city, last year,
was reported to be “Sat on by Father.”
ONE-HALF PER CENT. SOLUTIONS OF CREOLIN are be-
coming popular for vaginal injections, for washing out
the bladder, and as injections in dysentery.
ALUMNI OF CHARITY HospiraL.—At the meeting of
the Medical Society of the Alumni of Charity Hos-
pital, held on the evening of December roth, Dr. A. T.
Muzzy read a very interesting paper, entitled “ The Preven-
tion of Ophthalmia Neonatorum.” Dr. Joseph O’Dwyer
presented some new laryngeal tubes, which are shorter
than his former models and of much larger calibre—in
fact, giving a passage very little smaller than the trachea
itself, thus facilitating the removal of membrane, mucus,
etc. Another modification is having the collar at the top
of the tube hinged to the shaft in front, so that removal
is easily performed by the finger. The collar, which is
held in place by springs, lifts up readily, forming a ring
into which the tip of the finger is inserted and the tube
readily withdrawn without the use of instruments. The
following officers were elected: President—Dr. D. Bryson
Delavan; Vice-President—Dr. Ramon Guitéras; Secre-
tary—Dr. W. L. Baner ;
HYDROTHERAPY vs. HyDROPATHY: A CORRECTION BY
Dr. Barucu.—Dr. S. Baruch writes: I desire to ask the
correction of an error which has crept into your valuable
report of my paper, “ A Plea for the Practical Utilization
of Hydrotherapy.” Your reporter refers constantly to
hydropathic measures, hydropathic treatment, hydropathy.
The following extract from the paper will furnish my
reason for asking the correction. I said that “ hydro-
therapy is the utilization of water, at any temperature and
in any form (from ice to vapor), internally or externally,
for the treatment of disease. Ido not say the cure of
disease. By this definition we emancipate it from hydro-
pathy, a cold-water cure, and place it in the front rank of
therapeutic measures.” It is my aim to draw the line dis-
tinctly between a therapeutic and a sectarian term, be-
cause the adoption of the latter (hydropathy) by em-
pirics has long estranged the profession from the use of
Treasurer—Dr. A. T. Muzzy.
‘a remedy whose utilization can be clearly traced (as I did
in the address) to the fathers of legitimate medicine.
AN OPPORTUNITY FOR THE STUDY oF CONTAGIOUS
Dıseases.— The Health Department of the City of New
York will throw open for competitive examination two
positions as Assistant Physicians in the Willard Parker
Hospital and the Hospital at North Brother’s island re-
spectively, thus giving an opportunity for the clinical
study of the different contagious diseases. Applicants
may address Dr. D. M. Stimson, 11 West Seventeenth
Street.
PRIVATE ESTABLISHMENTS FOR THE CARE OF THE
INSANE IN New York STATE.—The following resolution
was recently adopted by the State Commission in Lunacy :
“ Resolved, that hereafter no license for the establish-
ment and keeping of an asylum or institution for the care,
treatment, or custody of the insane or persons of unsound
mind, for compensation or hire, shall be granted except
to a duly qualified medical practitioner of recognized pro-
fessional skill and standing, who is a graduate of a legally
incorporate medical college, and has had actual expen-
ence in the care and treatment of the insane.”
MEDICAL STUDENTS AS HOSPITAL ATTENDANTS.— Dr.
N. Roe Bradner, of Philadelphia, offers a suggestion to
the effect that the service in hospitals and asylums, espe-
cially the latter, might be very greatly improved were medi-
cal students selected by preference to fill the places of
nurses and attendants upon the sick. The students would
be content with a moderate salary, since the work would
be in the line of their studies, and an opportunity might
also be afforded them to attend lectures and to keep up
with their reading. ‘The chief objection to such a plan
would be the difficulty in so arranging the hours of work
in an institution of any kind as to permit the attendants
to absent themselves during a large part of the day in or-
der to hear the necessary lectures.
December 21, 1889]
THE MEDICAL RECORD.
687
THE Jouns Hopxms HosriraL BULLETIN is the title
of a monthly publication issued under the auspices of the
Jobns Hopkins Hospital, and containing the proceedings
of its Medical Society and various official announcements.
A PAIR oF Forceps LEFT IN THE ABDOMINAL Cav-
ITY.— Two prominent surgeons in Pittsburg are charged
with having left a pair of forceps in the abdominal cavity
of a woman after a laparotomy. ‘The presence of a for-
eign body was discovered by another surgeon, whom the
patient had called in, and the wound was reopened and
the forceps removed by him.
THE FRENCH GOVERNMENT has decided that here-
after foreign physicians (more especially English) will not
be allowed to practise medicine in France, except “ in
instances presenting very exceptional claims.” This
means that the English physicians can no longer under-
take to practise in the Riviera, or at the various Medi.
terranean health-resorts of France. If this rule is to be
made to apply to Americans, it would be only fair to
undertake reprisals. There are a good many French
physicians who come over to practise in this country, and
it is a poor rule that doesn’t work both ways.
THE REPORT OF THE UNITED STATES MARINE Hos-
PITAL SERVICE for 1888-89 is a voluminous document,
made so chiefly. by the official account of the yellow fever
epidemic in Florida, and numerous contributions to the
pathology of this disease. The clinical and pathological
reports are quite numerous, but do not contain much of
interest. The work of the Service continues to increase
annually, and during the past year 49,518 sick and dis-
. abled seamen were relieved, as against 20,922 ten years
ago.
Dr. Tuomas B. Harvey, one of the leading physi-
cians of the West, died at his home in Indianapolis, on
December sth. His death was caused by cerebral
hemorrhage, coming on while delivering a clinical lect-
ure. Dr. Harvey was born in Clinton, O., in 1827. He
was Professor of Gynecology in the Indiana Medical
College. l
A Suit Broucut By TyPHOID FEVER SUFFERERS.—
During the great typhoid fever epidemic at Plymouth,
Pa., in the spring of 1888, which carried off hundreds of
people, the Plymouth Water Company were held respon-
sible for the outbreak of the fever, and suits for damages
were instituted against the organization by the relatives of
the victims. A test case was called for trial for the first
time December roth. Mr. Buckingham, who lost two
children, is the plaintiff. He claims $10,000 damages.
The company has an able array of counsel.— Boston Med-
ical and Surgical Fournal.,
THE NEw STATE OF WASHINGTON.—The medical men
of this energetic young State, says the Pacific Medical
‘Fournal, are to all appearances wide-awake and hard at
work. They have already accomplished splendid results
by having engrafted into their State Constitution a pro-
vision rendering it obligatory upon the legislature to en-
act laws regulating the practice of medicine, surgery, and
pharmacy in the State. This one successful step puts
them in the beginning in advance of every other State in
the Union on this important question.
GRADUATES OF AN EASTERN MEDICAL COLLEGE DE-
BARRED.—A report in the daily papers states that a grad-
uate of Jefferson Medical College was refused license to
practise medicine in Minnesota, because the length of
that college’s term does not come up to the requirements
of the Minnesota law. This law requires the applicant
for examination for license to practise in that State to
have attended at least three courses of lectures of six
months each. Each six months’ course is reckoned at
twenty-six weeks. The course at Jefferson College lacks
eight or nine days of the required length.
AT 1TS SEPTEMBER MEETING THE VIRGINIA MEDICAL
EXAMINING Board received twenty-six applications for
examination. Sixteen were rejected, two withdrew, and
eight were given permits to practise medicine. The low-
grade medical schools should advise their graduates not
to appear before this Board.
THE New York Docror’s Gic.—We are told by the
College and Clinical Record that many of the physicians
in New York have recently adopted a distinctive vehicle,
a buggy, with a top or hood which 1s a complete protection
from the weather. It differs from a light trotting buggy,
as the box is big, roomy, and comfortable, and the hood
is arranged in several joints, so that a portion of it may
be pushed back at a time. The wheels are almost heavy
enough for a light T-cart. The doctors drive two horses,
usually handsomely matched, well-built, and stylish ani-
mals, with docked tails. The coachman is uniformly in
snug livery, with corduroys and varnished boots.
Obituary.
CHARLES HENRY NICHOLS, M.D., LL.D.,
NEW YORK.
Dr. CuHaRtEs H. NICHOLS, superintendent of the
Bloomingdale Insane Asylum, died in this city on Decem-
ber 16th, of cancer of the liver and peritoneum, in the
sixty-ninth year of his age. He had been in failing health
for several months, and had taken a trip to Europe in the
summer, partly in the hope of regaining his strength, but
it was only within a few weeks that any apprehensions of
a fatal termination to his illness were felt. He was for-
tunately spared much severe suffering, and the end came
quietly as the peaceful closing of a useful life.
Dr. Nichols was born in Maine in 1820, and graduated
in medicine from the University of Pennsylvania in 1843.
He became assistant to Dr. Brigham in the Utica Insane
Asylum in 1847, and soon after went to the Bloomingdale
Asylum, where he served as physician for three years,
resigning this position to accept an appointment as Super-
intendent of the Hospital for the Insane at Washington.
It was here that the opportunity, which is said to come to
most men, came to him, and it found him ready. In the
face of much opposition he worked on and constructed,
on original plans of his own, a hospital which will long
endure as a monument to his genius. About twelve years
ago he was recalled to the Bloomingdale Asylum, where
he remained up to the time of his death.
Although the equal of any as an alienist, it was as an
organizer and as an executive officer that his abilities
shone pre-eminent. He was astern disciplinarian—almost
a martinet at times—yet none could ever complain of in-
justice at his hands, and he possessed the happy faculty of
winning and retaining the affection of all his subordinates.
Dr. Nichols’ was a well-spent life, and one that reflected
honor upon the profession to which he belonged, and his
death leaves a void which will not easily be filled.
688
THE MEDICAL RECORD.
[December 21, 1889
Society Reports,
NEW YORK NEUROLOGICAL SOCIETY.
Meetings of November 5 and December 3, 1889.
Dr. GEORGE W. JACOBY, PRESIDENT, IN THE CHAIR.
In March, 1887, a commission consisting of Dr. E. C.
Seguin, Chairman, Dr. M. A. Starr, Secretary, and Dr.
W. R. Birdsall, together with two ophthalmologists, Drs.
W. O. Moore and David Webster, and two other gentle-
men nominated by Dr. Stevens, viz., Drs. C. L. Dana
and Frank P. Foster, was appointed by the Society to
investigate, in conjunction with Dr. G. T. Stevens, the
treatment of ocular irritations as a therapeutic measure
in certain neuroses. ‘This commission presented its report
on the
TREATMENT OF EPILEPSY AND CHOREA BY THE CORREC-
TION OF OCULAR DEFECTS
in November, the discussion being concluded at the
December meeting. Immediately preceding the reading
of the report the following protest was presented by Dr.
G. T. STEVENS :
“ MR. PRESIDENT, AND GENTLEMEN OF THE NEURO-
LOGICAL SOCIETY : I respectfully protest against the re-
ception of the report now announced, for the reasons :
1st, That the commission, having failed to perform its
part of the agreement upon which the report is to be
founded, the report is not now in good order; 2d, be-
cause the report is not a report on the proposition at
issue; 3d, because the report is inconsistent with the
facts and is misleading ; and, 4th, because it is an zx-
parte report and objectionable in spirit and motive.”
The President then called for the report of the com-
mission, which was read by its Chairman, Dr. E. C.
Seguin. The more important features of this report
were as follows: After a plan of proceedings had been
agreed upon between the commission and Dr. Stevens,
the members began to send patients to the latter in April,
1887. i
Each patient was examined by two neurologists, who
agreed upon the diagnosis and compiled a history of the
case. The patient was then sent with the history to Dr.
Stevens, who examined the ocular conditions. Subse-
quently the ophthalmologists of the commission examined
the eyes and reported their results to the Secretary, who
added these notes to the copy of the history in his posses-
sion. When an operation was undertaken, notice of it
was sent by Dr. Stevens to the Secretary, and he in turn
notified the ophthalmological members and also the neu-
rologist who had furnished the patient. These members
then attended the operation and noticed the conditions
found in the eyes before and after it, sending their rec-
ords to the Secretary. ‘Their non-attendance, however,
did not prevent operations from being done, and the
records of these operations, as well as records regarding
prisms and glasses prescribed by Dr. Stevens for the
patient, the commission had been unable to obtain from
him.
The patients from time to time visited the member of
the commission by whom they were sent to Dr. Stevens,
and notes of the conditions found were made and sent to
the Secretary. In the cases of epilepsy the record of
attacks had not in all cases been kept in duplicate, Dr.
Stevens having the record on the blanks furnished by the
commission, and in these cases the records had not been
accessible.
The total number of patients examined by the com-
mission and sent to Dr. Stevens for examination was 28;
23 epileptics and 5 cases of chronic chorea.
All were found to have ocular insufficiencies; 5 were
withdrawn without any treatment; 3, a month after
examination ; 1, two months after ; 1, three months after ;
2, four months after; 1, five months after.
The reasons for withdrawal were as follows: Five were
unable to attend regularly. Two were declined by Dr.
Stevens on the ground of organic disease. Five were
withdrawn by mutual consent of member sending case
and Dr. Stevens, for satisfactory reasons, such as non-
attendance. Three were discontented because of increase
of symptoms.
Hence of the 28 cases there were only 14 who were
treated for four months or over, and these were the only
ones available for conclusions. These cases were tabulated
as follows, showing the duration of treatment, the date at
which the patient was sent to Dr. Stevens, the date of tle
last report of the condition of the patient, and a statc-
ment of the apparent result of treatment.
Su .
esa
2 HE Date of first | Date of last
Cases Disease. F E Tinie ae Result.
EFL
P
| erence were aan
Elizabeth C... | Chorea.. | 30 | April, 1887. | Oct, 1889. na meee
john MG Eal | MON eer | Oct, seen: | amend
Gang ace sn 33 May, 1887 € Ict., 1889. | Slightly improved.
Aggie H... | Epilepsy. | at an., 1888. | Oct., 1889. Not improved.
C; Diriiimeis : Epilepsy. 4 Mech., 1888 ely: 1888. | Unknown.
| ae eee ee orea.. Mch., 1888.. Nov., 1888. | Not improved.
G. H...00.55 Epilepsy. | 12 | Mch., 1888. | Mch., 1889. | Impro -
David S...... Epilepsy, April, 1888. | Sept., 1888. | Not improv d:
rn, Sieiiacees orea.. | 38 j ay, pe May ersa | plane siii
Seer orea.. | 10 uly, 1888. A ., Im d.
Gertrude W.. | Epilepsy. 6 il, 1889. | Oct., 1889. Slightly improved.
Mary McK... | Epilepsy.| 5 May, 1889. | Oct., 1889. | Not improved.
Agnes H..... Epilepsy. s | May, 1889. | Oct, 1889. | Not improved.
ee =B
The results could, then, be summarized thus :
Disease Cured. | Peel d. Improved. FA =- d. Unknown. | Total
Chorea ......... None i I 2 2 5
Epilepsy ........ None. | None. 3 5 r 9
I | 5 7 x 14
Some analysis of the results was necessary. It was
evident that six cases were put down as improved. Of
these three had been presented to the commission by Dr.
Stevens from his private practice, and no exact data had
been obtained regarding them. This was especially to be
regretted, as the exact degree of improvement could not
be ascertained. In the other three reported as improved,
the first improvement began in one after thirty weeks, and
the patient had never been entirely free from chorea for
one month ; she had at times been better under the ocu-
lar treatment, at times worse, even now having choreic
movements, usually before menstruation. In another
the chorea was only slightly less than at the outset. The
sixth case, an epileptic, was having about the same num-
ber of attacks as she had under bromide treatment, but
far less than when she had no treatment whatever. _
As regarded those not improved, many of the patients
would say they felt better in spite of the written records
proving the increased frequency of the attacks. _ This
was in part due to increased hope and confidence in the
success of the treatment and also to the freedom from
depression of mind and bodily functions produced for-
merly by the use of the bromides. Others had complained
much of headache and vertigo which had appeared dur-
ing the treatment, and in several a condition of diplopia
had been produced and now remained. A few of the
patients had been made exceedingly miserable by the great
increase in frequency and severity in the attacks, which
had finally necessitated an abandonment of the ocular
treatment and a return to drugs. This statement applied
to a number of cases which had been withdrawn.
It would be noticed that none of the cases having been
cured, all remained indefinitely under treatment, a per
fect permanent ocular equilibrium not having been se-
cured in any case. If it were impossible to secure such
equilibrium, a cure could not be expected, granting the
theory of Dr. Stevens. If it were possible to secure such
equilibrium, it was to be supposed that it could be se
`
December 21, 1889]
cured in at least two years ; yet four of these cases had
been under constant treatment for two and a half years
without this result.
The following paragraph in the report represents the
final conclusions of the committee :
“In view of these facts, your committee cannot but ex-
press the opinion that, as far as tbis investigation has war-
ranted a conclusion, the method of Dr. Stevens does not
afford a sufficient degree of relief to patients suffering
from chorea and epilepsy to warrant its adoption or rec-
ommendation to the members of the Neurological Society .
as a means of cure or as the sole therapeutic measure.”
Dr. STEVENS then read a reply to the report of the
commission, of which only the outline can be produced
here. He said that whatever might have been the orig-
inal condition of the majority of the cases sent to him
during the first year, it was certain that they had long
ceased to be cases of functional disease. While, as a mat-
ter of fact, everyone of these unfortunates belonged to
the class of incurables by any of the ordinary methods of
treatment, and while they had grown worse under such
treatment continued during many years, they had in every
instance under the present mode of treatment materially
improved in health and in respect to the special diseases
for which they were treated. All this improvement had
been brought about without recourse to the deadening
results of bromides or the toxic effects of enormous doses
of arsenic. ‘The following is a summary of the salient
features of Dr. Stevens’ reply :
“ From the beginning, the commission entered upon
its work in a manner entirely inconsistent with the true
spirit of inquiry. It pursued it in a manner ealculated
to induce vexation, misunderstanding, and controversy.
It occupied many months in securing a few cases, and has
never yet complied with its own stipulations. It has
through more than two years occupied itself in selecting
the most unfavorable cases for treatment and has taken
the favorable cases to itself. The spirit of the report is
calculated to produce prejudice and tends to mislead.
The report is now made in violation of every principle of
right or fairness. The report is represented as an investi-
gation of two diseases and not of a principle, in direct
violation of the pledges of the commission. ‘The com-
mission has repeatedly sent cases well known to be un-
suitable for the inquiry, and has, contrary to the articles
of agreement and contrary to the private promises of
members, in this report paraded these cases in long detail
with the effect of misleading the judgment of those who
are unacquainted with the facts. It has reported the re-
sults of treatment of the cases by minimizing the impor-
tance of the malady at the beginning of treatment and by
magnifying all the unfavorable conditions now existing.
The results represented are not in conformity with the
actual facts, but are grossly at variance with them. It
has reported as resulting from treatment unfavorable oc-
ular conditions which do not exist, and has in this respect
made mistakes which, by ordinary care, should have been
avoided.”
Dr. HAMMOND had seen eight of the cases described, in
company with Drs. Weir, Webster, Ranney, and Amidon
the day before the meeting. The patients and their
friends all admitted that the cases had been improved
very much by Dr. Stevens’ treatment, a fact which was at
great variance with the statements made by the same
patients to the commission.
DR. Secum said that that part of Dr. Stevens’ remarks
which reflected upon the fairness and integrity of the com-
mission needed no reply, the names of the members of
the commission being a sufficient answer. Dr. Stevens’
statements as to the evil effects of the arsenical treatment
of chorea, and of the bromides in epilepsy, appeared to
pander to popular prejudice, and were altogether un-
warranted by fact. Some clinical experience and knowl-
edge of practical therapeutics would have prevented such
expressions. Arsenic was almost never harmful to cho-
reic patients, and the evils of bromism could be prevented
THE MEDICAL RECORD.
689
and corrected by watchful management and appropriate
associated treatment.
It was true that the commission had had the greatest
difficulty in inducing patients to undergo the treatment,
but their failure to obtain twelve cases within the first few
weeks was not through neglect or violation of the agree-
ment. It was simply an impossibility to supply the
necessary material in a given time: enough had been
furnished in all. Dr. Stevens, in not furnishing data as
to the course and progress of the cases as stipulated in the
agreement, had violated the compact. The report had no
personal animus and was not made up of the ideas of any
one or two members. It expressed the opinions of all of
the members of the commission, even of those selected
by Dr. Stevens himself.
As regarded the statements of friends and relatives in
medical investigations, these should be received with
scientific doubt, particularly when they differed from the
facts as shown by the commission.
As far as his own cases were concerned, one had been
nearly killed by the ocular treatment involving the omis-
sion of bromides, passing into a status epilepticus, but
improved again under bromides. Another had been under
ocular treatment for fifty-two weeks before improvement
became marked. Another, the girl with chorea, showed
no tangible improvement until after the lapse of seven
ths. His own experience in cases of chronic chorea,
ee, when of five to seven years’ duration, was that they
were not merely improved very soon under arsenical treat-
ment with rest in bed, but, as a rule, cured in from two to
three months. This girl, though improved under the oc-
ular treatment, had now transient diplopia for far and
near, while the second case alluded to saw double at the
present time on looking to the nght. The improvement
in these cases (which were the best of the series) could
not therefore be ascribed to the ocular treatment, but was
to be attributed to improved health and time. Dr.
Stevens had reported fifty per cent. of cures of epilepsy
in his own (former) series of cases, but in the cases ex-
amined by the commission there was not one. Moreover,
he had reported his cures as taking place in a few weeks
after beginning the ocular treatment, while in these cases,
where improvement of any kind had taken place, many
months had been required before decided change had been
manifested.
Dr. STARR, in regard to the remarks made by Dr.
Hammond, referred to the records of the cases already
read to the Society, which demonstrated in each case an
increase in the number of attacks, in some of them to
three times as many as formerly. It was well known that
the statements of epileptics were unreliable concerning
their own seizures, and in several of these cases it was
evident from their own records of their attacks that any
statements they had made that they were better were in
direct opposition to the real facts. The recollections of
such patients regarding their past states could not be con-
sidered as at all comparable with the actual observations
taken during such periods.
In one case, pronounced by Dr. Webster as normal
ophthalmologically, and in every respect a purely func-
tional case, Dr. Stevens claimed to have found optic
atrophy, and called it an organic disease.
Dr. BIRDSALL had seen an epileptic, one of the cases
mentioned by Dr. Hammond as having reported 1 improve-
ment to him, and whose sister corroborated the patient’s
statement. He had asked the sister why she had made
this statement. She had replied that she did not refer to
the number of fits, which was unchanged, but meant that
the patient seemed to be brighter without the bromides.
The record showed, however, that the number of attacks
had increased, and that the patient was in reality much
worse under Dr. Stevens’ treatment.
Dr. Dana said he had been nominated for the com-
mission by Dr. Stevens himself, and felt that he repre-
sented him in a measure, but naturally his chief object had
been to obtain the exact truths in the matter. He had
690
sent twelve cases of his own to the commission, and had
tried hard to get others to go. He had made every effort
to get suitable cases, but he had seen no case much im-
proved under Dr. Stevens’ treatment. One case seemed
to be improved, but he could not feel sure that improve-
ment was due to the ocular treatment. He had lost most
of his faith in it as a therapeutic measure. We ought,
however, to pay some tribute to Dr. Stevens for perfect-
ing the technique in his procedures, even though he had
pushed his theory to extravagant conclusions.
Dr. STEVENS said that when the investigation was com-
menced, cases were accepted by the commission which
ought never to have been taken. One was a pronouncedly
organic case, and, in fact, not one of the cases was func-
tional. |
Dr. WEBSTER stated that the diplopia now existing
in one of Dr. Seguin’s cases did not amount to much. It
was trivial. He had seen Dr. Stevens operate many times,
and had learned very much from him as to the technique
in the treatment of insufficiencies. Dr. Stevens had, more-
over, greatly improved the nomenclature in this direction.
Not being a neurologist, he did not feel able to’ judge
of the therapeutic effects of the operations in these cases.
Dr. STEVENS said that the operative technique was ex-
ceedingly delicate and difficult, and that the greatest skill
was required, such that he did not claim yet to have himself
attained ; but the more skilful the operator becomes,
more valuable will prove to be this therapeutic measure.
Dr. L. C. Gray had listened with interest to the report
and its discussion, and was wholly unprejudiced on either
side. He did not believe that Dr. Stevens had substan-
tiated his serious charges against the commission, or
caused any particular improvement in the cases. Esquirol
showed in 1828 that temporary improvement took place
in all cases of chronic epilepsy in La Salpétriére when
treated by drugs known at that day. A decrease of from
six to three fits daily could not be considered a permanent
improvement, because such decrease was often sponta-.
neous, and, in some cases, fits spontaneously ceased for
years. He agreed with Dr. Seguin that where improve-
ment did not begin before fifty-two weeks after treatment
had been begun, any improvement that might take place
could not fairly be ascribed to the measure employed. If
Dr. Stevens had claimed merely that headaches and other
trivial neuroses had been relieved by his method, many of
the gentlemen present would have coincided with him ;
but he had undertaken too much, and was extreme in his
claims. The same therapeutical principle underlay his
system as that ot Sayre, who cut prepuces, and that of the
English surgeon who amputated clitorides for the cure of
the slighter neuroses.
Dr. AMIDON said that he had been invited, with a num-
ber of others, by Dr. Ranney to see the cases described
at Dr. Stevens’ office, and they had the complete histories
of the cases at the time upon which to form an opinion.
He intended to oppose the acceptance of the report of the
commission, for it was clearly apparent that Dr. Stevens
had brought about improvement in these patients without.
resort to medication, which was more than any of us could
do.
Dr. SEGuIN said, with reference to the work done by
Dr. Stevens, that all of the members of the commission
had appreciated it highly and had felt like adding some-
thing commendatory of his skill to the report, but re-
frained from so doing because, under the circumstances,
it might have appeared hypocritical, and was really alien
to the subject assigned to the commission, viz., the deter-
mination of results.
Dr. J. L. Corninc thought that Dr. Dana’s tribute to
the good work done by Dr. Stevens was in exceedingly
good taste. Dr. Stevens’ work was unusually scientific
and original, and there seemed to be very little of that
sort of work done in New York, where compilation and
the importation of foreign ideas were the order of the
day. Hence this discovery of Dr. Stevens ought to meet
with wide recognition.
THE MEDICAL RECORD.
[December 21, 1889
A motion to adopt the report of the commission was
then carried by a vote of five to four out of the eighteen
members present, the members of the commission refrain-
ing from casting their votes.
The following motion, made by Dr. AMIDON, was unan-
imously carried :
“ That the thanks of the Society be extended to Dr.
Stevens for the assiduous labor he has devoted to the
work of the commission, and that the Society assure Dr.
Stevens that it highly appreciates the ingenuity and
technical skill he has shown in the prosecution of his
method.”
Besides the report of the Stevens Commission, the
following contributions were made at the two meetings
of the Society.
Dr. Ira Van GIESON read a paper entitled
A CONRTIBUTION TO THE PATHOLOGY OF THE LARYN-
GEAL AND OTHER CRISES IN TABES,
and described a case of tabes with laryngeal attacks dur-
ing the last year of the illness. One of the crises proved
fatal. Microscopical examination showed the lesions of
a chronic neuritis of the roots of the vagus and accessary
portion of the spinal accessary nerves on both sides. Neu-
ritis of the root-fascicles or trunks of one or both of these
was regarded as more frequently the cause of the laryn-
geal crises than central lesions.
The author divided laryngeal crises into two classes:
A first class in which the glottis constrictors and dilators
were normal, and the crises occurred by reflex spasm of
the adductors ; a second more numerous class of cases,
in which the constrictors and dilators are in a greater or
less degree of paralysis.
The first form of the crisis mght be produced by a
neuritis of the roots of the accessary portion of the elev-
enth nerve, irritating the sensory fibres of the larynx, and
being responded to by motor impulses through the vagus,
which would produce closure of the glottis by contraction
of the adductors. The second form of the crisis might
be produced by a destructive stage of the neuritis in the
vagus, inducing a motor inability of both the adductors
and abductors. But as it has been shown experimentally,
in animals, that the adductors are stronger than the ab-
ductors, a reduction of power in both sets of muscles
would render the equilibrium of the two sets of muscles
so unstable that reflex irritation of the motor laryngeal
fibres, or direct irritation of these fibres in the vagus by
the neuritis, would be responded to by a contraction of
the stronger adductors, analogously to the results of arti-
ficial stimulation of the motor laryngeal fibres in animals.
When the neuritis affects both the vagus and accessary
nerves together, the conditions are favorable for the pro-
duction of violent crises. A localization of the lesions
causing the other crises in tabes was based on Gaskell’s
description of the distribution of the sympathetic system.
Dr. A. SCHAPRINGER presented a case of
CONGENITAL BILATERAL ABDUCENS PARALYSIS WITH FA-
CIAL PARALYSIS.
The patient was a girl, eight years of age, with congen-
ital paralysis of both facial nerves, and inability to rotate
the eyeballs either to the right or to the left. The fac-
ulty of rotating the eyeballs upward and downward was
unimpaired, and so was the faculty of convergence. This
condition of the motor apparatus of the eyeballs is termed
by certain authors “bilateral abducens paralysis,” which
designation Dr. Schapringer considered insufficient and
misleading, and he therefore proposed the term “bilateral
pleuroplegia” as a substitute. There were only four sim-
ilar cases on record, viz., one each described by Alfred
Graefe, G. C. Harlan, Julian Chisolm, and P. J. Moebius.
Other co-existent anomalies present in the child exhibited
were: A protuberant glabella, bilateral epicanthus, a slight
deformity of the terminal phalanx of the left index-finger,
a bifid uvula, and a sunken sternum, representing a rudi-
mentary form of “funnel chest” (Zrichterbrust of the
December 21, 1889]
THE MEDICAL RECORD.
691
German authors). There was also a partial implication
of the motor portion of the fifth and of the hypoglossal
nerves.
2Dr. Schapringer considered the phenomena within the
sphere of the cranial nerves as due to a lack of develop-
ment of the brain involving the nuclei of the fifth, sixth,
seventh, and twelfth nerves.
Dr. SACHS was acquainted with the ‘case reported by
Moebius, which, however, differed from this in that there
were four nerve-nuclei affected in the latter. It was a
question whether this was a congenital condition or a
poliencephalitis superior occurring shortly after birth. He
referred to a case of his own of congenital bilateral ptosis,
and thought it was probably similar to those just described.
Dr. Secum had observed such a condition to follow
traumatism. A lady, ten years ago, was thrown from her
carriage, and made unconscious for several hours. She
had a double abducens paralysis, lasting several years.
He thought there was hemorrhage into the nuclei of these
nerves.
Dr. Corninc had seen a case precisely like that of Dr.
Seguin following a blow upon the neck.
Dr. BirDSALL described a case of double abducens
paralysis, occurring in a man whose head was caught be-
tween two car-buffers.
Dr. SCHAPRINGER said he had frequently seen cases of
double abducens paralysis, but that he knew of only four
TE there was in addition disease of other cranial nerve
nuclei.
Dr. C. A. HERTER read the clinical history and report
of the autopsy in a
CASE OF CERVICAL PARAPLEGIA FROM DISLOCATION.
J. F—, a mason, fifty-seven years of age, fell head first
from a scaffolding, a distance of twelve feet, striking wıth
his head against a board. Patient was conscious on admis-
sion to the hospital. Examination failed to elicit evidence
of fracture or dislocation in any part of the cervical spine,
but there was great tenderness of the sixth and seventh
vertebræ. There was complete motor paralysis below the
arms. ‘The forearms and arms were normal, but there
was weakness of the muscles of the hand. There was
also anesthesia and analgesia of the lower extremities ;
and of the trunk extending high up on the chest. On the
arms the anesthesia involved, roughly speaking, the dis-
tribution of the ulnar, internal cutaneous, and lesser in-
ternal cutaneous nerves, and was highly symmetrical.
With the exception of the plantar reflex of the left side,
both superficial and deep reflexes were absent when the
patient was admitted. There was a cincture pain about
the lower part of the neck, and above and below the
clavicles there was hyperalgesia. Below the neck there
was pronuunced myoidema, and fibrillary contraction
could readily be elicited. Respiration was purely dia-
phragmatic. Temperature on admission, 97.2° F. Reten-
tion of urine, and incontinence of feces.
Nine hours after admission it was found that the sensory
loss was the same as before, but the motor paralysis had
spread so as to involve the flexors and extensors of the
wrist, the triceps, and, to a less extent, the pectoralis
major, and the pronators and supinators. Very slight
power remained in the biceps. At the time no reflex
could be obtained. Respiration continued diaphragmatic.
The pulse was somewhat feebler than on admission, but
good. The temperature had risen during the afternoon
following admission to 104° F.
On the day following admission the patient’s condition
was about the same, except that the biceps was somewhat
feebler. During the afternoon of this day there was some
embarrassment of respiration, and on the second day after
admission the patient died from respiratory failure, having
survived the injury forty hours.
The autopsy, which was conducted after death, revealed
a dislocation forward of the sixth cervical vertebra, and an
oblique fracture through the left superior articular process
of the sixth vertebra. The forward displacement of the
sixth vertebra was probably not more than one-third of an
inch. How much pressure was being exerted on the cord
at the time of the autopsy could not be determined. Ex-
amination of the cord showed that the eighth cervical seg-
ment was extensively disintegrated, and that the seventhwas
considerably softened by the displacement of the vertebra.
At the junction of the sixth and seventh segments the
central canal was distended by hemorrhage and there
seemed to be some extravasation into the surrounding
gray matter. Above the sixth segment the cord was nor-
mal. ‘The case supported the view that the peculiar dis-
tribution of the sensory disturbance noted in the upper
extremities depended on a lesion of the eighth cervical
and first dorsal segments, and that in this case the biceps
was represented at a lower level than is considered
usual, #.¢., in the lower part of the sixth segment.
Dr. STARR said our knowledge was not yet complete
with regard to localization in the cord, and every such
case was very valuable. In his table he had located the
biceps-nuclei in the fourth segment because it was so
often associated with the deltoid in paralysis, and this
was the level of the latter muscle. It seemed, from Dr.
Herter’s case, that the biceps-group of cells had a vertical
arrangement of greater length than he had supposed, ex-
tending probably from the fourth down through the cord
as low as the seventh segment.
. Dr. HERTER thought that the nuclear arrangements
might differ in various people, and in his case the biceps-
nucleus may have been lower than usual.
Dr. Dana hoped that Dr. Herter would examine his
experiments with Dr. Abbe in two cases where, in opera-
tions upon the spine, he had applied electricity to the
nerve-roots, and shown that there was much more over-
lapping of cell-groups than was ordinarily supposed.
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, December 5, 1889.
ALFRED L. Loomis, M.D., PRESIDENT, IN THE CHAIR.
Tue following nominations were made: For Vice-Presi-
dent, one to be elected, Drs. R. C. M. Page and Joseph
D. Bryant ; for Zrustee, Dr. Laurence Johnson ; for mem-
ber of Committee on Admissions, fullterm, Dr. A. Caillé—
short term, Dr. French, of Brooklyn ; member of Commit-
tee on Library, Dr. Egbert H. Grandin.
Dr. J. D. BRYANT read a paper on
THE HEALTH DEPARTMENT AND THE CONFERENCE COM-
MITTEE OF THE ACADEMY OF MEDICINE.
The subject of the paper, he said, was certainly of
great interest to the Health Department (of which he was
a member), and should be of interest to the medical pro-
fession of the city. He knew of no good reason why
legalized action for the prevention and treatment of dis-
ease, as embodied in the Health Department, should not
receive the earnest support and hearty co-operation of
that profession, which sought the same end, although by
somewhat different means. It was true, no doubt, that
unavoidable friction would here and there arise, but
“ friendly and considerate friction makes good friendship
brighter and keener, while unkind and thoughtless oppo-
sition darkens, dulls, and often destroys it, substituting
confusion for order, defeat for victory, disaster for suc-
cess, and not infrequently death for existence.”
The Commissioners of the Health Department recog-
nized the need of the sympathy, advice, and support of
the medical profession, and he thought no wiser thing had
been done than when, at its suggestion, two years ago,
the Academy appointed a conference committee to confer
with it, consisting of five members. The gentlemen then
appointed were Drs. Agnew, Janeway, Stephen Smith, and
Derby ; the then president, Dr. Jacobi, also becoming a
member. Valuable suggestions and aid had been ren-
dered by this committee and the pathologists of the de-
partment, Drs. Prudden, Biggs, and H. P. Loomis, in
692
THE MEDICAL RECORD.
{December 21, 1889
matters concerning quarantine against imported disease,
diagnosis of Asiatic cholera based on bacteriological in-
vestigations, the getting up of a disinfectant plant situ-
ated at the Willard Parker Hospital, the prevention of
tuberculosis, etc. A warm compliment was paid Dr. Ag-
new, who, as a member of the Conference Committee, had
manifested his usual devotion to the public welfare at the
sacrifice of personal interests. The department had not
only established a disinfectant plant at the Willard Park-
er Hospital, where infected material cquid be promptly
and safely destroyed, but it was its purpose to found dis-
infecting laundries where infected textile fabrics could be
disinfected and returned to the owners. The author gave
a condensed statement of some of the work done by the
department, with the aid and advice of the Conference
Committee; since its appointment in 1887. ‘The number
of buildings inspected during that time, in which there
had been contagious diseases, was (we give the round
numbers) 35,000. Of the forms of disease, there were a
few cases of typhus fever. 2,000 typhoid, 16,000 scarla-
tina, 10,000 measles, 13,000 diphtheria, 285 cerebro-
spinal meningitis, 216 small-pox, 878 phthisis, 128 tu-
bercular meningitis, 52 dysentery, 61 malaria, 23 tabes
mesenterica, 4 entero-colitis; total, 44,000. The num.
ber of rooms fumigated was 33,000; number disinfected,
116,000. It was not uninteresting to note that SO, was
as good an agent for disinfecting as any. It would be
noticed that the department was investigating the question
of contagion and spread of tuberculous disease, and if it
found sufficient reason for it, physicians would be re-
quested to report cases coming under their notice, and
like precautions would be taken as in certain of the con-
tagious fevers. Visiting houses where contagious diseases
existed had led to eight thousand complaints of the sani-
tary condition present, which otherwise would not have
been reported, or at least not so soon.
During the thirty-two months ending with November
Ist, over one thousand cases of contagious diseases had
been received at North Brother Island Hospital, and 1,780
at the Willard Parker Hospital. In the latter hospital
the mortality rate in scarlet fever in children, out of 425
cases treated, was 20.7 per cent.; diphtheria, 519 cases
treated, 20.85 per cent. At North Brother Hospital,
small-pox, cases treated over 300, mortality rate 19.69
per cent. ; scarlet fever in adults, cases 361, mortality
rate 10.87 per cent.; measles, about 200 cases treated,
mortality rate less than seven per cent. ; whooping-cough,
cases 32, mortality rate 16.62 per cent. ; typhoid fever,
cases 4, mortality rate seventy-five per cent. A few
cases of typhus, mumps, chicken-pox, all recovered. Out
of 1,001 cases treated, the average mortality rate had
been 13.49 per cent. ‘These results compared fairly with
cases treated outside in the city of New York from Janu-
ary 1, 1888, to November 9, 1889, as follows: Scarlet
fever, cases (round numbers here given) 14,000, mortal-
ity rate 16.44 per cent.; diphtheria, cases 11,000, mor-
tality rate 29.33; measles, cases 13,000, mortality rate
7-77; typhoid fever, 2,300, mortality rate 26.63 ; chick-
en-pox, cases 16, mortality rate 31.25 per cent. These
were the only diseases which could be used for compari-
son. He added that the four cases of typhoid fever ad-
mitted to North Brother Island Hospital were very severe
cases when they entered.
In the vaccination department, the total number of
vaccinations in 1888 had been 83,000; of the primary
vaccinations eighty-three per cent. had been successful ; of
the secondary vaccinations 47.5 per cent. had been success-
ful at the first attempt, and twenty-four per cent. at the
second attempt. The figures for 1889, as far as they had
been made out, were in nearly the same proportion. During
the past five years the record of births per year had aver-
aged 32,407, while the number of primary vaccinations by
the department had averaged over 24,000 per year. He
said it would thus be seen that the city was well pro-
tected against small-pox.
The importance of having in the city sufficient and
suitable accommodations in which cases of contagious
diseases could be treated among transient people and
others who, by reason of their affluent circumstances,
could avail themselves of the attention which they would
like to receive, and were excluded from hotels and pri-
vate houses, should be given most earnest consideration.
This became more important in view of the proposed In-
ternational Fair, sHould it be held here.
Other work done by the department had been to thin
out the overcrowded rooms in the Italian districts. ‘The
population of such crowded rooms had been reduced
during the past sixteen months by seven thousand people.
The prevention of the adulteration and sale of un-
wholesome food had not been lost sight of by the depart-
ment. In less than two years it had condemned and de-
stroyed 17,741 quarts of milk, 827 tons of fish, 428 tons
of meat, 1,546 tons of fruit and vegetables. The arrests
and fines made in connection with these seizures had
proven somewhat salutary, as was shown by the following
statement: In 1888 there were 450 arrests, with fines
amounting to $13,027 ; in 1889, to November rst, there
had been only 264 arrests, with fines amounting to $8,835.
Since 1879 the Department had had the power of ap-
proval or disapproval of all plans for the construction of
tenements and lodging-houses, as related to light and ven-
tilation ; also the approval and disapproval and supervision
of all changes made in buildings to be used as tenements
or lodging-houses, as regarded light and ventilation ; apd
since 1881 the department had had the approval and dis-
approval and supervision of the plumbing of buildings
erected in the city. This involved great responsibility
and labor, and a high degree of special knowledge and
vigilance on the part of those engaged in the work. ‘The
last two years, ending with November 1, 1889, the plumb-
ing plans supervised had been 3,157 ; light and ventila-
tion, 1,935 ; covering, so far as concerned plumbing, over
6,000 houses, and for light and ventilation over 3,500
houses.
It was not necessary to speak of vital statistics, with
‘which the profession was already familiar, and other de-
tails which would grow wearisomely long. It would be
of interest, however, to state that the Health Commis-
sioners contemplated the enforcement of an approved
method of the disposal of stable manure on or about the
ist of May. The permanency of position and promo-
tion of those engaged in the service of the department
would depend upon the faithfulness and ability with which
they discharged their duty. The department requested
the earnest support of the profession and laity in the dis-
charge of its duties, and requested that the vacancy in
the Conference Committee made by the death of Dr.
Agnew be filled, and that the President of the Academy
be always a member.
Dr. A. Jacosi, being requested to open the discussion,
said he hoped that at the proper time two motions would
be introduced and prevail. (They were introduced and
adopted later as new business, making the President a
member of the Conference Committee, and requesting Dr.
Bryant to read a report on the disposal of manure at the
next meeting of the Section on Public Health and Hygiene.)
Dr. Jacobi went on to say that he was ever of opinion
that every man had a right and a duty to give the very
best he had in the service of the community. Now, the
best which the Academy had was its collective knowledge.
He was not at all of the opinion that every individual
physician was an expert in everything that might pertain
to the Department of Public Health, but he did know that
the medical profession, as represented in the Academy of
Medicine, was and ought to be expert in everything medi-
cal. Heincluded among things medical dietetics and hy-
giene, in all their aspects. When, as President, he invited
Dr. Bryant to read his paper before the Academy, two
years ago, in which it was suggested that a conference
committee be appointed, he knew that the Academy would
certainly show its willingness to aid the Health Department,
and it had done so whenever it had been expected of it.
December 21, 1889]
ee in
The Academy had been recognized for some time as rep-
resentative of the medical profession in this city, and
justly so, and the medical profession had been recognized
as at least fit to be associated with the Public Health De-
partment. It was known that for a long time past a med-
ical man had been a member of the Health Department.
That was not more than could be expected. But some-
thing more might have been expected. For instance,
there was a law forbidding a medical man being president
of the Department of Public Health. Some were of
opinion that that was a good law ; many of the profession
believed that it was not ; but this much was sure, that for
a good many years past the men at the head of the Health
Department had done everything in their power to facili-
tate the work of the medical men who had charge of med-
ical matters. We had all been in contact a good deal
with the former president of the Board of Health, and
had found that he was efficient and willing to serve the
interests of the community ; and he knew from the very
best possible source that the present incumbent tried to
obey the same law, and left medical matters in charge of
the medical member ; and on this fact the Health Depart-
ment, the public, and the medical profession could be
congratulated. | .
He wished to make a few suggestions. First, that the
attention of the department in the future be directed to a
part of the furniture of buildings inspected for their gen-
eral sanitary condition, or because of the presence of con-
tagious disease within their walls. For instance, in tene-
ments and flats occupied by eight to twenty families, the
stairs would be found covered with carpet which became
the receptacle of all sorts of disease-germs, including such
contagious diseases as scarlet fever, diphtheria, etc. He
approved of the author’s remarks on the need of a hospi-
tal for the reception of strangers and others taken down
with contagious diseases, and said he thought there was
need of as many as a score throughout the city for all
classes, citizens and strangers. A child with diphtheria
was exposed to repeated attacks when confined to one
room in order to isolate it from other members of the
family ; relatives and friends feared to receive it when
convalescent, as they did also its healthy brothers and sis-
ters. It would be well to have a quarantine station at
which the healthy members could be received for a time un-
til danger of contagion in their homes could be removed.
Mr. C. C. WILson, president of the Board of Health,
said: Thanks for your kind invitation, I have been able
to listen this evening to the reading of a paper upon a sub-
ject which is most interesting to me at the present time, :
namely, the best means of enabling the Board of Health
to promote the well-being and the good of the people of
the city of New York. It seems to me, from the position
taken by the author, that the paper admits of scant criti-
cism. From observations made during the six months I
have been connected with the Health Department, and
from a careful investigation of its records since 1873, I
am convinced of the wisdom and necessity of maintain-
ing close relations between the medical profession of this
city, the Conference Committee of the Academy of Med-
icine, and the Board of Health. Your honorable body
is not only well abreast the science of the day, but it
makes it practical, and transforms the dream of the theorist
into the reality of the philanthropist.
The powers of the Board of Health are ample, but it
needs at all times your active co-operation and support.
It has been well said that all laws are but as ink and
parchment unless supported by public approval, and in
your special province no class or profession wields so
powerful an influence, and is so widely heard, as yours.
Hence we welcome suggestions from you as to what is
best, and join hands heartily with you in breaking down
prejudice and objection. With your aid, the Board of
Health will be enabled at all times to strike telling blows
at the foundation of disease.
Without going into details, the several bureaus of the
Board of Health are so constituted, in my opinion, espe-
THE MEDICAL RECORD.
693
cially with regard to the hospital service, and the bureau
of contagious diseases, as to be ready at all times for any
emergencies they may be called upon to meet. For my-
self, I have mapped out a course since I have had the
honor to act as one of the Commissioners of Health, and
that is, to stand shoulder to shoulder with my colleagues,
while managing the department as economically as pru-
dence suggests. While doing this, let me assure you, one
and all, and I know I voice the sentiments of my asso.
ciates, every suggestion of your Conference Committee
will be well and favorably received and considered, and
carried out if possible. ‘Thus favored with your advice
and moral support, who shall say that, of all great cities,
ours is not only the one from which disease and pestilence
is shorn, but also the one most blessed with that happiness
which springs of freedom from suffering. i
Dr. D. B. St. Joun Roosa said he thought it would
not be considered offensively eulogistic, inasmuch as he
would later have something to say which could not at all -
be considered in that light, if he remarked in the beginning
that, no matter what else we may have been fortunate in
in the Board of Health, we had been extremely fortunate
in the medical men who had represented us. But, he said,
he had not come to the meeting in any complacent mood. .
He was not satisfied with the condition of things in New
York. He considered the great work done by the Board of
‘Health (and no man appreciated its greatness more than
he did) as but rudimentary. Every city that maintained
itself at all in the category of decent cities ought to super-
intend the meat and milk, the tenement-houses, to vac-
cinate the children—those things which had been done so
well here. Dr. Jacobi had said that the medica] matters
of the Board were referred to the medical member. But
there was not a matter, from A to Izzard, which came
to the hands of the Board of Health, which was not a
medical matter, and the majority of the Board ought to
be medical men. ‘The present law, which said thåt a med-
ical man could not be president of it, was an offence to the
profession. The distinguished president of the Board had
said that the powers of the Board were ample. He was
glad to hear it. Yet, with all this power, we had to wait
until the rst of May for the correction of the manure nui-
sance. Besides, in this matter he would say, with due re-
spect to the Board, that he would believe when he saw.
Then, consider the condition of our streets: Yet he had
never even heard it suggested that the Board of Health
ought to do. anything about that. He would advise more
ample powers. And so of the death-dealing electric wires,
the subways, etc. |
Dr. E. G. Janeway remarked that there were two
sides to every question, and if he might say a word apropos
of the remarks of the last speaker, he might assert that
there were two sides even to the manure question. There
were certain controlling methods by which the Board of
Health was alone able to exist and retain its powers. If
it should attempt to carry out all that the law had given
it power to do, it would soon kill itself. Arbitrary and
radical measures, carried out in a way to compel changes
in an instant in the method of doing thirgs, would
be impossible, or would arouse such public indignation
as would crush the Board and put it out of existence.
Some of the most urgent criticisms upon the Board which
he had heard came from medical men. We made those
criticisms when the matter came home to ourselves, but
when it concerned other people we wanted to see radical
and instantaneous relief. In the matter of co-operation,
there was no doubt a great deal could be done by the
medical profession in assisting the Board of Health. It
could be done in two ways: by kindly assistance, and
withholding invidious criticism. Regarding the found-
ing of other hospitals for contagious diseases, he said
there would be great difficulty in selecting a site, as there
was in the case of the Willard Parker Hospital, neighbor-
ing property owners and others objecting even where
grounds could be purchased. In the event of the Inter-
national Fair being held here, a hospital should be estab-
694
lished near, but not on, the fair grounds. As to the elec-
tric wire question, it had been settled that power rested
in another department. Finally, he would suggest to
those who had criticisms to make on the actions of the
Board, that they make them to the Board, and in a spirit
to assist in correcting the evil; or, if their impressions
were erroneous, to have themselves set right, and thus
avoid unnecessary irritation. Let none recommend per-
sons for a position in the department for whose fitness he
could not personally vouch.
Dr. DANIEL Lewis said that in past years he had him-
self thought an injustice was being done physicians in
disqualifying them by law for the presidency of the Board
of Health. But since he had become better informed of
the duties of that office, he had come to the conclusion
that it would be utterly impossible to secure a physician
of repute in this community who would take it and per-
form all the duties pertaining thereto. For instance,
would Dr. Roosa be willing to go down at nine every
morning and remain in the office three hours looking over
coal bills, signing checks, and the like? It was true, as
he said, that these matters were all medical, but they
were attenuated to the third and fourth dilutions. He
for one was satisfied, for he believed we had a Board of
Health with which we might and ought to co-operate.
Regarding the powers of the Board, they were no doubt
ample, and the danger was that it might exert those pow-
ers to the full extent. At least that was the fear of some
citizens. Take the hospital for contagious diseases,
there were many parents who objected to having the
presence of scarlet fever in their family reported, through
fear their child might be taken from them and placed
under the care of a strange physician and strange nurse,
and for that reason they sought to evade the law and not
have the case reported. Nor was it conducive to recov-
ery to have these little patients transferred in an ambu-
lance from Harlem down to Sixteenth Street, to the Willard
Parker Hospital. Thus it was evident that in all the
Board of Health did the public interest, the interests of
individuals, must be taken into consideration. The per-
centage of recoveries from contagious diseases outside the
hospitals was probably greater compared with that in the
hospitals, given by Dr. Bryant, for the reason that many
cases without recovered, not having been reported at all.
Dr. H. J. Biccs wished to call attention to the fact that
the action taken by the Board of Health, with regard to in-
fectious diseases, showed that in this respect it was fully
abreast the most advanced ideas on the nature of these
diseases. ‘This was shown in its providing for the disin-
fection of clothing; its investigations regarding the best
method of preventing the spread of tuberculosis, eta
Yet there was probably only a small proportion of the
profession who yet took practical note of the fact that
tuberculosis was contagious.
Dr. Cyrus Epson, of the Health Department, said, in
order to prevent misapprehension, that the department
did not take children to the hospital without consent of
their parents, unless great danger to others was incurred
by leaving them at their tenement-homes. As to new
hospitals for contagious diseases, he said the difficulty of
obtaining sites might be met by erecting separate build-
ings on the grounds of present hospitals. Mount Sinai
Hospital, for instance, had a good ward for contagious
diseases, as had also the Nursery and Child’s Hospital.
Dr. Bryant said, in closing the discussion, that the
danger of the Health Department taking charge of the
street cleaning, if it could do so, would be in its going be-
yond that work which was recognized as coming directly
under sanitary matters in the accepted sense of the term,
and not in the broad sense of the term which Dr. Roosa
had mentioned. With regard to the electric wire, counsel
had decided that it could not interfere. Regarding the
Willard Parker Hospital, they had good nurses there to
take care of the little patients, but mothers could come if
they wished, and could send the family physician to take
charge of the patient.
THE MEDICAL RECORD.
[December 21, 1889
MEDICAL SOCIETY OF THE COUNTY OF NEW
YORK.
Adjourned Annual and Stated Meetings, November 25,
1889.
ALEXANDER S. Hunter, M.D., PRESIDENT, IN THE
CHAIR.
Jutius ALTHAUS, M.R.C.P., and Henry Morris,
L.R.C.S., London, were elected to honorary membership.
THE PRESIDENT read a brief address, in which he ex-
pressed appreciation of the renewed expression of conf-.
dence shown in his re-election, stated that essentially the
policy of last year regarding scientific work would be ad-
hered to, and made some strictures upon the medical
journals in their relations to the societies. He then ap-
pointed the following
COMMITTEES.
Committee on Ethics—Dr. E. L. Partridge, Chairman ;
Drs. H. E. Crampton, O. B. Douglas, A. M. Jacobus, and
E. S. Peck. On Hygiene—Dr. Simon Baruch, Chair-
man; Drs. R. C. M. Page, J. E. Janvnn, Cyrus Edson,
and Henry D. Chapin. On Prize Essays—Dr. L. Bolton
Bangs, Chairman; Drs. E. H. Grandin and Andrew F.
Currier. Auditing Committee—Drs. William Stevens and
R. M. Fuller.
Dr. Marcom McLean then read a paper (see p. 676)
entitled
CONSERVATISM IN GYNECOLOGY AND OBSTETRICS.
Dr. THomas ADDIS Emmet fully indorsed the views
expressed by the reader of the paper. The pendulum, he
said, had swung far enough in one direction, and it was
certainly time for it to begin to retum. He had fought
the extreme tendency toward operative interference,
shown especially by the younger members of the profes-
sion, for some years, and felt that in doing so he had
about lost caste. By some of his younger frends his
want of appreciation had been attributed to advancing
age, but he himself did not think this could be true, since
he felt even more eager to learn now than he did twenty-
five years ago. So far as the gynecological abuses which
had called forth a paper of this nature were concerned,
especially in the direction of removing the tubes and
ovaries by surgeons in this country, he felt himself some-
what responsible. It was six or seven years ago that he
was in Europe, and hearing Mr. Tait much spoken against
in London he thought it probable some injustice was be-
ing done him, and, although he had no personal acquaint-
ance with him, he went to see him, was received with
marked courtesy, and became convinced from what he
observed that he was doing a good work. He showed
him about seventy-five or eighty pairs of tubes put up in
bottles, with full histories, and gave him opportunity to
see some patients operated upon, and there seemed to be
no question that the condition present demanded the
operation. Dr. Emmet was given some specimens,
which, on his return, he presented at the first meeting of
the Obstetrical Society, and indorsed the operation. Up
to that time it had been practically unknown in this coun-
try, but he fully expected within a week to find a case de-
manding it. Three years, however, passed before a case
presented itself to him in which he thought the operation
was justifiable, but in the meantime, in the hands of the
younger men it had spread like wildfire on a prairie, and
he had to turn and fight it in its destructive progress.
One of his younger friends had said that he was honest,
but was getting too old to learn anything new. Certainly
there were cases of pyos&lpinx of clearly gonorrhceal his-
tory which could not be relieved in any other way than
by an operation, but they were very few. He had found
that over fifty per cent. of the cases which had come to
him after other surgeons had said they could not get well
without removal of the tubes and ovanes did get well at
his hands without an operation. He could recall such a
case even in which the origin of the tubal disease could
December 21, 1889]
be clearly traced to gonorrhoea, yet the patient subse-
quently conceived and bore a child. Indeed, many of
the cases in which removal of the tubes and ovaries had
been pronounced a necessity would get well without any
treatment whatever at the hands of a physician. Nature
would sometimes cure a pyosalpinx as she would cure
any abscess, by adhesive inflammation after discharge of
the tubal contents had taken place through the uterus.
Regarding too frequent removal of the ovaries, he had
never sanctioned their removal except for malignant dis-
ease or cyst.
He had at one time ceased his attendance on the Ob.
stetrical Society because it had come to be really an
ovarian society, a soup-plate full of ovaries being served
up at every meeting, many of which were simply under-
going the vesicular degeneration pertaining to their normal
function, and he was unwilling to admit the position that
it was necessary to spay a woman in order to cure her of
nervous symptoms which he claimed were due to impaired
nutrition or anemia. Such an admission was a reflec-
tion on our skill as physicians. He had cured many
such cases, but some men seemed to be too lazy, or
lacked the skill to carry out the necessary steps, and
save the patient from the mutilation of the knife. In the
operation for repair of the cervix with which his name
had been connected, surgeons so often exhibited such im-
patience, or lack of skill, or want of judgment in the se-
lection of cases, that he sometimes thought the operation
had in the aggregate done more harm than it had done
good. In dysmenorrhcea, gynecologists were not satis-
fied to cut the cervix, but must tear it open even by the
most violent means ; yet if his experience of forty years
had taught him anything, it was that obstructive dysmen-
orrhoea was only a myth; that the dysmenorrhcea was
due to impaired nutrition of some form. He might thus
go on criticising meddlesome gynecology indefinitely, did
time permit. He would mention one point in regard to
conservatism in obstetrics. The Woman’s Hospital was
first founded for the treatment of vesico-vaginal fistula,
and there came under his charge, either directly or
through the service of Dr. Sims, over five hundred cases.
In analyzing them some time ago he was surprised to find
that the cause was, in nearly all instances, not instru-
mental delivery, but delay. It taught a valuable lesson,
namely, that it was very dangerous to delay the use of the
forceps when they were called for. As soon as impac-
tion took place, the sooner the woman was delivered the
better. Mr. Barnes, of London, had written him several
years ago rather reflecting on our skill as obstetricians in
this country, since one man had seen as many as five
hundred cases of vesico-vaginal fistula, but, on looking up
the histories of those cases, Dr. Emmet found that fifty-
eight per cent. of them were immigrants recently landed
from Europe, especially parts of Ireland where they were
too poor to obtain proper medical service.
Dr. H. C. Cor said he had been strongly impressed by
a concluding sentence in the paper bearing on the proper
instruction to be given at the postgraduate schools. He
had found in that field that conservatism in gynecology
was an exceedingly unpopular position to take. In fact,
one who took that stand on days when the hospitals of-
fered an opportunity to witness a laparotomy was likely
to be mortified on entering the lecture-room to find many
vacant seats. It seemed to him we were in danger of
forgetting that laparotomy constituted only a very small
part of gynecological practice. It had been his constant
attempt to impress students with the fact that when they
returned home they would probably have ten cases of re-
troflexion of the uterus to one of laparotomy; probably
the ratio would approach more nearly ninety-nine to one.
He had discussed the pathological side of the question
pretty thoroughly several years ago, and in doing so had
come pretty constantly in collision with Mr. Tait, yet he
had not found any reason to alter his views. His stand
was that removal of many of the tubes and ovaries, exhib-
ited at the societies, was hardly justified by the findings of
THE MEDICAL RECORD.
695
the pathologist. He believed, however, that there were
now far fewer uterine appendages removed which were only
slightly diseased than there were three or four years ago,
and he further believed that four years hence the number
would be much smaller still. He firmly believed that the
triumphs of the future were going to be in other fields
than laparotomy ; that extra-uterine foetation, retroflexion
and fixation of the uterus, etc., would become of greater
interest because of being met with every day, even by the
general practitioner.
Dr. EcBERT H. GRranpin thought the Socitty could
not be too grateful to Dr. McLean for his conservative
paper. The opinions which it expressed were:so thor-
oughly in accord with those which he had always held
that he could find absolutely nothing in it to criticise.
He had seen, and was still seeing, in a somewhat active
gynecological practice, scores of women with uterine and
peri-uterine disease, yet he had seen very few whose tubes
and ovaries he had been obliged to remove in order to
render them comfortable or in some even to effect an ab-
solute cure. He was satisfied that the laparotomy craze
which had started from Birmingham a number of years
ago had done more harm to womankind than it had done
He was also satisfied that we had about reached
the end of it. So far had it gone that it was not uncom-
mon to hear gentlemen who had but recently been gradu-
ated from a medical school boast of having opened forty,
fifty, or seventy bellies. He had made it a rule for him-
self to consider no woman’s tubes or ovaries in a condi-
tion demanding the knife, with two exceptions, which he
presently mentioned. Although on examination he found
the uterus adherent, and felt bogginess on either side in
the region of the appendages, and the patient in consider-
able pain, he was still willing to try what could be done
by the use of the glycerine tampon, blisters, prolonged
hot douches as recommended by Dr. Emmet, mild gal-
vanism, etc. If, after months of persistent treatment of
that kind (if he were able to keep her out of the hands of
some laparotomist that length of time), he was still unable
to make her comfortable, he would be willing and ready
to open the abdomen and take out the uterine append-
ages. But in his experience such treatment was capable,
usually, of putting the patient in a condition of comfort.
It might not cure her, some physical signs might remain,
but if she was comfortable, and might remain so to the
end of her life, it was not necessary to tell her that she
was still diseased, or to take out her tubes and ovaries to
be able to assure her that a radical cure had been effected.
The two exceptions alluded to were in cases in which the
ovary was really cystic, not simply covered with normal
Graafian follicles, and cases of distinct pyosalpinx with the
tube behind the uterus, its purulent contents below its
uterine extremity, incapable of being drained into the ute-
rus. In those two conditions one should not temporize,
but should operate at once, and check progress toward a
worse condition. Other treatment than by laparotomy
would be likely to do harm, while it could do no good.
In obstetrics he thought physicians were likely to use
the forceps too soon ; that is, where they were not really
indicated. Often where these instruments were applied
version would answer a better purpose. The diameters
of the pelvis should be carefully measured before resort-
ing to the forceps; if contraction existed, and the head
had not engaged, version would prove more conservative
than the use of the forceps. But when the cervix had di-
lated and the head had engaged, if delivery did not take
place within half an hour it was his custom to put on the
forceps. It spared the woman pain and also the compli-
cations to which Dr. Emmet had referred.
Dr. COLLYER said he had seen some cases at the dis-
pensary, with symptoms due to dysmenorrhcea, which
evidently might have been cured by curetting, and perhaps
otherwise treating the endometnum, yet they had fallen
into the hands of enthusiastic laparotomists in the begin-
ning of their career and had been subjected to removal of
the tubes and ovaries. One case was that of a woman
696
THE MEDICAL RECORD.
[December 21, 1889
suffering from dysmenorrhea, who had retroflexion and
some enlargement of the tubes, whether a hydrosalpinx or
a pyosalpinx he was unable to say. She consulted many
surgeons at their offices, who advised laparotomy, yet she
recovered under the use of glycerine tampons, galvanism,
and subsequent use of Cutter’s pessary. She had then
been free from pain two years. He had seen other cases
of retroflexion with adhesions, and enlargement of both
ovaries and tubes, in which conception and the birth of a
healthy child afterward took place. In one of those cases
the pyosalpinx originated in a gonorrheea. In obstetrics
he had seen many cases of injurious consequences follow
delay in the use of the forceps, and some from misapplica-
tion of the forceps, the physician being ignorant even of
the kind of presentation.
Dr. H. J. BoLpT had been much pleased with the paper
of the evening. It recalled to mind one which he had
written some time ago, in which he took about the same
ground. He held that it was wrong to remove the tubes
and ovaries, although the tubes were distended, unless
three or four months’ treatment failed to produce any
benefit, the patient continuing to grow worse rather than
better. It was impossible to say at the operating table
that the condition present was simply one of catarrhal
salpingitis ; it could be determined only by a pathological
examination. In pyosalpinx a cure could not take place
unless the -extremity of the tube was patent. It was not
right to jeopardize the life ofthe patient by postponing an
operation when one had. become convinced that the tube
contained pus and was closed. If pathogenic micro-or-
ganisms were present in the tube, if the condition were an
active one, any delay would subject the patient to the
dangers of rupture into the abdominal cavity. As long as
pus escaped into the uterine cavity laparotomy should not
be done, but he had seldom seen such cases. Where actual
tumors of the ovary existed an operation should be done
at once ; they should never, in his opinion, be punctured
through the vagina. He quite agreed with the author
regarding the treatment of parametric conditions, such as
. adhesions with displacement. But there was no one mode
of treatment which could be regarded as a panacea for all
cases.
Dr. A. P. Duprey said he appreciated the paper, for
he believed in conservatism himself, yet he had perhaps
operated pretty often for a young man. In the figure of
the turning of the tide, he said he thought it was getting
full of experience and was moving more slowly. The
key-note in the paper really was one of diagnosis and
differential diagnosis. He believed he had seen tubes and
ovaries removed many times in the past when they should
not have been sacrificed. He was not yet convinced that
there was nothing in the idea of pelvic cellulitis; that
there might not be a swollen condition around the tube
while the tube itself remained comparatively healthy, and
that conservative treatment would relieve the patient and
enable her to bear children. But he felt assured that
where pyosalpinx existed, necessarily with some adhesion
at the fimbriated extremity to permit the dilatation, the
patient would never be likely to conceive. He did not
think that the comparison instituted by the author between
epididymitis and pyosalpinx was at all applicable to the
argument, for the conditions in the two localities were
entirely different. In woman adhesive inflammation was
likely to take place among organs which would subse-
quently give rise to most aggravated symptoms. ‘The in-
dications for removal of the tubes and ovaries mentioned
by Dr. Grandin were well founded, and the question
reduced itself to one of diagnosis and differential diag-
nosis. An important work for postgraduate schools was
to teach men to recognize the condition present. Like
Dr. Grandin, he had been thirteen years getting together
about seventy-two abdominal sections, and it seeme? to
him want of conservatism was manifest when quite recent
graduates were able to report a larger number. In all
his cases, however, he had found sufficient disease to more
than warrant the operation. ‘The patients were nearly
always first subjected to the treatment described by Dr.
Emmet. The author had said that frequently patients
were not benefited by the operation, and Dr. Dudley
thought one chief reason for that fact was the custom,
especially in the past, not to move the bowels for some
days after the operation. This allowed adhesions to take
place, giving rise to intestinal and other symptoms. He
now uniformly moved the bowels within the first twenty-
four hours, and refused to give morphine.
Dr. R. A. Murray believed in conservatism in surgery,
especially abdominal surgery, but he feared too many had
learned to aspire after brilliant results rather than good re-
sults unattended by mutilation, when the latter could not
be brought about except by patience and labor. More-
over, that which required time was not likely to be sub-
mitted to by the patient. Much had been said about
laparotomy being done too frequently, but it had certainly
taught one important lesson, namely, how best to do it and
the little danger which attended it. As Dr. Dudley had
said, the key-note to the whole discussion was one of diag-
nosis. It was very easy to make a mistake in diagnosis in
abdominal conditions. Even the most expert had some-
times said they would assert what was in the abdomen af-
ter they had opened it, but not before. There might be
cases in which that statement was proper, but generally
it was quite inexcusable. There was a field for conser-
vatism which had received too little attention, namely,
prophylaxis. Many cases in which abdominal section
had been made might have been prevented by the correct
management of labors and abortions, gonorrhoea] inflam-
mations, endometritis, etc. ‘The greatest advance in the
future would, he thought, relate to the proper treatment
and early cure of acute inflammations before adhesions
and chronic conditions resulted. Here much would de-
pend upon the general practitioner, since it was for chronic
conditions that patients usually came to the specialist. <A
radical operation, however, was sometimes in the highest
degree conservative, and was indicated in conditions men-
tioned by Dr. Grandin and other speakers.
Dr. MCLEAN, in closing the discussion, expressed his
appreciation of the honor conferred in the presence of Dr.
Emmet, and of his remarks, which, as always, were to the
point. Nothing in his paper should be construed to mean
that he was otherwise than fully in accord with his views
regarding the cause and prevention of vesico-vaginal fistula.
In general, he quite agreed with the remarks of the other
gentlemen, but he would like to ask Dr. Boldt how often
he had seen fatal peritonitis from rupture of the tubes.
The accident, he believed, occurred so seldom that the
fear of it should not be made the excuse for so frequent
abdominal section where conservative measures might
have spared the tubes and ovaries.
If the conditions of those organs present in many speci-
mens which had been exhibited at the societies in the
past demanded their removal, he believed that four-fifths
of the women of to-day were fit subjects for ovariotomy.
How was it, he would ask, that the accidents to which
these women were said to be liable so infrequently
occurred in the past when laparotomy was seldom per-
furmed ?
Dr. BoLDT replied to the question, that he had himself
operated in four cases for peritonitis due to rupture of a
pyosalpinx, and had seen two other cases not operated
upon; two years ago he attended an autopsy at the New
York Hospital by Dr. Ferguson, who said the fatal peri-
tonitis was due to rupture of a pyosalpinx. He knew also
of two or three other cases. With regard to what became
of so many of these cases in the past, he said they were
called cases of idiopathic peritonitis.
‘THERE is no time when a hospital manager feels his im-
portance more than when a respectable medical man begs
him for his vote to obtain a position on the medical board.
Yet every medical man must do it, and every manager’s
head swells accordingly.
December 21, 1889]
Correspondence.
OUR LONDON LETTER.
(From our Special Correspondent.)
THE ELECTROLYTIC TREATMENT OF URETHRAL STRICTURE
-—EROSIONS OF THE OS UTERI IN MONKEYS, AND THEIR
PATHOLOGICAL RELATIONS TO CANCER IN HUMAN FE-
MALES— THE RECENT SESSION OF THE GENERAL MEDI-
CAL COUNCIL—DESIRABLE REFORMS IN THE METHODS
OF REGISTRATION OF DEATHS—MEDICAL CASES IN THE
LAW COURTS.
Lowpon, December 7, 1889.
AT the last meeting of the Medical Society of London, a
discussion took place on the treatment of urethral strict-
ure by electrolysis. The general tone of the discussion
was far from favorable to the electrolytic method. The
subject was introduced by Mr. Bruce Clarke, who read a
paper in which was embodied his experience of the
method for four years and a record of fifty cases. It was
extremely necessary, he said, that the surgeon should be
master of his apparatus, as electricity was a dangerous
remedy in unskilful hands. He argued that the process
was not in reality a destructive one, but consisted in modi-
fying and softening the cicatrices by which the strictures
were produced ; this could be witnessed by anyone who
would take the trouble to treat thus a stricture of the ure-
thral orifice. Mr. Bruce Clarke then explained the de-
tails of the treatment. He thought some of the cases
could not be explained merely on the theory of absorption.
He mentioned one case where an ulcer was present and
electrolysis produced a rapid cure. Just as a rectal strict-
ure might begin by spasm of the muscular fibres, so ure-
thral stricture could, and often did, begin similarly—an
irritable ulcer being the starting-pomt. Caustic alkali was
set free by the negative pole of the battery and cured the
ulcer—thus relieving the muscular spasm ; if it failed to
cure the ulcer, it might, in rare cases, aggravate it and
make the stricture worse, and instances of this were nar-
rated. Of the 50 cases of urethral stricture treated by
electrolysis, 23 were known to be well after periods vary-
ing from one and a half to three years; in 2 cases no re-
lapse had taken place after four years; only 9 were known
to have required subsequent treatment.
Mr. Reginald Harrison opened the discussion on Mr.
Bruce Clarke’s paper, and remarked that he had seen a
number of cases which had been submitted to electroly-
sis in this country and in America, but none of them had
increased his regard for the method. The amount of
thickening that had taken place in these cases was con-
siderable, but he was not prepared to say whether this
was incidental to the stricture or to the treatment em-
ployed. He much preferred gradual dilatation, and had
had no reason to complain of want of success by this
method. Mr. Harry Fenwick observed that in twenty
cases in which he had tried the electrolytic treatment
they were all considerably worse after the treatment. He
considered that the only forms of stricture amenable to
electrolysis were those in the deeper part of the urethra
associated with spasm. He concluded by quoting the
remark of an American practitioner, viz., “ that the brill-
lant results said to have been obtained by electrolysis of
stricture depecded upon the credulity of. the patient and
the ingenuousness of the practitioner, or possibly upon
some fortuitous act of providence upon which it would
not be safe to count.” Mr. Lockwood asked Mr. Bruce
Clarke whether he adopted the precaution of relieving the
more anterior strictures before dealing with those further
in. Dr. Routh asked what pole had been used to the
stricture. When the electrical current was applied to
the uterus, his own experience was that the negative pole
dilated the uterus, while the positive tended rather to con-
tract it. Mr. Bruce Clarke then rephed. He insisted
upon the great attention to technical details which was
necessary to insure satisfactory results, and said he was
THE MEDICAL RECORD.
697
to attribute most of the non-successes to either
want of knowledge or want of the requisite attention.
The method, moreover, was only applicable to certain
cases. He would have been glad to know how far these
strictures began as spasmodic strictures. He always used
the negative pole with a strength of from five to ten mil-
hampéres.
A research which promises to have important results
was brought before the Pathological Society at their
last meeting. Messrs. Bland Sulton and Gordon Brodie
(who made the communication) said that they had for
some time been accumulating material for an investiga-
tion of cancer, especially in connection with the uterus.
It appeared that uterine cancer, though so common in
the human female, was rarely met with in other mammals.
This induced them to study the cervix uteri in monkeys.
Menstruation in monkeys was carefully studied. Last
summer a macaque was particularly watched. It suf-
fered from leucorrhoea and menorrhagia so profuse as to
render it unfit for exhibition. Being of small value, it was
killed. ‘Ihe uterus was found to be acutely retroflexed ;
the cervix was enlarged, the os patulous, and a flond-
looking mass projected from the os identical in appear-
ance with what was termed in gynecology an erosion.
Sections of the parts were examined microscopically, and
under a low power the mass protruding from the os, as
well as a polypoid mass some distance up the canal, re-
sembled a cervical adenoma, and appeared to be identi-
cal in structure with the glandular tissue held to be
characteristic of erosions in women, the acini being appa-
rently lined by columnar epithelium. Many of the most
typical acini were filled with a singular, apparently homo-
geneous, material. Under higher powers and careful illumi-
nation the supposed columnar cells were seen to be club-
shaped, and in favorable sections the supposed glandular
crypts turned out to be rosettes fringed with the clubs so char-
acteristic of actinomyces. The clubs varied somewhat in
shape. Many of them fringed the rosettes with the great-
est regularity ; in other places they occurred in “ banana-
like ” bunches, especially when stained with fuchsin. The
clubs surrounding the rosettes stained with difficulty. In
some places a cluster of clubs had been cut transversely ;
in such, a characteristic mosaic was produced. They
could not detect the filaments, but this was probably duc
to their lack of skill in staining methods, but a number of
granular bodies presented themselves in various parts of
the section. Thus far the microscopic characters were
consonant with actinomycosis. On examining the centre
of the rosettes, some distinctly rounded bodies caught the
eye, associated with clumps of epithelioid-looking cells ;
when these central bodies were critically examined they
resolved into cysticerci with the head and neck retracted.
Whether their presence in the midst of the rosettes was
accidental or otherwise, would require further elucidation ;
so far as they had examined the sections, the cysticerci
appeared to have some causative relation to the rosettes.
Messrs. Sutton and Brodie stated in their communication
that, although they wished at first to limit this preliminary
statement to facts connected with monkeys, they could
not refrain from observing that they had detected, so far
as the rosettes and clubs were concerned, exactly analo-
gous conditions m erosions from the human cervix uteri,
and in a case of cancer of the cervix. They further
found that Dr. John Williams, in one of the plates illus-
trating his “ Lectures on Cancer,” had depicted, as ap-
pearing under a high power, cancer cells, but they found
these columnar cells identical with their clubs, and the
peculiar clump of cells in the drawing was identical with
those seen in the monkeys in association with the cysti-
cerci. Again, in the beautiful plates in vol. xxxii. of the
Pathological Society’s ‘Transactions, they found that Mr.
Harrison Cripps had accurately delineated clubs and ro-
settes under the name of adenoid cancer of the rectum.
Many of his exquisite drawings represented the micro-
scopical characters of the lesions in their monkeys, and in
the erosions of women. ‘They deemed it right to men-
698
tion these things to show how wide a field was opened
I referred some time ago to the conduct of the Medi-
cal Battery Company in relation to the Zauder Institu-
tion purchased by them. The vagaries of the so-called
Medical Battery Company have engaged the attention of
the Medical Council at their recent session, with the re-
sult that the medical officer of the company (Mr. Leeson)
has had his name struck off the Medical Register for hav-
ing acted as a “cover” to Mr. Harness, who represented
_ himself as the consulting medical electrician to the Com-
pany, but who, it was alleged, practised as if he were a
duly qualified medical man. Within the last year or two
the Council has displayed unusual activity in dealing with
various irregularities, and especially in regard to the
“ covering ” of unqualified men by legally qualified prac-
titioners. At their recent session, however, they sanc-
tioned the restoration of two names to the Register which
had been expunged therefrom. Among the subjects
discussed at the Council’s session was the registration of
midwives and of trained nurses; but perhaps one of the
“most important subjects brought. before the Council was in
regard to the present system of the registration of deaths.
Dr. Glover brought forward a motion to the effect that
the Government be requested to issue annually to every
registrar of births and deaths a copy of the Medical
Register, so that the registrar could ascertain whether the
person certifying the cause of death was a registered
medical practitioner. This motion was agreed to, as was
also another brought forward by Dr. Glover, which was to
the effect that the Registrar-General be memorialized by
the Council to cause the forms of certificates of the cause
of death to be numbered, and to instruct registrars, in issu-
itg them to applicants, to ascertain that the latter were
registered practitioners, and to keep a record of the num-
ber of certificates given to each applicant.
Two cases of interest to the profession have just been
decided in the law courts. In the one, a medical practi-
tioner, sued for damages for the alleged wrongful giving of
a certificate in lunacy, was able to stay proceedings under
a clause of the new Lunacy Act, and thus avoid enormous
trouble and expense. ‘The other case was one in which a
provincial parish doctor sued a local newspaper for libel,
for having attributed to him heartless conduct for refusing
to see a child without an order from the relieving officer.
Evidence was given that the position of the mother was
not that of a pauper. The jury awarded the doctor
twenty pounds damages.
CIVIL SERVICE EXAMINATIONS FOR PHYSI-
CIANS.
‘To THe Epitor or THe MagpicaL Racorp.
Sır : In Dr. Dawbarn’s letter to THE MEDICAL RECORD
of December 7th, the following sentence occurs :
“The first Civil Service examination for permanent
positions for medical men, ever held in New York, I be-
lieve, was that of February 3 and 4, 1885.”
The first held was in October,:1884, as will be seen
from the following quotations from the Annual Report for
1884 of the Hudson River State Hospital for the Insane.
These quotations further show that whatever may be the
iniquities practised by the political managers of such ex-
aminations in the cities of this State, the methods of the
State Civil Service Commission at that date, both as re-
gards appointments of examiners and fairness of dealing
were above reproach :
“The competitive examination was held at the Acad-
emy of Medicine, in the city of New York, beginning Oc-
tober 20, 1884. The Examining Board was constituted
as follows: Dr. Stephen Smith, State Commissioner in
Lunacy, Chairman; General Silas W. Burt, Chief Ex-
aminer of the Civil Service Commission, conducted the
personal examination of the candidates ; Professor Henry
Drisler, of Columbia College, prepared the examination
paper on General Education ; Drs. James R. Leaming
THE MEDICAL RECORD.
[December 21, 1889
and Darwin E. Hudson that on General Medicine ; Dr.
Allan McLane Hamilton that on the Anatomy, Physiol-
ogy, and Pathology of the Nervous System; Dr. ‘Theo
dore H. Kellogg that on Insanity ; Dr. A. N. Bell that on
Preventive Medicine ; Dr. Stephen Smith, for Dr. Lewis
Balch, that on Surgery ; Dr. A. E. MacDonald that on
Hospital Administration.”
“ Soon after the conclusion of the examination a com-
munication, dated October 28th, was received from Gen-
eral Burt, Chief Examiner, as follows: ‘I had hoped to
give some definite intelligence concerning the recent ex-
amination before this, but we have to await the conven-
lence of the examiners, who are physicians in large prac-
tice and cannot be hurried. Of the sixteen applicants
there appeared thirteen, and of these only eleven went
through the whole examination, which occupied three
days, the greater part of the last one being devoted to a
personal test of the applicants at Ward’s Island Asylum,
by Dr. MacDonald. I inclose a set of all the p
used, except a short one by Dr. MacDonald, at Ward's
Island. I think the examination was rigid, and, as the first
effort of the kind, will be very satisfactory. Dr. Smith
thinks that at least two will be of superior standing. I
will acquaint you with the result as soon as all the ex-
amination papers are marked and reported.’ Under date
of November 13th, Mr. Clarence B. Angle, Secretary of
Civil Service Commission, writes to Colonel Amasa J.
Parker, Jr., President of the Board of Managers : ‘ I have
the honor to transmit herewith a certificate of the candi-
dates on file as eligible to the position of first assistant
physician in your institution. I also inclose a statement
of the standing of such candidates upon the several ob-
ligatory and optional subjects of examination, and also
their original application papers. Should your honorable
body desire any other information on file with the com-
mission, I shall take pleasure in responding to your re-
quests.’ The minutes, as furnished by General Burt, of
competitive examination for the position of first assistant
physician in the Hudson River State Hospital, giving the
Standings on the several subjects of the two compettors
who passed above the minimum standing, show the high-
est markings to be for Dr. Frederick Peterson, of Buffalo,
N. Y. Dr. Peterson’s markings are as follows: Ods:ga-
tory subjects : General Education, 86; General Medicine,
92 ; Physiology, Anatomy, and Pathology of the Nervous
System, 100; Insanity, 75; Preventive Medicine, 75;
Surgery, 85 ; Administrative, 62. Optional subjects: Mi-
croscopy, 100; Latin, 60; German, 91; Swedish, 70;
Translation from French, 70. The relative weights given
to the obligatory subjects respectively were the follow-
ing : General Education, 3; General Medicine, 3; Anat-
omy, Physiology, and Pathology of the Nervous System,
4; Insanity, 5; Surgery, 2; Administrative, 3; total,
20. ‘The standing of a candidate is reached by the fol-
lowing method : The marking of every examination paper
is multiplied by the given weight of the corresponding
subject. ‘The results are adaed and the product divided
by the sum-total of the weights. The quotient gives the
average standing.on the whole examination. The stand-
ing of Dr. Peterson was 82.20.”
As a result of this examination I was appointed per-
manently to the position (resigning January t, 1888).
For some months before October, 1884, the competitive
examination was advertised extensively in several New
York daily papers and in Tue Mepicat Record. At the
time of the examination I did not know who the examiners
were, nor had I any acquaintance with any manager or
officer of the Hudson River State Hospital, or any politi-
cal influence whatever. I was deeply impressed with the
perfect equity in the conduction of the whole affair. Be-
sides the above quotations, the Annual Report referred to
published also the whole series of examination papers.
This was Civil Service appointment in the highest sense
of the term. Very truly yours,
FREDERICK PETERSON, M.D.
201 Wast FIFTY-FOURTH STREET.
December 21, 1889]
THE MEDICAL RECORD.
699
To THe EDITOR or THE MgDICAL RECORD.
Sır : My attention has been called to the following para-
graph, clipped from your issue of December 7, 188ọ :
. Dr. A B C, a former student of mine,
did not, until after the fact, hear of the examination held
this summer for the ‘Summer Corps’ of physicians to as-
sist the regular corps of the Board of Health. He was
but a day or two late, and determined to try political in-
fluence. In this he was successful, for a well-known city
oficial, of his own language and religious belief, procured
for him a copy of the questions, which he answered at hes
leisure at home, and doubtless to his own satisfaction. His
paper was then duly handed to his political friend, was
slipped in among the other papers, and in a short time
he received his appointment as a member of the ‘Sum-
mer Corps,’ in which he remained throughout the sea-
son... . . |
(Signed) “ ROBERT H. M. Dawsarn, M.D.
“345 West Fiery-sixtu Street, New YORK.”
Will you kindly permit me space to characterize this
statement as utterly false.
Respectfully yours,
G. K. ACKERMAN,
Secretary and Executive Officer.
New Yox Crry Civic Service Boards, Coorer UNION,
New York, December 16, 1889.
HOW TO PREVENT AN EPILEPTIC WHO FALLS
IN THE STREET FROM BEING COMMIT-
TED AS A DRUNKARD.
To tHe Eprror or Tue Mapicat Recorp.
SIR: John Wiesler, 606 East Fourteenth Street, an inof-
fensive, sober, poor workingman,’is epileptic.
Twice he happened to have an attack of his disease in
the street ; each time he was arrested, and, on the errone-
ous charge of drunkenness, first fined ten dollars, the last
time sent to Blackwell’s Island for ten days. He served
this term from September 4, to September 14, 1889.
Punishment for epilepsy !
The man speaks German only, and had certainly no op-
portunity to explain himself or to communicate with his
wife and child while he was under sentence.
I have learned that the experience of John Wiesler ts
also the experience of other epileptics of this city.
This rough handling of an unfortunate by a policeman,
and the punishment inflicted by a police justice, reminds
us of some of the customs of the middle ages.
From what I have seen myself, and what has been seen
by others with whom I spoke on the subject, it appears that
some policemen, when they find a person unconscious on the
street, never think for a moment that there could possibly
be any other cause of unconsciousness but drunkenness.
This should be remedied ; there should exist precautions
against such revolting errors of police and police justices,
and, I think, above all, it is each and every physician’s duty
to assist in finding means to that purpose
I wish to suggest that medals should be distributed, -to
be worn by epileptics ; these medals should be familiar
to every policeman ; there should be a certain mode of
attachment and a certain part of the body where they
would have to be looked for (for instance they might be
attached to a rubber band around the neck—like the
checks of valuables in the surf-baths), and by means of
these medals policemen would be enabled to distinguish
an unconscious epileptic from a drunkard.
In bringing the case of John Wiesler, through your col-
umns, before the medical profession, I hope the crying
wrong described will be noticed and acted upon by some
of our societies, for instance the Medico-Legal Society.
A. Rose, M.D.
208 Saconv» Avenues, New YORK.
THE VANDERBILT CLINIC is as bitterly complained of
by practitioners on the west side of town, for treating pa-
tients who are able to pay, as is the Presbyterian clinic
on the east side.
Army and Hany Mews.
Official List of Changes in the Stations and Duties of Ofi-
cers serving in the Medical Department, United States
Army, from December 8 to December 14, 1889.
HALL, Jonn D., Major and Surgeon. Leave of absence
granted for ten days, to take effect upon being relieved
from duty at Fort Niagara, N. Y. Par. 4,5. O. 285,
A. G. O., Washington, December 7, 1889.
CARTER, Epwarp C., Captain and Assistant Surgeon.
By direction of the Secretary of War, will be relieved from
duty at Willet’s Point, N. Y., upon the arrival at that
station of Major Clarence Ewen, Surgeon, and will then
proceed to Fort Walla Walla, Wash., and report in person
to the commanding officer of that post for duty, reporting
also by letter to the commanding general, Department of |
the Columbia.
Oficial List of Changes in the Medical Corps of the United
States Navy for the week ending December 14, 1889.
Ross, J. W., Surgeon. Detached from Navy Yard,
Pensacola, Fla., and placed on waiting orders.
Kure, I. W., Assistant Surgeon. Detached from Naval
Hospital, Philadelphia, Pa., and to Navy Yard, Pensacola,
Fla.
Rocers, B. F., Surgeon.
Norfolk, Va.
LEACH, Puiuip, Passed Assistant Surgeon. Ordered to
duty at Naval Academy, Annapolis, Md.
Ordered to special duty at
Medical Atems.
‘CONTAGIOUS DiIsEaAsES—WEEKLY STATEMENT. — Re-
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending December 14, 1889:
Typhus fever oo iitascceiiec nt teases eens eee koeeee
Typhoid fever ...... ccc cece ccccccce cece ere
Scarlet [EVER cies osuan CA vxevewes veces deen
Cerebro-spinal meningitis................seseeeee
Measles .....ccceccescscsccsccsscscccsscscosssces
COOLING THE Bopy BY Spray.—Dr. S. Placzek, fol-
lowing up some laboratory experiments by Preyer and
Flashaar, on the effect of spraying a considerable part of
the body surface of animals with cold water, has applied
the spray for the purpose of reducing febrile temperature
in human beings. In the case of a man suffering from
phthisis, whose temperature was high, he found that by
spraying about a pint of water at between 60° and 70° F.
over his body, the temperature fell to normal, and con-
tinued so for several hours. Again, a similar method was
satisfactorily applied in the case of a girl with diphtheria.
In the healthy human subject the spray lowered the tem-
perature nearly 2°, and in animals which had been put
into a condition of septic pyrexia by injections of bacteria,
the temperature was reduced to normal by the spray.—
Lancet.
PREVENTIVE INOCULATION FOR YELLOW FEVER.—The
following report was presented to the Academy of
Sciences, France, by Dr. Domingos Freire, Professor of
Organic Chemistry and Biology in the Faculty of Medi-
cine of Rio de Janeiro, Brazil: “ The epidemic of yellow
fever that developed in Rio de Janeiro in 1888 and 1889,
700
and which propagated itself in several other places in the
interior of Brazil, has been the means of demonstrating for
the fourth time the value of inoculations by means of the
attenuated microbe of yellow fever. The maximum of
the epidemic was between the months of December and
March, the first sporadic cases having appeared about the
end of the month of May, 1888, and the last in June,
1889. During this period there were inoculated 3,570
people, to wit, 988 strangers and 2,582 Brazilians, divided
thus: ‘The city of Rio, 2,138; city of Campinas, 651;
town of Vassouras, 199; city of Nicteroy, 166 ; city of San-
tos, 133 ; Desengano, a village of 425 inhabitants, 102 ;
Serraria, a small town, 80; city of Rezende, 54; Cata-
guazes, avillage of 2,000 ‘inhabitants, 50. The disease
swept with great intensity in all of these spots, and the
vaccinations were made, for the most part, during the
height of the epidemic. Of the 2,582 Brazilians, there
were 1,740 that should be added to the 988 strangers, as
this figure embraces not only individuals coming from the
interior and resident in the city of Rio for less than six
years—that is to say, non-acclimated—but also children,
who, according to our experience, are just as susceptible
as the strangers themselves. The rate per hundred of
mortality among the vaccinated was 0078; at Santos, at
Rezende, at Serraria, and at Cataguazes, the immunity
from the disease was absolute. Here is the rate per cent.
from each locality : Rio, 0.98 ; Campinas, 0.46 ; Vassouras,
0.05 ; Nicteroy, 0.75 ; Santos, 0.00 ; Desengano, 0.09 ; Ser-
raria, 0.00 ; Rezende, 0.00 ; ; Cataguazes, 0.00. The mortal-
ity from yellow fever among the non-vaccinated was 4,135,
divided thus: City of Rio de Janeiro, 2,407 (this includes
the dead from the Marine Hospital) ; Campinas, 812;
Vassouras, 15; Nicteroy, 177; Santos, 650; Desengano,
221 ; Serraria, 21 ; Rezende, 11; Cataguazes, 20. Among
the 4.1 35 there were about 2,800 strangers, of whom 1,176
died in Rio (and 750 of these in the Marine Hospital),
63 at Nicteroy, 500 (about) at Santos, 300 (about) at
Campinas, 7 at Desengano, 3 at Rezende, 3 at Vassouras.
Thus one-fourth of the deaths were among Brazilians who
were unaccustomed to the poison, inasmuch as they re-
sided in localities where the epidemic appeared for the
first time this year. In order to make the efficacy of the
inoculations more marked, it suffices to remember the pro-
portion established by M. Jemble in Senegal, to wit, that
among the strangers who had been there from one to
three years, 75 per 100 were attacked by yellow fever, and
68.06 per hundred died. Applying these facts to the vac-
cinated strangers, or the provincials who had from a few
days to three years’ residence in the infected locality, we
obtain the following results: At Rio we vaccinated 1,183
people under the above conditions, of whom at least 591
should have succumbed to the disease, but only 18 died.
Thus 573 lives were saved. At Campinas, a city that
never before had an epidemic of yellow fever, and where
the 651 inoculated might be considered as new arrivals,
of whom 325 should have died, the unsuccessful inocula-
tions were but 3. At Vassouras, 5 should have died;
_ one only died, who was not a recent arrival. At Nicte-
roy the 11 strangers, under the conditions cited above,
should have furnished five deaths; one only. was a vic-
tim. At Santos, of 57 persons under the same conditions,
28 should have died, but the immunity from disease was
absolute. At Desengano, the two unsuccessful inocula-
tions were among strangers who had lived from six to
eight years in the country. But in view of the fact that
the disease obtained for the first time, all of the 102 per-
sons inoculated were as susceptible as strangers who had
just arrived. Among them 51 should havedied. At Ser-
raria, according to the main calculation, 39 should have
died, whereas the immunity from the disease was absolute.
The same reflections apply to Rezende, where the 54 vac-
cinated should have furnished 27 deaths, and at Catagua-
zes, where the 50 vaccinated should have furnished 25
deaths, in view of the fact that the epidemic made its
first appearance in these two localities ; still the immunity
was perfect, without exception.
THE MEDICAL RECORD.
{December 21, 1889
“ General Résumé.—We have vaccinated, since 1883 to
1889, 10,524 people, with a mortality of 0.04 per hundred.
Vaccinations made i in 1883-84006 ses cases sescee 418
1884-85... cee ec cecsceces %OSE
“ á 1885-86... ..oesesseccssso 3:473
s 1888-B6 ios ee bc kde cence 3,582
10, 524
“ I had to cease vaccinating in 1887, owing to my trip
to Europe and in the United States. The mortality from
yellow fever among the non-vaccinated, during the four
epidemics mentioned above, was close on to seven thou-
sand. Let us add, in closing, that all the results given
have been authenticated by a large number of medical
men, and municipal and police authorities. The vaccina-
tions were made without fee. This succinct statement
proves, without question, the truth of all the doctrines
founded by our eminent master, M. Pasteur.”
DIAGNOSIS OF CEREBRO-SPINAL MENINGITIS BY PUNCT-
URE OF THE Liver.—Dr. C. Bozzolo reports a case of
cerebro-spinal meningitis, in which the diagnosis was
assisted by bacteriological observations made on the
fluid obtained by puncturing the liver. A man, aged
fifty-four, who had been ill for five days previously,
was admitted into the clinic at Turin suffering from fever-
ishness, pain in the right side of the neck, jaundice, en-
largement of the spleen, painful enlargement of the liver,
bronchitis, and albuminuria. A rigor occurred more than
once. Except the pain in the neck and vomiting, no
Symptom whatever of meningitis existed. Six days after
admission the patient died, having been slightly delirious
for the previous forty-eight hours. Diagnosis being difi-
cult, the author had on the fourth day after admission
made an exploratory puncture of the liver, which was still
painful. The blood extracted showed by cultivation and
after experiments on animals the existence in it of Fraen-
kel’s diplococcus of pneumonia. This result, in the absence
of pneumonic and pleuritic symptoms, with the existing
pains in the neck and vomiting, encouraged Bozzolo to
diagnose meningitis, a diagnosis which was confirmed by
the post-mortem examination. In addition to the mor-
bid changes in the meninges, gall-stones and acute endo-
carditis were found.— Lancet.
ANTIPYRIN Hasit.—To the already long list of drugs,
the use of which, under proper restrictions, is both bene-
ficial and proper in combating the various ills to which
flesh is heir, but whos2 abuse becomes a curse to human-
ity, another has recently been added. Scarcely have we
learned to properly use antipyrin than the tocsin of alarm
must be sounded against its abuse. ‘The recent discovery
of its value as a nerve-tonic places it on the list with
morphine, chloral, cocaine, etc., so seductive is its gentle,
soothing influence upon the overstrained nerves. Its vic-
tims are already found, especially among society women,
whose nerves, strung up to a high pitch by the over-
whelming demands of a winter season of gayety, seize
eagerly upon anything that will afford relief from the
headaches and other disorders arising from prolonged
fatigue and overtired nerves. So pleasing is the eff=ct
that it is soon used for every tnfling ill feeling, until the
patient finds herself unable to live without it, and the
fascinating ‘“‘antipyrin-habit” is formed. Properly used
as a nerve-tonic, its effects are admirable, but adused, the
victim becomes even more hopelessly entangled than the
morphine or cocaine victim. ‘The effects vary with the
dose. In large doses it produces complete relaxation
with loss of reflex action. In moderate doses, continued,
it induces convulsions. As a stimulant its effect is much
like that of quinine.—/nternational Dental Journal.
THE AMERICAN ACADEMY OF MEDICINE has so amended
its constitution as to permit the Academy to admit as
members those of the profession who have pursued courses
of study ca.ling for an equivalent of mental training to
that necessitated in the securing the degree of A.B.
~The Medical Record
A Weekly Fournal of Medicine and S urgery
Vol. 36, No. 26
==
@riginal Articles,
CARDIAC THERAPEUTICS.'
By JOSEPH M. PATTON, M.D.,
CHICAGO, ILL.
Divromnc diseases of the heart into those which are acute
in their course, and are accompanied by the usual mani-
festations of acute diseases, and those which are slow in
development and chronic in nature, and which are, as a
rule, secondary to some acute condition, we have in the
latter those which demand most often our attention, both
as to diagnostic ability and therapeutic skill. It is to the
latter that I wish to call your attention, and as the ori-
fices of the left heart enjoy almost a monopoly of the
diseases so catalogued, it will facilitate matters to con-
sider, in turn, the conditions which may present through
disease of the aortic and mitral valves and their thera-
peutics. :
An intelligent consideration of the treatment of these
conditions implies a concomitant study of the pathologi-
cal condition involved, as without a knowledge of the
pathological changes, and the sequence of their produc-
tion, the scientific application of the more important
remedies cannot be made.
The affections of the aortic valve appear later in life,
as a rule, than those of the mitral; the latter are more
often due to endocarditis, while aortic disease is gener-
ally due to atheroma, arterio-sclerosis, and like conditions
giving rise to changes in the aortic ring and valves.
Stenosis of the aortic semilunar valves is the most
favorable of all valvular lesions, from a prognostic stand-
point. It may exist for years without the necessity of
medicinal aid, at least so far as the heart itself is con-
cerned ; the simple hypertrophy of the ventricle relieves
the condition, and until this becomes excentric the heart
is not in need of aid so far as its pumping powers are
concerned.
With insufficience of the valve it is different ; the hy-
pertrophy here is excentric from the beginning, and while
cases are recorded where regurgitation alone, or in con-
nection with stenosis, existed for years in laboring men
without serious difficulty, still rupture of compensation
occurs quicker in insufficience, because of the constant
intra-ventricular pressure during diastole caused by the
additional stream of blood.
There are, however, symptoms occurring during the
period of compensation, or hypersystolic state of Fernet
and Huchard, which will demand relief. These symp-
toms are common to both conditions, but are generally
more marked in regurgitation, because of the dilatation
of the aorta which obtains through the larger volume of
blood discharged, and the greater force given it because
of the immense hypertrophy which develops in regurgi-
tation.
Retardation of the circulation is effected in both in-
stances. In stenosis the arteries are scantily filled,
anæmia of the brain develops on slight exertion, syn-
cope, fainting, dizziness, palpitation from nervous excite-
ment.
_In regurgitation the pulse is bounding, a high-up stroke
with absence of the dicrotic wave, a pointed summit,
3 Read before the Chicago Pathological Society, October 15, 1889.
New YorK, DECEMBER 28, 1889
Whole No. 999
voluminous but maybe weak and irregular on slight exer-
tion, the- so-called Bellingham or Corrigan pulse. Pas-
sive hyperemia of the brain and aortic system, dizziness,
ringing in the ears, cyanosis, pain under sternum, along
clavicle, and down the left arm, due, according to Peter,
to inflammation of the cardiac plexus. Angina pectoris
may occur. Loss of mental power, insomnia, or even
insanity, may result from the condition of the cerebral
circulation, as cerebral activity is in close relation to the
condition of the circulation, as has been shown by Rer-
nard and Mosso.
Patients with cardiopathies of this class with a rheu-
matic ongin do well on the iodide of potash combined
with the bicarbonate of potash, and generally take it
indefinitely without trouble. Iron, attention to the nutri-
tion, moderate exercise are necessary. Dujardin-Beau-
metz relies on opium for the relief of cerebral anemia
and dyspnoea. Gubler states that the action of opium
is due to the congestion it produces. Picard and Reathi
think it acts on the cardiac ganglia, as its effect is mani-
fest on the heart after section of the vagi. The relief
afforded by other vascular dilators would correspond
with the former theory. The cerebral symptoms would
appear to result from lack of blood-supply through pas-
sive congestion, both in stenosis and regurgitation, and by
vascular dilatation the blood-pressure is lowered and the
heart, for the time being, keeps up the supply. The
dyspnoea may be relieved in the same way, or bv sedation
of the cardiac plexus. Subcutaneous injection is the
method recommended, but there are objections to this,
unless it be in acute conditions like angina pectoris.
Nitrite of amy] by inhalation is useful as a vaso di-
lator, but its effects are very transient. Tri-nitrine, three
to four drops of a one per cent. solution, or by hypodermic
use, may be used in true or pseudo anginas.
Antipyrin has appeared as a remedy for angina pectoris,
as it has for most everything else. Eloy says it is to be
avoided in true angina, because of its injurious effect on
the heart muscle, and because of the danger of dilatation.
On the contrary, Professor Sée says it is perfectly safe, and
very efficient in gramme doses, one hour apart, till four or
five grammes are given, or in hypodermic injection half
a gramme in distilled water, with none of the unpleasant
after-effects produced by the hypodermic use of morphia.
Galvanism is of benefit in some cases of neuralgia or
angina of cardiac origin. |
For the paroxysmal dyspnoea and cardiac asthma bro-
mide of potash is useful ; cicutine, the alkaloid of conium
maculatum, is also recommended. In the hypersystolic
condition, with increased vascular tension, aconite is a
valuable remedy ; two drops of the tincture every three or
four hours, followed by one drop three or four times a
day, will give marked results in many instances.
With the occurrence of degeneration and rupture of
compensation the demand for aid to the heart comes,
while mitral disease is in many instances but a sequence
of aortic trouble. Some writers would indicate that this
condition, called by Fernet and Huchard the hyposystolic
state, develops only when mitral disease has been added,
and apply, therefore, the true cardiac tonics only to con-
ditions resulting from mitral disease. Franck and De-
borde claim that dilatation and hypertrophy of the left
auricle is the factor in compensating aortic regurgitation,
the blood being discharged into the ventricle with suffi-
cient force to overcome the pressure in the ventricle.
This assumes that it is necessary to have the above con-
702
dition of the auricle in order to obtain compensation in
aortic regurgitation ; this I do not believe. As the auricular
contraction takes place before the ventricular, I do not
see how it can aid in compensating the ventricular dilata-
tion. I believe that with the production of mitral re-
gurgitation and auricular dilatation and hypertrophy, you
have the beginning of the end. Objections have been
made to the use of heart tonics in aortic stenosis, because
they prolonged the systole ; this is the effect desired. By
prolonging the systole and increasing the force you get
more blood through and postpone the development of an
asystolic condition, and in regurgitation you enable the
ventricle to empty itself and obtain the same result.
Cardiataxia may render the administration of these
remedies necessary in aortic lesions uncomplicated by mi-
tral disease, but the passive congestions which demonstrate
heart-failure in mitral lesions are wanting, and while the
indications for their use are the same, the necessity is not
present to as great an extent. |
I cannot accept the statement of some wniters, that
stenosis and regurgitation of the mitral erifice never oc-
cur separately ; it is true that to stenosis is added insuffi-
cience, but stenosis may exist single for a longtime. Re-
gurgitation may exist indefinitely and cause death by
cardiac failure without being complicated by stenosis.
In stenosis auricular hypertrophy compensates and there
will be little trouble except on exertion, where the rapid
heart’s action does not give the auricle time to empty it-
self. The auricle may succeed in freeing itself of blood
with slow heart’s action, and thus the pressure in the pul-
monary circulation is not so constant as in regurgitation.
In either instance, when the mitral valve is primarily af-
fected, the compensation effected by the right heart obvi-
ates medicinal treatment until failure occurs. ‘Ihe sys-
temic circulation calls on the left heart and moderate
hypertrophy results; when mitral disease is secondary to
aortic lesion it comes with compensatory failure, and the
relief you can furnish is in inverse ratio to the amount of
fatty granulo degeneration of the muscle-fibre.
_ In compensated conditions there are various rules to be
followed, which are of more utility, when observed in time,
than therapeutic measures ; they apply alike to all condi-
tions of compensated heart lesions. Out-of-door exercise
- should be had in moderation, all active exertions should
be interdicted. Mountain-climbing has not leen as well
supported as might have been expected from the claims
of its originator ; it is no doubt of use when properly and
carefully observed, but any exclusive method of training
would probably result in harm in many cases. All pro-
fessions and occupations entailing exposure and fatigue
should be avoided. ‘The diet should be nourishing and
strengthening, the days of restricted diet for the limitation
of hypertrophy are past.
All alcoholic drinks should be strictly forbidden. ‘Tea
and coffee sparingly or not at all. Tobacco should be
absolutely forbidden. The most desirable climate is one
of. steady, uniform temperature, moderate, with a dry at-
mosphere, with an elevation of not over two thousand five
hundred feet.
- Baths of compressed air have been recommended by
Lambert and Waldenberg, as a means of relieving the
work on the heart ; Ducrocq and Fontaine maintain that
they are useless, or even deleterious.
An interesting question arises in relation to pregnancy
and the cardiopathic state. Women with organic disease
of the heart should seriously consider the question of
marriage. ‘Ihe altered condition of the blood in the preg-
nant state and extra demand on the heart cause hypertro-
phy. In the normal heart this disappears after accouche-
ment, but organic disease may be seriously aggravated.
‘These patients are especially liable to miscarriage.’
In relation to abortion, mitral regurgitation is said to
be most dangerous; the least dangerous is aortic regurgi-
` & Durosier reports 21 abortions or tags births in 41 cases.
"Out of 40 births from cardiopathic mothers, 37 died before six years.
THE MEDICAL RECORD.
tation.
labor is concerned, than regurgitation, according to Sée.
Mothers suffering from cardiac lesions should not be
allowed to nurse their children.
The medicinal treatment of the compensated state is
nutritive tonics at the earliest sign of failure, with per.
haps some of the sedative bromide in cases exhibiting a
nervous temperament. Bromide of potash is the favorite
salt ; in many cases better results can be obtained from the
bromide of sodium; the principal medicines to be used
here are iron, quinine, strychnia, and arsenic. Locke
considers the latter a cardiac stimulant. The objection
is made against iron, that its tendency to produce con-
gestions should prohibit its employment ; I do not believe
It does injury in this way, and think the period of com-
pensation may be much prolonged by its use. I employ a
fresh carbonate of iron pill, or the tincture of the citro-
muriate with tincture of cinchona.
Attention to the state of the stomach and abdominal
viscera is always an important element in treatment; the
connection between the cardiac ganglia and the abdomi-
nal sympathetic ganglia, through the nerves of cyon and
other connections, readily explains the effect on the heart
of disturbances of the abdominal viscera.
Notwithstanding our efforts in these various directions,
the time comes when something further must be done.
In many instances the patient presents himself for the first
time for the relief of symptoms occurring as a sequence
to failure of compensation. Degeneration of the muscu-
lar fibre reduces the integrity of the muscle, and prevents
it from longer resisting the blood-pressure, transforms
simple hypertrophy into excentric, or in excentric hyper-
trophy allows: of the extension of dilatation. This di-
minishes the pumping power of the heart, and gives rise
to a series of symptoms indicative of the necessity for
heart tonics.
The heart’s action becomes labored on slight exertion,
dyspnoea with slight cough, slight swelling of the feet and
ankles at night, evidences of gastro-intestinal catarrh ; on
examination you find the action of the heart out of pro-
portion to the tension of the vessels and condition of the
circulation ; the muscular element of the first sound is not
clear and distinct, later on cedema at the base of the
lungs develops. These symptoms, in a heart where com-
pensation has sufficed for the requirements of the circula-
tion, admonish you that the time has arrived for the
employment of remedies which heretofore have been
contra-indicated.
First, by nght of seniority, is digitalis, this time-honored
remedy still maintains its place at the head of the list of
cardiac tonics. Withering employed it in the Birming-
ham hospital in 1775, and in 1785 published a work on
it. Contradictory opinions have been given from time to
time in regard to its action, but to-day all observers who
have placed themselves under similar conditions of ob-
servation, agree pretty closely as to its action. Moderate
doses slow the pulsations, increase their force, fulness,
and regularity ; the vascular tension is Increased, as shown
by Chauveau, Marcy, Siredy, Legroux, Gubler, and others
through sphygmographic tracings, also by Briquet’s hæ-
modynamometer. According to Sée, digitalis slows the
heart by exciting the cardiac inhibitory nerves and gang-
lion, as the action is omitted if the vagi be cut. Accord-
ing to Cavazinini there is little action on the auricles, the
ventricular tone is increased, with a secondary action on
the vessels. Gubler, who has made extensive observa-
tions, says there is first a slowing of heart’s action, doses
too long continued produce irregular, intermittent heart’s
action, and cardiac exhaustion from prolonged stimula-
tion. The best effects are obtained after some days of
administration, and may remain some time after ceasing
the drug. The chemistry of the drug has developed a
so-called alkaloid, digitaline, which is rather a glucoside
than an alkaloid, besides other principles and extractives.’
1 The amorphous digitaline of Quivenne and. Homolle is eneracced
from the leaves, the German digitaline from the seeds. The digi-
[December 28, 1889
Mitral constriction is less dangerous, as far as
es
December 28, 1889]
THE MEDICAL RECORD.
793
‘The lack of definite chemical data in regard to these
substances is a serious bar to their therapeutic employ-
ment. Digitaline may be used hypodermically. Gubler
claims good results, using a five per cent. solution of
amorphous digitaline in alcohol and water, and injecting
„about one milligramme. Powdered digitalis is not relia-
ble; the tincture is the best form for action on the heart,
the infusion when stimulation of the kidneys is desired.
‘The particular valvular lesion originating the trouble is
of little import in determining the necessity for its use ;
the comparative amount of hypertrophy and dilatation,
and the integrity of the muscular fibre, are the conditions
which determine the indications or contra-indications for
its employment. Fatty heart, or granulo-fatty degeneration
of the muscle fibre, are positive contra-indications, where
the majority oí the fibres have been subjected to this change.
Dujardin-Beaumetz says the failure of the drug to act
in these cases constitutes a therapeutic test, and relates a
hospital case in which it failed utterly and death. re-
sulted. ‘The question naturally arises as to how much
the digitalis had to do with the period at which the fatal
result was attained.
It is certainly better to depend on our diagnosis of de-
generation for contraindication, than on experimental
evidence obtained at the risk of the patient's life.
When degeneration is in excess, a veritable digitalis
asystolia may result from its use. Moreover, the action
of the drug in contracting the vessels throws more work
on the heart, while no additional pumping force is fur-
nished the organ.
James Stewart recommends for serious heart-failure
rest in bed, forbids liquids, full doses of digitalis ; if good
results follow, diuresis is increased; if the amount of
urine falls after increase by digitalis, the drug should be
stopped ; he gives forty minims of tincture four times
daily during three days, but as much as half an ounce may
be ne :
According to Huchard, digitalis is of benefit in transi-
tory asystole with venous stasis from asthenic conditions
of vessels and heart muscle. Useless in compensated
state. Harmful in hypertrophy with increased arterial
tension, and in permanent asystole with embarrassed cir-
„culation, and irremedial fibroid changes of cardiac muscle.
Cardiac arythmia to be treated by digitalis if due to valvu-
lar lesion; if due to myopathic, reflex, toxic, or nervous
is useless.
Stiicker recommends ergot with digitalis in diminished
arterial tension, aortic insufficiency, idiopathic dilatation,
certain stages of arterio-sclerosis, and sometimes after
violent bodily exertion. With increased arterial tension,
as in chronic nephritis, with rapid and irregular heart’s
action, digitalis may not be safe, alone ; lower the vascu-
lar tension with nitro-glycerine, or other nitrites ; he thinks
caffein may be better in such cases.
The combination of vascular dilators with cardiac
tonics, has not received the experimental attention which
$2 promising a theory deserves; it is recommended by
Stficker, Da Costa, and others. The ideal cardiac tonic
may yet be obtained, and the most efficient aid rendered
the heart by this means.
It does not seem to me that the cumulative effects of
digitalis, about which so much has been said, need inter-
fere with its administration as much as has been claimed.
If the case is a proper one for the drug, and the dose
properly managed, it will seldom interfere in this man-
ner. In most cases it is better to interrupt the adminis-
tration for a few days every ten days.
The most serious trouble will be encountered through
its Irritating action on the intestinal tract, which in some
instances will effectually prohibit its employment ; recourse
may then be had to some other drug of the same class,
and the principal one of these is strophanthus.
taline of Nativelle is similar chemically to the amorphous, but much
more powerful. Roucher'’s digitaline-globular resembles the amor-
phous. The German of Hosmann and Merck is less powerful than the
amorphous.
_ Improvement.
Professor Fraser, of Edinburgh, furnished a journal
article on strophanthus in 1885; the active principle he
claimed to be strophanthin, its action on the heart in the
frog similar to digitalis, but more powerful. The chief
therapeutic difference being its failure to contract the
blood-vessels.’
Various results have been obtained by other observers.
Popper, through experiments on dogs, concludes that it
increases arterial pressure by action on the heart, as it
occurs if vaso-motor paralysis be previously produced,
increased venous pressure is not constant, the vagi may
be paralyzed, but the accelerator nerve remains intact."
Whatever may be the direct method of its action, it is
undoubtedly a useful cardiac tonic. I have used it in
quite a number of cases, and while I an. not prepared to
rank it with digitalis, when the latter can be properly ad-
ministered, I have not had any distinct failures with it,
and have had much satisfaction in its use in cases which
were not suited to digitalis.
One patient, a wood-turner by occupation, suffering
from mitral stenosis, to which was subsequently added
insufficiency with a dilated and hypertrophied auricle,
with rapid and very irregular heart’s action, was totally
unable to take digitalis from gastric intolerance; it also
seemed to increase the irregularity. At favorable times
the auricular and ventricular contraction could be dis-
tinctly separated ; on the slightest exertion the heart be-
came irregular, with marked throbbing of the carotids,
dyspnoea, cough, and gastric irritation from passive con-
gestion.
Strophanthus, in ten-drop doses in laurel-cherry water,
improved his condition so that he could perform his daily
labor for over a year. Recently I was called to see him
and found him in a very bad condition, unable to lie
down or sleep ; cedema of the legs, congestion of the liver
with slight jaundice, and very weak irregular heart. He had
not been taking the strophanthus regularly, and thinking
that perhaps it had lost its effect, I gave caffein with
benzoate of sodium, 74 grains daily, which is highly rec-
ommended by Dujardin-Beaumetz in such conditions.
No effect. I then gave the more soluble citrate of caffein,
increasing his distress. He was also taking citrate of pot-
: ash and buchu. I then determined to again try strophan-
thus, and gave twelve drops three times daily with imme-
diate improvement, cedema disappeared, could lie down
and sleep, feeling much better, the diuretics were also
continued, with moderate catharsis.
I have at present a young woman with the same double
lesion, who is taking seven drops three times daily, with
The drug has seemed to me to be espe-
cially useful in mitral stenosis, or double lesion at the
mitral valve. If its want of action on the vascular sys-
tem should be proven in man, it would be a great point
in its favor, and would make it useful in cardiac failure
in pneumonia, typhoid fever, and kindred conditions.
Convallaria maialis was used as early as the sixteenth
century for diseases of the heart. According to Sée, it
augments vascular pressure, and the ventricular energy,
is useful in palpitations, and cardiac arythmia, even if
due to valvular lesions. He also claims that its diuretic
powers are greater than those of any other cardiac tonic.
Others regard it as a very moderate diuretic.
Caffein is particularly recommended by Dujardin-Beau-
metz in asystolic conditions ; I have not had marked suc-
cess with it in such conditions; its action is similar to.
digitalis. Huchard regards it as a true cardiac tonic and
diuretic in last stages, to be given with sodium benzoate
in distilled water. Semmola has found caffein of great
1 A solution of one part of digitalin in 20,000, when passed through
the vessels of the frog, contracted them so as to prevent the passage
of the solution. Aso ution of stro hanthin, one part in 3,000, caused
no noticeable change, and only a slight transitory action by a ‘solution
of one part in 2,000.
3 Rummo and Ferranini claim that spartein and caffein affect the
cardiac nerves and the muscle little, or not at all; adonidia and
convallaramin, both the nerves and muscle simultaneously; while
digitalis, strophanthus and its alkaloid affect the muscle primarily,
and the nerves secondarily.
704.
ee ee ee -
value in cardiopathies of bulbar origin and cardiac aryth-
mia.
Spartein is hardly reliable in serious heart failure ; in
functional disturbances, in neurasthenic subjects, or where
compensation is not seriously interrupted, it may be use-
ful. Its action is rapid, but it is not always well borne
by the stomach. From two to five grains daily may be
given.
Adonis zstivalis, and adonis vernalis belong to the
category of heart tonics, and are said to be good some-
times where digitalis fails. In the various other drugs,
from which good results have been obtained are generally
found the same or similar alkaloids which give to the
above remedies their virtue.
Attention should always be given to the state of the ab-
dominal viscera in treating heart lesions, and particularly
the kidneys. I will not enter into a discussion of the in-
dications for diuretics, cathartics, etc., but in many cases
more can be accomplished toward removing cedema and
effusions, and the many results of cardiac failure, by prop-
‘er management of the secretions and excretions than
can be done by the use of those remedies which affect the
heart alone ; and the judicious combination of this branch
of therapeutics, with that applying to the heart, becomes
of supreme importance in the management of the later
stages of cardiac affections.
Contraction of the smaller arteries with increased arte-
rial tension, is a condition often associated with cardiac
disease ; heart failure being directly due to this condition,
which may also be associated with chronic congestion,
chronic degeneration, and chronic inflammation of the
kidneys—which conditions are well described by Delafield.
The arteries may be slightly or considerably thickened,
due to a more or less irregular increase of the tissue of
the intima; the contraction may be spasmodic and tem-
porary, or may be continued.
This condition may be due to direct irritation of the
arteries by a pathological condition of the blood, or such
a condition of the blood may disturb the nervous centres
controlling the vaso-motor system ; the cause is not quite
clear. This condition is most often associated with aor-
- tic disease, and the association of aortic changes, general
arterio-sclerosis, and chronic kidney changes, would in
dicate that some pathological state of the blood is the
source of these various changes.
Vascular dilators are the remedies for this condition,
and the efficacy of opium, as lauded by Beaumetz in aortic
disease, is probably due to relief of arterial contraction as
much as to any other action. I have had considerable
success in relieving spasmodic intermittent attacks of
heart failure in advanced heart disease through the use of
opium.
I cannot take up more time by considering the kidney
changes involved, but they are exceedingly interesting,
taken in connection with the above condition, and should
be carefully studied, as the amount of urea, albumin, and
casts present or absent at various times, give valuable
therapeutic indications.
THE PHYSIOLOGICAL ACTION OF TYPHOID
FEVER POISON.’
By N. S. DAVIS, Jr., A.M., M.D.,
PROVESSOR OF PRINCIPLES AND PRACTICE OF MEDICINE, CHICAGO MEDICAL
COLLEGE.
Tue only positive evidence of the existence of typhoid
fever is the discovery after death of typhoid ulcers and
signs of the accompanying catarrhal inflammation in the
intestines. Except in rare cases, a diagnosis can be made
during life without difficulty from the presence of the so-
called “typhoid state ” and the symptoms of the intestinal
lesions. .
While studying annually a rather large number of cases
! Read before the American Academy of Medicine, November 14,
1889.
THE MEDICAL RECORD.
[December 28, 1889
of this disease, the very considerable variation in intensity
of some of the symptoms and variable existence of others
has attracted my attention and called for explanation.
For example, one of the most frequent variable symptoms
is that of sweating. Often we see in the hospital patients
lying side by side, suffering with equal severity in the .
same stage of the disease, the one bathed with a constant,
profuse perspiration, and the other with a skin as con-
stantly dry and hot ; or, again, one will be in wild deli-
rium, and the other stupid or semi-comatose.
The question then suggests itself, what symptoms are
the result of the typhoid infection, and what the result of
superimposed infection or of other causes? From a clin-
ical study these questions can be answered only imper-
fectly. ,
Cases are recorded in which death has occurred from
sudden intestinal perforation, the result of typhoid ulcer-
ation in persons who were not feeling ill until the fatal
catastrophe occurred. It is evident, therefore, that ty-
phoid inflammation of the intestines may exist without co-
incident and resulting typhoid intoxication. ‘This neces-
sitates distinguishing between the primary infectious agent
causation of the disease, and what, for convenience, I term
in this paper typhoid poison or intoxicant, which results
usually from the development of the disease in the in-
fected person. This fact of the occasional absence of
typhoid intoxication in those infected can be explained in
several ways: Either the intoxicant is eliminated as fast
as manufactured or destroyed before gaining access to
the nervous system and tissues generally, or it is not ab-
sorbed from its source. The typhoid poison is probably
manufactured in the inflamed adenoid structures of the in-
testines, and possibly also within the intestines. In apy-
retic cases there is no evidence that absorption from the
intestine or its walls is hindered. Elimination of poisons
absorbed from the intestines takes place by the liver, or
by organs in the circulatory tract more distant, such as
the kidneys, lungs, and skin. Absorption of the typhoid
poison we might, 2 priori, suppose would take place
chiefly, if not wholly, by the lymphatics. ‘Therefore it
would be likely to be disseminated throughout the system
and produce some general disturbance before it could
reach the organs of elimination. It does not seem prob-
able that the liver is the organ by which general infection
is prevented, for what evidence we have points to a dim-
inution of the eliminating power of this organ during an
attack of the disease. I think we must conclude that in
such cases the toxic principle is destroyed and rendered
inert before absorption occurs, but in what way we do not
yet know. It is also evident from these cases that the
general symptoms, such as fever and tissue-waste, are not
dependent directly and wholly upon the local inflamma-
tion in the intestines, but upon something that may orig-
inate from this inflammation. Considering this subject
from a clinical standpoint, the physiological changes which
occur with uniformity in all cases that present general
symptoms must be regarded as due to the typhoid intox-.
icant, and such as are of variable occurrence as due to
the superimposed infection or to changes in the suscep-
tibility of organs.
All practitioners meet with mild cases and abortive
ones. ‘These are probably to be accounted for, as are the
febrile cases, by supposing that the poison is partly de-
stroyed, and that it finds its way into the general circula-.
tion in small quantities, or sometimes intermittently.
The most characteristic results of the disease are there-
fore the intestinal lesions, such as the diarrhoea that re-
sults from the catarrhal inflammation which accompanies
the more characteristic typhoid inflammation of the ade-
noid bodies of the intestines ; the hemorrhages which oc-
casionally occur, and result from ulceration of the intes-
tines ; the perforation, which still more rarely occurs, and
produces various forms and degrees of peritonitis.
Fever is the most characteristic of the effects common
to all cases of generalized typhoid poisoning. It is un-
doubtedly due to the action of the toxic agent upon the
. December 28, 1889]
nervous system. It is generally said that the increase of
bodily temperature is accompanied by, and grows out of,
an increase of cellular metabolism, chiefly in the muscles
and large glandular organs. ‘This does not seem to me to
express the whole truth. There is an increase of metab-
olic activity, but not of the usual or physiological type,
for it does not result in the customary products of physio-
logical metabolism, such as normal secretions from gland-
cells or mechanical energy from muscles.
how they differ from the products of physiological cell-
activity, chemists have not yet told us. The most exact
information that we have of the character of these changes
is obtained from a study of the waste products of the sys-
tem which are eliminated by the kidneys. In this way it
has been shown that the nitrogenous elements of waste
are eliminated in a comparatively imperfectly oxidized
condition. Therefore, in the severest cases urea is ex-
creted in diminished amount, and especially in diminished
amount as compared to the total amount of nitrogenous
matter eliminated. In milder cases, and in the majority,
the amount of urea excreted is actually increased; but
still, compared with the total nitrogenous matter, its pro-
portion is small. Among these nitrogenous bodies we
may surmise, with considerable assurance, that there are
leucomaines.
These urinary changes have been most thoroughly
studied and interpreted by Robin. Henocque has reached
practically the same conclusion, é.¢., that oxidation is im-
perfectly accomplished, by a different method of inquiry,
by the use of his hematoscope, which shows that the quan-
tity of oxyhzemoglobin in the blood is diminished, and that
the activity of its reduction is lessened. Flint has urged
that water is normally formed in the system by oxidation,
and that in fever the formation of water is diminished or
suppressed. This view is based chiefly upon facts ob-
tained from the clinical study of typhoid. If true, it, too,
means that oxidation in the physiological manner is in
typhoid diminished. But, as Regnard’s experiments have
shown, carbonic-acid gas is exhaled in increased amounts,
and oxygen is taken up in still larger proportion, and: is
used, but more slowly than natural (Henocque), in the
production of new compounds or of those peculiar to the
disease. All these facts viewed side by side with the im-
pressive clinical lesson which is taught by every case of
typhoid, that an excessive waste is taking place, point un-
mistakably to an excessive but perverted metabolism.
The molecular changes in the cells of many of the tis-
sues of the body which grow out of these chemical ones
point with equal clearness to the pathological character of
the cellular activity which has existed during the fever.
These grosser changes consist chiefly in the production
of cloudy swelling of the cells of many glandular organs,
and subsequently, in some instances, of fatty degeneration.
In muscle-fibres here and there are seen spots of waxy de-
generation. Such changes as these are not peculiar to
typhoid fever, but are to be found in other diseases when
the metabolism of the cells is similarly affected. Not
only do anatomical changes thus grow out of the chemi-
cal, but the physiological action of many organs is quite
as strongly and deleteriously modified. ‘This increased
metabolism of fever is supposed, from evidence obtained
from pyrexias which have been experimentally produced,
to be governed .by the nervous system. I know of no
evidence to show that the perversions of tissue change
which are peculiar to each species of fever are dominated
by the same agent. That there are characteristically dif-
ferent metabolic products produced by scarlet fever and
small-pox, by typhoid and rheumatism, which produce
different forms of intoxication, is undoubtedly true.
‘These peculiarities may be due to the direct action of the
poison on the tissues. I do not wish to imply that the
sole intoxicant in all fevers is the result of perverted tis-
sue-change, for poisons of extraneous origin undoubtedly
often play a prominent part in the production of charac-
teristic symptoms.
THE MEDICAL RECORD.
Just what the
chemical products of this fever metabolism are, ard just.
795
Inhibition, or, at least, very great diminution, of tissue-
repair is a change quite as important and characteristic
of fever as perverted metabolism. Indeed, the total re-
trograde tissue-change during fever is less than during
health, but compared to tissue-repair under the same con-
ditions of diet, rest, etc., it is great. I have often ad-
ministered to typhoid patients quantities of liquid nourish-
ment as great as would maintain in health an equilibrium
of strength, and apparently, judging from the appearance
of the stools, the food was properly digested and absorbed ;
still these patients steadily lost flesh and strength. Under
the condition of the fever, there was evidently a greatly
lessened appropriation of nourishment.
The pyrexia is undoubtedly almost entirely due to the
comparatively excessive tissue-waste, for the mechanisms
of heat-dissipation are in no constant state in typhoid
fever. Heat-dissipation takes place chiefly from the skin
and lungs, and is influenced much by the amount of moist-
ure which is eliminated from these surfaces. But the elimi-
nation of the latter varies greatly in different cases, and on
different days in the same case, without materially influenc-
ing the degree of bodily heat. Compared with the normal
state, an excessive heat-radiation always exists in fever.
The blood does not undergo uniformly any morphologi-
cal changes. In the larger proportion of cases it 1s probable
that a comparative excess of white corpuscles exists. Dur-
ing the height of the disease, often a greater number of cor-
puscles per cubic centimetre can be counted than is.natu-
ral. In a word, the blood is more concentrated. During
convalescence, on the contrary, the blood becomes less con-
centrated and the proportion of corpuscular elements is re-
duced. The concentration of blood does not seem to be
dependent on the diarrhoea which is so apt to be profuse,
nor upon the hemorrhages, nor upon diaphoresis, for it can
be observed even when none of these causes is especially
active. This fact has suggested the thought that prob-
ably the diminished formation of water within the body,
which Flint had pointed out as occurring in fever, may
account for the diminished amount of water in the blood.
During convalescence the volume of the blood is restored,
but the red corpuscles, which undoubtedly are in part de-
stroyed during the active progress of the fever, are not so
easily restored, and therefore a true anzemia is produced.
Although the corpuscles are apparently more numerous
than normal during the height of the fever, their sudden
and great reduction in number during convalescence can
only be explained by supposing that destruction was going
on, although masked by the concentration of the blood.
Fibrin does not usually form as abundantly in typhoid
blood as in healthy, although this is not a constant or in-
variable charactenistic of it.
During the early and progressive stages of typhoid the
peripheral vessels are relaxed and the blood-pressure in
them lowered. Whether this change is effected by agents
acting indirectly through the nervous system, ‘so that the
normal vascular tone is lessened, or by agents acting di-
rectly on the vascular walls, it is impossible to say.
Probably both the nervous and muscular mechanisms are
simultaneously influenced in the same direction. The
heart muscle is frequently weakened by degenerative
changes, which are the result of a morbid metabolism
similar to that taking place in the other tissues of the
body. The quickened pulse is shown by Martin to be
due to the effect of the heated blood upon the heart
itself. ‘The degenerative changes account for the weak
and quick pulse which is often noticeable long after the
pyrexia has ceased.
The increased frequency of respiration is fully explained
by the action of the heated blood upon the respiratory
centre. ‘The nasal passages are rarely inflamed, although
they are usually dry. The pharynx, and usually the lar-
ynx, are in the same condition. The bronchi are almost
uniformly more or less inflamed. So usual is this bron-
chitis that by many it is regarded as due to the typhoid
infection. Proof of this, I think, is insufficient, and such
an explanation is certainly unnecessary; for the dry
706
THE MEDICAL RECORD.
[December 28, 1889
condition of the mouth and throat, and the infrequent
acts of swallowing, of coughing, or of otherwise removing
what gathers about the larynx, trachea, or bronchi during
the period of mental dulness, readily explain many of the
cases of true bronchitis. Often the physical signs of a
mild bronchitis are present very early. ‘This, I believe, is
due to an unnatural dryness of the bronchi rather than
to inflammation, and is similar to the change that is ob-
servable in the pharynx and mouth. ‘The dryness is the
result of diminished secretion by the mucous glands.
When moist rales are heard in typhoid bronchitis they
are due to inflammatory exudates. Most of the other
changes that occur in the lungs and air-passages are
superimposed and complicating diseases, and not direct
outgrowths of the fever.
In typhoid fever there is a diminution of normal glan-
dular activity, as a rule. This is well illustrated in glands
‘along the alimentary tract. ‘The dryness of the throat
and mouth is too well known to need mention. ‘This is
due almost exclusively to the diminished formation of
saliva. We possess little experimental evidence of the
condition of the secretions in the stomach. ‘The dele-
terious influence of solid food upon the inflamed intes-
tines is well known. Disinclination for food, and the
occasional vomiting of undigested food, point clearly to
slow and imperfect digestion. Glujinski, in a moderate
number of cases, found by direct examination of the con-
tents of the stomach that hydrochloric acid was wanting
except during recovery, but that pepsin was secreted as
usual. This change is not due to the pyrexia, evidently,
for digestion is not at all uniformly interfered with in
chronic pyrexias.
The diminution in the amount of urine during the
period of fever, its acidity, high specific gravity, and the
increase in the urea and uric acid in it, are changes too
well known to need recalling. ‘They are dependent largely,
if not wholly, upon the changes that first occur in the
general metabolism of the tissues. ‘That they are thus
dependent seems evident from the fact that the degree
of change in their quantity depends upon the severity and
progress of the pyrexia and other general symptoms.
‘They do not depend directly upon the degree of temper-
ature, but change with its permanent fall. On post-
mortem examination the kidneys are usually found some-
what enlarged, and their epithelial elements in a state of
cloudy swelling. It is probable that these changes are
the result of the perverted metabolism which exists in all
the tissues, and in the renal among the rest. Necessarily,
these changes must interfere more or less with the func-
tional power of the organ. Uric acid and the incom-
pletely oxidized waste-products are increased out of pro-
portion to the urea. Ammonia and kreatinin are voided
in Increased amounts. ‘The chlorides are usually dimin-
ished, and the coloring matters increased. All of these
changes are most intense in the first, and early part of the
second, week. After this, the urine by degrees becomes
more abundant, and the proportion of the constituent ele-
ments approaches more nearly the normal. During con-
valescence it is pale and dilute.
Among the symptoms most uniform in their occurrence
are those connected with the nervous system. Indeed,
they chiefly characterize the so-called ‘typhoid state.”
While there are a large number of cases that present
varied mental symptoms, the greatest number are very
uniformly characterized. Usually the disease is intro-
duced by headache. ‘This, I believe, is largely the result
of changed blood-pressure, and possibly of a commencing
change in the nutrition of the brain-tissue. Soon pain
ceases, and mental hebetude, or greater or less stupidity,
is noticeable. ‘The patient gradually becomes less and
less conscious of his surroundings, and when addressed,
or requested to make certain motions, responds with slow-
ness, as his mental acts are retarded. Forgetfulness is
also a usual characteristic. The stupidity gradually is
intensified until a semi-comatose condition is developed.
‘The hebetude is not due to somnolence. It is accom-
panied by more or less of delirium, which generally shows:
itself in low mutterings or occasional starts or attempts
to rise, that are readily pacified and quickly checked by
the attendant.
In a smaller proportion of cases the delirium is persist-
ent, and even violent. I wish particularly to call atten-
tion to the marked similarity of these symptoms in their
development to those progressively produced in narcotic
poisoning. There is a stage of mental sluggishness or
_torpidity which so far prevents the action of the higher
inhibiting centres, that more or less of delirium is pro-
duced. ‘This inhibiting may go so far as to permit wild
delirium, just as we find in the narcotic poisoning of cer-
tain individuals delirium, when ordinarily we would ex-
pect stupidity or somnolence. Usually, as the poisoning
deepens, more or less complete unconsciousness develops,
which rarely passes into actual coma. This progressive
poisoning, or narcosis, if we may call it such, is probably
the result of the successive involvement of different parts
of the brain, and of their varying susceptibility in indi-
vidual cases to the poisons generated in the course of the
fever. Variable phenomena are cutaneous hyperzesthesia,
anesthesia, noise in the head, dizziness, muscular tremors,
etc. These are probably due to accidental causes, or to
idiosyncrasies of the person, and not directly to the ty-
phoid poison. .
But, we ask ourselves, how are the usual mental symp-
tons of typhoid produced? Are they the result of the
direct action of the infective agent or cause of typhoid
fever, or of some agents produced within the body as a
result of the fever and changes incident thereto? Robin
has insisted, in answer to this question, that the phenom-
ena are the result of the accumulation in the system of
products of unnatural or incomplete tissue-change, which
act poisonously upon the nervous system. He would
conclude, therefore, that the infecting agent was not the
direct cause of the mental symptoms. To substantiate
this view he points to the fact that, when the so-called
typhoid state develops, there is always a marked diminu-
tion of complete tissue-oxidation. The same symptoms
arid the same pathologico-chemical conditions are observ-
able in other diseases than typhoid fever, as, for instance,
at times in pneumonia and rheumatism, although there is
no anatomical evidence of a complicating typhoid. The
experiments of Robin and deductions therefrom are all
the facts that as yet throw light upon the question which
we have just asked.
The dry skin of most typhoid patients is the result of
the same diminished functional activity that we observe
in the glands of the mouth and elsewhere. It is probable
that the diminished quantity of water in the system also
aids in producing the functional inactivity. A positive
cause of the profuse perspiration that is occasionally seen
cannot be named. It is quite probable that it is an at-
tempt to vicariously do work which the kidneys cannot
accomplish ; but it may be the result of the presence in
the blood of some sudorific. ‘That the lack of perspira-
tion is due to an active cause, and that it is not a passive
effect, is evident, as the hot blood would of itself, in a
normal condition of the tissues, be a powerful diapho-
retic. An explanation of the characteristic rash is want-
ing. The rare pustular and furuncular eruptions are un-
doubtedly produced by superimposed infection. How
the typhoid poison is eliminated is problematical. ‘The
most natural supposition is that it takes place through
the kidneys.
The limits of this paper will not permit a discussion of
numerous other variable changes and complications, which
are in some instances the result of coincident infection
by the poison of other diseases, and in others the result
of the pecuharities of susceptibility of organs and tissues
In given cases.
We may summarize our conclusions as to the physio-
logical action of the typhoid poison as follows: 1. The
cause of typhoid fever produces inflammation of the
adenoid bodies in the intestines; and the accompanying
December 28, 1889]
THE MEDICAL RECORD.
797
catarrhal inflammation. 2. General symptoms are not
the result of the typhoid ulceration of the intestines, but
of something (an intoxicant) formed and usually absorbed
in the course of the inflammation. 3. The lymphatics
are probably the vessels by which the toxic agent is at
first chiefly carried from its source. 4. The typhoid
poison, presumably by acting upon the nervous system,
produces pyrexia, which is the result of increased tissue-
change that probably, by the direct action of the poison
on the tissues, is perverted in a manner peculiar to the
disease and is characterized chiefly by imperfect oxida-
tion. 5. The typhoid poison also inhibits tissue-repair,
and therefore produces bodily waste. 6. ‘These tissue-
changes result in various anatomical changes, such as
cloudy swelling of most glandular organs, waxy or fatty
degeneration of many muscles, and destruction of some
blood-cells. 7. They also result in various physiological
changes, such as diminished secretion from glands, sali-
vary, gastric, hepatic, renal, sudorific, and probably bron-
chial mucous. 8. The heated blood increases the rapid-
ity of the respiration and of the heart’s action. 9. Some
of the products of the perverted tissue-changes act toxi-
cally to the nervous system, and produce the mental and
nervous symptoms characteristic of the disease. 1o.
Bronchitis is probably the result of irritation of the dry
and unprotected membranes by the inspired air. The
frequent coincident attacks of catarrhal pneumonia are
due to an extension of the bronchitis ; croupous pneumonia
to superimposed infection; hypostatic engorgement to
weakened circulation, respiration, and the prolonged dor-
sal decubitus. 11. Peritonitis is due to the extension of
the onginal inflammation from the intestines to the peri-
toneum, or more frequently to perforation of the intestine
by ulceration. 12. Parotitisis due to superimposed infec-
tion, probably from the mouth, which takes place with es-
pecial ease while the gland is functionally inactive. 13.
Pustular eruptions are also due to superimposed infec-
fion.
Clinical Department.
FATAL POISONING BY CHLORATE OF POT-
ASH.
By WILLIAM ANDERSON, M.D.,
BROOKLYN, N. Y,
IN view of the wide-spread domestic use of chlorate of
potash, and from the fact that fatal cases of poisoning by
it are somewhat rare, I consider it useful to report the
following case, the first one I have met in nearly twenty
years’ practice.
Mrs. M—, aged about seventy, in fair health, but
suffering from constipation, dissolved nearly one ounce of
chlorate of potash in water, and drank it all, thinking it
was Rochelle salts. No special disturbance was felt at
the time, but the mistake being discovered about an hour
after, some mustard and oil were taken, to produce vom-
‘iting, which was accomplished. Two hours after the
drug had been swallowed I was called in, and found the
old lady quite comfortable, suffering no pain or distress
of any kind. Being misinformed as to the quantity of
the drug used, and believing it to be probably about
two drachms, I gave a favorable opinion, prescribed a
dose of castor-oil, to be followed by a solution of bis-
muth. Four hours afterward I was again called, and
found the patient in a state of collapse. While defecat-
ing, she had fainted. The lips were blue, the tongue of a
purplish color, and the face ashen. On rallying a little,
she declared she had no pain, but immediately com-
menced to vomit a profusion of mucus. ‘There was no
sign of blood in the discharge. ‘The temperature was
100° F., and the pulse about 100—weak, but not irregular.
No oppression of breathing; feet warm. Judging that
trouble was to be apprehended from the heart, I pre-
scribed small doses of digitalis and whiskey to be fre
quently given during the night. She kept quiet and
drowsy from this time, ro P.M., till about 3 A.M., when
she went asleep (probably became comatose), and died
quietly about 6 A.M., fifteen hours after partaking of the
poison. She urinated freely after taking the draught, but
I did not get an opportunity to examine the water. As I
did not see her during the last eight hours of life, the im-
mediate symptoms preceding death can only be guessed
at; but I believe it might be said she died of “ heart fail-
ure.” e
A CASE OF UNUSUAL TOLERANCY OF THE
PREGNANT UTERUS.
By CHARLES L. LANG, M.D.,
NEW YORK.
On the roth of last May I happened to be in S——, a
lovely summer-resort in this State. During the day Dr.
S—— , one of the best local physicians, requested me to
see with him a case in consultation. He had begun the
treatment three months previously, the patient at that
time being a few months past her confinement, which had
left her not as well as she wished. ‘The doctor diagnosed
subinvolution of the uterus with considerable peri-uterine
cellulitis. His treatment had been fairly regular from
February to May, and had consisted of local applications
to the cervix and fomices, the use of the hot douche,
and, as he believed, two very thorough scrapings of the
endometrium with Thomas’ dull curette.
Arrived at the home of the patient we found Dr.
W , whom the husband had summoned to meet us,
as he was not satisfied with the progress his wife was
making. After Dr. S—— had repeated the history of
the case, we each made a vaginal and bimanual examina-
tion of the patient. The uterus was as large as it should
be at four months’ pregnancy. ‘Then Dr. S—— introduced
the curette for the purpose of measuring the depth of the
organ, and it passed in easily till the ebony handle blocked
up the os. The diagnosis of chronic metritis was reluc-
tantly made, none of us being very clear about the case.
Pregnancy would seem to be excluded both by the treat-
ment and the previous history. However, Dr. W——
writes me that the case being left largely to nature, and no
more active treatment of the uterus being allowed, she
was delivered of a healthy baby late in September.
180 EAST SavENTY-SECOND STRERT.
HAEMATEMESIS IN TYPHOID FEVER,
By A. A. GILLETTE, M.D.,
WESTERNVILLE, ONEIDA COUNTY, N. Y.
In Tue MepicaL Record of November 16th two cases
of intestinal hemorrhage are reported in which blood was
vomited, but none passed by the anus.
On August sth I lost a typhoid-fever case in a similar
manner. The patient was a young farmer, about thirty-
five years of age. The fever was well.marked and typi-
cal, with diarrhoea, tympanites, pulse 120, and temperature
of 105° F., with slight morning remissions. He was just
beginning the third week of fever, and all seemed to be
going well, when I was hastily summoned, early on the
morning of the above date, to find my patient in a state
of collapse. During the previous night, while his bowels
were moving, he was suddenly seized with agonizing ab-
dominal pain, followed by increased tympanites and ten-
derness, and accompanied by a severe chill. His agony
was so great that I was sent for at daylight. I found my
patient with a pulse so rapid and feeble that'it was diffi-
cult to count.
Soon after my arrival he began to vomit large quanti-
ties of blood. ‘Ihe friends said there had been none in
the stools, and this was confirmed by a perfectly blood-
less movement a short time before death, which soon fol-
lowed.
708
THE MEDICAL RECORD.
[December 28, 1889
THE MEDICAL RECORD:
A Weekly Fournal of Medicine and Surgery.
eee me
GEORGE F. SHRADY, A.M., M.D., EDITOR.
- E
PROPRIETORS AND PUBLISHERS
WM. WOOD & Co. Nos. 56 and 58 Lafayette Place.
— —
New York, December 28, 1889.
THE NON-TUBERCULAR AN® NON-CARDIAC
HÆMOPTYSES OF ELDERLY PERSONS.
AT a recent meeting ' of the Medical Society of London,
Sir Andrew Clark read a paper with the above title, in
which he described a form of pulmonary hemorrhage oc-
curring in persons somewhat past middle age, and which
is not associated with any tuberculous or cardiac affec-
tion. His attention was first called to this condition
many years ago by the occurrence of a fatal case of
hemoptysis in a man between fifty and sixty years of age,
who had been admitted to the London Hospital for
treatment of a subacute bronchitis. ‘The patient had for
several years been the subject of a moderate progressive
osteo-arthritis, and for the past four or five winters had
suffered from severe bronchitis. It was during one of
the latter attacks that he was admitted to the hospital.
About two weeks after admission he began to cough up
small quantities of blood at short intervals. In spite of
rest, restricted diet, the application of ice to the chest,
and the liberal use of astringents, the bleeding persisted,
and within a week the patient died. At the autopsy the
heart was found to be normal, and no evidence of tuber-
culous disease could be detected anywhere. Within the
lungs were seen several isolated patches of emphysema
surrounded by hemorrhagic extravasations. Examination
under the microscope showed that the seat of the hemor-
rhage was in the immediate neighborhood of these em-
physematous patches, and that the minute arteries in
these localities were always diseased, the structural
changes being limited to nuclear proliferation in the mid-
dle coat, and an amorphous and hyaline infiltration of it
and of the intima. ‘Ihe first change, the author believed,
occurred in a terminal branch of the pulmonary or bron-
chial artery, and this resulted in obstruction of the blood-
supply throughout a certain territory. Following this was
degeneration of the capillaries and venous radicles, de-
termining a true atrophic emphysema, and, the integrity
of the vessels being thus impaired, the formation of
thrombi or recurrent conditions of pressure brought about
the fatal hemorrhage.
Subsequent to this observation, Sir Andrew met with
quite a number of similar cases, in all of which the usual
treatment by astringents was without effect. Finally he
determined to try another method of treatment. In a
case which he saw in aisha aia having instituted
? British Medical Jasoa October 26, 1889.
the ordinary treatment without obtaining an arrest of the
hemorrhage, he put the patient upon a light and rather
dry diet, gave a dose of calomel at night followed by a
saline cathartic in the morning, and ordered an alkaline
mixture containing ammonia. This was entirely success-
ful, the bleeding ceased within thirty-six hours, and the
patient recovered perfectly.
The following are the author’s conclusions in regard to
this form of pulmonary hemorrhage :
1. There occurs in elderly persons free from ordinary
diseases of the heart and lungs a form of hemoptysis
arising out of minute structural alterations in the terminal
blood-vessels of the lung. °
2. These vascular alterations occur in persons of the
arthritic diathesis, resemble the vascular alterations found
in osteo-arthritic articulations, and are of themselves of
an arthritic nature.
3. Although sometimes leading to a fatal issue, this
variety of hemoptysis usually subsides without the super-
vention of any coarse anatomical lesion of the heart or
of the lungs. >»
4. When present, this variety of hemorrhage is ‘aggra-
vated or maintained by the frequent administration of
large doses of strong astringents, by the application of
ice-bags to the chest, and by an unrestricted indulgence
in liquids to allay the thirst which the astringents create.
5. The treatment which appears at present to be the
most successful in this variety of hemoptysis consists in
‘diet and quiet, in the restricted use of liquids, and the
‘stilling of cough ; in calomel and salines ; in the use of
alkalies with iodide of potassium ; and in frequently re-
newed counter-imitation.
COMPULSORY VACCINATION IN THE UNITED STATES.
WitTH the exception of Massachusetts, there is, so far
as we are informed, no State in this country in which
vaccination is directly and specifically required of all chil-
dren. Practically, however, in most States vaccination is
indirectly made compulsory. Dr. Rauch, Secretary of
the Illinois State Board of Health, recently made some
interesting statements regarding this subject before the
Royal Commission on Vaccination (Zhe Lancet). Dr.
Rauch said that in the army, orders as regards the vacci-
nation of men in regiments were carried into effect on a
mere rumor that small-pox existed in some neighboring
brigades. Again, during the Chicago fire, when four thou-
sand people were housed in a barrack, the importation of
one case of small-pox led to an order that every person
should be vaccinated, and all obeyed except “an Eng-
lishman,” who threatened anyone who should vaccinate
his children. Nevertheless they were subjected to the
operation, and it may be recorded that, a few weeks
afterward, the man, finding his children were saved from
small-pox, made an apology for his behavior. In Novem-
ber, 1881, small-pox was on the increase in Chicago and
Illinois, and an order was issued for the vaccination of all
pupils admitted to public schools in each of the twelve
thousand school districts of the State, and in the end six
hundred and fifty thousand children were vaccinated in
the public and parochial schools. Vaccination is permis-
sive, but school attendance is compulsory, and all attend-
ing school are compelled to be vaccinated. And if
December 28, 1889]
small-pox is found in a house the building is “ quaran-
tined, placarded up, and everybody vaccinated and re-
vaccinated.” Here, in the case of others than school-
children, the compulsion is indirect. Those submitting
to vaccination are allowed out of their houses, and have
certain privileges ; those refusing are compelled to remain
in-doors under a police requirement. Much the same
style of compulsion applies to persons entering the State
of Illinois, the unvaccinated being subjected to the opera-
tion either before starting for their journey from the
port, or in the railway cars during transit. If they refuse
—and a case of three Englishmen was cited as to this—
they are not allowed to enter the State. In the end, they
preferred Illinois and vaccination to being sent back to
the place whence they came. ` Apart, therefore, from
compulsion as to school-children, the compulsion as to
vaccination in Illinois is actually on a very wide scale,
and it mainly comes into operation at times when small-
pox is imminent or actually prevalent.
In England the law compels all children to be vacci-
nated. ‘This arouses a good‘deal of opposition, and not
without reason. It appears to us that the matter is man-
aged much more judiciously and sensibly in this country.
The State has no right to vaccinate a child as long as
the child is kept at home and is not a source of public
danger. But if the child is to enjoy the benefits of edu-
cation and the privilege of coming in contact with others,
then the State may take precautions and enforce vaccina-
tion.
FLORIDA JOINS THE PROCESSION.
THE question of the State regulation of medical practice
is One concerning which some honest difference of opin-
ion exists even within the ranks of the profession itself.
An esteemed correspondent has recently offered as an
objection to such measures that any attempt to control
medical practice is an encroachment upon personal lib-
erty, and he holds that public opinion will of itself, and
in its own good time, bring about the elevation of the
medical standard of education so that no State interfer-
ence will be necessary. ‘The same argument might apply
equally to bunco-steering and sawdust swindles. There
can be no question that public opinion is against such
practices, yet few sensible men will deny the right of
the State to repress them whenever it has the oppor-
tunity. We may admit that society frowns upon dishon-
esty, that the schools teach morality, and even that the
world is growing better every day, but we cannot yet af-
ford to erase all laws from the statute-book, to open the
prisons, or to close the courts.
It is possible that a better way to protect the commu-
nity from the injury done by charlatans and ignorant prac-
titioners than State regulation may yet be found, but at
present none other exists in practical shape. Whether
that will be effectual can be demonstrated only by a prac-
tical experience, and for this reason, if for no other, we
are glad to see one State after another falling into line
and putting to the crucial test of actual trial the utility of
such a measure.
Florida is the latest of the commonwealths to pass a
law of this nature. The act provides for the appoint-
ment of a board of medical examiners in each Judicial
District, and in addition one board of homeceopathic medi-
THE MEDICAL RECORD.
709
cal examiners for the whole State. The members of these
boards are to be practising physicians of good standing
and graduates of some medical college recognized by the
American Medical Association and by the American In-
stitute of Homceopathy, respectively. They are to be ap-
pointed by the Governor of the State and are to serve for
four years. ‘The boards are to meet twice each year in
their respective districts for the examination of candidates
and the granting of certificates. The subjects for exam-
ination, as specified in the act, are anatomy, physiology,
surgery, gynecology, therapeutics, obstetrics, and chem-
istry ; but, strangely enough, no provision is made for ma-
teria medica or practice of medicine unless therapeutics
can-be construed to embrace both these branches. Only
those receiving certificates shall be entitled to practise
medicine in the State, but those already engaged in prac-
tice at the time of the passage of the act need not under-
go an examination, the presentation of a diploma from
some recognized medical college being sufficient to en-
title them to a certificate from the board.
Governor Fleming has requested the State Medical As-
sociation, through its president, Dr. R. A. Lancaster, to
recommend physicians for appointment on the several
examining boards, and it is believed that all the boards
will have organized and held their first examination be-
fore the beginning of the new year.
It will be seen that this act differs in some respects
from those already in force in some of the other States,
and it would seem that the framers of the law might have
done better had they followed more closely in the foot-
steps of their predecessors in some other parts of the
Union. Nevertheless this is a beginning, and we hope.
the time is not far distant when every State will have some
such law, and we shall then learn whether the community
is able or not to protect itself by legislative enactment
from the dangers of quackery.
THE NOTIFICATION OF INFECTIOUS DOCTORS.
THE London Zmes is agitating the subject of placing
restraint upon the practice of physicians who are attend-
ing infectious diseases. It is urged that the doctor who
is attending a case of diphtheria, scarlet fever, whooping-
cough, or measles, should not treat at the same time fam-
ilies in which no infectious disease exists. It prints the fol-
lowing remarks of a general practitioner upon this subject :
“ He (the doctor) comes across a case of scarlet fever,
small-pox, or other infectious disorder ; his other patients
are needing his visits—a midwifery case may be—and so
he goes on with his work until his round is finished. In
the evening, surgery work again. Each day brings simi-
lar work, only the infectious disorder has become more
infectious. Now, how is he to prevent spreading infec-
tion, working in the way I have stated? ‘True, he could
go home and change his clothes, and in other ways disin-
fect himself ; but does he ? Does the conscientious doc-
tor do this? And what about his own household? I
certainly think with your correspondent that ‘a notifica-
tion of infectious doctors’ is as much wanted as a ‘ Noti-
fication of Infectious Diseases Act.’”
This picture, though much exaggerated, 1s to some extent
true ; but unfortunately our social organization is imperfect
and we see no radical way of remedying the difficulty. ‘The
710
THE MEDICAL RECORD.
[December 28, 1889
plan of having a special physician for infectious cases is
utterly impracticable, especially in small towns and the
country. Itis the duty of conscientious physicians to dis-
infect themselves and protect themselves as much as pos-
sible ; and, in fact, we doubt very much if infectious dis-
eases are often carried by physicians to the houses which
they visit, oftenest they bring them to their own homes
because there they come in close and frequent contact
with their children.
Doctors are almost universally careful about taking
midwifery patients while attending septic cases, or cases
of erysipelas and scarlet fever.
The public notification that a doctor is attending a
case of infectious disease would instantly put a stop to
their notification of such diseases, or else it would throw
ninety per cent. of medical men out of practice.
Rews of the Week.
THe HEALTH OF THE PRINCE OF WALES.—The Prince
of Wales is said to be in poor health and suffering from
great depression of spirits and weakness. It is with great
difficulty that he keeps up a show of strength in striving to
meet his engagements. All this, together with the rumor
that he is suffering from Bright’s disease, has it ssignificance.
ANOTHER CASE OF COCAINE POISONING has been re-
ported in Philadelphia.
DEATH oF Dr. TRUMAN H. Squire.—Dr. T. H. Squire,
widely known as one of the leading surgeons of Western
New York, died at his home in Elmira after a long and
painful illness. He was born in Russia, N. Y., in 1823,
and graduated at the College of Physicians and Surgeons
1848. In 1861 he enlisted as volunteer surgeon in the
Union Amny, and earned for himself the distinction of
being one of the most efficient surgeons in the Army
of the Potomac. His name has also been prominently
associated with the jointed catheter, which he invented,
and for which invention he received the Prix Argenteuil
awarded by the Imperial Academy of Medicine of Panis.
He was a frequent and valued contributor to medical
literature and was an honored member of various medical `
societies.
THE Russtan EPIDEMIC INFLUENZA.—A St. Petersburg
correspondent of the British Medical Journal describes
the epidemic in that city as follows: “ It is frequently
spoken of: in the lay papers as influenza, but the typical
symptoms of this disease are far more frequently absent
than present, and the only features in common are the
rapid course, the extremely rapid spread, and the frontal
headache, the great running at the nose and eyes being ab-
sent in all the cases that Ihave seen. The two most promi-
nent symptoms in the present epidemic are those of high
temperature and great frontal headache, accompanied in
many cases by pain in the eyeballs, and in all by foul tongue
and breath, constipation, and general malaise. ‘The onset
is rapid, the temperature running up at once to 39°, 40°
C., or even higher. The pulse in those cases I have seen
is not raised proportionately with the temperature. In
some cases there are added the symptoms of catarrh of
the nose and frontal sinuses, in others there are sore
throat and catarrh of the deeper air-passages, and in
many there are vague rheumatic pains about the back
shoulders, and limbs. The duration is short, averaging
from three to five days, though sometimes prolonged to six
or eight days, or even longer, and convalescence is rapid.”
THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF
MARYLAND proposes to adopt a three years’ graded course
of instruction, and requires a general average of seventy-
five per cent. of those who pass the examinations. ‘The
leaven of Johns Hopkins Hospital is working through
Baltimore.
MEDICAL REGISTRATION IN NORTH CAROLINA.—The.
State Board of Health of North Carolina has issued the
following: ‘All physicians in the State must register
with the Clerk of the Superior Court before January 1,
1890, if they intend to practise thereafter and collect
their fees for services rendered. There will be no sub-
terfuge allowed. ‘The law must be enforced.”
A Fire BROKE OUT IN THE PRESBYTERIAN Hospi-
TAL of this city on December rgth, and destroyed most
of the north wing. Eighty-one patients, who were in this
wing, were safely transferred to other institutions, and no
lives were lost. * The incident showed how generously
New York is supplied with hospital accommodations.
One hospital offered to take thirty patients, another eighty,
another sixty. The fire will not cramp the hospital ac-
commodations of the city. The loss to the hospital is said
to be fully covered by insurance.
Dr. CHARLES O’DONOVAN, 2 prominent physician of
Baltimore, and President of the Alumni of the Maryland
University, died December 23d, of heart trouble.
THE LATE PROFESSOR VOLKMANN AS A POET AND LiT-
TERATEUR.—Volkmann was exceedingly skilful and elegant
as an operator, he was fertile in resources, and a great in-
ventor of new procedures. His pupils idolized him, for
he was not only a teacher who joined the greatest ele-
gance with the highest clearness of diction, but he was, up
till his death the students’ sincere and warm-hearted
friend. In spite of his high rank in society and in the
hierarchy of science, he remained a Bursch to the last. In
Halle many amusing stories are current about Volkmann’s
good-humor. In the midst of his overwhelming profes-
sional work, he found time to gain the laurel wreath of a
poet. His Zräumereien an fransdsischen Kaminen—tales
which he sent home to his children during his sojourn in
France in 1870 and 1871—were published under the
pseudonym “ Richard Leander,” and had a great success.
His Leeder aus dem Saalethal added to his literary reputa-
tion, and many of his fairy tales, told in the first instance
to his own little ones, found their way to the hearts of
German children. In Volkmann Halle has lost its chief
medical attraction, the German army one of its foremost
surgeons, and the art of surgery one of its most brilliant
exponents.
THE THREE BROOKLYN FAITH-CURE Fanatics who
were arrested for endangering public health by refusing
to allow a sick wife and child to have medicine, were
convicted, and fined $200, $150, and $100, respectively.
A LarGE Brain.—The brain of the insane homicide
and suicide Daley was found to weigh fifty-nine and one-
quarter ounces, and to show no gross pathological lesions.
This is just the weight of the murderer Ruloff's brain ; an
ounce heavier than Jim Fisk’s, and six ounces heavier than
Daniel Webster’s.
December 28, 1889]
Correspondence.
CIVIL SERVICE EXAMINATIONS FOR MEDI-
CAL MEN.
To tHe Eorror or Tur Mepicat Recor.
Sir : During the weeks which have followed the publica-
tion of my letter concerning Civil Service matters in THE
Record of December 7th, I have received many com-
munications from physicians, both in New York and
places far away. The writers have gratified me exceed-
ingly by upholding heartily the position I there took re-
garding certain municipal medical abuses ; and in several
instances they referred to other and additional Civil Ser-
vice obliquities which they had experienced. I wish
these gentlemen would publish in this journal the same
statements which they have made in private. Such pub-
lic evidence of approval would doubtless help in abating
the abuses of which we are all aware.
To those gentlemen whose kindly messages I have re-
ceived, but through stress of work have not answered, I
take this means of tendering my thanks and my apprecia-
tion.
In the latest number of THE Recor there appear let-
ters from Dr. Frederick Peterson and Mr. G. K. Acker-
man. Regarding the first, it interested me, as I had not
before heard of the examination in 1884, which this
gentleman so creditably passed. However, my paper
referred to New York City (not State) examinations, and
so far as these are concerned my statements were, I think,
correct.
Perhaps the profession would have been more inter-
ested, and some good might have resulted, if instead of
devoting an entire article of more than a column to the
details of his examination, and to laudation thereof, the
doctor had said just a few words regarding present ex-
aminations—inefficient because hasty and not practical—
and their accompanying political queernesses.
Regarding Mr. Ackerman: This gentleman, in his
communication mentioned, cuts out a portion of my pub-
lished letter and pronounces it a falsehood. This he
does with such emphasis and brevity as to be equivalent
to saying “ damn !”—and that is all.
- The portion to which he refers was, as I stated, simply
a quotation on my part, which I have reason for thinking
true. How it will surprise and even sadden the doctor
who told me how he attained the “ Summer Corps,” when
he learns that Mr. Ackerman contradicts him !
In the Evening Post of December 17th is an interview
with Mr. Ackerman, in which this gentleman practically
admits the more important of the facts alleged, barring
the taking of the papers home by the doctor. That is,
he admits that a certain few physicians were allowed a
special examination a day or two later than the regular
one.
lf a certain one or two are, as a favor, allowed to take
their examination a day or two days later than that of the
vulgar herd, and are—as we are informed—asked the
same questions as the latter, what fairness is there in this
arrangement? Even if different questions are asked,
what fairness? It is, for obvious reasons, a simple trav-
esty on a competitive examination, and the political cloven
hoof is apparent.
If the men who were allowed a later examination in
this instance were nof asked the same questions as the
others, it ought to be easy for Mr. Ackerman to prove this
by allowing to reporters free access to the examination-
papers written both by these favored doctors, whose names
lS given in the Lvening Post, and by the rest of the
class.
I have no personal quarrel with Mr. Ackerman. He is
probably a politician of much probity ; and therefore there
are a few points on which, in common with many other
physicians, I find myself puzzled.
THE MEDICAL RECORD.
-unless the uterine appendages were removed.
711
Will not some other among the professional readers of
THE RECORD add his personal quota to the problem under
discussion, as, at the request of the editor, I have done ?
Rosert H. M. Dawsarn, M.D.
345 Wast Firry-sixtTH STREET.
A PROTEST AGAINST THE REMOVAL OF THE
UTERINE APPENDAGES.
A LETTER FROM Dr. THOMAS ADDIS EMMET.
To THe EpiTror oF THE MgpiIcaL Rgcorp.
Sir: In the issue of THE MepicaL Record for Decem-
ber 21, 1889, my views are not clearly stated in the re-
port on the discussion which followed the reading of
Dr. Malcolm McLean’s excellent and well-timed paper.
Much that I did say is reported accurately, but either I
failed to make myself understood, or enough has been
omitted to give the impression that I was opposed to the
operation for the removal of the uterine appendages.
From the beginning I have been uncompromising in
my opposition to the removal of the ovaries for dysmen-
orrhoea and other nervous disorders, due to perverted or
impaired nutrition, and where the fault lies in the nerve-
centres. ‘The training of a lifetime to close observation
would save me from the error of denouncing any opera-
tion until I had clearly defined the grounds for doing so.
Mr. Tate introduced a valuable procedure which has its
place, but it lies in a more narrow limit than he, or many
other operators at the present time, are willing to admit.
It is an operation which I never hesitate to recommend,
or to perform, when I think it indicated. I have simply
opposed at every turn the fearful abuse of the operation
which has existed, as a disgrace to the profession and as
a reflection on our knowledge of the healing art. No
one can deny the fact that there are members of the pro-
fession, in this city, who average more than one opera-
tion a week for the removal of the uterine appendages.
My field of observation is certainly as large as any other
operator, and yet I have seen but three cases during the
past year when I thought the operation justifiable. I
operated on these with the result of restoring two invalids
to perfect health, and, I believe, no other procedure
could have accomplished so much, while the third case
has been but little benefited.
I have had under treatment in my private hospital a
number of women where judgment had been passed, by
some of our best men in the profession, to the effect that
restoration to health was impossible in their condition,
I am
within the bounds of truth when I state that more than
half of these women have in time gotten well, and several
have borne children since their discharge.
To my regret some yielded to outside pressure, and
left me to have the operation performed before the ne-
cessity, at least from my stand-point, had been determined,
and the others have passed away from my observation.
Doubtless the greater portion of these women who were
restored to health will remain sterile, from obliteration of
the tubal canals, but not a single instance of insanity or
of melancholia has occurred. Can the same be claimed
as the result after the appendages have been removed ?
Those who operate so frequently must take the trouble
to keep a record of their cases, and report honestly the
condition of each individual a year after the operation.
Every one in gynecological practice knows that not in-
frequently he is consulted for relief after this operation
has been performed, and where the patient has received
no benefit. With not a few the suffering has been greatly
aggravated by the formation, it is supposed, of peritoneal
adhesions, which have been formed after the operation,
and these cases are of far too frequent occurrence to be
accidental or exceptions to the rule.
The burden of proof must rest with those who claim
so much for the operation, to show that the after-condi-
tion of their patients justifies its frequent performance.
712
THE MEDICAL RECORD.
[December 28, 1889
If they neglect to vindicate themselves the verdict must
be, if it rests on the judgment of others, that while it may
prove a source of pecuniary profit to the operator, a very
large number of women who have trusted to their honesty
have not been benefited, and their condition has been
made a more deplorable one. Yours truly,
THomas Appis EMMET, M.D.
ANTISEPTICS AND THE COUNTRY DOCTOR.
To Tue Epitor or ‘Tue MunicaL Recorp.
Sir: It seems as if the whole medica] world was going
crazy, or is already crazy, on the subject of antiseptics.
The poor, miserable bacilli and cocci are hunted down,
and starved, and bombarded with all sorts of antiseptics
imaginable, from poisonous sublimate solutions to that
vilest of all compounds, iodoform. Whether micro-organ-
isms are the result or the cause of disease, it is now the
proper thing to deluge the living tissues with all sorts of
vile and poisonous substances in the name of antisepsis.
I know it requires a great deal of nerve at this age of the
world to even doubt aloud, much more, indeed, to put
your doubts on paper. I have been a constant reader of
THE MepicaL Recor for over thirteen years, and must
confess that much that appears in it in the way of reports,
communications, etc., is well calculated to amuse the
country practitioner, if not to instruct him. Labor, orig-
inally a purely physiological process, is treated by the great
guns of the profession in the cities as though it were
pathological. The woman is harassed and tortured with
antiseptic injections and antiseptic pads, etc., until she is
sorry that she had a baby at all. Our city brethren tell
us that nothing should be introduced into the vagina ex-
cept under antiseptic precautions, as it is dangerous. In
miscarriages, abortions, etc., we are told to curette the
uterus and inject antiseptic solutions into it to get out all
débris, etc. They omit to tell us of the great danger that
not infrequently accompanies such a procedure, even death
not being unheard of. In ordinary vaginal examinations,
again, vaginal injections and the finger made strictly anti-
septic is the proper form in the cities. I suppose, next,
the act of coition will be proclaimed pathological, and not
allowed except under strict antiseptic precautions. May-
be, in the future, eating and defecation will be subject to
the same conditions. In surgery, likewise, the same craze
prevails. ‘The most trivial operations are made occult
and mysterious and burdened down by elaborate antisep-
sis. Who shall ever know the number of victims that
have been slain in the large cities, in hospital and private
practice, on the altar of this Moloch of antisepsis ?
“ Cleanliness is next to godliness,” is a good text to go by
in obstetrics and surgery. No surgeon should think for
an instant of using dirty knives and leaving his hands un-
washed in an operation. No obstetrician should think for
a moment of attending a woman with dirty or pus-stained
hands. Ordinary common-sense would forbid any such
thing. In a moderate obstetric practice extending over a
period of fourteen years, I never lost but one case, and
that from cardiacembolism. I never had but one case of
puerperal septiczemia, and then the woman was attended
by a midwife. I have delivered by forceps and turning,
after women have lain three and four days in labor, at-
tended by ignorant midwives, and under the most unfa-
vorable surroundings, and they all made good recoveries
without a set-back. Abortion much the same way. Ial-
ways used strict cleanliness, and rarely anything more
than hot carbolized vaginal injections, and then not often.
But I suppose some would say that this is antisepsis ; but
if it is, it is not antisepsis as it is understood in New
York and other large cities. Last year I read the direc-
tions for conducting a strictly antiseptic labor by Profes-
sor Blank, of New York, and will only say that should the
average country practitioner attempt to follow them, he
would speedily lose most of his obstetric practice. About
the only notice the country doctor gets, in nine cases out of
ten, is when labor is in the second stage, or after the child
is born, too late for elaborate antisepsis. My experience
is the experience of every country practitioner, and there
are no statistics to show that the common-sense, intelligent
doctor in the country has any poorer results than his anti-
septic-saturated brother of the city. In surgery I have
never had any cause to feel dissatisfied with my results.
I have performed many of the different amputations,
extirpation of the breast, operation for strangulated hernia,
operations on the rectum, and many more operations such
as fall to the lot of the general practitioner, and some-
times I have used corrosive sublimate, carbolic acid, and
other antiseptics, and sometimes hot water, and I am
compelled to say that I could see no difference, as they
all made good recoveries ; and I do not recollect now of a
case where the temperature went at any time over 99° F.
Of course, strict cleanliness was observed in all of these
operations. I assisted once at two ovariotomies ; one case
recovered and the other died on the fifth day after the op-
eration, very suddenly, probably from heart failure. No
antiseptics were used in either of these cases, only hot water
and thorough sponging out of the peritoneal cavity before
closing the incision, and in neither case did the tempera-
ture go at any time over 101°, and then for a short time
only. I performed once the principal part of the operation
of laparotomy for the relief of intestinal strangulation of
a week’s duration. ‘The surroundings were of the most
unfavorable character and no antiseptics were used, but
the patient recovered without any unpleasant symptoms,
and although the thermometer was ranging from twenty to
thirty degrees below zero at the time, the patient was walk-
ing out-doors in twenty days after the operation. Strict
cleanliness and hot water were of course used, and the
peritoneal cavity thoroughly cleansed before closing the
wound. Perhaps some of the ultra-antiseptic enthusiasts
will claim it was a special dispensation of Providence that
the man recovered, others that it was the purity of the
climate, etc. ; but I am sure there are many country doc-
tors who have exactly the same experiences and think it
nothing unusual.
One case more I wish to relate, and that will be sufh-
cient.
Some years ago I was called in the country to see a man,
aged fifty-four, who had hurt his knee. On arriving at
his house I found the patellar ligament torn across and
an external wound almost eight inches in length across the
knee, exposing the articular surfaces of the joint. The
head of the tibia had been partially broken off and com-
minuted, loosening a part of the articular cartilage, and the
joint was full of dirt and small gravel. The family lived
like hogs, and there was not a clean thing in the house.
Not knowing the nature of the injuries, I had brought no
bandages with me, and it being ten miles from town, I
had to make them there. I got a sheet that was so dirty
that I had to take it to the spring and wash it myself be-
fore I made the bandages out of it. I then cleaned out
the joint, removed six pieces of bone, cut off with a
scissors all the loose and torn fragments of cartilage, and
closed the wound with about fifteen sutures. I used in
this case only a weak solution of carbolic acid, and placed
the leg on an inclined plane and used a long bandage wet
with carbolized water. ‘The man recovered without an
unusual symptom and no deformity, and at the end of
seven weeks could walk around with the aid of a hght
cane, without any trouble whatever. Motion was perfect,
and the only difference he noticed was that he could not
walk upstairs as easily as he could before. Every country
doctor who reads this article will, I have no doubt, call to
mind similar cases falling within his observation. Had
this case been treated in a city with full and complicated
antiseptic measures, it would be considered a great triumph
of antiseptic surgery.
Gynecological surgeons tell us that antiseptics are use-
less in the peritoneal cavity, nay, absolutely harmful, and
their use has been discontinued. Now if this is so, and
I do not doubt for one instant that it is, what is the use
December 28, 1889]
THE MEDICAL RECORD.
of such an elaborate antisepsis in ordinary operations? I
must confess that I do not see any, I know that my experi-
ence is not different from others in rural practice in this
regard. ‘There is altogether too much slavishness shown
to the city brother by the country doctor. It is deemed
heretical to differ from the great authorities, and very few
ever put their views and experience into print when they
differ from the recognized leaders of the profession. Sur-
gery has indéed made wonderful strides in the last few
years, and he who stands well as a skilful and successful
surgeon has much to be proud of; but I think that success
and skill come more from increased knowledge and im-
proved technique and instruments, together with surgical
cleanliness, than from poisonous and vile-smelling anti-
septics. The greatest surgeons differ as to which is the
best antiseptic, some claiming one thing and some another,
according to whim or fancy, but they, all unite in claiming
good results, which in the present state of human nature
is not to be wondered at. Just now creolin is the coming
antiseptic. In a short time it will be laid aside and some
other article will take its place, only soon to be forgotten.
Carbolic acid, iodoform, corrosive sublimate, and creolin,
have each posed on the surgical stage, and had their
admirers and detractors. A few short months, perhaps,
will hail the birth of some new antiseptic that will fill a
long-felt want, only to be discarded in turn by a new
rival for surgical favor. In the midst of this clash of
opinions and war of antiseptics, the level-headed, intelli-
gent country doctor will keep on the even tenor of his way,
and in the end show as good results as any of them. I
have already written too long an article, but if any of my
colleagues in the country will feel emboldened by this
communication to also express their sentiments through
THE MEDICAL REcoRD, my highest wishes will be ful-
filled. F. W. Van Dyke, M.D.
Grant’s Pass, ORE.
MALE AND FEMALE RISKS IN LIFE INSUR-
ANCE.
To THE Epitror or Tue Mepicart RECORD.
Sır: Allow me briefly to call the attention of those of
your readers interested in life insurance, to the very able
report of Dr. L. D. Witherill, Supreme Medical Ex-
aminer of the “ Knights and Ladies of Honor,” a well-
known fraternal order, dispensing life insurance on the
assessment plan.
The information given in this little pamphlet is as in-
teresting as it is manifold ; but of chief importance is the
result that: ‘‘ Female risks have proven to be better than
male risks.”
We quote from pages 7 and 8 of the report :
© « . . « “Our experience during the past eleven
years has been that with a larger female membership than
males, the former risks have each year shown a smaller
percentage of deaths than the latter.”
From December 26, 1877, to February 20, 1889,
three thousand members died. The membership during
that period rose from about three thousand in 1878, to
about forty-seven thousand in 1888. The number of
female was always somewhat larger than that of the
male members. Thus, out of a total membership of
22,046 in 1882, 10,448 were male and 11,598 were
female members ; while in 1888, out of a total member-
ship of 46,935, 22,601 were male and 24,334 were
female members.
In spite of this slight preponderance of the so-called
weaker sex in numbers, the proportion of deaths was
smaller with the latter than with the stronger sex—not
only as tothe ratio, but as to the actual number, of deaths.
Of the 3,000 members who died, 1,601 belonged to the
male and 1,399 only to the female sex. ‘The ratio of
deaths to membership for the ten years was 11.42 for
males and g.10 only for females, 10.25 being the figure
for both together. |
Perfectly in conformity with the results just super-
713 |
ficially sketched is Dr. Witherill’s observation—which he
reaffirms with well-deserved emphasis—to wit :
“ Evidently the dangers, exposures, and various vicissi-
tudes to which males are subjected, together with the
evils of intemperance, more than counterbalance the risks
of maternity and the climacteric epoch.”
In regard to the latter subject, is is of interest to note
that of the 1,399 female deaths, 214. are attributed to
“diseases of females.” Of these again, 10g are directly
due to childbirth (88 died in the puerperal state, 13 dur-
ing childbirth—7 of these were cases of placenta previa
—the rest from various causes) ; 85 are cases of cancer
of the female sexual organs (womb, 57, ovarian, 8, breast,
20), while the remainder is credited to a variety of diseases
of the uterus, its appendages, and the pelvic tissues in gen-
eral.
Scanning the numerous tables which Dr. Witherill has
embodied in his report, the causes of death which in some
way counterbalance this large debit on the female side
are found to be principally those resulting from diseases
of the respiratory organs (pneumonia more especially), of
the nervous system, and accidents and suicides.
The number of all deaths by accident was 137; of
these 120 were males and 17 females. The number of
all suicides was 91 ; of these 83 were males and 8 were
females.
This short synopsis may suffice to call attention to a
subject which, I believe, has rarely been treated more
ably and explained more clearly on the basis of absolute
facts as has been done by Dr. Witherill in his report.
Yours respectfully,
GEORGE W. RacHEL. M.D.
Army und Hany Hews.
Official List of Changes in the Stations and Duties of
Officers serving in the Medical Department, United
States Army, from December 15 to December 21, 1889.
ALEXANDER, CHARLES T., Lieutenant-Colonel and Sur-
geon. By direction of the Secretary of War, will be re-
lieved from duty as medical director, Department of the
Columbia, on receipt of this order at the headquarters of
that department, and will report in person to the com-
manding general, Division of the Atlantic, for the pur-
pose of preparing for, and becoming familiar with, the
duties of attending surgeon in New York City. He will
also, upon his arrival in New York, assume the duties of
examiner of recruits in that city. . i
WarTERS, WILLIAM E., Major and Surgeon. Will take
temporary charge of the office of medical director, De-
partment of the Columbia, upon the relief of Lieutenant-
Colonel Alexander. S. O. 291, A. G. O., Washington,
December 14, 1889.
BaLL, R. R., First Lieutenant and Assistant Surgeon.
Is relieved from temporary duty at Fort Sill, I. T., and
will return to his proper station, Fort Riley, Kan.
Headquarters Department of the Missouri, Fort Leaven-
worth, Kan., December 12, 1889. S. O. 182.
~Macautey, C. N. B., Captain and Assistant Surgeon.
With the approval of the Secretary of War, the leave of
absence granted in S. O. 166, November 8th, Department
of Missouri, is extended one month. Par. 10, S. O. 294,
A. G. O., December 18, 1889.
MCCREERY, GEORGE, Captain and Assistant Surgeon
(Fort Warren, Mass.). Leave of absence for one month
is granted, to take effect upon the arrival at that post, for
temporary duty, of Captain Samuel Q. Robinson, Assist-
ant Surgeon. Par. 6,S. O. 289, Division of the Atlantic,
December 18, 1889.
ROBINSON, SAMUEL Q., Captain and Assistant Surgeon
(Fort Hamilton, N. Y. Harbor). Will proceed without
714
THE MEDICAL RECORD.
[December 28, 1889
delay to Fort Warren, Mass., and report to the post com-
mander for temporary duty. Par. 5, S. O. 289, Division
of the Atlantic, December 18, 1889.
Official List of Changes in the Medical Corps of the United
States Navy for the week ending December 21, 1889.
Kite, I. W., Assistant Surgeon. Promoted to be a
Passed Assistant Surgeon.
STONE, E. P., Assistant Surgeon.
Passed Assistant Surgeon.
Norton, O. D., Assistant Surgeon.
a Passed Assistant Surgeon.
HENRY, CHARLES P., Assistant Surgeon.
the retired list.
PICKERELL, GEORGE McC., Assistant Surgeon. Or-
dered to Navy Yard, Washington, D. C., for temporary
duty. .
Promoted to be a
Promoted to be
Placed on
Medical Items.
ConTacious DISEASES—WEEKLY STATEMENT. — Re-
port of cases and deaths from contagious diseases report-
ed to the Sanitary Bureau, Health Department, for the
week ending December 21, 1889:
Cases. | Deaths.
Typhus LOVER’ goa adine cen cecbesd Sak she seoneiwesees o o
Typhoid fever .....esosssesssesesesoseoes EEA 16 5
SCArlet LOVER sisse osri anarias C EE ERES 54 Io
Cerebro-spinal meningitis. ...........ccccceccccee I o
easles cono onesie eres aaa n N a ene 55 5
Diphthenaiesisse tc cxiievccaswectes eio tests 100 24
SMAM+POX. 625s ds anvase sous waseoiGeacaaieex es pues re) o
MATIOlA seinan oni AE sews NEEE 6 re)
POQtusSiS soo os os cas SEE wacuisea oes eats! o o
A REMARKABLE CASE OF MATERNAL IMPRESSION.—In
a recent issue of T'he Lancet, Dr. A. R. Paterson describes
a case of maternal impression as follows: “I was asked
to see a woman in a neighboring village who was being
attended by a midwife ; the latter, however, being unable
to effect delivery by herself, wanted a doctor. On intro-
ducing my finger to ascertain the presentation I perceived
something unusual—a long, round, and slightly tapering
fleshy substance, which struck me at the time as feeling
like the shape of an ordinary carrot, but of course not so
hard. But to what part of the body this substance was
attached was a puzzle, until I discovered what I took
to be an ear and the eyes. I then concluded it must
be attached to the head. Giving a dose of ergot, and
stimulating the uterus by other methods as much as pos-
sible, I soon had come into the world what I at once saw
was a monster. Instantly wrapping it into the piece of
flannel ready to receive it, and without saying a word
either to mother or nurse, I carried it into an adjoining
bedroom, followed by the latter. Here I found the
fleshy substance spoken of to be projecting from the floor
of the skull, the roof of which was entirely absent, and so
closely did this substance resemble a cow’s teat—or, as
the nurse called it, ‘pap’—that at the same instant we
both made the same exclamation, ‘How like a cow’s
teat!’ Cautioning the midwife to observe the strictest
silence while I questioned the mother, we again pro-
ceeded to her room, when I quietly said to her, ‘I am
sorry to have to tell you, Mrs. C——, that the child is
dead, although it breathed a few moments; and perhaps
it is as well, because the baby was not “all right.”’
‘Ah!’ said she, ‘I thought that such would be the case.
What is wrong with itr’ I replied, ‘Tell me your story
first. What caused you to think it would not be “all
right?”’ ‘Well,’ she proceeded, ‘I got a most awful
scare when I was carrying it at the fore part of my time.’
Here she paused, but, leading her on by an inquiring
Yes?’ she went on again, ‘One day I was in the cow-
house, milking the cow, sitting upon the stool beside her
and milking away, when a rat or something in the roof
made such a row all at once as to startle the poor animal
almost out of her wits, and before I knew where I was
she had tumbled me on the floor, milk and all together, and
there I was, lying upon my back, still hanging on to the cow’s
pap like grim death, and thinking that I would be tram-
pled to death every moment. Oh, the scare! I shall
never, never forget it! for it made me downright ill and
nervous for weeks after it. I could not get it out of my
head, and kept dreaming about it even, and I feared all
along for my child.’ Having thus spoken, she made
signs for me to bend down my ear toward her, when she
whispered : ‘Has it horns upon it, doctor?’ Nothing
would induce the mother or friends to give up the body
of the child, nor would she allow me to touch it further,
which caused me the sharpest disappointment. ‘The
‘teat’ seemed to be a prolongation of the spinal cord,
and to be all there was to represent the brain. Other-
wise the body was well-developed and perfect.”
Tue DIFFICULTIES OF THE MEDICAL PROFESSION. —
“« An Old Doctor” deplores the visible decadence of the
profession in a long letter of lamentation in 7he Lancet.
Among other things, he says: “ In these advertising days,
in medicine, as in everything else, people who know little
or nothing of a subject, who presume ignorantly to ad-
dress the public in the daily and weekly press, attract
more notice than those who have devoted their lives to
their particular work. It is a misfortune that in this
country (f.e. England) a very large amount of medical
practice (and that the most easy and profitable) is lost to
the profession by the fact that almost all chemists pre-
scribe largely. This is a great and crying evil. The
practice is, instead of diminishing, largely increasing.
This should be stopped. The chemist nearly always pre-
‘scribes, but generally says, to cover himself, ‘If worse,
take patient to a medical man.’ And so the medical
man reaps all the hard work (often without being paid)
and the chemist most of the profits. Then, again, hos-
pitals, both special and general, take away largely from
the proper, legal, and rightful profits of the profession.
The public have a notion that they get advice and medi-
cine of the highest character from the hospitals for noth-
ing, but if they pay for it to the general practitioner they
get a second-rate article. This is a bad system. Why
not set up legal dispensaries for free legal advice, free
places to get married in, free clothing establishments, free
meat-stores, etc., all paid for by subscriptions or rates?
The fact is, the medical profession is gradually and surely
committing suicide, and its career on the downward path
should be promptly arrested. If we were true to our-
selves (which we are not and never have been) the pres-
ent increase in the profession would be insufficient to sup-
ply the needs of the public. But, if we go on working
on the ‘sweating system’ (for who sweats more, mentally
and physically, than the hard-worked medical practitioner,
night and day doing his best to preserve the health and
life of the people ?), often indeed without reward, then
we shall be fools indeed. ‘This idea, that medical ser-
vices can be had for nothing, and so ought to be paid for
at that price, is spreading. We are doing away with all
professional reserve. We make everything plain, and it
is valued accordingly. The more a profession is lowered
in the eyes of the public the less respect it receives.”
THE BACILLUS OF WaRTS.—Dr. Kuhnemann has found
in sections of warts (verruca vulgaris) a bacillus which is
always present in the prickle layer. It has distinctive
qualities as regards its capacity for color, and is found
both between and in the cells. Its form is that of exceed-
ingly delicate, slender rods, the thickness bearing the pro-
portion to the length of one to six. It is seldom found in
the skin surrounding the warts, and is found most plenti-
fully when the wart is recent.
A
Abbott, Dr. George E., an obstetrical eye-
bandage, 317-
Abdomen, gunshot wounds of the, 493.
Abdominal disease, obscure, early operation
in cases of, 74.
Abdominal section, choice of sutures for, 319;
eighty-eight consecutive cases of, 331;
for traumatism, 18; twenty consecutive
cases of, 637.
Abducens paralysis, congenital bilateral, with
facial paralysis, 690.
Abortion, cardiac insufficiency in its relation
to, 328 ; death from sublimate irrigation
after, 517; management of, 554.
Abscess, cerebral, treatment by trephining,
317, 461; pelvic, in woman, 49.
Accommodation, some vagaries of, 133.
Acetanelide in pædiatric practice, 21.
Acetophone, 269.
Acid, dithio Malice 431.
Ackerman, Mr. G. K., civil service examina-
tions for physicians, 699.
Acne cachecticorum, 502.
Acting Assistant Surgeons, and the contract
system, 614; Association of the, 28,
485; the hard lot of the, 485.
Actinomycosis hominis, 517; of the brain,
trephining for, 333.
Addison’s disease, 48.
Air in the veins, 345.
Air-passages, upper, effects of natural gas
upon, 24; foreign bodies in the, intuba-
tion in cases of, 311.
Alandz, a Latin periodical, 292.
Albumin in the urine, new test for, 664;
tests for minute amounts of, 476.
Albuminuria, clinical significance of, 546;
prognosis of, with special reference to
life insurance, 324.
Alcohol, germicidal value of, 114; habit,
strychnine in the, 255; injection of, in
nevus, 346; viper-bite treated by, 318,
431.
Alcoholic trance in criminal cases, 7.
Alcoholism, crime, and insanity, 321.
Alexander’s operation, 49.
Allen, Dr. Charles W., concerning some un-
usual eruptions, 116.
Allen, Dr. Dudley P., treatment of injuries
to the head, 141.
Allport, Dr. Frank, a new mastoid retract-
ing speculum, retractors, and lance-
pointed discission-knife, 643.
Alonzo Clark scholarship, 129.
Alopecia areata, parasitic theory of, 22;
bacillus of, 341.
Alpine climates for phthisis, 525.
American Academy of Medicine, amendment
of the constitution of the, 700.
American armamentarium chirurgicum, book
notice, 186.
American Association for the Advancement
of Science, 268.
American Association of Obstetricians and
Gynecologists, 438.
American Dermatological Association, 469,
500.
American Medical Association, fortieth an-
nual meeting, 18, 46; section on der-
matology and syphilography, 21; sec-
tion on diseases of children, 21; section
on laryngology and otology, 22; section
on obstetrics, 48 ; section on practice of
medicine, 46 ; section on surgery, 18.
American Medical Editors’ Association, 28.
American Neurological Association, 105.
American Ophthalmological Society, 130.
INDEX.
American Orthopedic Association, 440.
American Otological Society, 134.
American Pediatric Society, 414.
American Public Health Association, 465,
499.
American Resorts, with notes upon their cli-
-mate, book notice, 216.
American Rhinological Association, 580.
Americans, native, and immunity from phthi-
sis, 154.
Amputation, primary triple, for railroad in-
jury, 318.
An elementary treatise on human anatomy,
book notice, 186.
Anemia, and chlorosis, relation between,
353 ; puerperal, and its treatment with
arsenic, 374.
Anesthesia, artificial, produced during sleep,
263, 526; chloroform, effects of pro-
longed, 461.
Anesthetic, exalgine a new, 399; local,
strophanthus as a, 399.
Anastomosis, intestinal, an experimental
study of, 613.
Anatomical Society of Great Britain, 269.
Anatomical work, an old, 140.
Anatomie of the bodie of man, book notice,
215.
Anatomy, proper teaching of, 363.
Anchylosis of the knee, exsection for, 494.
Anderson, Dr. I. Wallace, notice of book
by, 216.
Anderson, Dr. J. Hartley, an anomalous
right ‘external carotid, 683.
Anderson, Dr. William, fatal poisoning by
chlorate of potash, 707.
Andrews, Dr. E., notice of book by, 490.
Aneurism, abdominal, novel treatment of,
16; traumatic, ligation of the anterior
tibial artery for, 542; tuberculous pul-
monary, 398.
Aneurisms, multiple, 247.
Anglo-American Vienna Medical Association,
608.
Ankle, caries of the, treatment of, 441.
Antifibrin in the treatment of ‘headaches,
430; in tonsillitis, 604; phenacetin, and
antipyrin, comparative value of, 486.
Antipyretic, a new, 102.
Antipyretics, abnormal or contrary effects of,
546; analgesics, and hypnotics, 471.
Antipyrin and chloral, incompatibility of,
588 ; antifebrin, and phenacetin, com-
parative value of, 486; danger of, 431 ;
habit, 700; in diabetes, 39, 392; in
labor, 398.
Antisepsine, 240.
Antiseptic dressing, a new, 561.
Antiseptic ointment in obstetrical practice,
578.
Antiseptic treatment of wounds, the most re-
cent, 482.
Antiseptics and the country doctor, 712;
germicidal value of, 113; in the treat-
ment of otorrhcea, 92; inibito ac-
tion of, 34.
Antrum, maxillary, and neighboring cavities,
tumor of the, 208.
Anus, imperforate, 264.
Anvard, obstetrical works of, book notice,
436.
Aortic aneurism, simultaneous deligation of
left carotid and left subclavian arteries
for, 171.
Aphasia, as gee of, 360; sensory,
pathology of, 109.
Aphthe, saccharin i in the treatment of, 504.
Apostoli’s clinic in Paris, 138.
Army medical board examination, 251.
Army medical service, 241.
Army News, 56, 83, 140, 168, 196, 224, 251,
279» 307, 334, 364, 392, 419, 446, 475,
ee 530, 557, 587s 615, 644, 669, 699,
Arenie germicidal value of, 11 53 ; in the
treatment of ar en anzmia, 374.
Arthritis, acute, of infants, 443.
Artificial feeding of infants, 417.
Artificial leg after amputation at the hip-
joint, 3 391-
Arytenoid, fibroid tumor of the, 26.
Ascites, a popular remedy for, 559 ; chylous,
51.
hesceiation of Acting Assistant Surgeons,
28, 485.
Association of American Physicians, 349.
Asthma and the uterine system, 604.
Astragalus, compound triple dislocation of,
146.
Astringents, action of, 240.
Athrepsia, a wasting disease of childhood 37: 3.
Atlas of venereal and skin diseases,
notice, 186.
Atrophy, muscular, as a cause of joint pains,
210.
Atropine in enuresis, 21.
Auditory canal, a pea in the, for nineteen
years, 137; a pea in the, for thirty-two
years, 209.
Auditory canals, closure of both, by bone,
136.
Aultz, Dr. A. E., triplets with but one pla-
centa, 644.
Auricle, cysts of, 137.
Auscultation, new method of, 98.
B
Babcock, Dr. John Lord, notes on entero-
colitis in infants: its causes and treat-
ment, 35.
Bacigalupi, Dr. E. G., notice of book by,
Bacilli on a bald head, 341. e
Bacillus, typhoid, in the foetus, 343.
Bacteria, prize essay on, 243.
Bacteriological test of drinking-water, rs 367
Baker, Mr. W. Morrand, notice of by,
216.
Baldy, Dr. J. M., early diagnosis of extra-
uterine pregnancy, 309, 435.
Bancroft, Dr., stricken with apoplexy, 552.
Baran, Dr. J. antipyrin in labor, 398.
Barber’s itch, 301.
Barbour, Dr. W., resolutions on the death
of, 28.
Barclay, Dr. Robert, the relation between
the diseases of the teeth and ears, 119.
Bardeleben, Dr. Adolf, unveiling of a bust
of, 608.
Bartholomew, Dr. Ira Hawley, death of,
464.
Baruch, Dr. S., hydrotherapy vs. hydroe
pathy, 686.
Bashore, Dr. Harvey B., a clinical note on
chloroform water, 631; ; antifebrin in
the treatment of headaches, 430.
Bastin, Edson S., notice of book by, 186.
Baths, tepid, in the treatment of pneumonia,
260.
Beale, Dr. Joseph, death of, 348.
Beane, Dr. Frank Dudley, a convenient an-
gesthetic inhaler, 669.
Beck, Dr. W. M., a gargle in quinsy, IIO.
Beecher, Dr. Harris H., death of, 71.
‘* Belly-disorder ” of children, 519.
716
INDEX.
[December 28, 1889
Belt, Dr. W. A., poisoning by tansy, 342.
Benjamin, Dr. D., hysterectomy for large
fibromyoma, 12.
Berg, Dr. Henry W., rachitic pseudo-para-
plegia, 534. |
Bergmann, Professor, honors to, 269.
Bernheim, Dr. H., notice of book by,
492.
Bile-duct, common, primary carcinoma of
the, 160.
Billings, Dr. John S., on vital and medical
statistics, 589, 617, 645.
Birth returns, 154.
Black eye, cure of a, 547.
Blackmail, an attempt at, 102.
Blackwell, Dr. E., the dangers of bottled
milk, 1
Bladder, construction of a new, after exci-
sion, 532; contracted, treatment of by
hot water dilatation, 638 ; double, 249 ;
injuries of, during laparotomy, 49; scir-
rhous carcinoma of, with vesico-rectal
fissure, 152; stone in the, dilatation of
the male urethra for the removal of,
IOI.
Blondes, 204.
Blood, germicidal action of, 432 ; gravita-
` tion in health and disease, 413 ; para-
sites in the, 372.
Blood-clot, healing under, after partial exci-
‘sion of the bones of the ankle, 494.
Body, human, electrical resistance of, 307.
Boerstler, Dr. S. W., subcoracoid disloca-
tion of the humerus reduced by Koch-
er’s method, 13.
Bogert, Dr. E. S., concerning examinations
for medical officers of the navy, 614.
Bogus diploma mills, 404.
Bone dowels, organization and absorption of,
19.
Books disinfection of, 671.
Boone, Dr. H. W., a case of fecal fistula—
operation—recovery, 263.
Boone, Dr. J. J., severe symptoms resulting
from an apparently trivial injury, 66.
Bowen, Dr. Cuthbert, notice of book by,
215.
Bowles’ Dr. F. J., uremic convulsions con-
trolled by morphine, 631.
Brachial plexus, spontdneous degenerative
neuritis of the, 106.
Bradley, Dr. Alfred E., costo-chondral dis-
location of the first to sixth ribs back-
ward, with partial dislocation of the
right clavicle upward and backward,
202.
Brain, abscess of, emptying into the naso-
pharynx, 581 ; abscess of, operation for,
110; abscess of, treatment by trephin-
ing, 317, 461; actinomycosis of, tre-
phirffhg for, 333; and moral culture,
672; human, pli du passage inférieur in-
terne in the, 108; identity of function
of the two occipital lobes, 16; cedema
of the, 483; pyzemic abscesses in the,
667 ; thrombosis of sinuses and veins of
the, 350.
Brain-weight of man and woman, 462.
Brakeley, Dr. Philip F., death of, 103.
Brazil, medical congress in, 291.
Breast, cancer of, recurrence after amputa-
tion, 602.
Brewer, Dr. George E., electrolysis and the
radical cure of iea why the chal-
lenge has not been accented, 56.
Bright’s disease, albuminous food in, 635 ;
chronic, 197; dietetic treatment of,
432; jaborandi in, 425.
British Medical Association, 245, 270; ad-
dress in medicine, 225; address in sur-
gery, 232; President’s address, 245 ;
section on medicine, 294, 324, 3573
section on obstetrics and gynecology,
327 ; section on public medicine, 272 ;
section on surgery, 329; split in the,
Brodie, Dr. William, the acting assistant
surgeons and the contract system, 614.
Bromide of potassium, accumulation of, in
the brain, 139.
Bromoform in whooping-cough, 672.
Bronchitis, plastic, 518.
Brooklyn Academy of Science, 13.
Brothers, Dr. A., an unusual case of laryn-
geal intubation, 97.
Brown, Dr. David Tilden, death of, 293.
Brown, Dr. Harvey E. death of, 293.
Brown, Dr. Moreau R., a nasal th ee
tome, 391.
Brown-Séquard, a precursor of, 672.
Brown-Séquard theory, an experimental
study of, 205.
Brown-Séquard’s injection, 69, 70, 81, 128,
205, 210, 323.
Browning, Dr. A. G., sulphonal : its dosage
and effects, 62.
Bryant, Dr. Joseph D., the treatment of
hernia, 505.
Buchman, Dr. A. P., colon-flushing in ty-
phoid fever, 340.
Buck, Dr. Albert H., brief memoranda in
practical otology, 513; notice of book
by, 436.
Bull, Dr. Charles Stedman, contributions to
the subject of tumors of the orbit and
neighboring cavities, 206.
Bullein, William, notice of book by, 215.
Burnett, Dr. Charles Henry, notice of book
by, 436. ;
Butler, Dr. C., triplets with but one pla-
centa, 644.
Butler, Dr. F. W. P., gangrene following
continued fever, i.
Butlin, Dr. Henry T., notice of book by,
186.
C
Cabell, Dr. James L., death of, 244 ; memo-
rial to, 608. s
Cabell, Dr. Robert Gamble, death of, 577.
Cæcum, suppuration in the neighborhood of,
advantage of early operation in, 8o.
Cæsarean operation, choice of sutures for,
319 ; improved, versus craniotomy, 610.
Calculi, vesical, dilatation of the male urethra
for the removal of, 101.
Calomel in croupous pneumonia, 383; in
pulmonary phthisis, 95.
Cammann, Dr. D. M., some cases treated
with hydrogen peroxide, 481.
Campbell, Dr. C. M., notice of book by,
188
Canadian Medical Association, 360.
Cancer, alleged micro-organism of, 104; and
in animals, 308; colloid, of the
gluteal region, 305; etiology of, 394;
inoculating, 488; morphine-vaseline as
a local application in, 550; of the
breast, recurrence of, after amputation,
602; of the pancreas, 162; of the rec-
tum, treatment of, 296; of the stomach,
oedema as a diagnostic sign in, 484; of
the uterus, treatment of, 300; primary,
of the common bile-duct, 160; scir-
rhous, of the bladder, with vesico-rectal
fissure, 152.
Canfield, Dr. William Buckingham, the re-
lation of dusty occupations to pulmonary
phthisis, 61.
Cannon-firing on the Eiffel Tower, effect of,
445-
Carbee, Dr. Moses D., death of, 487.
Carbolic acid, dangers of, 364; poisoning,
soap as an antidote to, 577; synthetic,
27.
Cardiac therapeutics,'7or.
Caries, green soap in, 644.
Carotid arteries, external, deligation of both,
172.
Carotid artery, an anomalous right external,
683.
Carpenter, Dr. A. B., surgical operations for
the repair of ruptured perinzeums, 540.
Carreau, Dr. Joseph S., treatment of dia-
betes, 39.
Cartwright lectures for 1889, 589, 617, 645 ;
prize essay, 104.
Castor-oil as a menstruum for cocaine, 125 ;
trust, 45.
Casuistry in obstetrics, 48.
Cataract, extraction of, without iridectomy,
390.
| Catarrh, acute nasal, abortion of, 472;
chronic nasal, treatment of, 582.
Catarrhal neuralgia, 629.
Catgut, preparation of, 49.
Cellulitis, pelvic, in women, 385.
Census, the U. S., in its relation to sanita-
tion, 467.
Centenarian surgeon, 356.
Cervix uteri, laceration of, use of the tam-
pon in, 285.
Chambers, Dr. Thomas King, death of, 268.
Chapman, Dr. J. Milne, on a visit to Bir-
mingham and to Mr. Lawson Tait, 148.
Charity Hospital alumni, 686.
Charcot, Dr. J. M., notice of book by, 187.
Cheesman, Dr. T. M., apparatus for steril-
izing milk, 39.
Chemical structure and physiological action,
relation between, 80.
Chemical structure and physiological thera-
peutics, 126.
Chetwood, Dr. Charles H., the toxic effect
of cocaine hydrochlorate, with report of
a case, 144-
Chicha poisoning, 420.
Childbearing period, 101.
Children, ‘‘belly disorder” of, ṣ5t9; dys-
peptic, fat in the fæces of, 427; eczema
in, 152; gastro-intestinal diseases in,
climatic treatment of, 639; rheumatism
in, 53; use of acetanelide for, 21;
use of strophanthus for, 603.
China, dispensaries in, 102.
Chinese doctors, 447.
Chloral, and antipyrine, incompatibility of,
588 ; hydrate in chapped nipple, 153.
Chloralamide, 468, 503, 553. :
Chlorine, germicidal value of, 11 $
Chloroform anæsthesia, effects of prolonged,
461; Hyderabad commission on the
action of, 434; internal use of, 72, 176;
local application of, in epididymitis,
343 ; water in false croup, 631.
Chlorosis, simple anzmia, and pernicious
anxzmia, relation between, 352.
Choked disk, due to intracranial tumor, 133.
Cholecystenterostomy, 299.
Cholecystotomy, 281, 585.
Cholera, behavior of the germs of, in milk,
butter, whey, and cheese, 483.
Chorea and epilepsy, treatment of, by the
correction of ocular defects, 684, 688 ;
pathological anatomy of, 437.
Choroiditis, double purulent, following men-
ingitis, 133.
Chromic acid in sweating of the feet, roo.
Chrysarobin in hemorrhoids, 521.
Chyle and chyle-like fluids, ion of, into
serous cavities, 35%.
Chylo-thorax, 351.
Cigarettes, a report on, 291.-
Cirrhosis of the liver, curability of, 211.
Civil service reform, medical examinations
and, 640, 698, 71:.
Claiborne, Dr. J. Herbert, Jr., a speculum
for applying caustics to the deep struct-
ures of the nasal cavities, 250.
Clavicle, partial dislocation of, 202.
Climate ot South Alberta, 361.
Climatic treatment of gastro-intestinal dis-
eases in children, 639.
Climatoterapia española en la tísis pulmonar,
book notice, 187.
Clothing in its relation to hygiene, 466.
Club-foot apparatus, a new, 668.
Cocaine, castor-oil as a menstruum for, 125 ;
hallucinations caused by, 515; in sur-
gery, 381, 566; toxic effect of, 144.
Cockcroft, Dr. William, death of, 577.
Cocoanut as a tieniacide, 400.
Cod-liver oil, administration of, 397.
Code of ethics, German, 128.
Coe, Dr. Henry C., a successful case of łap-
arotomy and supravaginal amputation
of the uterus for rupture, 478.
Ceeliac affection of children, 51
Cold, subjective false sensation of, as a
symptom, 354.
Collins, Dr. A. N., poisoning by tincture of
iodine, 98.
Collins, Dr. G. M., living twins with one
body, 209.
Collins, Dr Joseph, a case of poisoning
from opiuin-smoking, 288.
Collective investigation in England, the end
of, 212.
December 28, 1889]
- INDEX.
717
College botany, book notice, 186.
Colles’ fracture, 362.
Colo-colostomy, 579.
Cologne tippling, 213.
Colon, congenital narrowing of, 249.
Colon-flushing in typhoid fever, 340.
Color-blindness among seamen, 222.
Colotomy in cancer of the rectum, 297, 298;
inguinal, an improvement in the tech-
nique of, 398,
Compendium of dentistry, book notice, 215.
Confectioners’ fingers, 487.
Congenital dislocation of the hip, 332, 441,
537.
Ciian re sanitaria for, 607.
Contagious diseases, infective period in, 344 ;
weekly statement, 28, 84, 112, 140, 168,
251, 279, 308, 334, 364, 392, 419, 446,
475s 504, 531» 557» 587; 615, 644, 669,
714.
Continence and syphilis, 71; effects of, 128.
Convulsions, ursemic, contfolled by mor-
phine, 631. :
Cook, Dr. George J., villous tumor of the
rectum, 38.
Copeland, Dr. W. P., gaseous enemata for
intestinal obstruction, 278.
Corn-stalk disease, 576. |
Cornea, transplanting a chicken’s, 377.
Corneal abscess, 131; transplantation, 132.
Coroner system, 433.
Corrosion preparations, short methods for
making, 237.
Coryza, carbonate of ammonia to abort a,
577 ; relief of, 392.
Cough in its relation to morbid states of the
nasal eS, 25.
Country practice, fifty years of, 463.
Cow-pox, spontaneous, 291, 403, 659.
Craniotomy, improved Czesarean section ver-
sus, 610; the ethical question of, 49.
Creasote, germicidal value of, 114; in phthi-
sis, 145; intratracheal injections of the
oil of, 574.
Cremation in Paris, 635 ; progress of, 369.
Creolin, formulz for the use of, 447.
Crime, insanity, and alcoholism, 321.
Criminal cases, alcoholic trance in, 7.
Crothers, Dr. T. D., alcoholic trance in
criminal cases, 7.
Croup, chloroform water in, 631; mem-
branous, ina girl of twelve years, 414.
Cuba, annexation of, demanded by the sani-
tary interests of the United States, 500.
Curtis, Dr. B. Farquhar, knots, ligatures
and sutures, 449, 494- l
Cyclopædia of the diseases of children, medi-
cal and surgical, book notice, 491.
Cystitis, chronic, in woman, 50.
Cystotomy, supra-pubic, 169.
D
Dakeman, Dr. Wiliam H., a summer
health-resort, 120.
Damien, Father, an historico-medical coin-
cidence, 420.
- Dana, Dr. Charles L., electrical injuries,
477, 496.
Dandruff, treatment of, 558.
Davis, Dr. N. S., jr., the physiological ac-
tion of typhoid fever poison, 704.
Dawbarn, Dr. Robert H. M., civil service
examinations for medical men, 711;
medical examination and civil service
reform. Can these things be? 640; the
question of the pocket-case, 444.
Day, Dr. Walter De Forest, obituary of,
636 ; resignation of, as sanitary super-
intendent, 156.
Dead, seeking a resting-place for the, 573.
Deaf-mutes, alenat congress of, 213.
Deaf-mutism, 448.
Deafness in old age, 192; internal ear, 23;
preventive, 362.
Deans, Dr. Edward, death of, 465.
Death, by electricity, 69; dread of, 420.
De Beck, Dr. David, the single-tax theory
and the doctor, 165.
Delafield, Dr, Francis, chronic endocarditis,
7.
Delina, psycho-motor origin of, 632.
Dialogue against the fever
Dennis, Dr. Frederic S., fractures at the
base of the skull, 566, 580.
Dermatitis, generalized exfoliative, 276; her-
petiformis of Duhring, 277; papillaris,
501.
Diabetes and its associations, 586 ; antipyrin
in, 392; as influenced by the condition
of the pancreas, 586; conjugal, 447;
injurious effects of milk-diet in, 586 ;
treatment of, 17, 39.
Diagnosis and treatment of extra-uterine
pregnancy, book notice, 217.
H ‘pestilence, book
notice, 215. l
Diarrhoea in phthisis, treatment of, 559; in-
fantile, vaccine for, 604; summer, of
infancy, 417; summer, of infants, bac-
teria found in the dejecta in, 418.
Dictionary of Volapiik, book notice, 188.
Diet, relation of, to uric-acid formation, 393,
05. `
Dietetic treatment of gout, 183.
Dimon, Dr. Theodore, death of, 103.
Diphtheria, contagium of, 355; epidemic,
pathology of, 602; necessity of pro-
longed rest after, 415; of the pharynx
and cesophagus, 191; personal prophy-
laxis in, 415; treatment of, 559.
Diphtheritic sore-throat, 436.
Disciplining physicians, the legal right of,
12
7.
Discission-knife, lance-pointed, 643.
Diseased meat scare, 433.
Diseases and injuries of the ear: their pre-
vention and cure, book notice, 436.
Diseases, rare, lessons taught by, 14.
Disinfection in the control of epidemics, 273;
of dwellings by sulphur dioxide, 499,
533:
Dislocation, congenital, of the hip, 537.
Dispensaries, rich men’s, 487.
Dithio-salicylic acid, 431.
Diuretic, lactose as a, 44, 3773 Pilsner beer
as a, 408; salicylic acid as a, 315.
Diverticulum, intestinal, 189, 249.
Doctor, abolition of the title of, 633.
Doctor’s earnings, 488.
Doctors as beggars, 577.
Doctors, too many everywhere, 364.
Dolson, Dr. J. S., late pregnancy, 461.
Domestic remedies in the Transvaal, 444.
Drainage-tube, a lost, 543.
Draper, Dr. William H., the relation of diet
to uric-acid formation, 393, 405.
Dress, woman’s, absurdities and cruelties of,
04.
Drinki wale, bacteriological test of, 367;
contamination of, by lead, 274; pure,
195.
Drop-wrist and allied paralysis, mechanical
treatment of, 482, 495.
Drugs, some new, 384.
Drum membrane, antiseptic treatment of
perforations of the, 23; perforated, diag-
nosis of, 269; traumatic rupture of,
137
Ductus arteriosus, patent, 248.
Dukes, Dr. W. Clayton, cephalic version
eighteen hours after rupture of the mem-
branes, 543.
Dunham, Dr. Edward K., on the bacteri-
ological test of drinking-water, 367.
Dura mater, sarcoma of the, 569, 580,
Dusty occupations, relation of, to pulmonary
hthisis, 61, 446.
Dwellings, disinfection of, by sulphur di-
oxide, 533.
Dysentery, fraulina scorbilis in, 671.
Dysmenorrhoeal membrane, 343.
Dyspepsia, glycerine in, 104.
E
Ear, antiseptics in the treatment of otorrhcea,
92; middle, epithelioma of, 137.
Earl, Dr. George H., a new club-foot ap-
paratus, 668.
Ears and teeth, relation between diseases of,
119.
Eating before sleeping, 529.
Ecchondrotome, a nasal, 391.
Eclampsia, puerperal, venesection in, 74.
Eczema in childhood, 152; mercuriale, 471 ;
of the anus, treatment of, 501; sebor-
rhoicum, 21; treatment of, 431.
Edebohls, Dr. George M., a case of tubal
pregnancy successfully treated by elec-
trical foeticide, 628.
Edson, Dr. Cyrus, disinfection of dwellings
by sulphur dioxide, 533.
Education, preliminary medical, regulation
of, 69.
Egan, a P. R., jaborandi and pilocar-
pine in Bright’s disease, 425
Elam, Dr. Charles, death of, 129.
Electrical injuries, 477, 496.
Electrical resistance of the human body, 307
Electrical sunstroke, remedy against,
Electrical treatment of uterine fibroids,
French views on the, 547.
Electricity, deadly current of, 433; death
by, 69; execution by, 103, 129, 193,
223, 377; in gynecology, 328, 334, 401 ;
in the treatment of cancer of the rec-
tum, 299; in the treatment of intestinal
obstruction, 222; in the pagan of
tubal pregnancy, 539, 55 ‘
Electricity in the dhes of women, book
notice, 215.
Electrode, a new gastric, 530.
Electrolysis in cystic goitre, 22; in stricture
of the rectum, 19; in stricture of the
urethra, 56, 83, 6975 removal of hair by,
84; removal of hair by, a new needle-
holder for, 529.
Electromania, §52.
Electrothanasia, 223.
Electro-therapeutics ; or, electricity in its re- -
lations to medicine and surgery, book
notice, 217.
Elephantiasis. 3
64.
Elixir of youth, 69, 70, 81, 128, 205, 210,
323.
Ellis, Dr. R., severe case of insolation, his-
tory, treatment, and recovery, 287.
Ely, Dr. John S., tuberculosis of an artery,
illustrating one of the modes of dissem-
ination of the tubercle bacilli in the
body, 657. , ;
Emmet, Dr. Thomas Addis, a protest against
the removal of the uterine appendages,
7IL.
Emphysema, subcutaneous, in children, 414.
Endarteritis, chronic, 197.
Endoauscultation, 98.
Endocarditis, chronic, 337; ulcerative, 48.
Endometritis, chronic tubercular, 603; cor-
poreal, 327.
Enemata, gaseous, for intestinal obstruction,
278.
England and the opium trade, 560.
Enophthalmus traumaticus, 605.
Enteralyia and chronic peritonitis, 410.
Entero-colitis in infants, 35.
Entombment, sanitary, 500.
Enuresis, atropine in, 21; potassium bro-
mide and belladonna for, 408.
Epididymis, tuberculosis of, 219
Epididymitis, local applications of chloro-
form in, 343
Epilepsy and chorea, treatment of, by the
correction of ocular defects, 684, 688 ;
focal, trephining for, 109 ; mistaken for
drunkenness, how to prevent, 699; pro-
cursive, 549.
Epistaxis, a device for plugging the nares in,
168.
Epithelioma, early recognition and treat-
ment of, 362
Eruptions, medicamentous, 448.
Erysipelas and puerperal infection, 319.
Essentials of physical diagnosis of the chest
and abdomen, book notice, 216.
Ether explosion, death from, 634. =
Ethics, code of, for German physicians, 128.
Ethmoid cells, frontal sinus, and orbit, ab-
scess of the, 207.
Eucalyptol in headache, 104.
Exalgine, 283, 399.
Execution by electricity, 103, 129, 193, 223,
377. ;
Experimental surgery, book notice, 218.
Expert testimony in the Cronin case, §20;
the value of, 401.
718
INDEX..
[December 28, 1889
i auauua
Extra-uterine pregnancy dating back thirty-
three years, 307; diagnosis of, 435;
early diagnosis of, 309.
Eye, enucleation of, in panophthalmitis, 132 ;
irrigation of the anterior chamber, 131 ;
muscles of the, epilepsy and chorea in
relation to the, 684, 688; rheumatism
of the muscles of, 341 ; artificial atrophy
of, as a substitute for extirpation, 503.
Eyeball, associated movements of the, 196;
enucleation of, 250. ;
Eye-bandage, an obstetrical, 317.
Eyesight of American school-children, 17.
F
Father, the, and the race, 126.
Fat in the fæces of dyspeptic children, 427.
Faith-cure, Sam Jones on the, 292.
Farey in man, 4I 3,
Farquharson, Dr. Robert, notice of book by,
`. 185.
Fecal fistula, 263.
Fees, old-time, 15.
Femur, reunited fracture of, treatment of by |
portative apparatus, 443.
Fibroid tumor of the uterus, hysterectomy
for, 12; French views on the eleotrical
treatment of, 547.
har ad Matthew D., a Chinese paretic,
Fish po on prize for the investigation of,
. 578.
Fissure, vesico-rectal, 152.
Fistula fecal, 263.
Flat-foot, or pes valgus acquisitus, 10.
Flint, Dr. Austin, notice of book by, 492.
Foetus, a young living, 125, 244; macer-
"ated, as a complication of labor, 40;
typhoid bacillus in the, 343.
Fogarty, Joe, death of, 71.
Food in its relation to health, 498 ; treat-
ment by, of insomnia, 373.
Foods, artificial, official investigation of,
291; of different people, 400.
Forest, Dr. W. E., intussusception and the
use of injections, 371.
Fowler, Dr. George R., partial resection of
the head of the first inetatarsal bone for
hallux valgus, 253.
Fractures of the base of the skull, 566, 580;
of the base of the skull, hemorrhage in
- the middle ear in, 497; ununited, ad-
vance in the treatment of, 606.
France, depopulation of, 378.
Fraulina scorbilis in dysentery, 671.
Freckles, removal of, 336.
Fredigké, Dr. Charles C., vaginal tampon-
_ age, 313.
Frontal sinuses, empyema of, 24.
G
Galactocele testis, 518.
Gangrene following continued fever, 342.
Gangrene, symmetrical, 72.
Garbage, disposal of, at Milwaukee, 498.
Garter, the, and varicose veins, 633.
Gastralgia, a new form of, 545.
Gastric electrode, a new, 530.
Gastric mucous membrane, reproduction of,
Gastritis, acute, after the administration of
turpeth mineral, 190; diffuse phlegmon-
ous, 406.
Gastro-intestinal disorders in infants, me-
chanical treatment of, 418.
Gastrotomy for a set of false teeth, 464.
General paresis, ocular symptoms in, 132;
trephining for, 635.
German Congress of Internal Medicine, 158.
German measles, 376.
- Germany, condition of the medical profession
in, 185; medicine in, an American
view of, 476.
Gibbons, Dr. Richard H., protection for
railway travellers, 5209.
Gibney, Dr. V. P., the mechanial treatment
of drop-wrist and allied paralysis, with
presentation of a case, 482, 495.
Gillette, Dr. A. A., haematemesis in typhoid
fever, 707.
Giraffe, birth of a, 504.
Glanders, death of a Vienna physician from,
635; in man, 413.
Glaucoma, 74; chronic, operation for, 130.
Gleet and sexual asthenia, mechanical treat-
ment of, 265.
Glycerine in dyspepsia, 104; in the treat-
ment of ozæna, 336.
Glycerine-soap suppositories, 671.
Glycosuria and its associations, 585; as in-
fluenced by the condition of the pan-
creas, 586; injurious effects of milk-
diet in, 586. °
Goitre, cystic, 65; cystic, electrolytic treat-
ment of, 22.
Golding, Dr. J. F., syrupus acidi hydriodici,
333-
Gonococci, staining of, 568.
Gonorrhoea in a boy five years of age, 588;
some points in the treatment of, 180;
transmission of, as an indictable offence,
404; treatment of, 65, 474.
| Gonorrhceal rheumatism, treatment of, 448.
Gott, Dr. William A., case of compound
triple dislocation of the left astragalus,
with comminuted fracture—recovery
with a useful foot, 146.
Gougenheim, Dr. A., noticé of book by,
185.
Gout, dietetic treatment of, 183; nature and
treatment of, 160; uric acid and, 211.
Green, Dr. Traill, banquet to, 44.
Green soap in caries, 644.
Greene, Dr. J. L., pneumonia treated with
peroxide of hydrogen, 66.
Griffin, Dr. E. Harrison, a peculiar case of
tertiary syphilis of the throat, 289.
Grissom, Dr. E., acquitted, 129.
Grove, Dr. B. F., the Johns Hopkins Hos-
pital and the dispensary abuse in Balti-
more, 587.
Gruening, Dr. E., how is this? 643.
Guide to the practical examination of urine,
book notice, 188.
Guide to therapeutics and materia medica,
book notice, 185. |
Gummata, miliary, in various organs in a
young child, 163.
Gunshot wounds of the abdomen, 493.
Gynaia, a new disease, 464.
Gynecological work, report of, 609.
Gynecology and obstetrics, conservatism in,
676, 694; electricity in, 328, 334, 401 ;
in its relation to obstetrics, 611; recent
advances in, 408.
Gypsies, a good word for the, 154.
H
Habershon, Dr., death of, 291.
Heemopt the non-tubercular and non-
cardiac, of elderly persons, 708,
Hair-balls in the stomach, 189.
Hairs, removal of by electrolysis, 84; re-
moval of, by electrolysis, a new needle-
holder for, 529.
Hallux valgus, partial resection of the head
of the first metatarsal bone for, 253.
Hanchett, Dr. Mary E., death of, 184.
Handbook for the hospital corps of the
United States army and State military
forces, book notice, 186.
Handbook of general pathology, book no-
tice, 491.
Handbook of skin diseases, book notice, 215.
Handbook of therapeutics, book notice, 492.
Hanging, some personal experiments with,
291.
Hare, Dr. Hobard Amory, notice of book
by, 216.
Harris, Dr. Vincent Dormer, notice of book
by, 216.
Hart, Dr. B. F., ‘both right and both
wrong,” 526.
Harveian oration for 1889, 525.
Harvey, Dr. Thomas B., death of, 687.
Hawes, Dr. John B., viper-bite treated by
alcohol, 318.
Hay, Dr. C. M. øa case of tricuspid stenosis
associated with aortic and mitral lesions,
256.
Head, Dr. G. P., can naso-pharyngeal ca-
tarrh be cured ? 82.
Head, treatment of injuries to the, 141.
Headache, antifebrin in the treatment of,
430 5 eucalyptol in, 104.
Health, height and weight in their relation
to, 634 ; medical officers of, 272.
Health Department and the conference com-
mittee of the Academy of Medicine, 691.
Health-resort, a summer, 120, 212.
Heart, and kidneys, relations of lesions of,
355; congenital malformation of the,
416; first sound of the, 432; insuffi
ciency of, in relation to abortion, 328
lesions and malformations of, 247
massage of, 435 ; movable, 343; spon
taneous Bree of the, 447; therapeu
tics of the, 701.
Heart disease, iodide of potassiam in, 662 ;
Nothnagel on the treatment of,
Heart-failure as a cause of death, 71 ; pa
thology of, 587. |
Heart tonics, recent studies of, 279.
Heat, effects of, on the system, 670.
Height and weight in their relation to health,
634.
Hematemesis, arrest of, 319.
Hemoglobinuria, mode of, origin of, 317.
Hemoptysis, inhalations of cold air in, 559 ;
non-tubercular and non-cardiac, of el-
derly persons, 525.
Hemorrhage, concealed ante-partum, 328 ;
in typhoid fever, 660; intestinal, 554 ;
uterine, ligation of the uterine vessels
for, 284. oe
Hemorrhoids, chrysarobin in, 521; excision
of, and closure with the buried animal
suture, 389; pathogeny of, 670.
Henry, Dr. Morris H., the opportantty of
relief for the poor of New York suffer-
ing from diseases of the rectum, 643
Heredity, 314, 476; in infectious diseases,
; influence of, in the causation of
tuberculosis of bone, 550; of acquired
ae as 584; pathological bearings
of, 419.
Hernia, dinphraguiallé: 417 ; double femoral,
in a boy, 579; radical cure of, 73;
strangulated, 495 ; strangulated, mis-
taken for uremia, 13; strangulated,
treatment of, 472; treatment of, 388,
o5.
Hernia sac, malignant tumor in, 394. .
Herniotomy, direct,
Herpes zoster, 469; epidemics of, 102.
Hiccough, a simple remedy for, 364.
Hip, congenital dislocation of, 332, 44%,
lI wea@e |
37.
Hip 7 abscesses in, 441 ; immediate
disregard of malposition of the thigh in
the treatment of, 440; prevention of
the short leg of, 440; some practical
points in the treatment of, 411; treat-
ment of, 361, 44I.
Hip-joint, amputation of, application of an
artificial leg after, 391. `
Hitchcock, Dr. DeWitt, a lost drainage-
tube, 543.
Hoarseness, relief of, 420.
Hobbs, Dr. A. G., catarrhal neuralgia, 629.
Homceopathic Hospital, trouble at the, 685.
Homceopathy, the true status of, 15.
Hopkins, Dr. Howard H., snake-bite and
alcohol, 431.
Hosack Hall, 380.
Hospital, an aerial, 290.
Hospitals, half-filled, 43; inquiry concern-
ing, in London, 222.
Hotels, infectious diseases in, 273.
Humerus, subcoracoid dislocation of, reduced
by Kocher’s method, 13.
Hunter, Dr. James B., resolutions on the
death of, 28, 488.
Hunyadi Janos, the owner of, 283.
Hydrargyrism, fatal acute, 586.
Hydrarthrosis of the knee, treatment of,
602; treatment of, by subcutaneous
rupture, 267.
Hydriodic acid, syrup of, 333-
Hydroa, 277.
Hydrocele, nitrate of silver in, 363.
Hydrogen peroxide in pneumonia, 66; me-
dicinal use of, 321: some cases treated
with, 481.
Hydrophobia, prevention of, by Pasteur’s
method, 357.
December 28, 1889]
INDEX.
719
Hydrotherapy, plea for the practical utiliza-
tion of, 665; versus ydrapathy. 686.
Hygiene, thermometry of, 639.
Hyperostosis cranii, 106.
Hypnotic cases without suggestion, 584.
Hypnotics, influence of, on the process of
digestion, 155; new, 390.
Hypnotism, international congress of, 292 ;
prolonged, in hysterical dysphagia, 82;
some remarks on, 488.
Iiypodermic method, an improved way of
using the, 398.
Hypohzmatosis, 664.
Hysterectomy for large fibromyoma, 12; for
cedematous myoma, 515.
Hysteria, grave case of, 82; pilocarpine in,
139.
Hysterical fever, 151.
I
Ichthyol, thiol as a substitute for, 280, 372.
lleus, 158.
Imagination, hygienic uses of the, 270.
Immunity and immunization, 544.
Immunity through leucomaines, 186.
. Impetigo herpetiformis, 502.
Inches, Dr. Herman B., death of, 244.
Index catalogue of the library of the Sur-
geon-General’s office, U. S. A., book
Notice, 490
Indians, disease-ridden, f°.
Indigestion, rubber bandages in, 403.
Infant, scorbutus in an, 305.
Infantile diarrhoea, vaccine for, 604.
Infantile mortality, causes of, 500; causes
and prevention of, 466.
Infantile paralysis, orthopedics of, 473.
Infantile therapeutics, 472.
Infants, acute arthritis of, 443; entero-coli-
, tis in, 35; rheumatism in, 53.
Infection, by physicians, 548; physiological
resistance of the peritoneum to, 545;
some external sources of, in their bear-
ing on preventive medicine, 85.
Infectious disease, compulsory notification
of, 434, 661.
Infectious doctors, the notification of, 709.
Influenza, epidemic; 661; epidemic of, in
Russia, 635, 710.
Ingenuity, misapplied, 340.
Ingrowing nail, treatment of with tin-foil,
632.
Inhaler, a simple, 532; anzsthetic, 669.
Injury, trivial, severe symptoms from, 66.
Inoculation, antirabic, new method of, 664 ;
preventive, and the theory of its action,
182 ; preventive, for yellow fever, 699.
Insane in foreign countries, book notice,
492; our State, 633,
Insanity, alcoholism, and crime, 321; and
tobacco, 400 ; following mumps, "461; :
the shadow line of, 388.
Insolation, successful treatment of, 287.
Insomnia, food treatment for, 373.
Insufficiencies, muscular, of the eye, outline
tests for, 413.
Internal ear deafness, 23.
Internal strangulation, 190
International Congress of Dermatology and
Syphilography, 275, 301.
International pocket medical formulary :
with an appendix containipg posological
table, formulz, etc., book notice, 217..
Interviewer in the guise of a patient, 487.
Intestinal absorption, imperfect, and its
Management, 549.
Intestinal anastomosis, an experimental study
of, 612.
Intestinal anastomotic operations with seg-
mented rubber rings, 613.
Intestinal hemorrhage, 554.
Intestinal obstruction, 158; gaseous ene-
mata for, 278; overcome by the passage
of a rectal tube, 180; treatment of, by
electricity, 222.
Intestinal surgery, book notice, 218.
Intestines, gunshot wounds of the, 493;
large wounds of, a new procedure or
closing, 613; pigmentation of, 190;
syphilis of the, 484; tuberculosis of,
189.
.
gS e
Intra-cranial hemorrhage in a young child,
19I.
Intranasal pressure, chronic lymphatic œde-
ma of the upper lip coincident with, 63.
Intra-pelvic inflammations, pathology and
treatment of, 511.
Intra-tympanic muscles, physiology of, 136.
Intubation of the larynx, early indications
for, 25; feeding after, 312; for the re-
moval of foreign bodies, 391 ; in cases
of foreign bodies in the air-passages, 31 ; i
unusual case of, 97.
Intussusception and the use of injections,
371 ; coal-oil in, 336.
Iodide of potassium in heart disease, 662.
Iodides, alleged tolerance of, in late syphi-
lis, 502.
Iodides of potassium and sodium, relative
action of, 503.
Iodine in the treatment of warts, 448; poi-
soning by the tincture of,
Iodoform-oil, parenchymatous injections of,
in joint diseases, 575.
Iridectomy in glaucoma, 130.
Iris, multiple cysts of, 132.
Iritis, primary, diagnosis and treatment of,
41i.
Irregular practitioners, association of, in
Massachusetts, 663.
Isabella Heimath Retreat, 663.
Isolation, necessity of, 273.
J
aborandi in Bright’s disease, 425.
Nackica, Dr. J. Hughlings, on the compara-
tive study of diseases of the nervous sys-
tem, 225.
Jacobi, Dr. A., the influence and work of
the Academy, 365.
Jacobi, Dr. Mary Putnam-, notice of book
by, 21 °
janie” Dr f Bushrod W., notice of book by,
216.
Janeway, Dr. George J., death of, 323.
Joint diseases, parenchymatous injections of
iodoform-oil in, 575.
Joint pains, muscular atrophy as a cause of,
210.
Joints and tendon-sheaths, formation of
melon-seed bodies in, 374
Johns Hopkins Hospital and the dispensa
abuse in Baltimore, 587 ;
standing of, 348.
Jones, Dr. A. E., death of, 157.
Judkins, Dr. William, preparing for the in-
evitable, 667.
Jumpers, African, 558.
K
s ;
Kammerer, Dr. Frederic, a case of sarcoma
of the dura age Sa -gas of the longi-
tudinal sinus, 569, 580.
Kelsey, Dr. Charles B., an improvement in
the technique of inguinal colotomy, 398.
Kemper, Dr. G. W. H., the physician in
the Sunday-school, 194.
Kennedy, Dr. Thomas C., scirrhous carci-
noma of the bladder, with vesico-rectal
fissure, 152.
Kentucky State Medical Society, 76.
Keratitis, malarial, 131.
Kidney, chronic lesions of, early diagnosis
of, 473; medullary cancer of, 219 ;
stone in the, 329.
Kidneys, and heart, relation of lesions of,
355 ; surgery of the, 329.
Kime, Dr. J. W., tuberculous pulmonary
aneurism—rupture—death i in early stage
of the disease, 398.
King, Dr. Clarence, neurotic or hysterical
fever, 151.
King, Dr. William Harvey, notice of book
by, 217.
Kirk, Dr. T. T., a young living fœtus, 125.
Kirk? handbook of physiology, book notice,
216.
Klebs, Dr. Edwin, notice of book by, 491.
Knee, excision of the, 174; hydrarthrosis of,
treatment, 602 ; suppurative osteitis of
the, 495.
Knots, ligatures, and sutures, 449, 494.
Kola nut, 214.
Kozloff, Dr. Nicholas I., death of, 644.
Kraske’s method of excision of the rectum
for cancer, 580.
Kreider, Dr. George N., the treatment of.
nia by tepid baths, 260.
Kyp basilar, 681.
L
La prostitution au point de vue de l'hygiène,
book notice, 188,
Labor, antipyrin in, 398; bloodless, 181 ;
macerated foetus as a complication of,
40; normal posture in, 42.
Lacerated perineum, new operation for, 243; A
surgical operation for the repair of, 540.
Lachrymal gland, adeno sarcoma of the, 206.
Lactose as a diuretic, 44, 377.
Land-tax theory and the medical profession,
155, 164.
Lang, Dr. Charles L., a case of unusual tol-
erancy of the pregnant uterus, 707.
Laparotomy, and supravaginal amputation
of the uterus for rupture, 478; choice
of sutures for, 319; early, in suppura-
tion about the cecum, 80; for ruptured
pyo-salpinx, 385; injuries of the bladder
during, 49.
Laryngeal phthisis, menthol in, 23.
Laryngeal pouch, an artificial, 558.
Laryngitis, acute rheumatic, ‘of gonorrheeal
origin, 25.
Larynx, intubation of, 25s 97, 311, 382, 391 ;
syphilis of the, 78.
Latham, Mr, Thomas, maternal i impressions,
252.
Laura, Dr. Pietro, death of, 487.
Lavage de la vessie sans sonde, book notice,
185.
Lavaux, Dr. J. M., notice*of book by, 185.
Lawn tennis as a rejuvenator, 532.
Lea, Dr. I. O., resolutions on the death of,
196.
Lead in the urine, 355.
Lead-poisoning, sources of, in the arts and
manufactures, 274; unsuspected, 344.
Leçons de clinique chirurgicale rokas à
la Salpêtrière, book notice, 492.
Leçons de gyuécologie opératoire, book
notice, 492.
Lecture, didactic, history and course of the,
100.
Lectures on Bright’s disease, book notice,
187.
Lee, Dr. Robert, the cause of rickets, 167.
Left- -legged men, 552.
Left side, pathological inferiority of, 250.
Leg, vaccination on the, 560.
Legal matters of interest to the pbysician,
427.
Leidy, Dr. Joseph, notice of book by, 186.
Lemon-juice in nosebleed, 392.
Lepers, royal, 464.
» anæsthetic, 107 ; danger of spread
of, in the United States, 52; diagnosis
of, 470; personal observations in
Mexico and the Sandwich Islands,
Letchworth, Dr. William P., notice of
by, 492.
Letter, London, 80, 192, 221, 502, 525,
585, 697 ; Paris, 81, 222, 306, 503, 586
Leviseur, Dr. F rederick J., a new needle-
holder for removing hairs by electrolysis,
529. ‘
Lewis, Dr. Bransford, some points in the
treatment of gonorrhcea, 18.
Lewis, Dr. Daniel, a malignant tumor in an
umbilical hernial sac, with remarks on
the etiology of cancer, 394.
Liberia, a hospital for, 489.
Library, an ancient, 157.
Liceaga, Dr. E., the treatment of pulmonary
tuberculosis, 95.
Lichen, discussion on, 275.
Life insurance, importance of rectal examina-
tions in, 79; male and female risks in,
713; Medical Directors, Association of,
663 ; prognosis of albuminuria, in refer-
ence to, 324.
Life register, book notice, 492. `
720
Ligature, transfixion, someof the uses of,
88.
ee sutures, and knots, 449, 494.
Lint, sterilized, ‘608.
Lip, chronic lymphatic oedema of the upper,
coincident with intranasal pressure, 63.
Liquorice powder, compound, 252.
ues Sir Joseph, a new antiseptic dressing,
561.
Liver, abscess of, treatment, 327 ; acute yel-
low atrophy of the, 192; cirrhosis of,
curability of, 211; multiple cavities in
the, from post-mortem decomposition,
163; periodical engorgement of the,
"* 405; surgery of the, 578. |
Lives, worthy, the lessons of, 531.
London, female physicians in, 364.
London letter, 80, 192, 221, 502, 525, 585,
Je
ee Dr. Henry P., an experimental
theory of the Brown-Séquard theory,
205.
bore Pesta Pietro, suicide of, 184.
Lowman, Dr. William R., résumé on ma-
ternal impressions, 176.
Lunacy law, the proposed new, 428.
Lung, collapsed, reinflation of, while an open-
ing remains in the pleural sac, 415.
Lungs, blood-vessels of the, 402; engorge-
ment of the, 421.
Lupus erythematosus ending in death, 500.
Lataud, Dr., notice of book by, 492.
Lydston, Dr. G. Frank, apparent cancerous
transformation of syphiloma of the
tongue—excision of the tongue by the
galvano-cautery, 45.
Lymphocele, 351. °
M
McAdie, Mr. Alexander, electrical resistance
of the humaf body, 307.
McCaskey, Dr. G. W., the inhibitory action
of antiseptics, 34.
McCoy, Dr. Juan W., a device for plugging
the nares to control epistaxis, 168.
McLean, Dr. Malcolm, conservatism in gyne-
cology and obstetrics, 676, 694.
McMurtry, Dr. L. S., on the pathology and
treatment of intra-pelvic inflammations,
5H.
Mackenzie, Sir Morell, vindication of, by
the Royal College of Surgeons, 603.
Macphatter, Dr. Neil, cholecystotomy, 281 ;
large œædematous myoma—hysterectomy
—recovery, 515.
Magnet, extraction of pieces of steel from
the vitreous by, 132.
Maladies de la langne, book notice, 186.
Malaria as a cause of degenerative diseases
- of the spinal cord, 105; in children,
diagnosis and treatment of, 417 ; para-
sites, resemblance of, to those of febris
recurrens, 399.
Malarial fever, an ‘‘ infallible antidote ” for,
463; obscure forms of pelvic cellulitis
simulating, 638.
Malarial paroxysms in the foetus of a healthy
woman,
Male fern and calomel for tape-worm, 372.
Malpractice, suits for, 375.
Manual of diseases of the ear for the use of
students and practitioners of medicine,
book notice, 436.
Massage in rickets, 371; of the heart, 435 ;
use and abuse of, 41.
Masseur, a plea for the, seriously considered,
556; invasion of the, 462.
Massey, Dr. G. Betton, notice of book by,
215. .
Mastoid disease and cerebral abscess, 135.
Mastoiditis, sclerosing, 24.
Materia medica, pharmacy, and therapeutics,
book notice, 215.
Maternal impressions, 176, 252, 316, 714.
Mayer, Dr. Nathan, slow pulse, 658.
Mediastinal disease, book notice, 216.
Medical college term, proposed extension of,
in Canada, 17.
Medical congress in Spain, a proposed, 489.
Medical education, preliminary, regulation
of, 69.
INDEX.
Medical examinations and civil service re-
form, 640.
Medical examining board for New York
State, 527.
Medical examining boards and liberty, 662.
Medical experts, a discussion on the question
of, 401.
Medical journals and the names they go by,
267.
Medical men and the land-tax theory, 155,
164.
Medical profession, and the world’s fair, 401 ;
difficulties of the, 714.
Medical Society of the County of New York,
53, 407, 694; annual meeting, 489.
Medical Society of Virginia, 381, 408.
Medical Society of West Virginia, 156.
Medical students, dress of, 551; English, a
five years’ course of study for, 616; pre-
liminary examination of, 403; State ex-
amination of, 378; the way to educate,
> 549
Medicamentous eruptions, 448.
Medicine, practice of,- recent advances in,
410; practice of, mode of, in Germany,
521; relation of, to the problem of
socialism, 673.
Medico-legal cases, 262.
Meigs, Dr. Arthur V., chronic endarteritis
and its clinical and pathological effects,
197.
Melancholia, diagnostic signs of, 109.
Melon-seed bodies, formation of, in the joints
and tendon-sheaths, 374..
Meltzer, Dr. S. J., intubation in cases of
foreign bodies in the air- s; with
remarks concerning feeding after intu-
bation, 311.
Membrana tympani, antiseptic treatment of
perforations of, 23 ; diagnosis of perfora-
tions of, 269; traumatic rupture of,
137. °
Mendelson, Dr. Walter, professional over-
crowding and the single tax, 164; State
examining boards, 642.
Meningitis, cerebro-spinal, and multiple
neuritis, 110; cerebro-spinal, diagnosis
of, by puncture of the liver, 700.
Menstrual optic neuritis, 372.
Menstruation and pregnancy after removal
of both ovaries, 612.
Mental depression, excretion of uric acid in
relation to, 374.
Menthol in laryngeal phthisis, 23; in vom-
iting of pregnancy, 465; some of the
recent applications of, 574.
Merck’s index, book notice, 216.
Mercury salts, germicidal value of, 113.
Merrill, Dr. O. H., remarkable hemorrhage
in typhoid fever, 660.
Mesentery, chylous cyst of, 18,
Methacetin, a new antipyretic, 102.
Meyer, Dr. Paul, death of, 184.
Meyers, Dr. S. Oscar, an easily cleaned
pocket-case, 139.
Microbes found in tumors, pathogenic prop-
erties of, 576; suppuration without,
45.
Microb infection, immunity from, 586.
Micro-organism of cancer, 104.
Middle ear, hemorrhage in, in fracture of the
base of the skull without external signs
of hemorrhage, 497.
Midwifery practice, antisepsis in, 299
Milk, and its products, behavior of the germs
of cholera, typhoid fever, and tuber-
culosis in, 483 ; apparatus for sterilizing,
39; bicarbonate of sodium in, 644;
bottled, the dangers of, 194; from tu-
berculous cows, 356; shaken, 175 ; sugar
of, as a diuretic, 44.
Milk-diet, injurious effects of, in diabetes,
586.
Miller, Dr. John A., uterine hemorrhage
and ligation of the uterine vessels as a
therapeutic expedient, 284.
Milwaukee, disposal of garbage at, 498.
Mississippi Vallą Medical Association, 471.
Missouri physicians and the State Board of
Health, 194.
Mitchell, Dr. S., Jr., castor-oil as a men-
struum for cocaine, 125.
Mithradatism, 127.
[December 28, -1889
Money, Dr. Angel, notice of book by, 216.
Monks as physicians in the middle ages, 671.
Montanye, Dr., death of, 213.
Moral culture, the brain and, 672.
Morgan, Dr. sone C., shaken milk, 175.
Morgan, Dr. W. F., a pea in the auditory
canal for thirty-two years, 209.
Morphine, elimination of, by the stomach,
373; influence of, on the uterine ap-
paratus, 99; new source of, 436; urz-
mic convulsions controlled by, 631.
Morphine-vaseline as a local application in
cancer, 550.
Morrow, Dr. Prince A., notice of book by,
186.
Mortality among nurses, 400; infant, causes
of, 500.
Morton, Dr. Daniel, Missouri physicians
and the State Board of Health, 1
Mott, Dr. Alexander Brown, death ef, 212.
Mouth-gag, a new, 25.
Mumps, insanity following, 461.
Munich, tuberculosis and typhold fever in,
640.
Murderer’s guilt and surgeon’s responsibility,
211.
Murmur, presystolic, without mitral dis-
ease, 326. .
Murmurs, spienic, 67.
Muscular atrophy, as a cause of joint-pains,
210; progressive peroneal type of, 110.
Muscular insufficiencies of the eye, outline
tests for, 413.
Muscular pseudo-hypertrophy, 110.
Myoma, cedematous, hysterectomy for, $15.
Myopia, hereditary, 222.
Myopic eye, 472.
Myxosarcoma, interpeduncular, 107.
N
Nachtel, Dr., honors to, 223.
Neevus treated by injection of alcohol, 346.
Nagle, Dr. John T., the acting assistant
surgeons and the contract system, 614.
Naphtha habit, 70.
Nasal catarrh, acute, abortion of, 472.
Nasal ecchondrotome, 391. -
Naso-pharyngeal catarrh, can it be cured?
82
Naso-pharynx, brain abscess opening into
the, 581.
National Academy of Sciences, 584.
Navy, U. S., circular for the information of
persons desiring to enter the medical
corps of the, 615; examinations for
medical officers of the, 614.
Navy news, 56, 84, 168, 224, 251, 364,
392, 419, 446, 475, 531, 557» O15, 644,
669, 699, 714. f
Necrosis, phosphorus, propagis of, Saw
Needle-holder for removing hairs by electro-
lysis, 529.
Nelson, Dr. Wolfred, yellow fever, 29.
Nephrectomy by abdominal section, 153.
Nephritis, chronic diffuse, in a child, 219;
following whooping-cough, 67; tuber-
culous, report of a case of, 287.
Nephro-lithotomy, followed by nephrectomy,
494-
Neohrarhabhy, disadvantages of, 329.
Nervous diseases, lectures on, book notice,
492. : :
Nervous system, comparative study of dis-
eases of, 225.
Neuralgia, catarrhal, 583, 629; facial, neu-
rectomy for, 412.
Neurasthenia, gastric, 354.
Neurectomy for facial neuralgia, 412.
Neuritis, multiple, and infectious cerebro-
spinal meningitis, 110; spontaneous de-
generative, of the brachial plexus, 106.
Neuroma, painful subcutaneous, 22.
Neurotic or hysterical fever, 151.
New Jersey Sanitary Association, 639.
New York Academy of ee 26, ste 5 3s
, 493. 665, 6913; description of t
see building: 379; Hosack Hall, 380;
influence and work of the, 365; laying
the corner-stone of the new building,
379; new building for the, 345, 376,
379; section on obstetrics and gyne-
December 28, 1889]
cology, 554; section on surgery, 493,
579; section on theory and practice of
medicine, 522.
New York Neurological Society, 688.
New York Pathological Society, 160, 189,
219. 247, 304, 666. pen
New York State Medical Association, 376,
385 ; officers elect, 436.
New York State, medical examining board
for, 527.
Newcomb, Dr. James E., a clinical note on
the use of creasote in phthisis, 145.
Newton, Dr. Richard Cole, a successful and
convenient method of treating puerperal
eclampsia, 257.
Nichols, Dr. Charles Henry, obituary of,
687.
Nicolson, Dr. William Perrin, case of im-
perforate anus, 264.
Night-sweats, sulphonal in, 336.
Niles, Dr. H. D., climatic treatment of con-`
sumption, 122.
Nipple, chapped, chloral hydrate in, 153.
Nitrate of silver in hydrocele, 363.
Noble, Dr. George H., the use of the tam-
pon in pregnancy, 285.
Nomenclature, some suggestions concerning,
290.
Northern Kansas Medical Society, 84.
Northrup, Dr. W. P., article in Sersbner’s
by, 634. . ;
Northwestern Medical and Surgical Society,
twentieth anniversary of the, 636.
Nose, anæmia, from stenosis of, 23 ; chronic
lymphatic cedema of the upper lip, co-
incident with intranasal pressure, 63;
cough in its relation to morbid states
of, 25; epilepsy caused by disease of,
23; injury to the middle ear from spray-
ing the, 24; internal ear deafness from
disease of, 23; morbid perforations of
the system, 25; reflex symptoms of dis-
eases of the. 581; surgical treatment of
diseases of the, 583 ; tooth in the, 396.
Nosebleed, lemon-juice in, 392.
Nothnagel on the treatment of heart disease,
606
Nova Scotia Medical Society, 156.
Nurses, mortality among, 400,
O
Obesity, danger in the treatment of, 319;
partial, 524.
Obstetrics, conservatism in, 676, 694; gyne-
cology in its relation to, 611; recent
advances in, 409.
Obstruction, intestinal, 125.
Occipital lobes, identity of function of, 16.
Ocular reflex symptoms in nasal disease, 582.
O'Dwyer, Dr. J., intubation for the removal
of foreign bodies, 391.
(Edema as a diagnostic sign in carcinoma of
the stomach, 484; of the brain, 483.
(Euvres completes de J. M. Charcot, book
notice, 187.
Offspring, limitation of, 608.
O’Hanlon, Dr. Philip F., intestinal obstruc-
tion overcome by the passage of a rectal
tube, 180.
Old age, changes in the bones in, 587; deaf-
ness in, 192; eruption of teeth in, 560;
non-tubercular and non-cardiac hemop-
tysis in, 525; syphilis in, 347.
Omphalo-mesenteric canal, persistence of,
189.
Ontario Medical Association, 72.
Operative treatment of hypertrophied pros-
tate, book notice, 188.
Ophthalinia neonatorum, prevention of, 299.
Ophthalmology, decay of, 320 ; relations of,
to general medicine, 525.
Ophthalmoplegia, nuclear, with poliomyeli-
tis, 105.
Opium, substitutes for, in chronic diseases,
352 ; habit, cures for the, in China,
104; smoking, case of poisoning from,
288 ; trade, England and the, 560.
Optic nerve, sarcoma of, 132.
Optic neuritis, menstrual, 372.
Orbit, caries and necrosis of, 132; tumors of
the, and of neighboring cavities, 206.
INDEX.
Orchitis, chronic, 220.
Orris root in America, 29I.
Orthopedic surgeon, the ideal, 671.
Osteitis, rarefying, 304.
Osteomyelitis, acute, following tubercular
osteitis of long anemi 164.
Otis, Dr. Fessenden N., résumé of the ex-
perience of seventeen years in the oper-
ation of dilating urethrotomy, 57.
Otis, Dr. William K., electrolysis and the
radical cure of stricture—why the chal-
lenge has not been accepted, 56.
Otitis media, acute catarrhal, accompanied
with facial paralysis and impaired ac-
conimodation, 136.
Otitis, suppurative, death following, 135.
Otology, brief memoranda in, 513.
Otorrhoea, antiseptics in the treatment of,
2.
Ova, epithelioma of, 556; removal of,
menstruation and pregnancy after, 612;
removal of, psychical and physical
changes following, 558.
Ovarian cystoma, intraligamentous, 75.
Ovarian tumor, pregnancy as a complication
of, 48.
Ovariotomy, physical and mental changes
after, 344.
Overshadowing our homes, 465.
Oxygen, combined with nitrogen monoxide
in the treatment of pulmonary and other
affections, 370; inhalation therapeutic
value of, 1, 26.
Ozena, glycerine in the treatment of, 336.
P
Peediatrics, recent advances in, 409.
Paget’s disease of the nipple, parasitic nature
of, 559.
Pain, the mystery of, 335.
Pancreas, carcinoma of the, 162; conditions
of the, causing diabetes, 586.
Panphobia, 551.
Paralysis, congenital bilateral abducens, with
facial paralysis, 690; general, early
stage of, 349; of the arm and subluxa-
tion of the shoulder-joint following an
injury. 579; pressure, operations on the
spine for, 444.
Paramonobromacetanilide, 240.
Paraplegia, ataxic, 390; cervical, from dis-
location, 691; rachitic pseudo-, 534;
spastic, 418. .
Parasites of the blood, 372
Paresis, general, in a Chinaman, 660.
Paris exposition, medical department of the,
348; therapeutic work at the, 322.
Paris letter, 81, 222, 306, 503, 586.
Parker, Dr. William Thornton, one of the
causes of typhoid fever, 627.
Parotitis, double, of reflex origin, 588.
Parreidt, Julius, notice of book by, 215.
Parsons, Dr. E., death of, 243.
Pasteur’s method in the prevention of hydro-
phobia, 357.
Patella, treatment of fracture of, 140.
Patellar tendon, suture of the, 579.
Patton, Dr. Joseph M., cardiac therapeutics,
Ol.
Pectoral muscles, absence of, 378.
Pelvic abscess in woman, 49.
Pelvic cellulitis in women, 385; obscure
forms of, simulating malarial fever, 638.
Pelvic inflammation, acute, abortive treat-
ment of, 609.
Pelvic surgery by abdominal section, 18.
Pelvic tumors, extirpation of, by perineot-
omy, 602.
Pelvis, female, some abnormalities of the
contents of the, 407 ; how to deal with
pus in the, 611; trephining the, for sup-
purative psoitis, 319.
Pemphigus, discussion on, 276; foliaceus,
relapse of, after eleven years of quies-
cence, 502.
Penis, amputation of, by an improved meth-
od, 41; epithelioma of, 219.
Pericardium, tuberculosis of the, 247.
Perineal lacerations, 111.
Perineotomy, extirpation of pelvic tumors
by, 602.
721
Perineum, lacerated, new operation for, 242 ;
ruptured, surgical operations for the re-
pair of, 540.
Peritonitis, acute suppurative, following vul-
vo-vaginal catarrh, 416; chronic, and
enteralgia, 410 ; chronic, differential di-
agnosis of some of the varieties of, 522 ;
open abdominal treatment of, 637;
treatment of, 18; tubercular, surgical
treatment of, 102, 517.
Peritoneum, physiological resistance to in-
fection of the, 545; washing out the,
81.
Peroxide of hydrogen, medicinal use of, 321 ;
in pneumonia, 66; some cases treated
with, 481.
Persia, an American hospital in, 608.
Pes valgus acquisitus, 10.
Peterson, Dr. Frederick, civil service examie
nations for physicians, 698; electro-
thanasia, 223; notes on exalgine, 283 $
the proposed new lunacy law, 428.
Peyer's patches, pigmentation of, 189.
Pharynx, adenoid hypertrophy of the vault
of, 23.
Phenacetin, artipyrin, and antifebrin, com-
parative value of, 486.
Phenylhydrazine hydrochlorate, antiseptic
properties of, 82.
Phosphorus in rickets, 242 ; necrosis, proph-
ylaxis of, 560..
Photography, why physicians should culti-
vate, 514.
Phthiriasis pubis, treatment of, 484.
Phthisie laryngée, book notice, 185.
Phthisis pulmonalis, Board of Health rules
for the prevention of, 45; carbonic
acid in, 323 ; climatic treatment of, 122;
contagiousness of, 474; contagiousness
of, popular belief in the, 560; creasote
in, 145; food in the treatment of, 47 ;
functions of the stomach in, 159; hot-
air treatment of, 25, 53, 356; immun-
ity from, among native Americans, 154 ;
notification of, as a contagious disease
43; prevention of, 306, 468; rarity of,
among London Jews, 296; relation of
dusty occupations to, 61; special hos-
pitals for, 634; treatment of, 95, 474;
- treatment of diarrhoea in, 559.
Physician, in the Sunday-school, 194; should
be either a Christian or a philosopher,
278.
Physician's family and the provision he leaves
for it, 575.
Physicians, ip the civil service, 67 ; infection
by, 548; legal matters of interest to,
427; Prussian chambers of, 404.
Physiological action and chemical structure,
relation between, 80.
Physiological Congress, the first, 434.
Physiological notes on primary education
and the study of language, book notice,
217.
Pianoforte practising, 308.
Pilocarpine in Bright’s disease, 425; in hys-
teria, 139.
Pityriasis rubra, discussion on, 276. |
Placenta, abdominal palpation of the, 80;
previa centralis, 318; previa, treat-
ment of, 300.
Plaster-of-Paris apparatus, an easy method
for the removal of, 542.
Plastic bronchitis, 518.
Pleurisy, intropleural injections in, 671.
Pneumonia, acute traumatic, 344; croupous,
discussion on, 382; etiology of, 521 ;
heroic treatment of, 560; remarkable
epidemic of, 44; treated with proxide
of hydrogen, 66; treatment of, by tepid
baths, 260.
Pocket-case, a new, 195; an easily cleaned,
139; the question of, 444.
Podophyllum, a new source of supply of, 292.
Poisoning by tansy, 342; by tincture of
iodine, 98.
Polioencephalitis superior and poliomyelitis,
105.
Poliomyelitis anterior acuta, 21.
Polk, Dr. William Mecklinburg, relation of
medicine to the problem of socialism,
673.
Pond, Dr. A. E. M., death of, 71.
722
INDEX.
[December 28, 1889
Rorcher, Dr. F. Peyre, a pathological condi-
tion of the lungs, hitherto undescribed
in this country, but which is not infre-
- quent, 421.
Post, Dr. Sarah E., basilar kyphosis: its re-
lations to certain cerebral deformities,
681; macerated foetus as a complication
of labor, 40.
Post-graduate course in London, 435.
Post-mortem sweating, 183.
Post-partum shock, a possible cause of, 266.
Potassium chlorate, fatal poisoning by, 707.
Potato disease, treatment of, 392.
Potatoes as a substitute fot laparotomy, 280.
Potter, Dr. Theodore, artificial anzesthesia
during sleep, 263.
Poverty and its causes, a physician’s study of,
68.
Practice, success in. 345.
Practices, medical, trading in, 289.
Practitioners’ Society of New York, 405, 495.
Pregnancies, late, 101, 399, 461, 539.
Pregnancy as a complication of ovarian tu-
- mor, 48; extra-uterine, 77; extra-uter-
ine, dating back thirty-three years, 307 ;
extra-uterine, early diagnosis of, 309;
extra-uterine, successful operation for,
50o; extra-uterine, treatment of, 48,
610; tubal, advancing to term without
rupture, 77; tubal, discussion on, 386;
tubal, successfully treated by electricity,
628; tubal, treated by the faradic cur-
rent, 539, 553; use of the tampon in,
285. -
Preputial contractions, nervous phenomena
due to, 72.
Presbyterian Hospital, New York City, fire
at, 710.
Prescribing, wholesale official, 685.
Prevention, policy of, in some of its social
cts, 503.
Preventive oenlation, and the theory of
its action, 182 ; for yellow fever, 699.
Preventive medicine, bearing of some exter-
nal sources of infection on, 85.
Prim, Dr. A. B., notice of book by, 187.
Primiparæ, old, 336.
Prize for an essay on prisons for minors, 268.
Proceedings of the Connecticut Medical So-
ciety for 1888, book notice, 217.
Propre ive muscular atrophy, peroneal type
of, t12.
Prolapsus recti, due to a large stone in the
bladder, in a girl of three years, 417.
Prostatic hypertrophy, 220; operative treat-
ment of, 461; treatment of retention of
urine from, 331.
Proctectomy in cancer of the rectum, 297.
Prostitution, regulation of, 320.
Prurigo in America, 471.
Pruritus, 21.
Prussian chambers of physicians, 404.
Pseudo-hypertrophy, muscular, 110,
Psoas contraction as a symptom, 440.
Psoitis, suppurative, ; trephining the pelvis
for, 319.
Psorospermial cysts of ureters, 99.
Psychology as a natural science applied to
the solution of occult psychic phenom-
ena, book notice, 217.
Puberty, mechanics of, 300.
Pubic bone, congenital reduplication of, 19.
Puerperal anzmia and its treatment with
arsenic, 374.
Puerperal cases, auto-infection in, 544.
Puerperal eclampsia, treatment of, 257;
venesection 1n, 74.
Puerperal septicemia and erysipelas, 319;
etiology and prophylaxis of, 409; pre-
. vention of, 75.
Pulmonary aneurism, tuberculous, 398.
Pulmonary cavity, drainage of, 19.
Pulmonary diseases caused by dusty occupa-
Signs, 446.
Pulsation, abdominal, sphygmographic trac-
ings in a case of, 405.
Pulse, slow, 352, 658.
Pupillometer, 167.
Purpuras, the, 402.
Pyzmic abscesses in the brain, 667.
Pylorus, stricture of the, 159.
Pyosalpinx, ruptured, laparotomy for, 385;
some points in the diagnosis of, 439.
i
| Ricord,
Q
Quadriceps femoris, result of suturing the
tendon of the, 579.
Quadruplets, 322.
Quarantine station, New York, improve-
ments at the, 468.
Quinsy, a gargle in, 110.
R
Rachel, Dr. George W., male and female
risks in life insurance, 713.
Rachitic pseudo-paraplegia, 534.
Radcliffe, Dr. C. B., death JA 44.
Railway cars, some of the dangers that
threaten invalids in, 363; injury, pri-
mary synchronous triple amputation for,
318; casualties, 322; travellers, pro-
tection for, 529.
Randolph, Dr. Robert L., a clinical study
of some antiseptics in the treatment of
otorrhæœa, 92.
Rane, Dr. C. G., notice of book by, 217.
Ranney, Dr. Ambrose L., notice of book
by, 492.
Rare diseases, lessons taught by, 14.
Reading in bed, 532.
Rectal and anal surgery, with description of
the secret methods of the itinerant
specialists, book notice, 490
Rectal examination, importance of, in life
.insurance, 79.
Rectum, cancer of, treatment, 296; excision
of, for cancer by Kraske's method,
580; malignant disco of the upper
part of the, 190; stricture of, electro-
lysis in, 19; villous tumor of, 38.
Reed, Dr. Boardman, why physicians should |
cultivate photography, 51
Reference handbook of the medical sciences,
book notice, 188.
Reflex nervous phenomena due to preputial
contractions, 72.
Reflex symptoms in nasal diseases, 581.
Refraction, errors of, oleate of veratrine in
the determination of, 134.
Reilly, Dr. J. H., report of a case of tuber-
cular nephritis, with autopsy, 287.
Remington, Dr. Frederick, a case of stran-
gulated hernia mistaken for one of
ursemia in a patient known to be suffer-
ing from chronic interstitial nephritis—
autopsy, 13.
Report of the Connecticut State Board of
Health for the year 1888, book notice,
215.
Reprints, uniformity in, 377.
Resorcin in whooping-cough, 672.
Respiration, noisy, in children, 416.
Respiration-chair, 214. °
Retinoscope, pupillometer, and strabismom-
eter combined, 167.
Reuss, Dr. L., notice of book by, 188.
Rheumatism, acute, treatment of, 214;
acute suppurative, drainage of the knee
for, 579 ; bee-stingsin the treatment of,
157; in infancy and childhood, 53;
modern views of the etiology of, 238 ;
of the ocular muscles, 341 ; scarlatinal,
559.
Rhinal diseases, reflex symptoms of, 581.
Rhinitis, chronic, five reasons for failure in
freating, 570, 581.
Rhinolith, a case of, 396.
Rhinology, therapeutic measures in, 582.
Khino-pharyngeal inflammation, importance
of constitutional treatment in, 583.
Ribs, congenital absence of five, 444; costo-
chondral luxation of the first to sixth,
backward, 202.
Rice, Dr. E. P., some suggestions in regard
to treating, gonorrhoea, 65.
Richardson, Dr. Charles H., an easy method
for the removal of plaster-of-Paris ap-
paratus, 542.
| Rickets, etiology of, 167, 277; massage in,
371 ; phosphorus in, 242.
r. Philippe, anecdotes of, obituary
of, 465.
Ridlon, Dr. John, report of a case of con-
genital dislocation of the hip, 537.
Riley, Mr. Henry A., legal matters of inter-
est to the physician, 427 ; recent medico-
legal cases, 262. °
Ringer, Dr. Sidney, notice of book by, 492.
Ringworm, 3or.
Ritzman, Dr. Otto, death of, 403.
River pollution, statistics on, with observa-
tions relating to the destruction of gar-
bage and refuse matter, 498
Roberts, Dr. John B., the proper teachin;
of anatomy, 363. |
Rodenhurst, Dr. DeWitt C., a case of in-
testinal obstruction, 125.
Roosa, Dr. D. B. St. John, notice of book
by, 216.
Roosevelt, Dr. J. West, simple methods for
making corrosion ab pala showing
the gross anatomy of large viscera, 237.
Rose, Dr. A., how to prevent an epileptic
who falls in the street from being com-
mitted as a drunkard, 699.
Rotheln, 376.
Rumbold, Dr. Thomas F., five reasons for
ae in treating chronic rhinitis, 570,
I.
Russan army, food inspection in the, 511.
Russian workshops, hygiene of, 616.
S
Saccharin, as a means of aing the arine,
541, 553; disturbance of digestion by,
504 ; is it injurious? 396.
Sachs, Dr. B., execution by electricity, 103,
193-
Safranine for the detection of sugar, 333.
Salicylic acid, diuretic action of, 315;
germicidal value of, 114; in the treat-
ment of malignant scarlatina, 671; ir
the treatment of small-pox, 67; in the
treatment of tonsillitis, 339.
Salol in scarlet fever, 265; test, diagnostic
value of in motor insufficiency of the
stomach, 636.
Salptngitis, gonorrhoeal, 249.
Salpingostomy, 663.
Salt in milk, 336.
Sanitaria for consumptives, 607.
Sanitary congress in England, 503
Sanitation, U. S. census in its relation to,
467.
Sarcoma of the neck, large vascular, of fif-
. teen years’ duration, 579.
Satyriasis caused by varicocele, 181.
Saundby, Dr. Robert, notice of book of, 187.
Saxlehner, David Andreas, the owner of
Hunyadi Janos, 283. >
Scabies, treatment of, 501.
Scandals, the pathology of, 548.
Scaphoid, carpal, simple fracture of the, 580.
Scarlatinal rheumatism, 559.
Scarlet fever and its complications, treat-
ment of, 415; malignant, salicylic acid
in the treatment of, 671 ; salol in, 265.
Scepticism, medical, 99.
Schapps, Dr. John C., the preparation of
catgut, 40.
Sciatica, chronic, pathology and treatment
of, 20.
Sclerema neonatorum, 416.
Scorbutus in an infant, 305.
Searcy, Dr. J. T., heredity, 314.
Sea-sickness, prevention of, §27; regulation
of breathing in, 343.
Secheyron, Dr. Laurent, notice of book by,
492.
Senator, a medical, 616.
Senile changes in the bones, 587.
Senn, Dr. Nicholas, notice of books by, 213,
492.
Senn? gas-test, is it infallible and always
devoid of danger ? 472.
Septiczemia, puerperal, prevention of, 75.
Septum auriculorum, absence of, 248.
Septum narium, atrophy, hypertrophy, and
deviations of the, 582.
Serous cavities, chylous effusion into the, 351.
Serous membranes, tuberculous disease of
the, 294.
Sex, determination of, 333, 528.
Sexual congress, therapeutic position in, 414.
Sexual hygiene, 320.
December 28, 1889]
INDEX.
723
annn
Shimer, Dr. Henry, the internal use of | Stout, Dr. Henry R., society fever versus | Tetanus, traumatic, 77.
chloroform, 176.
yellow fever, 193.
Shorthand in medical study and work, 81, ; Strabismometer, 167.
_ 280.
Silk thread, danger in, 432.
Silver salts, germicidal value of, 114.
Sinners, breeding of, 364.
Sinus, longitudinal, ligature of the, p09» 580.
Sister Thérése, a nursing heroine, 664.
Skin diseases, new remedies for, 98 ; of in-
, fancy and early life, book notice, 188.
Skin, malignant tumors of the, 470 ; unusu-
al eruptions of, 116, .
Skull, fractures of the base of the, 566, 580;
fracture of the base, hemorrhage in the
_ middle ear in, 497.
Sleeping, eating before, 529.
Smail-pox, antiseptic treatment of, 376; il-
— lustration of, 486; salicylic acid in, 67.
Smart, Dr. Charles, notice of book by, 186.
Smith, Dr. Andrew H., saccharin as a means
of acidifying the urine, 541, 553.
Smith, Dr. lloward, observations at the
clinic of Dr. Apostoli in Paris, 138.
Smith, Dr. J. Lewis, Jr., death of, 71.
Smith, Dr. J. R. N., late pregnancies, 399.
Snake-bite and alcohol, 318, 431.
Snoring, cure for, 16.
Snow, Dr. Irving M., the etiology of pick-
ets, 278.
Snowden, Dr. Thomas, death of, 435.
Soap as an antidote to carbolic acid, 577.
Socialism, relation of medicine to the prob-
lem of, 673.
Society fever versus yellow fever, 193.
Somnol, a new hypnotic, 551.
Sordes and thrush, remedy for, 488.
South Alberta, climate of, 361.
Southern Surgical and Gynecological Associ-
ation, 609, 637.
Spain, proposed medical congress in, 489.
Spectacles, colored, 480.
Speculum, mastoid retracting, 643; nasal,
for applying caustics to the deep struct-
‘res, 250.
Spermine, 484.
Spinal column, relation of the thoracic and
abdominal walls to the, 440.
Spinal cord, degenerative diseases of the,
caused by malaria, 105 ; suspension in
the treatment of affections of the, 472.
Spine, lateral curvature of, new exercise in
the treatment of, 443; operations on,
for pressure paralysis, 444; surgery of,
20; the typhoid, 440.
Spleen, insertion of, into the abdomen, 378.
Splenic murmurs, 67.
Spondylitis, when may treatment be dis-
pensed with ? 443.
Sprains, treatment of, 551.
Spray, cooling the body by, 699.
Squire, Dr. Truman H., death of, 710.
Stable refuse, disposition of, 663.
Stark, Dr. Henry S., a new pocket-case,
195.
State examinations for license to practice,
242, 642; Florida joins the procession,
7
Statistics, vital and medical, 589, 617, 645,
684 ; vital, deficiencies of our, 43.
Stenosis, tricuspid, associated with aortic
and mitral lesions, 256.
Sterility in woman, 473.
Stevens, Dr. George T., the prevention of
sea-sickness, 527.
Stillman, Dr. Charles F., notice of book by,
217.
Stockton, Dr. Charles G., a new gastric
electrode, 530.
Stomach, acids of the, 632; carcinoma of,
cedema as a diagnostic sign in, 484;
dilatation of, 159; dilatation of, in ter-
tiary syphilis, 303; effects of acids on
the functions of the, 374; elimination
of morphine by the, 373 ; motor insuf-
ficiency of, diagnostic value of the salol
test in, 636; multiple ulcers of, in an
opium habituée, 221; reproduction of
the mucous membrane of, 604; rest and
cleanliness of the, 48.
Stomach-brush, 557.
Stools, colorless, in unjaundiced persons,
124.
Strahan, Dr. John, notice of book by, 217,
Straughn, Dr. J. H., twins with one pla-
centa, 461.
Stricture, urethral, electrolysis in, 83, 697.
Strophanthus as a local anæsthetic, 399.
Strophanthus, use of, in children, 603.
Strychnine in the alcohol habit,.255.
Study, Dr. Joseph N., high temperature in
typhoid fever, 660.
Sublimate irrigation after abortion, death
from, 517.
Sugar, detection of, by safranine, 333; of
milk as a diuretic, 44, 377.
Suggestive therapeutics, book notice, 492.
Suicide, workings of the law against, 14.
Sulphonal, 362; death from, 185; dosage
' and effects of, 62; in night-sweats, 336;
long sleep from, 560.
Sulphur dioxide, disinfection of dwellings
by, 499. $33.
Summer diarrheea of infancy, 417; bacteria
found in the dejecta in, 418.
Summer health-resort, 120, 212.
Sunstroke, successful treatment of, 285.
Suppuration without microbes, 545.
Surgeon’s responsibility and murderer’s guilt,
2I.
Surgery, a treatise on, book notice, 490;
cocaine in, 566; detail in, 232.
Surgical bacteriology, book notice, 492.
Surgical cases, general management of the
patient and sick-room in, 73.
Suspension in affections of the spinal cord,
472.
Suture button, a new form of, 400.
Sutures, choice of, in abdominal section and
the Cæsarean operation, 319; knots and
ligatures, 449, 494-
Sweating of the feet, chromic acid in, 100.
Sycosis, clinical notes on, 501; of the upper
lip, treatment of, Sor.
Synopsis of human anatomy, book notice,
490.
Syphilis, dilatation of the stomach in, 303 ;
in old age, 347; injection of insoluble
mercurial salts in, 471; laryngeal, 78 ;
late, alleged tolerance of the iodides in,
g02; of the intestines, 484; tertiary,
302, tertiary, of the throat, peculiar case
of, 289 ; thymol-mercury in the treat-
ment of, 575 ; transmission of, through
surgical instruments, 586 ; treatment of,
302 ; tropho-neurosis as a factor in the
henomena of, 637 ; ways and wander-
ings of the contagion of, 67.
Syphiloma of the tongue, apparent cancerous
transformation of, 456.
T
Tabes, pathology of the laryngeal and other
crises in, 690.
Tachycardia, essential, 605,
Teeniacide, cocoanut as a, 400.
Tait, Mr. Lawson, a visit to, 148.
Tampon, use of the, in pregnancy, 285.
Tamponage, vaginal, 313.
Tansy, poisoning by, 342.
Tape-worm, male fens and calomel for, 372.
Tarbox, Dr. O. C., report of sixteen cases
of typhoid fever, with remarks, 209.
Tauszky, Dr. Rudolf, death of, 608.
Taylor, Dr. Morse K., death of, 616,
Taylor, Professor Isaac E., obituary of, 490 ;
resolutions on the death of, 520, 551.
Teale, Mr. T. Pridgin, detail in surgery,
232.
Teeth, and ears, relation between diseases of,
119; eruption of, in old age, 560.
Telegraphers, sensibility of, 335.
Tendon. sheaths, excision of tubercular bodies
in, 494.
Tendons, divided, suture of, 493.
Terrillon, Dr, O., notice of book by, 492.
Testicular fluid, injection of, as a rejuvena-
tor, 69, 70, 81, 128, 205, 210, 323.
Testis, congenital absence of right, and
ectopia of left, 631 ; tuberculosis of the,
in childhood, 416.
SS SS SS SSS SSS ara
Tetany, 349.
Texas fever in cattle, 468.
Text-book of human physiology, book notice,
2.
The Rre insurance examiner: a practical
treatise upon medical examinations for
life insurance, book notice, 217.
The old hospital and other papers, book
notice, 216.
The student’s text-book of practice of medi-
cine, book notice, 216.
The year-book of treatment for 1889: being
a critical review of the practice of medi-
cine and surgery during 1888, book
notice, 218.
Theophyllin, a new constituent of tea, 547.
Therapeutic work at the Paris exposition,
22.
Therapeutics, physiological, and
structure, 126.
Thermo-palpation, 672.
Thiol, a substitute for ichthyol, 280, 372..
Thomas, Dr. J. D., an improved urethrotome,
chemical
279.
arian posi Dr. Austin White, death of, 71.
Thompson, Dr. James B., determination of
SEX, 333. m ,
Thompson, Dr. W. Gilman, the therapeutic
value of oxygen inhalation, with exhibi.
tion of animals under high pressure of
oxygen, 1, 26.
Throat, tertiary syphilis of the, 289,
Thrombosis of the cerebral sinuses and veins,
350; of the middle cerebral artery, 666.
Thrush and sordes, remedy for, 488.
Thymol-mercury in the treatment of syphilis,
575.
Thyroid gland, accessary, at the base of the
tongue, 16.
Thysotomy for the removal of a sarcoma, 26.
‘‘ Tip-cat,” the danger of, 532.
Tissier, Dr. Paul, notice of book by, 185.
Titus, Dr. E. C., a few clinical cases.show-
ing the value of oxygen combined with
nitrogen monoxide in the treatment of
pulmonary and other troubles, 370.
Tobacco and insanity, 400.
Tobacco hysteria, 663.
Tonghinine, a new heart poison, 104.
Tongue, accessary thyroid gland at the base
of, 16; apparent cancerous transforma-
tion of syphiloma of the, 456; fissur
of, 265; tonsil of the, 22. .
Tonsil, lingual, 22; so-called third, 24.
Tonsillitis, antifebrin in, 604; salicylic acid
in, 339-
Torticollis, functional, 443.
Trachea, erosion of, from aneurism of the
aorta, 304; movement of the, 586.
Trachoma, anterior, the curette in, 133.
Traité d’hystérotomie et d’hystérectomie par
la voie vaginale, book notice, 492.
Transactions of the American Surgical As-
sociation, vol. ii., book notice, 491.
Transactions of the American Surgical As-
sociation, vol. vi., book notice, 216.
Transactions of the Association of American
` Physicians—third session—book notice,
| 490.
Transactions of the New York State Medi-
cal Association for the year 1888, book.
notice, 490.
Transactions of the Royal Academy of Medi-
cine in Ireland, book notice, 216.
Transactions of the thirty-fifth Annual Ses-
sion of the Medical Society of North
Carolina for the year 1888, book notice,
215.
Transfusion, reciprocal, in typhoid fever,
r? 269.
Trephining for actinomycosis of the brain,
333; for cerebral abscess, 317, 461 ; for
general paralysis, 635 ; successful treat-
ment of cerebral abscess by, 317; the
lateral ventricle, 291.
Tricuspid stenosis associated with aortic and
mitral lesions, 256.
Triplets with one placenta, 644.
Tri-State Medical Association, 588.
Tubal pregnancy, discussion on, 386.
Tubercle bacilli, mode of dissemination of,
in the body, 657. |
724
INDEX.
Tubercular peritonitis, surgical treatment of, | Uterine apparatus, influence of morphine
102, 517.
Tuberculosis, anew form of, in cattle, 223;
acute miliary, 192; behavior of the |
germs of, in milk, butter, whey, and
cheese, 483 ; causes and prophylaxis of,
586; diagnosis and treatment of, 79;
in some of its surgical aspects, 221; of
an artery, 657; of bone, influence of
heredity in the causation of, 550; of
the testis in childhood, 416; prophy-
laxis of, 47, ; surgical, 193; the dis-
semination of, 464; transmissibility of,
79. °
Tuberculous disease of the serous membranes,
294.
‘Tuberculous infection through earrings, 267. |
‘Tuberculous pulmonary aneurism, 398.
‘Tumors, pathogenic properties of microbes
found in, 576.
Tunica vaginalis, hypertrophy of, 219.
Turner, Dr. Edward J., death of, 157.
Turner, Dr. S. S., determination of sex, `
528.
Turpentine, new eruption from, 545.
Turpeth mineral, acute gastritis following
the administration of, 190. -
Twins with one body, 209 ; with one pla-
centa, 461.
Tympanic attic, inflammation of, 134.
STORG posture in the treatment of,
265.
Typhlitis, relapsing, 330; surgical treatment
of the, 330.
Typhoid bacillus in the foetus, 343.
Typhoid fever, behavior of the germs of, in
milk, butter, whey, and cheese, 483;
cold-bath treatment of, in Australia,
348; colon-flushing in, 340; etiology
and pathology of, 46; hæmatemesis in,
707; hemorrhage in, 660; high tem-
perature in, 660; physiological action
of the poison of, 704; one of the causes
of, 627; reciprocal transfusion in, 269;
report of sixteen cases of, 209.
Tyson, Dr. James, notice of book by, 188.
U
Udell, Dr. P. S., an improved way of using
the hypodermic method, 398.
Ulexine, a new cardiac remedy, 546.
Umbilical cord, rational dressing and treat-
ment of, 387.
Ureemia, strangulated hernia mistaken for,
I
Uremic convulsions controlled by morphine,
631.
Ureters, psorospermial cysts of, 99.
Urethra, dilatation of the male, for the re-
moval of vesical calculi, 101; new
operation on the, 671; stricture of,
electrolysis in, 83. 697.
Urethrotome, an improved, 279.
‘ Urethrotomy, dilating, an experience of
seventeen years with, 57,
Uric acid and gout, 211; excretion of, and
its relation to mental depression, 374 ;
formation of, relation of diet to, 393,
405.
Urine, had in the, 355 ; new test for albu-
min in, 664; of business men, 475;
residual, symptomatic indication and
therapy of, 546; retention of, from pros-
tatic enlargement, treatment, 331;
saccharin as a means of acidifying the,
541, 553-
a ee pines:
upon, 99,
Uterine appendages, a protest against the re-
moval of the, 711.
Uterine injections, two-ways catheter for, 50.
Uterine system, asthma and the, 604.
Uterus, cancer of, treatment, 300; cancer
of, with involvement of the ovaries,
164; epithelioma of, 556; erosions of
the os, in monkeys, and their patho-
logical relation to cancer in human
females, 697; fibroid of, hysterectomy
for, 12; hemorrhage from, ligation of
the uterine vessels for, 284; partial in-
version of, 385; puerperal, irrigation
of, 265; rupture of, laparotomy and
supravaginal amputation for, 478; toler-
ancy of the pregnant, 707; ultimate re-
sults of extirpation of the,
Vv
Vaccination on the leg, 560; compulsory in
the United States, 708.
Vagina, tamponage of, 313.
Van Dyke, Dr. F. W., antiseptics and the
country doctor, 712.
Van euuerts Dr. Arthur, notice of book
Y, 215,
Varicocele, satyriasis caused by, 181.
Varicose veins, the gacter and, 633.
“t Vaso-motor centre itis,” 578.
Veins, air in the, 345.
Venesection in puerperal eclampsia, 74.
Ventilation in Iceland, 336
Ventricle, lateral, trephining the, 291.
Vermiform appendix, perforation of, 304.
Version, cephalic, eighteen hours after rup-
ture of the membranes, 543.
Vertebral pain, a new form of gastralgia,
545-
Veterinary practice, regulation of, 70.
Vicany, Thomas, notice of book by, 215.
Viper-bite treated by alcohol, 318, 431.
Viscum flavescens, an oxytocic, 118.
Vital statistics, 589, 617, 645; deficiencies
of our, 43.
Vitreous, vascular growth in, 132.
Vomiting of pregnancy, menthol in, 465.
Von Volkman, Professor Richard, obituary
of, 636; as a poet and littérateur, 710.
Vulliet, Dr., notice of book by, 492.
Vulva, new growth of, a hitherto unde-
scribed form of, sor.
W
Walker, Dr. Henry F., tubal pregnancy
treated by faradic current, 539, 553.
Wallace, Dr. T. C., the internal use of
chloroform, 82. 3
Warts, iodine in the treatment of, 448 ; local
treatment of, 644; tincture of iron in-
ternally for, 181.
Washburn, Dr. W., eating before sleeping,
ah”.
Washington State Medical Society, organi-
zation of, 608.
Wasp-stiny, fatal result of a, 547.
Water, relation of conduits to the healthful-
ness of, 639.
Water-supply of New York City, 403.
Waters, Dr., suicide of, 44.
Watkins, Dr. T. J., perineal lacerations,
IIL.
Watson, Dr. F. S., notice of book by, 188.
Weber, Dr. Leonard, on the modern views
of the etiology of rheumatism, with a
[December 28, 1889
clinical consideration of the treatment
of the same, 238
Weber, Dr. Leonard, pure drinking-water,
195.
Weeks Dr. John E., retinoscope, pupillom-
eter, and strabismometer combined, 167;
the relative germicidal value of the so-
called antiseptics, 113.
Weight and feeding, 662; and height in
their relation to health, 634.
Welch, Dr. George T., a case of cystic
goitre, 65; satyriasis caused by varico-
cele, and ceasing after successful opera-
tion for the latter, 18r.
Welch, Dr. William H., considerations con-
cerning some external sources of infec-
tion in their bearing on preventive medi-
cine, 85.
Well-water, contamination of, 672.
Wetherby, Dr. B. J.. a case of bloodless
labor, 181 ; maternal impressions, 316. .
Whitlow, painless, pathology of, 66,.
Whooping cough, inhibition of paroxysms
of, 404; nephritis as a sequel of, 67;
new remedies for, 465, 672 ; treatment
of, 4I.
Wickes, Dr, Stephen, death of, 44; resolu-
tions on the death of, 103.
Wilkinson, Dr. J. R., ligation of the an-
wor tibial artery for traumatic aneurism,
es Will the time ever come ?” 486.
Williams, Dr. Charles E., placenta previa
centralis, 318.
Williams, Dr. Hamilton, congenital absence
of right testis, ectopia of left, opera-
tion for ectopia, recovery, 631.
Williams, Dr. W. W., primary synchronous
triple amputation of left thigh, right leg,
and right arm for railroad injury, 318.
Williamson, Dr. George, death of, 664,
Winds and their sanitary effect, 503.
Witherstine, Dr. C. Sumner, notice of book
by, 219.
Wolfertz, Dr. Charles W., death of, 17.
Wood, Dr. M. W., notice of book by, 188.
Wood's medical and surgical monographs,
book notice, 187.
Wooldridge, Dr., death of, 81.
World’s Fair, the medical profession and the,
401. f
Wounds, most recent antiseptic treatment of,
482.
Wright, Dr. J. W., cerebral abscess success-
fully treated by trephining, 317, 461.
Wright, Dr. John W., rheumatism of the
* ocular muscles, 341. oo.
Wright, Dr. Jonathan, a case of rhinolith
and two cases of a tooth in the nose,
396; chronic lymphatic oedema of the
upper lip, coincident with intranasal
pressure, 63. !
Wrist-drop and allied paralysis, mechanical
treatment of, 482, 495. -
Wyeth, Dr. John A.. a medical examining
board for New York State, 527 , some
recent surgical cases, 169.
Y
Yellow fever, 29 ; preventive inoculation for,
699; recent reseaches relating to the
etiology of, 468.
Young, Dr. James K., flat-foot, or pes val-
gus acquisitus, I0.
Young, Dr. James K., notice of book by,
490.
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