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THE 



MEDICAL NEWS. 



^ tDeeklg iUebiml JoumaU 



VOLUME XLH. 



JANUARY-JUNE, 1883. 




PHILADELPHIA: 

HENRY C. LEA'S SON & CO. 
1883. 



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THE MEDICAL NEWS. 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



Vol. XLII. 



Saturday, January 6, 1883. 



No. I. 



ORIGINAL LECTURES. 



PHILADELPHIA COUNTY MEDICAL SOCIETY 
LECTURES. 

ON THE PHYSICAL EXPLORATION OF THE 

LimoS BY MEANS OF AUSCULTATION 

AND PERCUSSION. 

A count of three lectures delivered by invitation before the 
Philadelfhia County Medical Society. 

BY AUSTIN FLINT, M.D., 

moFKSSOIl OF THB PniMCIPLBS AMD PSACnCK OP MBDICim AMD OF 

cumcAL lumciint in the bbllwue HosrtTAL mcdicai. 

COLLBGB.. mw YORK. 



LECTURE I. 

THE TRUE MODE OF STUDY AND ITS REQUIREMENTS 

AS REGARDS AUSCULTATION AND PERCUSSION. THE 

SIGNS OBTAINED BY PERCUSSION. 

Delivered November 2S, i88a. 

Mr. President and Members of the Philadel- 
phia County Medical Society : The invitation to 
give a few lectures on some subject pertaining to prac- 
tical medicine was accepted by me with a full appre- 
ciation of the high compliment and the responsibility 
therein involved. I cannot adequately express the 
gratification which I shall feel if, at the close of the lect- 
ures, I may be able to persuade myself that any ex- 
pectations on your part, beyond the gratification of a 
complimentary disposition, have been measurably ful- 
filled. The subject selected, with the approval of the 
Committee on Lectures, is one to which for many years 
I have given much attention as a clinical student, and 
a clinical teacher. It may seem to be a hackneyed' 
subject, but 1 hope to succeed in showing that it is one 
which at the present time claims attentive considera- 
tion wijth reference to a further increase, and a more 
general diffusion of the usefulness of its practical ap- 
plications in the diagnosis of diseases. 

INTRODUCTORY REMARKS. 

The discovery of auscultation by Laennec in 1816, 
led to the resurrection of percussion as a method of 
physical exploration, a method brought into existence 
by Auenbnigger, but which the publication in Latin, in 
1761, of the inventttm novum, failed to keep alive, 
and which Corvisart, by his translation of Auenbrug- 
ger's treatise into the French language with abundant 
commentaries, published in 1808, had vainly attempted 
to reanimate. Restored to life by Laennec, percussion 
has since been hand in hand with auscultation. Each 
of these two methods has given invaluable aid to the 
other. They cannot with propriety be disjoined in 
practice, and they are necessarily associated in treating 
of the diagnosis of diseases. It would be of little use 
to discuss the relative advantages of the two methods. 
Doubtless, were we to be deprived of one of them, we 
could better afford to lose percussion than auscultation, 
but the advantages of either would be greatly dimin- 
ished by the loss of the other. A more useful point of 
inquiry is, What progress has been made in our knowl- 
edge of physical exploration by the two methods con- 
jointly smce the time of Laennec ? In answer to this 
inquiry, I have no intention to review in detail the labors 
of those who have cultivated this field in practical 
medicine since Laennec's day. They occupy a consid- 



erable space in the medical literature of the last half 
century. I shall offer some general statements, by way 
of introduction to the lectures, to which your attention 
'is invited. The facts in auscultation which Laennec 
discovered constitute much stronger evidence of his 
genius than the discovery of the method. The latter, 
as he relates, was accidental. It is a marvel that he 
ascertained so much of «rhat is known of auscultatory 
phenomena at the present time. The medical student 
of to-da^ may read his treatise with advantage on ac- 
count of'^'the accuracy of the observations, as well as 
affording a model of truth-loving candor and unaf- 
fected simplicity. It would have been strange indeed, 
if, in the interpretation of his observations, he had not 
fallen into some errors, and had he not failed to recog- 
nize all the directions in which the subject afford 
scope for clinical study. Of the many works which 
have appeared since the publication of Laennec's 
treatise, I will mention here but one, namely, the work 
of Skoda, published in 1839. This work passed 
through several editions, and was translated into the 
■French and the English language. A considerable 
portion of the work is devoted to a refutation of Laen- 
nec's physical explanations of auscultatory phenomena. 
The tone of criticism is dogmatical, and it might per- 
haps be said to be arrogant. The author substitutes 
his own theories for the explanations given by Laennec, 
classifies differently the physical signs obtained by aus- 
cultation and percussion, and designates their distinc- 
tive characters by different terms. I shall refer to this 
work repeatedly in the course of my lectures, and 
oftener with dissent than with concurrence. The work 
has had a controlling effect upon the views of German 
medical writers up to the present moment, and, also, not 
an inconsiderable influence on the views of writers in 
other 'countries. I do not hesitate in expressing my 
belief that thereby auscultation and percussion have 
been injured as regards progress and the diffusion of 
knowledge in these branches of practical medicine. 

Much as has been acquired by means of these two 
methods of exploration within the last fifty years, the 
place which they now hold in medical practice is not, 
as it seems to me, proportionate to the labor given to 
them, and the space which they now occupy in med- 
ical literature. Many practitioners make but little use 
of them. They are considered as constituting a 
specialty. There is lack of unanimity among those 
who bestow upon them special consideration, or regard 
the number of physical signs, the characters by which 
they are designated, and the significance which respec- 
tively belongs to them. The want of unanimity in the 
names used to designate different signs was so appar- 
ent in the discussion by the members of the Section in 
Medicine at the meeting of the International Medical 
Congress in 1881, that a committee was appointed to 
report an uniform nomenclature, at the next congress. 
This committee is composed of representatives from 
England, France, Germany, and the United States. 
It remains to be seen what they may accomplish.* 

Writers are apt to enter largely into theoretic discus- 
sions relating to the mechanism of physical sig^s, dis- 
cussions which are not essential, often unprofitable, 
and not infrequently leading to errors of observation. 



I The members of this committee are as follows : E>rof. Austin 
Flint, of New York, Chairman ; Prof. Ewald, of Berlin ; Prof. 
D'Espine, of Geneva ; Dr. Powell and Dr. Mahommed, of London. 



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ON THE PHYSICAL EXPLORATION OF THE LUNGS. 



[Medical News, 



By some writers signs have been needlessly multi- 
plied, and the subject has been rendered apparently 
mysterious and abstruse by over-refinements. These 
are obstacles which have retarded progress in the 
knowledge of auscultation and percussion, and limited 
their practical use by medical practitioners. 

THE TRUE MODE OF STUDY AND ITS REQUIREMENTS AS 
REGARDS AUSCULTATION AND PERCUSSION. 

The true mode of study has been overlooked. By 
adopting and keeping steadily in view the require- 
ments of the true mode of stuay, as I firmly befieve, 
the obstacles just referred to will be avoided, our knowl- 
edge of physical signs will have a degree of precision 
which will make them far more available in diagnosis 
than hitherto, and the practice of auscultation and 
percussion will have a simplicity which should place 
Its advantages in the hands of every intelligent, well- 
educated practitioner of medicine. What are the re- 
quirements for these desirable objects ? 

Firsdy. A recognition of the fact that the signs 
obtained by means of auscultation and percussion are 
not directly diagnostic of particular diseases, but that 
they represent abnormal physical conditions which are 
common to a greater or less number of different dis- 
eases. The sign which approaches nearest to a pathog- 
nomonic significance, namely, the crepitant rale, does 
not exclusively belong to pneumonia. Signs which 
denote solidification of lung, namely, bronchial and 
broncho-vesicular respiration, increased vocal reso- 
nance, and bronchophony, are incident to various, 
affections. The same is true of other signs. Given the 
presence of certain signs representing certain abnormal 
physical conditions in any case of disease, the diagno- 
sis is to be determined by these signs taken in con- 
nection with the previous history of the case, and 
the present symptoms. It would be superfluous here 
to give illustrations, and I need hardly add, that this 
first requirement involves, in addition to a practical 
acquaintance with physical signs, knowledge of the 
important abnormal physical conditions which the 
signs represent, and of the relations of these conditions 
to the diseases in which they occur. 

Secondly. It is to be acknowledged and borne in 
mind that positive proof of the diagnostic significance 
of the physical signs, as representing abnorm^ physical 
conditions, must be based exclusively on the constancy 
of the association of the latter with the former. The 
only solid foundation for practical knowledge of auscul- 
tation and percussion, thus, is on the facts obtained by 
clinical observation and by autopsical examinations, 
the facts from these two sources being ascertained in 
conjunction with each other. To establish physical 
diagnosis purely on the basis of principles of physics, 
is to build upon a sandy foundation. Not infrequently 
the conclusions concerning the significance of signs, 
logically deducted from physical data, are in direct 
conflict with facts derived from clinical observation. 
Reasoning d priori from the data of physics, the accu- 
racy of observation is apt to be impaired. I would by 
no means imply that it is not desirable to explain, on the 
principles of physics, the connection existing between 
morbid physical conditions and their representative 
signs, but the diagnostic significance of the latter 
should in no way be thereby affected. It is useful as a 
means of corroborating and illustrating the significance 
of signs, to imitate, by artificial contrivances out of the 
body, as nearly as practicable, the physical conditions 
which the signs represent ; and I hope to be able to 
show that the essential characters of nearly all the im- 
portant signs obtained by auscultation and percussion 
may be artificially represented. I shall also introduce re- 
sults of experimental observations which will show that 
many of the important physical signs may be profitably 



studied by making use of healthy and diseased lungs 
removed from the body. Most of the respiratory and 
vocail signs, as well as those obtained by percussion, 
may be reproduced after death by artificial respiration 
and the transmission into the air tubes of vocal sounds. 
The study of physical signs in this way is useful, in 
order to become familiar with their differential charac- 
ters, and also with reference to the mechanism of their 
production. 

The most unreliable course in forming judgments 
concerning the existence of certain morbid physical 
conditions, is to judge from the mental impressions 
produced by certain sounds, not heeding any well-de- 
fined characters of the latter. Here full sway is allowed 
to the imagination. The auscultator will be likely to find 

Eroof of physical conditions, the existence of which he 
ad already inferred from the symptoms. Even Laen- 
nec's treatise is open to criticism on this score. Thus, 
he distinguished cavernous respiration as a sound giv- 
ing an impression of air passing into a larger space than 
when the respiration is bronchial ; he described pec- 
toriloquy as complete when the voice seems to trav- 
erse the whole length of the stethoscope, whereas it 
traverses it partially when the pectoriloquy is incom- 
plete, and the sign which he called a masked-blowing 
murmur {souffle voile), was based on the idea of a 
movable veil between a cavity and the ear of the aus- 
cultator. 

Thirdly. Individual physical signs are to be recog- 
nized as such only when their constant connection with 
distinct abnormal physical conditions has been estab- 
lished. This requirement is a security against an 
undue multiplication of signs by individualizing sounds 
which may be variations of established signs, or the 
significance of which has not been ascertained. 

Fourthly. The differential characters of different 
signs would be distinct, clear, and simple. This re- 
quirement is of special importance as bearing on the 
true mode in which auscultation and percussion are to 
be studied. Naturally, the discoverer of auscultation 
was led to compare the sounds which he heard to those 
which are familiar. Hence, Laennec compared bronchial 
respiration to the sound of a current of air through a tube ; 
oegophony to the cry of the goat ; the crepitant rSle to 
the crackling of salt on co^s of fire ; and the normal 
respiratory murmur to the sounds from the mouth of a 
person sleeping and breathing tranquilly. Skoda and 
others have undertaken to give an idea of auscultatory 
sounds by imitating them in the pronunciation, with 
the whispered voice, of different letters of the alphabet. 
A little reflection must, I think, render it evident that 
such comparisons cannot supply differential characters 
of the different signs obtained by either auscultation or 
percussion with that distinctiveness, clearness, and 
precision which are essential. There is but one way in 
which these differential characters can be made clear, 
distinctive, and precise. This is by means of what 
I have termed, by way of distinction, the analytical 
study of the sounds in health and disease. By the 
analytical study I mean, resolving the sounds into 
those elementary characters by which all sounds, 
natural or artificial, musical and non-musical, are prac- 
tically discriminated. Now the chief differential points 
by which different sounds are distinguished from each 
other, relate to intensity, pitch, and quality. The dis- 
tinctive characters of the sounds obtained by ausculta- 
tion and percussion should be based mainly on points 
of difference derived from intensity, pitch, and quality. 
As thus derived, the differential characters may be 
made clear, distinct, precise, and also simple. Minor 
points of difference, which, however, are not to be 
overlooked, and in some instances are highly im- 
portant, relate to the duration of sound, the rhythmical 
succession of inspiratory and expiratory sounds, and 



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January 6. 1883.] ON THE PHYSICAL EXPLORATION OF THE LUNGS. 



the apparent distance from, or nearness to, the ear of 
the listener. More than thirty years ago, I was led 
to study the sounds obtained by auscultation and per- 
cussion with special reference to their variations in 
pitch. The results of the study were given in an essay 
which received a prize from the American Medical As- 
sociation, and which was published in the Transactions 
of the Association of 1852.* I believe I was correct in 
commencing the essay by saying that " Very little at- 
tention has hitherto been paid to variations in the pitch 
of sounds heard in the practice of percussion and pul- 
monary auscultation." Although since that date in- 
creased attention has been paid to auscultatory sounds 
and those obtained by percussion, the distinctions per- 
taining to this source of differential characters, which 
were pointed out in that publication, have not, as yet, 
been fully and generally accepted. I have indicated, 
since the publication of that essay, additional distinc- 
tions which, as it seems to me, are of much importance 
in their applications to diagnosis. In treating of phys- 
ical signs, in these lectures, it is but fair to my hearers 
to state that certain points of distinction relating to the 
pitch and quality of sounds originated in my own ob- 
servations, and, on the other hand, it is but Vight to 
claim whatever merit may belong to my orignal ob- 
servations. 

Fifthly. The last requirement to be mentioned relates 
to nomenclature. The names by which the physical 
signs are designated, and the terms applied to their 
distinctive characters, should be correctly and clearly 
expressive. It is, of course, very desirable that the 
nomenclature should be uniform, as regards words and 
their meanings, in all countries. Words which denote 
theoretical views are objectionable. An example is 
the term " consonating," applied by Skoda to certain 
sounds produced by the breath, and the voice, and to 
certain riles. The term denotes not only a theory, 
but one the correctness of which is maintained by few, 
if any. The terms " full " and " empty," applied by 
the same author to sounds produced by percussion, con- 
vey no well-defined ideas, and it is not easy to under- 
stand what the author means by them after carefully 
reading his explanations. These terms are still in use 
by German authors, as also another singularly unsat- 
isfactory term, namely, " indeterminate." Skoda ap- 
plies this term to respiratory sounds which are neither 
bronchial nor vesicular, not attempting to give any posi- 
tive.distinctive characters, and, indeed, declaring that 
this is impossible. I hope to show that it is not m the 
least necessary to use such a negative term as " in- 
determinate" in designating a group of respiratory 
signs. Such names as " wooden resonance." and 
" band-box resonance," are too loose to be appropriate. 
Especially objectionable is the designation of signs 
after the names of those who have described them. 
The names Williams, Skoda, Gerhardt, Biermer, and 
Wintrick have been introduced into the nomenclature 
of physical exploration by some German authors. 

PERCUSSION. 

It is usual to consider percussion before considering 
auscultation. The compass of the former is much the 
smaller, and its consideration prepares for that of the 
latter. Moreover, in the clinical employment of the 
two methods, percussion generally precedes ausculta- 
tion. 

PERCUSSORS AND PLEXIMETERS. 

Auenbrugger was content with percussing by the fin- 
gers directly upon the thoracic parietes. The introduc- 
tion of the pleximeter by Piorry was an improvement, 

' This essay was entitled " On Variations of Pitch in Percussion 
and Respiratory Sounds, and their Application to Physical Diag- 
nosis." 



but of vastly less importance than was claimed by him. 
It has perhaps never occurred to some of those present 
to practise immediate percussion. It will be found on 
trial less unsatisfactory, probably, than had been sup- 
posed. The credit of using a hammer, instead of the 
finger, as a percussor, is attributed to Wintrich. The 
hammer devised by him, and I believe still used in 
Germany, is a curiosity. As it has been but little used 
in this country, it may have interest in the way of nov- 
elty to some present, and I therefore exhibit it. As 
you see, the hammer part of the instrument, which is 
made of brass, is long and heavy. The point is tipped 
with India rubber. The handle is light and thin, with 
excavations to receive the ends of the thumb and fin- 
gers. It could hardly have been more clumsily de- 
vised to be used by striking directly upon the plexime- 
ter. This was not intended ; but the hammer is to be 
thrown upward by the movement of the hand in which 
it is held, and then allowed to fall upon the pleximeter. 
It is difficult to see in what respect this manner of per- 
cussing has any advantage over that in which the blows 
are made directly, and the disadvantages are obvious. 
It would not be profitable to discuss the different varie- 
ties of percussors which are in use with us. I shall 
simply show one which I have used for many years, 
and which I have found to answer admirably. It con- 
sists of a piece of India rubber in the form of a double 
cone, held in a ring at the end of a handle made of 
vulcanized rubber. It is light ; it makes but little noise 
in coming into contact with whatever is used as a plex- 
imeter, and it is durable. 

I need not say that as both a pleximeter and a per- 
cussor, the fingers of the two hands answer every pur- 
pose in private practice. The chief object of an artifi- 
cial pleximeter is to slive the fingers from injury by 
frequent percussion. The pleximeter which I show I 
have used for some time. It is made of vulcanized India 
rubber, is light, easily held, and readily applied to the 
chest. 

THE NORMAL VESICULAR RESONANCE ON PERCUSSION. 

A thorough practical knowledge of the characters 
which distinguish the sounds in health is, of course, 
essential, as preparatory for the study of the morbid 
signs furnished by percussion and by auscultation. I 
have always found it difficult to enforce sufficiently this 
obvious truth in teaching medical students, and I sus- 
pect that with practitioners difficulty in the recognition 
of morbid signs is often attributable to an imperfect ap- 
preciation of the characters distinctive of normal 
sounds. Studied analytically, the characters which 
distinguish the normal resonance on percussion are re 
solvable into those derived from pitch and quality, inas- 
much as the intensity varies in different persons and in 
different regions of the chest. Some exercise is neces- 
sary for a correct appreciation of pitch, as distinguished 
from quality, in the sounds obtained by percussion. 
Errors are sometimes attributable to a lack of this ex- 
ercise. The relative variations in pitch are easily ex- 
pressed by the terms high and low. On the other hand, 
the peculiar quality of any sound cannot be expressed 
in language. Let it be supposed, for example, that one 
should endeavor to describe the quality of the tones of 
a violin, or of any other musical instrument, to one 
who had never h^rd them. An idea of the quality of 
sounds can only be given by comparison, and it is rare 
for two sounds produced in different ways to resemble 
each other so closely that the one will give a clear idea 
of the other. Moreover, the variations in the quality of 
sounds are innumerable. As an illustration, let it be 
considered that the human voice has so many diversi- 
ties, irrespective of pitch and intensity, that among 
many thousand persons it would be difficult to find two 
voices precisely alike. Hence, the peculiar quality of 



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IN- 



ON THE PHYSICAL EXPLORATION OF THE LUNGS. 



[MKDICAL NBW^, 



sounds must be learned by direct observation. Now, 
as regards the pitch and quality of the normal pulmo- 
nary resonance, the quality is sui generis . It cannot be 
described. Evidently the quality is dependent on the 
fact that the air which gives tfie resonance is con- 
tained in the pulmonary vesicles or alveolae, and not 
in a free space, and, for this reason, the name vesicular, 
which is used to distinguish this peculiar quality, is ap- 
propriate. The pitch, as compared with the abnormal 
sound obtained by percussion, is low. I believe I am 
correct in saying that no abnormal sound obtained by 
percussing the chest is ever lower in pitch than the 
normal vesicular resonance in the same subject. The 
pitch of the normal resonance is evidently determined 
by the same physical conditions to which the vesicular 
(quality is attributable, for the pitch is lower in propor- 
tion as this quality is marked, and vice versa. 

In order to represent, artificially, vesicular resonance, 
an article must be found which resembles lung in the 
essential physical condition, namely, containing air in 
innumerable minute spaces. A feeble imitation is ob- 
tained by percussing a sponge. My friend. Dr. J. S. 
Thatcher, has suggested a much better article — a loaf of 
bread. _ Bread in the form of a loaf gives a resonance 
of considerable intensity, and it is a fair representation 
of the vesicular resonance. It should be covered with 
a cloth in order to diminish the noise produced by the 
contact of the fingers or the percussor, and thus to 
elicit better the sound from the air contained in the 
interstices of the loaf. The upper crust stands in place 
of the thoracic wall. The resonance elicited illustrates 
the lowness of the pitch, with a pretty close approach 
to the peculiar quality of the normal pulmonary reso- 
nance. 

When it is considered that all the knowledge fur- 
nished by percussion, which is available in the physical 
diagnosis of pulmonary diseases, may be comprised in 
four signs, one is led to exclaim. What is to hinder the 
possession of this knowledge to the fullest extent by 
every practitioner! There is no hindrance beyond 
unanimity in the recognition of the existence of these 
signs, and that practical acquaintance with their differ- 
ential characters which requires but a very moderate 
amount of time and attention. Arranged in pairs, the 
four signs are, ist, flatness and dulness ; 2d, tympa- 
nitic and vesiculo-tympanitic resonance. 

FLATNESS AND DULNESS. 

The first pair represent different degrees of the same 
morbid physical conditions, namely, either the presence 
of liquid in the pleural cavity, liquid in the vesicles, or 
in the interstitial lung tissue, or solidification of lung 
incident to pneumonia, phthisis, pleurisy, and other 
afi°ections, or morbid growths within or extending into 
the intra-thoracic space. It is to be understood that 
the term flatness means no proper sound or resonance. 
It is absence of sound. It cannot be defined more 
distinctly than by this statement. There can, of course, 
be no degrees or variety of flatness. 

In dulness, the resonance is more or less diminished. 
There are degrees varying from the slightest diminu- 
tion to that approximating as closely as possible to flat- 
ness. Flatness has, of course, neither pitch nor quality 
of sound. Dulness, considered as a distinct sign, always 
has more or less of the quality which belongs to the nor- 
mal resonance, that is, the vesicular quality. If this qual- 
ity be entirely wanting, the resonance is tyfnpanitic, as 
will presently be seen. A fact which I pointed out in 
my essay published in 1852, is that in dulness the pitch of 
sound is invariably higher than that of the normal res- 
onance of the person examined. This fact is of im- 
portance, as assisting in the recognition of a slight de- 
gree of dulness. It is of much importance in certain 
cases which will be referred to in connection with vesi- 



culo-tympanitic resonance. The elevation of pitch now 
generally enters into the account giveft by medical 
writers of dulness or percussion, which it did not prior 
to 1852. 

The essential distinction in the other pair of signs, 
namely, 

TYMPANITIC AND VESICULO-TYMPANITIC RESONANCE, 

relates to quality of sound. In a purely tympanitic 
resonance, there is complete absence of the vesicular 
quality which belongs to the normal resonance. Con- 
versely, a resonance in which th'e vesicular quality is 
absent is always tympanitic. This sign represents 
the following morbid physical conditions: air in the 
pleural space, pulmonary cavities, solidification of the 
upper lobe of a lung, the resonance then being derived 
from air in the extra-pulmonary bronchial tubes, and 
conduction of resonance from the stomach or colon. _ 

The tympanitic resonance, as just distinguished, is 
artificially reproduced whenever resonance is derived 
from air in a free space of greater or less size, instead 
of being derived from air in a collection of minute 
spaces like those of the pulmonary vesicles, or the in- 
terstices of the bread-loaf. The intensity of the reso- 
nance will depend on the amount of free air, the thick- 
ness, elasticity, and tension of the walls of the space 
containing the air, and other circumstances, aside from 
the force of the percussion. However feeble and dis- 
tant, the resonance is always tympanitic if it be devoid 
of that peculiar quality due to the fact that the air is in 
minute spaces, namely, the vesicular quality. It is, 
perhaps, a common impression that for a resonance to 
De tympanitic, it must be louder than the normal reso- 
nance. Intensity is an unimportant element so far as 
regards the distinctive characters of the sign. It may 
have any degree of gradati6n between much intensity 
and great feebleness Of sound. Air in the pleural 
space frequently yields a tympanitic resonance which 
is notably intense. As a rule, the resonance is com- 
paratively feeble over a pulmonary cavity, and where 
derived from air in the extra-pulmonary bronchi, the 
sound being conducted through solidified lung. 

A tympanitic resonance is invariably higher in pitch 
than the normal resonance. I believe this statement 
to be correct, although the reverse is stated by some 
medical writers, who are in error, as I suppose, either 
from reasoning incorrectly on principles of physics, or 
from not accurately distinguishing pitch from intensity 
and quality. The latter mistake is liable to occur with- 
out some training of the ear, and careful attention. It 
is by no means as easy to distinguish variations in the 
pitch of non-musical sounds as of musical notes. Some 
exercise is requisite to secure accuracy, and the dis- 
crimination is undoubtedly somewhat difficult for 
those who have not what is called a " musical ear." 

Other things being equal, the pitch is lowered the 
larger the free space containing air. The bass-drum 
has a notably lower tone than the kettle-drum, and the 
non-musical resonance from an inflated bladder or an 
India-rubber bag of considerable size, is lower than that 
from a small hollow India-rubber ball. Percussion 
over a flatulent caecum gives a higher pitch of reso- 
nance than over the stomach ; the pitch of resonance 
over the colon distended with gas is lower than the res- 
onance from either the stomach or caecum, and the re- 
sonance over the small intestine is still lower. Tension 
has much to do with pitch ; this is shown by the effect 
of tightening a drum-nead. The effect of the difference 
in the material of the walls of the space enclosing air, 
upon the pitch and intensity, is shown by comparing 
the sounds produced by beating a drum on its head 
and on its sides. The many variations corresponding 
to those in the physical conditions which give rise to 
tympanitic resonance, may have interest for some who 



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January 6, 1883.] ON THE PHYSICAL EXPLORATION OF THE LUNGS. 



are curious as regards the minutia of acoustic phenom- 
ena, but, if two varieties to be presently noticed be ex- 
cepted, the variations in tympanitic resonance are of 
no utility in their practical applications to physical 
diagnosis. They are burdensome and perplexing to 
the student of percussion who desires only to acquire 
the knowledge which is practically useful. One who 
wishes more than this will find in the treatise by Eich- 
horst on the Physical Methods of Investigating Internal 
Diseases, enough to gratify curiosity respecting minute 
and superfluous details. 

A practical point of importance pertaining to tympa- 
nitic resonance, is its ready conduction for a greater or 
less distance beyond the limits of the space whence it 
comes. In this respect it differs notably from the 
normal vesicular resonance. A gastric tympanitic reso- 
nance is often conducted upward over a considerable 
portion of the thorax on the left side. In like manner, 
the resonance from the colon may extend as far as, or 
even above, the upper boundary of hepatic flatness. 
It follows that this resonance is unreliable for deter- 
mining with accuracy the lower border of the liver, the 
boundaries of the spleen, and the space occupied by 
abdbminal tumors. 

AMPHORIC AND CRACKED-METAL RESONANCE. 

Tympanitic resonance, with either an amphoric or 
cracked-metal intonation, claims but a passing notice. 
The familiar illustrations of these varieties by filliping 
the check made more or less tense, and by striking the 
closed hands upon the knee, cannot be improved upon. 
The intonations may be produced by percussing India- 
rubber hollow balls of different sizes. Clinically, the 
fact that the intonations are sometimes heard on per- 
cussing over the solidified upper lobe of the lung in 
situations over the extra- pulmonary bronchi, is not to be 
overlooked. And the fact that, with this exception and 
the rare instances in which in these situations they are 
found in health, they are invariably cavernous signs, 
renders them of much value in diagnosis. Another 
practical fact is perhaps not always appreciated, 
namely, that these intonations may very often be per- 
ceived by the ear close to the open mouth of the pa- 
tient, when otherwise they escape observation. Still 
another fact deserves mention. With the pectoral ex- 
tremity of the binaural stethoscope close to the open 
mouth of the patient, they may be recognized when 
they are not readily perceived without this instrument. 
Finally, it is to be borne in mind that they are found 
at some times and not at other times, owing to the 
varying condition of cavities as regard emptiness, and 
of the bronchial tubes as regards freedom from ob- 
struction. 

The last of the four signs is the 

VESICULO-TYMPANITIC RESONANCE. 

I must hold myself responsible for the name and the 
description of the characters distinctive of this sign. 
The name expresses the most diagnostic feature. The 
vesicular and the tympanitic quality are combined in 
varying proportions. An essential feature, however, 
fe an increase in intensity. The intensification may be 
^eater or less in degree. The pitch of the resonance 
IS invariably raised. It is raised in proportion as the 
tympanitic predominates over the vesicular quality. 
This sign is therefore distinguished from the normal 
resonance by the presence of more or less of the tym- 

Eanitic quality of sound, by greater intensity, and by a 
igber pitch. It is distinguished from the tympanitic 
resonance by the presence of more or less of the vesic- 
ular quality of sound. It is distinguished from dulness 
by its intensity. The only difficulty in its recognition 
practically, pertains to its discrimination from tym- 
panitic resonance. The predominance of the tym- 



panitic quality, with a proportionate elevation of pitch, 
may be so great that it may seem to be purely tympa- 
nitic. This error may always be avoided by attention 
to coexisting physical signs. The sign represents an 
abnormal accumulation of air within the air-cells. It 
is, therefore, par excellence, the sign of pulmonary em- 
physema. Its practical value in diagnosis is chiefly in 
that pathological connection. It occurs, however, in 
other pathological connections. It is this sign which 
is obtained above the level of liquid when the quantity 
is sufficient to fill a third, a half, or even two-thirds of 
the thoracic space, be the liquid either serous or puru- 
lent. It is obtained in cases of pneumonia affecting 
one lobe of a lung, over the unaffected lobe of the same 
lung, be the latter either the upper or the lower lobe. 
I forego discussion of the question, wherefore is the 
sign present in these two pathological connections, 
simply stating that I suppose in either instance there 
is an abnormal accumulation of air and increased ten- 
sion of the alveolar walls within the lobes which yield 
the sign. 

The vesiculo-tympanitic resonance may be illustrated 
by means of the human lungs, or those of the calf or 
sheep, removed from the body; inflated artificially 
within the limit of a normal inspiration, the resonance 
represents the normal vesidular. Inflated considerably 
beyond that limit, the emphysematous condition is 
produced, and the resonance represents that condition. 

There is a liability to error in the non-recognition of 
this sign in certain cases of pulmonary emphysema ; 
and, consequently, to an unfortunate mistake in diag- 
nosis. As a rule, in emphysema, the upper lobes of 
both lungs are affected, and the lobe of the left in a 
greater degree than that of the right lung. Now, 
under these circumstances, the upper lobe in both 
lungs yields a vesiculo-tympanitic resonance, but this 
sign is moremarked on the left than on the right side, 
the difference corresponding to the difference in the 
degree "of emphysema. The error is in regarding the 
lesser degree of resonance on the right, compared with 
the greater degree of increased resonance on the left 
side, as dulness which, taken in connection with the 
symptoms, would point to a phthisical affection. This 
error of observation, and consequent mistake in diag- 
nosis, is a not very infrequent occurrence. The rela- 
tively lesser degree of resonance on the right side at 
the summit of the chest, which is supposed to be dul- 
ness, is, in fact, a vesiculo-tympanitic resonance, and 
the intensity is therefore greater than normal. The 
intensity seems to be diminished because it is relatively 
less than the still greater intensity on the left side. The 
error is avoided by attention to the pitch and the quality 
of the resonance on the two sides. If the disparity in 
respect of the intensity of resonance be due to a 
greater amount of emphysema on the left side, the 
pitch of the sound will be higher on that side than on 
the right side, and the quality will be distinctly vesiculo- 
tympanitic. On the other hand, were the disparity due 
to dulness on the right side, the pitch of sound should 
be higher on that side than on the left side, and the 
vesicular quality of the resonance on the left side 
should be without admixture with a tympanitic quality. 
A useful practical exercise is to select two patients, one 
affected moderately with emphysema, and the other 
with a moderate phthisical affection at the summit of 
the right lung. In the case of phthisis, the resonance 
at the summit of the right side of the chest will be less 
than on the left side, and higher in pitch, the resonance 
on the left side being vesicular in quality, and lower 
in pitch. In other words, there is abnormal dulness 
on the right side. In the case of emphysema, the reso- 
nance at the summit of the chest on the right side, as 
in the other case, will be less intense than on the left 
side; but the disparity is due, not to a diminished in- 



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SARCOMATOUS INFLAMMATORY FUNGOID NEOPLASM. [Medical Mtw*. 



tensity of the resonance on the right side, but to the 
greater increase of its intensity on the left side ; and 
this increased intensity is accompanied by a vesiculo- 
tympanitic quality, and a higher pitch than on the 
right side. That in this case the resonance on the right 
side is actually increased ; in other words, that on the 
right, as well as on the left side, the resonance is 
vesiculo-tympanitic, is shown by a comparison of the 
resonance over the upper with that over the lower 
lobe. In cases of emphysema, the standard of health, 
or an approximation thereto, is obtained by percussion 
over the lower lobes. 

ARTIFICIAL ILLUSTRATIONS OF THE SIGNS OBTAINED BV 
PERCUSSION. 

In conclusion, I hope it will not be deemed too trivial 
a matter for this occasion, nor an unworthy use of the 
"staff of life," to show how the signs obtained by per- 
cussion may be illustrated by imitating, out of the body, 
simply and roughly, the morbid physical conditions 
which these signs represent, using for this purpose, 
chiefly, the bread-loaf. A resonance analogous to the 
vesicular, as has been stated, may be produced by per- 
cussing a loaf of bread. The first of the four abnor- 
mal signs, namely, flatness, is easily enough illustrated. 
Any substance devoid of air suffices for an illustration. 
If a part of a loaf of bread be immersed in water for 
a few moments, the interstices become filled, and we 
have an imitation of pulmonary oedema ; over that 
portion of the loaf there is flatness. If the absorption 
of water be not sufficient to fill the interstices, there is 
dulness. A single loaf may thus be made to illustrate 
flatness, dulness, and the normal resonance. If, for 
water, a solution of gelatine be substituted, and a 
part of a loaf be allowed to remain immersed until the 
eelatine congeals, we obtain a representation of solidi- 
hcation of lung analagous to that in cases of pneu- 
monia. The three above-named signs may in this way 
be illustrated. 

Dulness may be illustrated and compared with an 
imitation of the normal resonance, by introducing into 
one-half of a loaf of bread pieces of some solid mate- 
rial. In the present illustration I use sticks of candy. 
The elevation of the pitch of the dull sound may in 
this way be shown. 

Tympanitic resonance is familiar, of course, from 
the percussion of the abdomen. The pitch, other things 
being equal, is higher the smaller the space containing 
air or gas. Artificially, a bladder, or an India-rubber 
bag inflated, gives an illustration of a tympanitic reso- 
nance. Comparing the resonance of an inflated bag 
of large size, with the resonance of an inflated lung, the 
higher pitch of the former may be observed. It is also 
shown by comparison with resonance from a loaf of 
bread. 

Amphoric and cracked-metal resonance may be 
illustrated by percussing an India-rubber bulb, such as 
is used in Davidson's syringe, held down to the ear. It 
will be seen that the cracked-metal intonation requires 
a small space with free openings. 

Tympanitic resonance within a circumscribed space 
is shown by removing a portion from the centre of a 
loaf of bread, leaving only the crust. The resonance 
over this space may be contrasted with that over the 
remainder of the loaf. By immersing the loaf for a few 
moments in water, the tympanitic resonance is brought 
into contrast with flatness on percussion. 

Circumscribed flatness may be shown by filling the 
space which had given the tympanitic resonance with 
some solid material. Dough containing no air is a 
good material for this purpose. 

The vesiculo-lympanitic resonance may be artifi- 
cially illustrated as follows : Take a common loaf of 
bread. By means of a hollow cylinder remove longi- 



tudinal sections in one-half of the loaf. The spaces 
thus produced yield a tympanitic resonance, and the 
portions of bread which remain give the vesicular reso- 
nance. The vesicular and the tympanitic quality are 
thus combined with elevation of pitch, the tympanitic 
quality and the elevation of pitch corresponding to the 
number of sections removed. 



ORIGINAL ARTICLES. 



A CASE OF SARCOMATOUS "INFLAMMATORY 
FUNGOID NEOPLASM." 

Bv LOUIS A. DUHRING, M.D., 

PKOPISSOIt OP SKIN DISKASBS IN THB UHIVBRSITY OP rBNMiTl.VANIA. 

The following case of this rare and grave disease 
presented itself at my clinic for diseases of the skin 
at the University Hospital, on Novemer 14, 1882. 
The patient was exhibited to the class and the promi- 
nent features of the afTection pointed out in the 
course of the lecture. The disease is of such r*rity 
and- interest as to entitle the case to a place on 
record, and I shall therefore, without further preface, 
briefly describe the most important symptoms. 
The history (for which 1 am indebted to Dr. Van 
Harlingen) states that the man, Charles Coyne by 
name, is a laborer, fifty-two years of age, and a 
native of Ireland. He enjoyed good health until 
he was thirty years old, when he was attacked with 
eczema of the hands, which gradually invaded the 
feet and other regions until in a short time almost 
the whole surface became involved. The eczema 
was always dry and slightly scaly, and itched 
severely. 

About eight years ago the disease under consider- 
ation made its appearance in the form of a. pea-sized 
tubercle situated over the left eyebrow. It was at 
first the same color as the surrounding normal skin, 
but afterwards became pale-red, and later somewhat 
purplish in shade. It, as well as all subsequent 
lesions, from the beginning, itched violently. It 
grew gradually, so that by the end of a year it was 
as large as a hazel-nut, and has since increased to 
its present size. About a year after the appearance 
of the tubercle referred to, a similar growth came 
upon the right eyebrow, which has followed the 
same course. Later, like formations, symmetric^ly 
disposed, manifested themselves behind the ears 
and the jaws, and several years afterwards they also 
made their appearance on the chest, and later on 
other parts of the trunk. On the chest there first 
appeared a highly inflammatory papular eruption, 
"resembling prickly heat," which after vanishing 
was succeeded by the present papular, tubercular, 
and nodular formations. Latterly, a few of the 
older lesions have softened and ulcerated sup>er- 
ficially, but this tendency is as yet not marked. 
The hemorrhagic symptoms, seen on some of the 
patches of the trunk and in places on the extreipni- 
ties, have existed only during the past six months. 
The general health has been gradually failing, and 
he has lost weight during the last year. He is now 
in poor health ; is spare and somewhat emaciated, 
and is weak. 

Occupying the eyebrows and forehead are two 



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January 6, 1883.] 



THREE CASES OF DIABETES INSIPIDUS. 



perfectly symmetrical, circumscribed, irregularly 
shaped, lobulated tumors the size of common hen's 
eggs. They are soft, fleshy, and have a fungoid 
look, and are of a dusky, dull, pale-red or vio- 
laceous color, and have slightly excoriated and 
scaly, rough surfaces, the result of scratching. 
They are irregularly ovoidal in shape, and project 
about an inch beyond the forehead, giving a heavy 
expression to the face. Upon the surface of either 
growth there exist several furrows or linear depres- 
sions. The color is a dull-red with a purplish tint, 
— 3. pale raspberry-red. 

Immediately above the tumor on the left side 
there is a flat, almond-sized and shaped, pale-pink- 
ish formation, which when taken between the 
fingers is found to be definfed in outline and firm in 
consistence. It is seated in the skin and subcu- 
taneous connective tissue. It illustrates the earliest 
stage of the tumors 

On either side of the head, occupying symmetric- 
ally the region in front of and behind the auricles, 
there exist extensive, highly developed masses of 
firm infiltration, having the same general character 
as the tumors of the eyebrows. The disease here 
extends from the temporal region down to the 
angles of the lower jaw, and is so pronounced as to 
cause considerable deformity. Behind the auricles 
it extends into the scalp as far as the parietal region, 
and thence on either side to the occipital protuber- 
ance. The posterior aspect of the neck is also 
similarly invaded. The whole mass is considerably 
raised and is irregularly furrowed, tuberculated, and 
nodulated, though not to the extent of the promi- 
nent tumors, such as those on the face. 

In addition to the lesions described, there exist 
numerous, variously sized, rounded or flat, raised 
patches of infiltration, of a reddish-purple or 
brownish-red shade, scattered over the trunk, the 
njost conspicuous of which are seated on the chest. 
These are five in number, two occupying the region 
of the nipples, and the others the sternum. They 
are large and prominent, varying in size from a 
walnut to an egg, and have a firm, fleshy feel, and 
a distinctly fungoid appearance. Upon various 
regions of the trunk, small and large, ill-defined 
patches of an inflammatory papular eruption (re- 
sembling disseminate papular eczema) exist, the seat 
of violent itching. More or less of this eruption is 
found over the whole surface, and appears to be 
eczematous in character, although peculiar in type. 
The general color of the skin of the trunk is a dusky- 
red, mottled, and in places violaceous or even bluish 
(hemorrhagic) in tint. 

Upon the arms and forearms are likewise patches 
of tubercular infiltration, and also of the inflamma- 
tory papular manifestation, some of them being dis- 
tinctly hemorrhagic. Upon the thighs and legs 
there are no large tumors or nodular formations, but 
here and there are patches of diffuse and papular 
infiltration, all of which are markedly hemorrhagic, 
so much so as to give the picture of purpura. Upon 
the hard palate, involving the uvula, is an elongate, 
circumscribed, raised, plate-like patch of infiltra- 
tion, about half an inch in diameter. The voice 
is in consequence thick. The cutaneous lesions are 



all accompanied by intense itching, which is almost 
constant. The scratch-marks, everywhere visible, 
attest this statement, and it is chiefly for this symp- 
tom that the man now seeks medical advice. 

The case represents the same disease that I 
brought before the American Dermatological Asso- 
ciation four years ago, a full report of which case, 
together with the remarks made by the writer, and 
by members of the Association, may be found in 
the Archives of Dermatology, January, 1879, and 
January, 1880, with the provisional title of "in- 
flammatory fungoid neoplasm." The inflammatory 
nature of the process was more marked in the first 
case than in the present one, although some of the 
lesions cannot be interpreted otherwise than as 
highly inflammatory. We shall find, however, with- 
out doubt, in the fully developed tumors the same 
formation as existed in the first case, viz.: a dense, 
small, round-cell infiltration involving the cutaneous 
and subcutaneous tissues, possessing the general 
features of sarcoma. The disease is liable to be 
confounded clinically with syphilis and with cancer, 
although the microscope would at once differentiate 
it from the latter disease. The prognosis is grave, 
for although the progress of the disease up to the 
present time has been slow, it will surely be more 
rapid within the next few years, and will prove fatal. 

On the subject of treatment, I have but little to 
say. The various anti-pruritic remedies that are 
found useful in papular eczema, such, for example, as 
thymol, carbolic acid, and the tarry preparations, 
will in a measure relieve and control the itching. 
The larger growths that occasion inconvenience may 
be removed with the knife, or, where possible, by the 
galvano-cautery wire, a much better method of 
operation. The tumors are vascular, and by means 
of the galvano-cautery the annoyance from hemor- 
rhage is lessened. The wound will probably heal 
without difficulty, and a recurrence of the growth 
at the point of the incision need not be feared, this 
opinion being based on my experience in the other 
case referred to. 

THREE CASES OF DIABETES INSIPIDUS 

SUCCESSFULLY TREATED BY ERGOT. 
By C. S. lacy, M.D., 

OF MACIDON, N. V. 

With the view of adding further evidence in 
favor of the value of ergot in the treatment of dia- 
betes insipidus, I desire to record the following 
cases: 

Case I. — J. S., aet. 18, family history good, and 
he had previously enjoyed good health, consulted 
me Sept. 10, 1877, "for some trouble with his 
kidneys. ' ' Some four weeks before he had attended 
a festival, and indulged in ice cream quite freely, 
and, as he expressed it, "had not been well sinqe," 
having passed large quantities of urine ever since, 
being obliged to get up in the night several times 
to micturate. Urine very light colored, acid re- 
action, specific gravity 1005, neither albumen nor 
sugar. The amount voided during twenty-four 
hours was 180 ounces. Put him upon valerian four 
times daily. 



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HOSPITAL NOTES. 



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Sept. 25. — Passed 220 ounces of urine, specific 
gravity 1008. He had become very much weak- 
ened, pale, and emaciated ; loss of appetite ; pain 
in the small of the back. In consultation with Dr. 
B., detemiined to try bromide of potassium 15 to 
20 grains, three times daily. 

Oct. 10. — Urine passed, 250 ounces; no traces 
of albumen or sugar; face and ankles oedematous; 
great weakness and prostration, shortness of breath ; 
indigestion, with acid eructations. He and his 
friends had given up all hopes of his recovery. 

In looking over my journals with a view of find- 
ing some new "points" upon the treatment of this 
case, I found in the August number for 1875, of the 
Monthly Abstract of Medical Sciences, Dr. Da Costa's 
account of a case treated by ergot. The 15th of 
October I put him upon drachm doses of the fluid 
extract of ergot, three times daily, and increased 
to two drachms, three times daily. Its effects were 
marvellous, there being a steady diminution in the 
daily amount of urine voided, and a marked im- 
provement in the patient's health. He may be said 
to have been well the first of January, 1878. There 
was a steady decrease in the amount of urine from 
the first giving of the ergot. The amount passfed 
at the time 1 began giving the ergot, Oct. 15th, 
240 ounces; Oct. i8th, 195 ounces; Oct. 2sth, 130 
ounces; Nov. 2d, 100; trom this time to the ist 
of Jan. the highest amount passed was 80 ounces; 
Nov. 20th, and from the time 1 ceased treating him, 
Jan. ist, 1878, to the present time, he has been a 
well man, and, as over four years have elapsed, I 
think we are warranted in claiming for ergot the 
credit of the cure. 

The history of the other two cases which I have 
to relate only confirm the efficacy of ergot in the 
treatment of diabetes insipidus. 

Case II. — Young man, 23 years of age, farmer, of 
good family history ; had been troubled two months 
when he consulted me. June 15, 1879, ^^ passed 
on an average 160 ounces of urine daily, slightly 
acid in its reaction; specific gravity, 1003; no 
traces of albumen ; no sugar. He said that he first 
noticed the trouble after some heavy work — plow- 
ing, etc. ; troubled with indigestion ; bowels con- 
stipated ; no disease of heart, lungs, or other or- 
gans ; temperature normal ; and he complained of 
nothing but a "tired feeling," being very much 
prostrated ; pale and emaciated, having lost some 
twenty-five pounds in weight during the two months. 
The amount of urine voided corresponded nearly 
with the amount of fluids taken. Ordered him to 
take drachm doses of the fluid extract of ergot four 
times daily, and gradually increased the quantity to 
two drachms three times daily. Much improved in 
a few days. Not obliged to get up at nights to 
micturate ; and, as he expressed it, " felt like a new 
man." Upon the fifteenth day of treatment the 
amount of urine passed was 80 ounces; thirtieth 
day, normal ; and from the day I ceased treating 
him, the 20th of August, 1879, to the present time, 
he has been a strong, robust man. 

Case III. — J. R., a boy, some twelve years of 
age. His mother has asthma; otherwise the family 



history is good ; and up to the time of my treating 
him, March 10, 1880, he had been a very healthy 
child. His parents had noticed for some linie 
that he passed more urine than seemed natural, 
having to get up during the night several times to 
micturate; was becomn g pale and emaciated ; no 
life or ambition; complained of wi-akness in back, 
loss of appetite, etc. His parents attribultd his 
condition to his growing rapidly ; but, findii g he 
did not improve, brought him to me. 1 here was 
no disease of any of the organs. He passed from 
eight to ten pints of urine daily, which far exceeded 
the amount of Huids taken. Specific gravity, 1005. 
He being very fond of milk, I put him upon a milk 
diet almost exclusively; gave him ergot, half 
drachm, four times daily; increased to one dracm; 
also gave cod-liver oil three times daily ; very much 
improved at the end of the tenth day; did not 
have to get up during the night; and the amount 
of urine passed was lour pints; and from that time 
until the middle of May, 1880, he improved. Utine 
normal; appetite good; gained in flesh, so that he 
did not look at all like the pale, puny boy that first 
visited me. He has enjoyed good health up to the 
present time, with the exception of a severe attack 
of dysentery, in the fall of 1881, from which he 
made a good recovery. 

I think these three cases will go far to establ'sh 
the claims of Dr. Da Costa for ergot. In the treat- 
ment of diabetes insipidus, like him, 1 do not con- 
tend that it will always cure, but that it merits the 
fullest confidence in this disease. 



HOSPITAL NOTES. 



BOSTON CITY HOSPITAL. 

(Service of W. C. B. FiFlELD, M D.) 

SCIATICA CURED BY STRETCHING THE SCIATIC NERVK. 

(Reported by RoYAL WHITMAN, M.D., House Surgeon.) 

The patient, a native of Boston, 39 years of age, en- 
tered the hospital October 19, 1882. His history was 
as follows : 

His first attack of sciatica occurred in 1872, and was 
induced, he thinks, by exposure to wet while working 
at his trade, that of a piano polisher. £ ich winter 
since this time, he has been confined to the house from 
three to six weeks with attacks of sciatica in the right 
leg, which have gradually increased in severity. Last 

iuly he had an attack of unusual severity, for which 
e entered the medical side of the hospital. At this 
time he could not fully extend the leg on account of 
the stifTness and pain, and was obliged to walk in a 
stooping position. He remained at the hospital for six 
weeks, and was then discharged partii<lly relieved, on 
crutches. He remained at home for five weeks, and 
then re-entered the hospital. At this time he was un- 
able to dress himself on account of the extreme pain 
in the leg and stifTness in the back. He remained seven 
weeks, and was then disi harged partially relieved. He 
continued in about the same condition during the sum- 
mer, being unable to walk without crutches-. 

He was then treated at the out-patients' department 
of the Massachusetts General Hospital, where ether 
was given, and an attempt made to stretch the nerve 
by forcibly flexing the leg upon the body. This was, 
however, followed by no relief, and the operation of 



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JANI'ARY 6, 1883 ] 



MEDICAL PROGRESS. 



II 



stretching the nerve was advised, and he accordingly 
entered the hospital. At this time his pain was intense, 
and the patient, as he expressed it, " lonj^ed to have a 
knife put into his leg." On the following morning 
ether was given, and Dr. Fifield made an incision six 
inches in length, commencing at a point two inches 
below the tuberosity of the ischium, over the biceps 
muscle. This muscle, with the semitendinosus, was 
drawn to the outside, and the nerve was exposed. A 
sound wa« then p issed beneath it, and it was pulled 
three times with sufficient force to lift the leg from the 
table. There was no hemorrhage. The wound was 
united with deep silver sutures. The operation was 
done under spray, and occupied but a few moments. 

Upon the following day the course of the sciatic and 
its larger branches could be traced by lines of ecchy- 
moses under the skin. The wound healed rapidly, and 
the patient was discharged well on the nineteenth d ly 
after the operation. There has been no pain or stiff- 
ness since ; and the only abnormal sensation noticed 
was a slight numbness in the calf of the leg. 



MEDICAL PROGRESS. 



Nerve-stretchi.s'g in Locomotor Ataxy. — In the 
Rei'Ut tie Afe.feiine [iio%. 10 and 11) there is a critical 
review of the results of nerve-stretching in locomotor 
ataxy and other diseases of the spinal cord With the 
latter class of cases we have at present nothing to do, 
but we think the results of inquiry into the formerclass 
of cases ought to be made known. In the review men- 
tion is made of 54 cases, published in various parts of 
the world, where the sciatic nerve was stretched for lo- 
comotor ataxy. Of these no fewer than 6 died, and in 
3 cases the death was directly attributable to the oper- 
ation. In 19 instances the patient derived no benefit 
whatever from the operation. In 18 instances there 
was either alleviation of one or more symptoms or some 
temporary benefit, or there was immediate benefit fr9m 
the operation but the ultimate result was not known. 
In the remaining 11 cases a lasting improvement was 
noted. Thus the outcome of this inquiry is that in 
about 54 per cent, of the cases the operation was fol- 
lowed by permanent or temporary benefit, and in 46 per 
cent, no good resulted from the operation, death ensu- 
ing in 1 1 per cent, of the cases. We must note the fact 
that in one instance Langenbuch had twice performed 
this operation with some benefit when the patient died 
after the third operation, and Westphal found the spinal 
cord perfectly healthy. This certainly was not the case 
in any of the fatal cases referred to above, but we can 
not help feeling that there is a possibility that some of 
these successful cases were not really cases of disease of 
the spinal cord at all. The operation is one which has 
not found much favor in this country, and in London 
it has found very few advocates indeed. We think the 
statistics we have given above will not tend to increase 
the favor of the operation in the eyes of those who 
m.ike the welfare of their patients their first considera- 
tion. — Midical Times and Gazelle, December 2, 1882. 

Cardiac Form of Typhoid Fever. — Prof. Bern- 
HEiM, of Nancy {Lyon Mid , Oct. 8, 1882) read a 
paper before the French Association on this subject. 
He distinguishes between the cardiac form proper, as 
he calls it. and those other forms of typhoid in which 
the symptoms of cardiac disease are simulated, or 
in which disturbances of the pulmonary circulation 
are manifested His cardiac form is marked by an 
acceleration of the heart's rhythm, without any organic 
lesion. The increased frequency of the pulse is not 
accompanied by any proportionate elevation of temper- 



ature. The symptoms appear at the beginning of the 
attack, and are due to a toxic action of the typhoid 
poison on the motor centres of the heart itself. It is a 
rare form. Bernheim has only met with six instances 
among 250 cases. On the other hand, it is a very grave 
form. No advantage is obtained by administering 
stimulants like alcohol and ether, and the use of dig- 
italis is dangerous. — jyaclilioner, December, 1882. 

Tricuspid Cardiac Murmurs Heard at the Apex. 
— Dr. Duroziez has studied a number of cases in 
which tl\ere were tricuspid murmurs, and states that 
ordinarily tricuspid murmurs can be heard over all the 
surface of the right ventricle, that is to say, over all the 
anterior surface of the heart. The points of maximum 
intensity vary, sometimes being below the sternum, 
sometimes at its inferior border, and sometimes at the 
apex. When only heard at the apex, they are often 
wrongly attributed to the mitral valve; the latter mur- 
murs, however, are also to be heard in the axilla and 
in the back, while the tricuspid murmur is never to be 
heard to the left of the apex, in the axilla, or in the 
back. 

Since the right ventricle, equally with the left, con- 
tributes to the forma'tion of the apex, there is nothing 
to prevent tricuspid murmurs being audible at this 
point. A tricuspid murmur may exist without a venous 
pulse, and vicf versa. A humming murmur is more 
frequently tricuspid than mitral, and indicates a very 
narrow insufficiency and energetic ventricle. — L' Union 
Medicale, November 26, 1882. 

Trachoma. — At the recent meeting of the Ophthal- 
mological Congress at Heidelberg, Prof. Satti.er 
made a communication upon the origin of trachoma, 
which he believes to be caused by micro organisms. 
His more recent experiments have fully borne out the 
results he obtained in 1881, which were read before the 
Heidelberg Congress in September of that year. He 
has again succeeded in cultivating the micrococci, and 
producing positive results by inoculation. The organ- 
isms are circular, are never seen with zoSglaea, but 
always singly or in pairs, separated by a small inter- 
space. Inoculation of the third generation of a culti- 
vation produced trachoma in the human conjunctiva. 
These micrococci alone produce trachoma ; all other 
substances used failed to do so. 

In the discussion which followed, Baumeister and 
Kerschbaumer advocated the use of iodoform in con- 
tagious conjunctival affections. Samelsohn remarked 
that he had seen the bacillus of tubercle in tuberculosis 
of the iris, and Leber that he always now finds micro- 
cocci in hypopyon keratitis. — Ophthalmic Review, 
December, 1882. 

Syphilitic Enlargement of Tonsils. — An abstract 
of the conclusions of Dr. Paul Hamonic is to be 
found in the Deutsche Med. Zeilung, No. 45. Hamonic 
distinguishes, during the secondary stage of syphilis — 
I. Sinipl:! hyperliophy, which is analogous to the 
swelling of lymphatic glands, is tardy in its develop- 
ment, and, as it occasions no symptoms, is often over- 
looked. Both tonsils are almost always affected, 
though to a different degree. The enlargement takes 
place forwards, bulging the anterior pillar of the 
fauces, and rarely gives rise to deafness. The tonsils 
are hard and somewhat elastic ; the normal depressions 
on their surfaces are exaggerated. The uvula tends to 
go over to the lar>!er tonsil. Sometimes the tonsil may 
be reduced in site by anti-syphilitic treatment. 2. Hy- 
pertrophy associated with angina. In this there is not 
so much fever as in ordinary acute angina; the dura- 
tion is variable, and relapses are very liable to happen. 
3. Hypertrophy complicated with syphilides. Most fre- 



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MEDICAL PROGRESS. 



[Medical Nkws, 



quently the syphilide appears on the tonsil and the an- 
terior pillar of the fauces. When syphilis affects a 
previously scrofulous tonsil the enlargement is very 
great, of pale color, often spongy and with large crypts, 
there is considerable pain, the voice becomes nasal, and 
the hearing, taste, and smell are altered. The course 
is generally chronic, and there is a great tendency to 
recurrence. Ordinary tonsillitis and sore throat may 
supervene even when the tonsils are syphilitically en- 
larged, but then, though peritonsillar suppuration may 
occur, it would appear that the tonsil itself never sup-~ 
purates. Hamonic states that there is no objection to 
excision of the syphilitic tonsils if they be very large. 
— Medical Times and Gazette, December 2, 1882. 

Gastrotomv in Extra-uterine Pregnancy. — Dr. 
N. Phenomenon (Arch, de Tocologie) reports the case 
of a peasant woman 22 years of age, who illustrated 
this accident. She began to menstruate at seventeen 
years of age, and this function was always performed 
regularly and normally. She married at eighteen years 
of age and continued in good health : she came to the 
author's clinic in January, 1881. Twenty-two months 
previous to that time the menses first failed to appear. 
The customary symptoms of pregnancy followed, even 
to the perception of foetal movements. Before the ex- 
piration of the customary nine months of gestation, 
the foetal movements became more feeble, she expe- 
rienced severe pains in the kidneys and in the lower 
part of the abdomen, and occasional paroxysms of 
fever. The time for delivery arrived, but no labor- 
pains appeared. The abdomen continued to increase 
m size for a month or two longer, and then remained 
in statu quo. During the first three-fourths of the year 
which followed she had occasional attacks of fever and 
. in the intervals was able to attend to her household 
duties and even to work in the field. Then an abscess 
formed and pointed at the navel, and a quantity of pus 
was discharged. Extreme weakness followed, and in 
this condition she appeared at the author's clinic. The 
tumor presented the following characteristics : ist. Its 
contour was very well defined. 2d. It was solid. 3d. 
It crepitated upon palpation. 4th. It was painful to 
the touch. 5th. It was immovable, but was not at- 
tached to the abdominal walls. A fistula existed at the 
navel, from which pus exuded. The diagnosis made 
was that of abdominal pregnancy. The abdomen was 
opened by M. Horwitz, and the cyst was found to have 
no adhesions anteriorly of any extent. The putrefied 
foetus was removed, and the cyst, which was firmly fixed 
at its sides, was secured by the sutures which closed the 
abdominal wound. The operation was performed with 
antiseptic precautions, and the patient made a good re- 
covery. 

As deductions from this case the author observes : 
1st. If the pregnancy continues through the customary 
period without mishap, there is no occasion for inter- 
ference, providing always that watchfulness against 
accidents is to be observed. This is contrary to the 
opinion of Gusserow, who advises operation at the be- 
gmning of the eighth month. 2d. In case of the oc- 
currence of some grave, complicating accident, equally 
dangerous for the foetus and for the mother, as, for ex- 
ample, rupture of the foetal sac, or internal hemorrhage, 
gastrotomy is indicated to be performed at once. This 
is contrary to Spiegelberg's experience and advice, and 
Parry estimates that seventy per cent, of the mothers 
die after such operations. The author replies that sta- 
tistics are not reliable, for the cases are never identical 
where the operation has been performed. 3d. If the 
normal period of pregnancy has passed, the foetus has 
died, and the case is presented to us for decision, the 
course of action must vary in accordance with the 
pathological process, which difiers in every case. Two 



issues are customary with such pregnancies, petrifica- 
tion or the conversion of the foetus into calcareous ma- 
terial, and a slow process of suppuration by means of 
which the contents of the foetal sac are discharged 
through fistulous openings. The former is the more 
desirable end, for it does not tax the vital resources as 
the latter does. The author does not believe in wait- 
ing for the formation of a fistula before operating, 
especially when the cyst is near the abdominal wall. 
One must always remember the grave complications 
which are possible if the cyst is allowed to suppurate. 
Of the active or the passive modes of treatment, then, 
the author is decidedly in favor of the former. — Amer. 
Joum. of Obstetrics, December, 1882. 

The Diagnosis of Pulmonary Syphilis. — In the 
Wiener Atedizinische Wochenschri/t, No. 46, an ab- 
stract of an alleged case of pulmonary syphilis may be 
found recorded by Dr. Guntz. The previous history 
of the man showed that two years after infection an 
eruption appeared on the skin, and a year later cuta- 
neous ulceration was noted ; five years af^er infec- 
tion the lung trouble was first noticed. The left lower 
lobe was affected with a circumscribed infiltration, the 
symptoms being cough and shivering. The dulness to 
percussion had not disappeared after a period of 
eighteen months' good general health, at the end of 
which the patient began to spit blood. This was soon 
followed by an increase in the size of the infiltrated 
area. For six days the expectoration consisted of 
chocolate-brown lumps; later, muco-purulent sputa 
were brought up. The pulse was 90; the breathing 26 
to 32 per minute ; but there was no fever. The physi- 
cal signs underwent no appreciable change ; there were 
dulness and pectoriloquy with some riles. The sputa 
were hardened in alcohol, and had become tough and 
membranous — some, nevertheless, were lighter than 
water. The microscope revealed a fibrillaii d stroma, 
with finely granular debris, old and young cells and 
nuclei, here irregularly scattered, there arraffged in 

f roups. No pulmonary tissue or vessels were detected, 
ome sputa were sent to Lancereaux, who also regarded 
the microscopic elements as of a gummatous nature. — 
Medical Times and Gazelle, December 9, 1882. 

Hypodermic Injections of Blood in Gastric Ul- 
cer. — Prof. BERNirrz {Gaz.des //g/., 64, 1882) has 
successfully treated two patients suffering from simple 
gastric ulcer with subcutaneous injections of blood. 
They were both much reduced, owing to incessant 
vomiting, everything swallowed being at once rejected. 
The blood, taken from the femoral artery of a large 
dog, was received in a warm vessel, and at once in- 
jected by means of a wanned Dieulafoy syringe. In 
the first case the blood was promptly absorbed, and 
sufficed to keep up the strength for two days. As the 
patient grew strong the vomiting ceased, and milk diet 
was resumed. Gradually the appetite improved and 
food of all kinds was well borne and digested. Fowl's 
blood was once tried, but its good effects seemed less 
lasting. The second case was similar, but the patient 
here was even farther gone through simple inanition. 
Here the first injection was not absorbed, and a phleg- 
monous inflammation started from the injection wound 
and spread over the arm. The gastric difficulties 
seemed however to decline as the inflammation .of the 
arm advanced. The obstinate vomiting ceased, and 
with it the gastric pain ; so that the patient was pres- 
ently able to enjoy the ordinary hospital diet. In this 
instance the blood could have little if any nutritive 
value, as it was not absorbed. Prof. Bernutz is in- 
clined to think the severe local inflammation in the 
arm may have acted beneficially in some reflex way 
on the gastric lesion. — Practitioner, December, 1882. 



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January 6, 1883.] 



DANGER IN THE ANESTHETIC STATE. 



13 



THE MEDICAL NEWS. 

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SATURDAY, JANUARY 6, 1883. 



TEE TBEATKEKT OF STMFTOKS IHBICATINO OAKGEK 
IV THE AKJBSTHETIC STATE. 

The anaesthetic state is a condition of danger. It 
means the suspension of the functions of animal 
life, the organic functions, especially respiration and 
circulation, continuing. This primal fact, then, 
indicates the danger to be provided against. Cteteris 
paribus, chloroform endangers the circulation ; ether 
the respiration. The measures of prevention, as 
well as the remedies, must be directed accordingly. 
This law is not absolute in its application. Some- 
times chloroform paralyzes the respiratory centre ; 
rarely ether paralyzes the heart. However, so uni- 
fornnly is the rule applicable, that the injunction in 
administering chloroform is to watch the pulse, and 
in giving ether to watch the respiration. Disre- 
garding, for the present, exceptional conditions, 
the treatment of dangerous symptoms in the anaes- 
thetic state resolves itself into the administration 
of remedies to prevent or relieve the tendency to 
cardiac paralysis on the one hand, or to respiratory 
failure on the other. 

The first prophylactic mea.sure on which we insist 
is the relinquishment of chloroform as the ordinary 
anaesthetic. We do not deny that there may be 
special conditions justifying the use of chloroform ; 
it may be necessary when operations are to be per- 
formed by the light of an ordinary candle or lamp, 
since ether vapor forms with atmospheric air an 
explosive mixture ; it may be preferable in obstet- 
ric practice, as the anaesthetic agent to assuage the 
pains of labor, and for various obstetrical opera- 
tions. With these limitations, the rule of practice 



should be to employ ether to induce the anaesthetic 
state under the conditions ordinarily requiring it. 
The next prophylactic measure consists in the use 
of morphine subcutaneously — before beginning the 
inhalation, according to Bernard ; after the inha- 
lation has proceeded far enough to induce analgesia, 
according to Nussbaum. The method of Ber- 
nard seems to us the better, because the effect of 
morphine prevents the sudden failure of the heart 
sometimes induced by a few whiffs of chloroform 
vapor, facilitates the inhalation by lessening the 
irritability of the air-passages, and diminishes or 
prevents the stage of tetanic rigidity, with its ster- 
torous breathing and cyanosis. We do not pretend 
to affirm that this method of "mixed anaesthesia," 
as it has been entitled, has received the unanimous 
assent of surgeons; but our belief is that the ex- 
perience thus far accumulated is largely in favor of 
its utility, and we have the high authority of Dr. J. 
C. Reeve in its support. 

To avoid accident, it is in the highest degree 
important to ascertain the condition of the subject 
to be anaesthetized. The habits of life, the absence 
of cerebral, of pulmonary, and of cardiac diseases 
of a nature experience has proved tocontra-indicate 
the use of anaesthetic agents, should be ascertained 
before beginning the inhalation. This survey and 
scrutiny of the patient should not be limited to a 
casual examination of the organs supposed to be 
concerned — it is usually satisfied by a superficial 
examination of the chest ; but it should be made a 
thorough investigation of the life history in its 
pathological aspects, as well as a minute study of 
the somatic state at the time. 

We have already, in our comments on fatal cases, 
alluded to the faults of administration which have 
been responsible in a large degree for the accidents. 
It would be a waste of our space and of our readers' 
patience to reiterate those points already set forth 
with sufficient particularity in respect to the mode 
in which anaesthetic vapors should be inhaled. The 
treatment of the danger-symptoms may, however, 
require a further exposition of our views. As these 
danger-symptoms are divisible into causes of cardiac 
paralysis and causes of respiratory failure, we have 
thus a natural classification for the arrangement of 
the data. The quickest mode of dying is by arrest 
of the heart's action. Unfortunately, in a large 
proportion of cases, the heart is incapable of further 
action when its embarrassment is ascertained, and 
hence the wisest measures may be futile. We must, 
in advance of the expression of our own views, piro- 
test against a practice which has become too com- 
mon : namely, the subcutaneous injection of digi- 
talis. If this agent acts rapidly enough to affect 
the circulation, the result must be disastrous, since it 
induces such a rise in the ajterial tension as to im- 



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SYMMETRICAL GANGRENE OF THE EXTREMITIES. 



[Medical Nkws, 



pose additional work on the heart. A remedy acting 
in the opposite way — to lower the tension at the 
periphery and thus diminish the resistance to the 
propelling power of the heart — seems, a priori, to 
be more suitable, and experience confirms this 
theoretical view. The subcutaneous injection of 
amyl nitrite has appeared to be of immense service 
in some cases of threatened cardiac paralysis. From 
three to five minims are injected beneath the skin 
at any point, or, if respiration is going on, the 
effect can be more speedily procured by inhalation. 
The good effect consists in the diminution of the 
peripheral pressure, which permits the heart to dis- 
tribute the blood more easily, and thus to supply 
more quickly and fully the centres of organic life. 

The intravenous injection of ammonia is, also, a 
promising expedient to arouse the heart. The Aus- 
tralian experience with this practice has abundantly 
proved that the intravenous implantation of one 
drachm of aqua ammoniae, diluted with two drachms 
of water, is perfectly safe, and a powerful cardiac 
stimulant. The time for its administration is when 
the action of the heart has become weak and 
fluttering and a stoppage imminent. Any con- 
venient vein may be selected; the needle of the 
hypodermatic syringe is thrust directly into it, and 
the ammoniacal solution is promptly, but without 
violence, delivered in the blood stream. A half- 
drachm should be administered at a time, the repe- 
tition of it being governed by the effect. 

Another agent having decided power to increase 
the heart's movements is atropine. Although this 
may not act as speedily as the intravenous injection 
of ammonia, it is next in respect to promptness of 
effect. As a rule, however, it is preferable to ad- 
minister atropine in combination with morphine 
before beginning the inhalation of the anaesthetic 
vapor. 

Acupuncture and electro-puncture of the heart 
have also been suggested, and, indeed, used in some 
cases, but after a careful survey of the whole ground 
we are forced to the conclusion that these expedients 
are rather injurious than beneficial. To puncture 
the heart — especially to send a faradic current 
through a needle inserted into its substance — must 
cause a more or less severe shock. All the world 
knows the effect of shock on the cardiac movements. 
Can such manipulation fail to depress the heart's 
functions? Again, the exact position of the per- 
forating needle should be known, since the inhib- 
iting ganglia may be stimulated rather than the 
motor. To stimulate the former, is to stop a heart 
which is in action. 

When the failure is respiratory — the chief danger 
in ether inhalation — the respiratory centre should 
be supplied with blood as quickly as possible. The 
method of N61aton, of inversion of the body, ac- 



complishes this. The tongue falling back in the 
throat forces down the epiglottis, and the violent 
inspiratory efforts increase the danger by converting 
the epiglottis into a valve. Hence, to draw out the 
tongue strongly is a most necessary expedient for 
freeing the entrance to the larynx. It accomplishes 
more. The strong traction on the basal attach- 
ments of the tongue exerts a reflex effect on the 
respiratory centre, and this, according to some, is 
the chief use of the practice. Faradization of the 
chest muscles, inhalation of ammonia, irritation of 
the Schneiderian mucous membrane by a bit of 
paper dipped in aqua ammoniae, are the means re- 
sorted to for reflex stimulation of the respiratory 
centre. Dashing cold water over the chest exposed 
to cold air from an open window is one of those 
doubtful measures often resorted to in the excitement 
of the moment, but which, of little use at the time, 
is apt to be followed by bronchitis or pneumonia. 
Certain stimulants of the respiratory centre may 
be employed subcutaneously. These are atropine 
and strychnine — the former generally preferable, be- 
cause more prompt. The alcoholic stimulants so 
often used hypodermaticaily are of doubtful utility, 
although apparently beneficial in some cases. As 
ether and chloroform are derivatives of alcohol and 
act in a similar manner on the centres of organic 
life, to administer the latter as^i remedy for depres- 
sion or arrest of function produced by the former 
seems to be an irrational procedure, and may, in- 
deed, in any doubtful case, determine the res^ult 
unfavorably, but the counter-irritant effect of the 
injection may, however, possibly exercise a favorable 
influence. 

STKIGETBICAL GAKOBENE OF THE EXTKEHITIE8, 
WITH ALBUMIIITTBIA. 

At a recent meeting, Oct. 27th, of the Medical 
Society of Hospitals in Paris, M. Roques reported 
a case of symmetrical gangrene of the hands and 
feet, accompanied by albuminuria, in a woman who 
was also the subject of intense congestion of the 
right lung and dyspnoea. To these symptoms were 
added enlarged liver, irregular and strong cardiac 
impulse, and dimness of vision, but there was no 
retinitis albuminurica. For three months she had at 
times experienced a decided sensation of coldness 
of the surface of the hands, the fingers becoming 
pale and apparently dead ; three days before ad- 
mission the same phenomena appeared on the sur- 
face of the great toe of the right foot, and four 
days later on the same toe of the left foot. The 
skin of these toes presented a purplish hue, which 
disappeared upon pressure, returning slowly upon 
its removal ; they were cold, painful, and deficient 
in tactile sense. There were also on the dorsal 
surface of the feet, and on the external surface of 



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January 6, 1883.] 



FETID BRONCHITIS. 



IS 



the leg and thigh, irregularly mottled patches, but 
no trace of oedema. These lesions were absolutely 
symmetrical but more marked upon the left side. 
There was an evident but feeble pulsation in the two 
pedal arteries. In the upper extremities the same 
conditions were present : all the fingers, except the 
thumb, were cold, insensitive, and purple ; the right 
ear was dry and shrivelled ; the hands and arms 
were mottled with livid patches. Some days later 
the little finger of the right hand and the right great 
toe became entirely sphacelated. At times the heat 
returned in the extremities, the livid patches disap- 
peared and the sensibility returned, but a fresh at- 
tack of the "local asphyxia" repeated the same 
phenomena. The dyspnoea and irregularity of the 
heart increased, and she died twenty-eight days 
after admission. At the autojjsy there were found 
splenization of the right lung, hypertrophy of the 
heart, a circle of soft villous vegetations on the aortic 
valves, but no mitral disease. There was a nutmeg 
liver, the spleen was healthy, and the kidneys were 
the seat of marked interstitial nephritis. There was 
no atheroma of the pedal or radial arteries. 

The question naturally arises. Can there be any 
causal relation between these two conditions? Ray- 
naud and Ddbove have noted albuminuria in several 
cases of symmetrical gangrene, and there have been 
observed in Bright'sdisease certain phenomena which 
are apparently due to vaso-motor influences, such as 
the localized oedemas which come and go suddenly 
and seem to be associated sometimes with traumatic 
nephritis of one kidney; such also are the phe- 
nomena of the "dead finger" and varied forms of 
pruritus recently noted by Dieulafoy. M. Roques 
is inclined to believe that the union of these 
two conditions is a coincidence, but admits that 
further observations are required. Such would 
indeed seem to be the only inference which can be 
drawn. 

Dr. M. Weiss of Prague, has recently published in 
the Wiener Klinik, a very interesting monograph on 
symmetrical gangrene, in which he collates seven- 
teen cases, including a very carefully studied one of 
his own. The first of these cases was recorded in 
1729, the last in i88a, so that it will be seen to be 
a very rare disease. It is defined by him as an af- 
fection of the central nervous system, characterized 
clinically by numerous vaso-motor, trophic, motor, 
sensory, and special sense derangements, while it 
receives its distinctive stamp from a symmetrically 
occurring gangrene of parts of the hands and feet 
(phalanges), and more seldom of other parts of the 
body. The term "symmetrical gangrene" was 
originally applied to the condition by Raynaud, 
who first described it in 1862; and although from 
the fact that the term recognizes but a single, yet the 
most striking, symptom, Weiss considers the title 



"neurotic gangrene" more appropriate, he retains 
Raynaud's title. 

That the case described by M. Roques is one which 
may be properly included in the category of sym- 
metrical gangrene we are by no means certain. In 
the first place, the disease seems not to have been 
usually fatal as in the present instance, but is par- 
oxysmal, the paroxysms beginning with pain, which 
is often extreme, in circumscribed spots on the af- 
fected extremities. This is succeeded by a gan- 
grene which may be superficial or may involve an 
entire phalanx ; the separation of the slough being 
succeeded by a repair which is proportional to the 
destruction. Along with this are numerous other 
local and general derangements which we have no 
space to detail. Such a paroxysm is succeeded by 
others at intervals of a month or more, in some in- 
stances coinciding with the menstrual period. The 
immediate cause of the gangrene must, however, be 
the same in each instance. The symmetrical char- 
acter of the process excludes the usual local causes 
of gangrene, such as obliteration or obstruction of 
afferent vessels, embolism, mechanical, chemical or 
thermic agents, etc., and there was no atheroma or 
ergotism ; so that there remains only the effect of 
a weak heart or some one of the trophic influences 
which can alone account for symmetrical gangrene; 
and a heart so feeble as to be the cause of symmet- 
rical gangrene in the extremities is scarcely likely to 
be present in a woman of 41, even if there be aortic 
obstruction, as may have been the case here. From 
such trophic influences must also be excluded vaso- 
motor spasm, because striking as are the functional 
results of such arterial contraction in experiments 
on animals, gangrene has never been produced by 
irritation or stimulus of vasoconstrictor nerves. 
They must, therefore, be trophic in the strictest 
sense of the term. Now no such slowly operating 
trophic influences have ever been known to exist in 
interstitial nephritis, or in any form of Bright's dis- 
ease, and we, therefore, conclude that the associa- 
tion of the two conditions is a purely accidental one. 



FETID BKOHCHITIS, AND ITS TBEATKERT BT THE 
HTFOSTTLPHITE OF SODIITH. 

Under the above title. Dr. E. Lancereaux, in 
a recent issue of the Bulletin de Thirapeutique, 
treats of fetid bronchitis chiefly from the therapeu- 
tical point of view. The real causes of the malady 
are not fully understood. Dilatation of the bron- 
chial tubes, and accumulation in the dep6ts thus 
formed, of the muco-purulent secretion, is probably 
the first step, decomposition of the muco-pus under 
the agency of atmospherical germs being then pro- 
duced. Butyric and valerianic acids are amongst 
the od(Jrous substances thus formed. Dr. Lance- 
reaux regards this a most fatal malaJy — an opinion 



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SEWERAGE AND HEALTH. 



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in which all experienced physicians will concur. 
It is well known that the lesions are not limited to 
the bronchi, but extend to the peri-bronchial con- 
nective tissue, and to the pulmonary parenchyma 
ultimately. So fatal is it, that all of the subjects of 
this disease admitted to taPitie, died, when treated in 
the orthodox way, with alcohol and quinine. Far 
different has been the result, when treated with hypo- 
sulphite of sodium. His observations are based on 
twenty cases — fourteen treated by the old method — 
which proved fatal, and six treated by the hypo- 
sulphite, all of which recovered. He gives the de- 
tails of the latter. 

The mode of administering the remedy is very 
simple. It consists in giving 4 to 5 grammes (about 
62 to 80 grains) in an ordinary solution daily for 
a month to six weeks, after which the amount used 
will be determined by the conditions present. The 
digestive functions are improved rather than em- 
barrassed, and no derangements of any kind are to 
be referred to its action. It does not produce the 
desired result immediately, but several days, often 
a week, will elapse before the curative results are 
manifest. The first effect of a therapeutical kind 
observed is a diminution in the odor of the sweat 
and of the muco-pus brought up from the bronchi. 
The amount of the secretion diminishes, and its 
character changes, becoming more distinctly mucous 
and viscid. Following this lessening of the ex- 
pectoration and disappearance of its fetidity, the 
appetite improves and the weight lost by the con- 
tinuance of the disease is regained, and the bodily 
forces are restored to their wonted activity. The 
time required to effect these marvellous results 
varies somewhat, but the rule appears to be that in 
from six weeks to three months the changes in the 
condition of these subjects, above described, will 
have taken place. Sometimes, it is true, in the 
course of the treatment, there may be a return of 
the fetidity, but it will be brief, and the evil odor 
will gradually disappear and permanently. 

How is the cure of these cases effected ? is the 
inquiry made by Dr. Lancereaux. There can be, 
at present, no correct answer made to this question. 
To offer a satisfactory solution of the problem, it 
will be necessary to know what changes the alkaline 
hyposulphites undergo in the system, and the mode 
of their elimination. To effect the cure of such a 
condition, they must act, not only on the process of 
decomposition in the muco-pus, but on the organic 
changes to which the pathological exudate owes its 
origin. It is, however, of comparatively inferior 
consequence how the medicament. acts. 

Does it cure? If so, we are put in possession of 
a most valuable agent, 'able to cure a malady hitherto 
beyond the resources of art. We need now further 
clinical experience. If Dr. Lancereaux's observa- 



tions are confirmed by others, if new facts of cor- 
responding significance are brought forward, we may 
safely postpone the consideration of the modus ope- 
randi to a more convenient season. 



In the December number of the Brooklyn Annals 
of Anatomy and Surgery the editors indulge in some 
personal reflections not inappropriate to the success- 
ful close of the third year of its publication. 

The Annals began as a modest record of the 
work of the young but vigorous Anatomical and 
Surgical Society of Brooklyn, whose example we 
commend most heartily to other less enterprising 
communities. But it has now, as it were, cut the 
umbilical cord, and becomes an entirely indepen- 
dent journal, for which the editors alone will be 
responsible. 

The announcement for 1883 is very attractive in 
the list of names of those from whom papers are ex- 
pected, and Dr. Geo. J. Fisher, we are glad to see, 
will continue his delightful and scholarly sketches of 
the " old masters." We notice with pleasure, also, 
that the proceedings of the New York Surgical So- 
ciety will appear in the Annals as well as in The 
News. This cosmopolitan publication of their 
proceedings by the various medical societies, we 
are happy to observe, is becoming very common. 
Certainly it bears good fruit in the stimulus tO' 
writers, who find that their papers appear promptly, 
and that their circle of readers is increased tenfold. 
By the ancient method they quietly slept for weeks 
or months till the " Priaceedings " appeared in the 
glory of a bound volume — which, in most instances, 
was immediately put upon the shelf — or were seen 
solely by the readers of the local journal that had 
the exclusive right to their publication. 



The New York State Board of Health has officially 
declared : " That the use of privy- vaults, privy- 
pits, and cesspools, is seriously affecting the public 
health;" and further, "That all excreta should be 
removed from the neighborhood of human dwell- 
ings, instead of being stored up near them in pits, 
vaults, or pools, to poison the water, earth, and air." 
In some European cities the abandonment of the 
old cesspool system has already been accomplished, 
and in others the measure is being seriously con- 
templated. A Commission of Inquiry is now en- 
deavoring to solve the problem of providing Paris- 
with a system of sewerage which shall take the place 
of the older plan, in which the excreta are detained 
in permanent cesspools, generally under the houses, 
and the more modern system in which movable res- 
ervoirs are made use of for catching.the solids while 
the liquids escape into the sewer. Dr. E. Vallin, 
Professor of Hygiene at Val de Grace, says that every 
one is agreed, at least in principle, upon one point. 



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namely, that permanent cesspools, as forming a 
structural portion of dwelling-houses, should be 
superseded. The question upon which there is still 
a difference of opinion, relates to the choice in the 
modifications of the water-carriage system which is 
to form the substitute. In this country this much- 
needed reform is likewise being agitated, and its 
accomplishment is only a question of time. 

Profs. Schutz and Loeffler have just succeeded, 
we learn from the Deutsche Medicinische Wochen- 
schri/t for Dec. 16, in isolating a micro-organism in 
subjects affected with farcy ; they have succeeded 
in growing several generations in culture fluids, 
and in transmitting the disease by inoculation to 
healthy horses. The details of this discovery, which 
has just been made in the Kaiserlich Deutsche Ge- 
sundhtits Amt, in Berlin, have not yet been pub- 
lished. 



SOCIETY PROCEEDINGS. 



NEW YORK SURGICAL SOCIETY. 
Stated Meeting December 12, i88z. 
The President, Dr. T. M. Markoe, in the Chair. 

EMPYEMA ; perforation OF THE BRONCHI AND 
DIAPHRAGM; RECOVERY. 

Dk. F. Lange presented a male patient, 19 years of 
age, with the following history. He was a healthy 
member of a healthy family, and a student. After 
repeated attacks of gastric disturbance in the summer 
of 1881, he was taken, September 2, with severe gastro- 
intestinal catarrh, which became so obstinate that he 
was confined to the bed from the eighth to the fifteenth 
of that month, and was under the care of Dr. Henkel. 
He had only a moderate fever, but gradually lost flesh 
and strength. Very soon after this, a deep-seated 
abscess developed in the inner aspect of the arm, and 
it seemed to take its origin in the muscular substance 
of the biceps. Dr. Lange opened the abscess in the 
presence of Dr. Henkel on the 26tl^ of September, and 
the wound healed without further trouble, but the pa- 
tient did not rally entirely. On the 7th of October he 
was taken quite suddenly with severe pain in the lower 
part of the thorax on the right side, and went to bed 
again. Very soon afterwards the physical signs of 
pleuritic effusion became apparent, and, in a compara- 
tively short time, the level of the fluid was as high as 
the middle of the scapula. The presence of crepitus 
and near bronchial breathing above the line of dul- 
ness made it probable that the inflammatory process, 
to some extent, affected the lung tissue. The area of 
dulness was considerably smaller in the axillary region 
than behind, and was almost absent in front. There 
was continued fever with exacerbations at night, and 
the patient had no appetite and lost flesh and «trength 
rapidly. 

On the night of the loth of October, perforation of 
the bronchi occurred and large quantities of pus were 
expectorated. On the following day the patient felt 
much relieved, although he was very exhausted. Dr. 
Henkel then found the physical signs of pyo-pneumo- 
thorax, especially the metallic sounds. The patient 
did not rally as had been expected, the fever did not 



cease, and the debility increased. It was impossible^ 
to make a thorough examination of the chest on ac- 
count of the extreme weakness of the patient, but it 
was ascertained that the respiratory murmur ceuld be 
heard from above, downwards to the fourth intercostal 
space in front, and to the middle of the scapula behind. 
At the latter point the breathing was amphoric in char- 
acter. The level of the fluid was considerably lower 
down ; ^uccussion sound could be obtained distinctly .- 
Dr. Lange saw the patient again in consultation, on- 
the 23d of October, and from the history of the case- 
felt certain that there was pus in the pltui al cavity, but 
aspiration gave a negative result. Puncture was made- 
at four different places, but only a few drops of blood- 
mixed with air were obtained. Assuming that the col- 
lection of pus might be near the centre of the lung,, 
deep punctures were made. Dr. Lange had already 
determined to desist from further surgical interference, 
when he discovered at the lowest part of the thorax,, 
toward the lumbar region and against the lateral 
border of the sacro-lumbalis, air under his fingers on 
pressure upon the deep tissues. He punctured at that 
point, found pus, and then opened the cavity by a free 
incision. There was an abscess below the diaphragm, 
along the under surface of which the finger could be 
passed after being introduced through the incision. 
Apparently the empyema had perforated the dia- 
phragm. The expectoration very soon ceased, and the 
patient made a rapid recovery. With the exception of 
slight retraction of the lower and front part of the right 
side of the chest, with diminished respiratory murmur 
in that region, there was scarcely any difference to be 
noticed when the two sides were compared. Dr. Lange 
thought that the point at which perlbration of the dia- 
phragm occurred was possibly at the gap between the 
vertebral and costal part of that muscle, which is some- 
times very large. He was unable to mnke out whether 
the abscess was intra- or extra-peritoneal, but thought 
it was probably the latter. The kidney, on account 
of swelling and infiltration of tissues around it, could 
not be felt distinctly. The outline of the liver was 
recognizable by palpation. Last summer. Dr. Lange- 
was shown, at Professor Thiersch's clinic in Leipzig, a 
patient who had sought admission because of a freely- 
discharging fistula over the anterior aspect of the right 
femur. The etiology of the abscess became apparent 
when purulent expectoration began simultaneously with 
the cessation of discharge of pus from the fistula.. 
The patient stated that this had occurred several times,, 
and examination of the chest upon the right side gave 
evidence of an encapsulated empyema, for which 
thoracentesis with resection of a rib was performed. 
Recovery followed rapidly. Dr. Lange was inclined 
to believe, although unable to prove it,, that there was 
a causal relation between the abscess in the biceps- 
and the empyema, the latter being the result of an em- 
bolic process. In reply to a question, he stated that 
the largest collection of pus was above the diaphragm, 
probably a pint being in the cavity below it. 

The President remarked that, in a similar case, he 
found the accumulation of pus much larger below than, 
above the diaphragm, pressing into and upon the ab- 
dominal cavity. 

Dr. Post asked which occurs most frequently, ab- 
scess originating in the thoracic cavity with perforation 
downwards, or abscess beginning in or near the liver 
with perforation upwards ? 

Dr. Briddon replied that he thought perforation- 
upwards occurred most frequently. In a similar case- 
admitted to the Presbyterian Hospital, probably a year 
ago, the cavity of the chest had been aspirated and 
a large quantity of pus removed. There was dul- 
ness on percussion up to the spine of the scapula, be- 
hind and to a line nearly upon the same level in the- 



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PROCEEDINGS OF NEW YORK SURGICAL SOCIETY. 



[Medical News, 



axillary region, and there was a large area of dulness 
in front. There was also a marked bulging in the 
neighborhood of the liver, which was mapped out 
quite accurately by the area occupied by an enlarged 
liver. Fluctuation was detected by palpation over this 
large swelling, and the sensation could be distinctly 
felt carried through to the lumbar region. Dr. Mc- 
Bride, one of the visiting physicians, examined the 
patient, and regarded it as a case of perinephritic ab- 
scess, which had pressed the diaphragm upwards, de- 
veloping a condition simulating empyema. Dr. Brid- 
don attempted to aspirate from behind, and passed the 
needle three or four inches deep without obtaining 
anything. He then aspirated in front and removed a 
large quantity of bloody serum. There was no appear- 
ance of pus to the naked eye in the fluid, but the 
microscope revealed a certain number of pus corpus- 
cles. He aspirated several times subsequently, and 
obtained the same kind of fluid, but never at any time 
fluid which had the usual appearance of pus. The 
patient subsequently came under Dr. L. A. Stimson's 
care, who made an incision behind into the cavity of 
the chest, and gave exit to a large quantity of pus. 
The patient subsequently expectorated large quantities 
of pus, and it was noticed that when the expectoration 
was obstructed or defi' ient in quantity, that the sub- 
diaphragmatic swelling would increase in size. At the 
time he had some doubt as to whether the abscess was 
sub- diaphragmatic or not. 

Dr. Yale added an item in the clinical history 
which filled up an interspace between the service of 
Dr. Briddon and that of Dr. Stimson. He saw the 
patient soon after Dr. Briddon first saw him. The 
man came into the hospital one afternoon greatly op- 
pressed in breathing, and Dr. Yale aspirated his tho- 
rax, and drew away a little more than ten pints of pus. 
This was followed by the operation already alluded 
to, and performed by Dr. Stimson. As he recollected, 
Dr. Stimson was not quite sure where the cavity was 
even after the operation had been performed. Dr. 
Yale thought, however, that the opinion of the majority 
of the visiting surgeons was that the case was one of 
perinephritic abscess which had worked its way up- 
wards. 

Dr. Lange then read a paper entitled , 

ANATOMICAL AND CLINICAL CONSIDERATIONS CON- 
CERNING THE RETRO-PERITONEAL SPACE IN THE 
REGION OF THE LAST RIB. 

Dr. Halsted asked Dr. Lange if he believed that 
the lower limit of the pleural cavity was lower than 
that which had been given by Dr. Hull. 

Dr. Lange replied that in some cases it was much 
lower, and in other cases it was higher. On the aver- 
age, however, he should say that it was lower. 

Dr. Weir remarked that it was not often he had 
the opportunity of testing upon the living subject the 
accuracy of the remarks made by Dr. Lange. Re- 
cently, however, he had had the opportunity of cutting 
down upon the tissues in that region which were toler- 
ably normal. The operation was one for making fast 
or anchoring a movable kidney. In that instance he 
found that the kidney fat, in a patient only moderately 
stout, was, on being incised, or torn through, capable 
of being readily separated, and in that manner en- 
abling him to expose the kidney, and by traction on 
the investing tissue to raise the organ towards the 
surface quite satisfactorily. However, even in this 
case of movable kidney, there was considerable diffi- 
culty in reaching and appreciating the pelvis of the 
organ. He put his finjcer in for the purpose of educa- 
tion, because one or two years ago he had placed upon 
record the view that in those cases in which there has 
been for years previous signs of obstruction of one 



ureter, and then signs of obstruction in the other 
ureter developed, one might proceed to a lutnbar in- 
cision, and by opening the pelvis of the kidiiey or 
ureter, above the site of obstruction, with a view to 
saving the patient's life; an operation which had re- 
cently, he said, been performed by Bardenheur with 
success. 

Dr. Lange remarked that the position of the kidney 
could be changed considerably in a lateral direction. 
He had also found that if the lower part of the kidney 
was pulled upwards and laterally, the entire organ 
would be pulled not only laterally, but at the same time 
its lower edge would be upwards and made to perform 
a sort of torsion. 

Dr. Briddon asked Dr. Lange what incision he 
would make in nephrectomy. 

Dr. Lange replied that he would make an incision 
extending from the apex of the last rib, if that could 
be felt; in other words, make Czerny's incision. If 
the rib could not be felt, he would take the line of the 
sacro-lumbalis, or the quadratus lumborum muscle. 
In reply to a question by Dr. Halstead, he remarked 
that counting from the spines could hardly be depended 
upon as giving proper directions for making the in- 
cision. 

vesical calculus; 

Dr. H. B. Sands presented five small vesical cal- 
culi, the largest being one-half of an inch and the 
smallest about one-third of an inch in diameter, which 
he had removed thirteen days previously by lateral 
lithotomy. The interest of the case consisted in the 
fact that this operation had to be performed in the 
place of the crushing operation, which would -have 
naturally been selected for the removal of stones of 
this size. The patient was a man fifty-seven year* of 
age, who had suffered from symptoms of stone for 
three years. He was seen by Dr. Van Buren between 
two and three years ago, when it was discovered thai his 
prostate gland was unusually large. On that occasion 
a sound was introduced into the bladder, but a stone 
was not detected. Some doubt seemed to have been 
felt by Dr. Van Buren as to whether or not a stone was 
present, for he told the patient that he wished him to 
return for another examination. Considerable irrita- 
tion following this exploration, the patient did not re- 
turn to have it repeated. He continued to suffer more 
or less from cystitis and irritable bladder, and about 
two months previous to the time when Dr. Sands first 
saw him, his symptoms became very severe. The 
patient suffered from spasmodic contraction of the 
bladder accompanied with great pain. Owing to pros- 
tatic hypertrophy, he had for nearly three months been 
unable to evacuate the bladder except by means of 
a catheter, which, however, was readily introduced. 
Previous to Dr. Sands' visit, the patient had been seen 
by Dr. Doughty, who had sounded him upon three 
occasions. At the first examination a calculus was 
detected, but it was observed that the sound, a Thomp- 
son's searcher, could not be moved as freely as usual 
in the bladder. The second and third examinations 
failed to detect any stone. When Dr. Sands visited 
the patient he administered ether, and made a careful 
exploration of the bladder and rectum. An instrument 
with a large curve passed readily into the bladder, but 
one having the curve of Thompson's sound, could not 
be made to enter. This fact had been previously 
noticed by Dr. Doughty. The prostate when exam- 
ined by the rectum, was found to be exceedingly large. 
The urethra was measured, and was ascertained to be 
nine and a half or ten inches in length. When the 
Thompson's searcher was introduced it would pass the 
entire length of the instrument, which was nine and a 
half inches, and still its point did not enter the bladder. 



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The instrument seemed to be arrested by some bar of 
prostatic tissue. Introducing the instrument as far as 
it would go, Ur. Sands endeavored to move it, but the 
point remained nearly stationary, apparently grating 
again>t a rough surface of prostatic tissue. A stone 
was detected situated upon the patient's left side, and 
apparently just at the neck. 

Dk. Sands decided to perform lateral lithotomy, 
and thirteen days ago he removed the five calculi pre- 
sented; four were whole, and the fifth one was in 
fragments. Each calculus consisted of a uric acid 
nucleus, covered with concentric la) ers of phosphates. 
The patient, a few hours after the operation, had a 
chill and began to suffer from retention of urine. Dr. 
J. C. Hutchison, who had assisted at the operation, 
was called and succeeded in introducing an instru- 
ment into the bladder through the penis. Using this 
33 a guide, he introduced a Nelaton's catheter through 
the perineal wound into the bladder and tied it in posi- 
tion. This gave the patient com plete rel ief, and through 
the instrument remaining in the wound the urine was 
allowed to trickle for eleven days. About two days 
after the catheter was introduced it was noticed that 
the point of the instrument tended to escape from the 
bladder into the deeper part of the urethra; believing 
that it would be better to let the instrument lie there in 
the wound than in the bladder, thus preventing the lia- 
bility to incrustation, it was allowed to do so, and every 
tHTo or three hours it was introduced far enough to allow 
the urine to escape. Two days a<o the catheter was 
removed from the wound, and has since been intro- 
duced through the penis, whenever necessary. 

Dr. Sands regarded the case as interesting in two 
respects. In the first place, it afforded an illustration 
of the fact that even when the stone was small all 
cases of vesical calculi could not be treated by the 
crushing operation. A similar case came under his 
observation about six weeks ago, in which he was 
obliged to perform lithotomy and remove a stone, not 
larger than an almond, because he failed after repeated 
attempts to seize the calculus with the lithotrite. In 
this case there was no difficulty in inserting the instru- 
ment into the bladder, but it could not be made to 
seize the stone, which lay in a pouch behind the pros- 
tate. This cavity, which was apparently bounded be- 
hind by a muscular band extending between the ori- 
fi es of the ureters formed a cavity which was not more 
than one inch in its longest diameter, large enough to 
contain a stone, but not large enough to allow the 
blades of the lithotrite to open and seize it. 

The second point of interest was the occurrence of 
retention after the operation of lateral lithotomy, in 
which a pretty free incision was made. This was the 
second case in which this rare complication had fol- 
lowed lateral lithotomy in his practice. Usually the 
urine flows freel> from the wound, and catheterism is 
not necessary. In the other case, as in this, the pros- 
tate gland was considerably enlarged, and he inferred 
from his experience that when lateral lithotomy is per- 
formed in such circumstances, especially where the 
bladder is wrak, the proper course would be, after ex- 
traction of the stone, to wash out the bladder, insert a 
flexible catheter and allow it to remain in position. In 
addition, he believed it to be advisable to allow the 
point of the instrument to recede from within the blad- 
der and subsequently to push it forward at regular in- 
tervals to permit the escape of the urine. 

Dk. Post referred to a case in which he assisted the 
late Dr. Buck in the performance of lateral lithotomy, 
and retention followed the operation. On introducing 
the catheter the next day, a large quantity of urine 
was drawn ofT. In that instance a fatal result occurred. 
There had not been retention during the operation. 

Dr. Weir referred to a case in which Dr. Buck 



operated, and in which retention followed the opera- 
tion, but in that instance another calculus was found 
in the bladder. 

Dr. Post remarked that Mr. Liston, of Edinburgh, 
once remarked to him that he was in the habit of in- 
troducing a catheter, and allowing it to remain after 
performing lithotomy, because he believed that the 
safety of the patient was promoted by it. 

PTOSIS WITHOUT STRABISMUS, AND AMAUROSIS WITHOUT 
A DILATED OR SENSITIVE PUPIL. 

Dr. Post narrated a case as follows : A boy, fifteen 
years of age, was brought to his clinic last Saturday, 
who had been in the enjoyment of fair health, except 
that he had suffered from headache during the last two 
years to a considerable extent. About five days before 
he was brought to Dr. Post, the patient was suddenly 
attacked with ptosis of one eye, and there was almost 
absolute loss of vision attending it. 1 here was bare 
perception of light. There was no strabismus, and the 
pupils of the two eyes corresponded with each other, 
and both were sensitive to light. The occurrence of 
ptosis without strabismus, and amaurosis without dila- 
tation or sensitiveness of the pupil, seemed to him to 
be unusual. 

NEW YORK ACADEMY OF MEDICINE. 

Stated Meeting, December 21, 1S82. 

The President, Fordyce Barker, M.D., LL.D., in 
THE Chair. 

After the report of the Secretary, the Correspond- 
ing Secretary reported the death of Sir James Al- 
derson, who died at an advanced age in London, in 
December of the present year; also that of Sir Thomas 
Watson, Fellow of the Royal College of Surgeons, 
who died in London, December 11, 1882. He was best 
known to the American profession through his lectures 
on the practice of medicine. 

The Statistical Secretary reported the death of 
Michael Hagan, a Fellow of the Academy, who died 
at the age of sixty-seven, on the 8th of December, 

The Secretary read a letter from the Secretary of 
the Northwestern Medical and Surgical Society of New 
York, enclosing a check for one hundred dollars as a 
gift to the Journal Department of the Academy. Upon 
motion of Dr. White, the Academy extended to the 
above Society a vote of thanks for its kind and gen- 
erous donation. 

The next business was the presentation of a marble 

bust of the late prof. JAMES P. WHITE, OF BUFFALO, 

by Dr. Austin Flint, Sr. This was the gift of the late 
Prof White's son, Mr. James P. White. The sculptor 
was Mr. J. G. Mitchell, of Rochester. 

Dr. Flint moved that the Academy extend a vote 
of thanks to James P. White for his generosity in pre- 
senting to it a marble bust of his father. 

The President called upon Dr. Thomas to second 
the motion, who responded in a few graceful and well- 
timed remarks, saying that he thought it eminently 
proper that the bust of our late honored Fellow should 
have a place in the hall of the Acadeniy opposite that 
of the greatest of living ovariotomists, Mr. Spencer 
Wells, of London. 

The motion was unanimously carried. 

The next business was the scientific work of the 
evening. 

Dr. T. Gaillard Thomas presented 

A contribution TO THE SUBJECT OF THE REMOVAL OF 
THE UTERINE APPENDAGES (TAIT'S OPERATION) FOR 
PROLONGED MENSTKUAL TROUBLES WITH RECURRENT 
PELVIC INFLAMMATIONS, WITH SPECIMENS. 

In the issue of the British Medical Journal for July 
29, 1882, appeared a remarkable essay by Mr. Law- 



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•son Tait, of Birmingham, England, enunciating views 
entirely at variance with those heretofore held by the 
medical profession, advocating pathological tenets 
which were altogether new, and recommending a plan 
'Of treatment which is at once original and bold. This 
article was entitled, " Remarks on the Diagnosis and 
Treatment of Chronic Inflammation of the Ovary." 

Dr. Thomas referred to the article at some length, 
first, because his own paper was based upon its sug- 
gestions ; second, because he felt sure that the positions 
which it assumed would interest the Fellows of the 
Academy, even if they denied their validity ; and third, 
because he himself was convinced that this bold and 
•original surgeon had advanced views which were des- 
tined to open a new field for gynecological surgery in 
■the future, and to exert upon this department ofmedi- 
•cine an enduring influence. 

While the speaker did not feel warranted from his 
-own experience and observations in accepting all the 
•conclusions of Mr. Tait, he believed that there was a 
sufficient amount of truth in some of them to make the 
essay above referred to one of the most valuable that 
this decade had produced for the gynecologist. 

Since that period, which constituted so remarkable 
an era in the history of gynecology, when Henry Ben- 
met, Simpson, and Marion Sims brought their eminent 
labors to bear upon this department of medicine, until 
ithe present time, a vast deal of attention had been 
directed to the uterus, vagina, the uterine Ugaments, 
and the pelvic peritoneum, and the areolar tissue, 
while the diseases of the ovaries and Fallopian tubes 
have been left enveloped in a cloud of ignorance and 
■uncertainty which few have endeavored to penetrate 
and dispel. Tilt, of London, the firm, persistent, and 
.able advocate of the claims of ovarian pathology, has, 
•during this time, stood almost alone, steadily and con- 
sistently enunciating views with which few sympathize 
and still fewer endeavor to sustain. At the present 
■time, however, it seemed that a wholesome revolution 
was occurring in this respect; that reflective men, de- 
voted to gynecology, were now recognizing the fact 
that a very large proportion of cases of menstrual dis- 
•order, pelvic neuralgia, and difKcult locomotion, which 
were formerly attributed to the uterus, its ligaments, or 
■the pelvic areolar tissue, are entirely due to ovarian 
disease, and that hundreds of cases in which this de- 
voted organ was cut, cauterized, and leeched, had the 
•same pathological origin. 

Mr. Tait assumed : First, that the view formerly held 
ihat laparotomy operations should be postponed until 
absolute risk to the life of the patient rendered them 
necessary, should now be abandoned ; and that in the 
hands of an expert they are at present so free from 
danger as to be practicable even when life is not jeop- 
ardized. Second, that the usually accepted doctrine of 
the dependence of menstruation upon the ovarium is 
wholly erroneous. Third, that the ovaries have noth- 
ing whatever to do with menstruation, and that this 
phenomenon is dependent upon the Fallopian tubes. 
Fourth, that the many cases of abnormal menstruation 
are justifiably treated, and are relievable in no other 
way than by extirpation of the ovaries and tubes. 
Fifth, that in chronic ovarian disease the tubes are in- 
variably involved, and that in most cases it is the tubes 
which are chiefly at fault. Sixth, that the mortality in 
his last thirty-five operations having been only one, 
even this slight loss of life is susceptible of diminution 
in the future. Seventh, that many of those cases here- 
tofore regarded as instances of menstrual or recurrent 
pelvic peritonitis or cellulitis are really due to tubal 
dropsy and ovarian disease ; an occasional- discharge 
-of the purulent accumulation of the former giving rise 
to slight and passing attacks of these affections. 

Dr. Thomas stated that the removal of the uterine I 



appendages, as it concerned his remarks, had nothing 
whatever to do with the subject of ovariotomy. The 
latter operation was resorted to for the removal of large 
and increasing tumors, which, if not removed, almost 
invariably destroy life within a few years. The former 
was performed for severe menstrual disorders and 
nervous troubles having their origin in the uterine an- 
nexe, which, while they do not jeopardize life, render 
it utterly miserable and intolerable. 

Dr. Thomas's contribution was merely a report of 
four cases in which very grave menstrual trouble ac- 
companied by all the symptoms of recurrent pelvic 
peritonitis and cellulitis were found due to tubal dropsy 
existing coincidentally with chronic ovaritis, exactly 
as Mr. Tait had described it. 

Case I. was a colored woman, 30 years of age, who 
commenced to menstruate at fourteen ; she had been 
married nine years, and was the mother of one child, 
eight years old. Her menstruation was perfectly nor- 
mal up to the period of weaning her child, eighteen 
months after delivery. At that time she was taken 
with very sudden symptoms resembling those of cellu- 
litis or peritonitis, accompanied with slight bloody dis- 
charges from the vagina. She was confined to bed 
for about a week, since which time she has been a 
confirmed invalid, her menstrual periods being painful, 
scanty, and irregular. Upon makmg an incision in the 
mesial line and passing two fingers into the iliac fossa, 
Dr. Thomas drew up an ovary about as large as an 
English walnut, distended by a multitude of small 
cysts, and the Fallopian tube resembling closely in size 
an ordinary sausage, and giving to the touch very 
much the feeling of a loop of intestine. Tube, ovary, 
and ovarian ligament were ligated with an aseptic 
banjo- string and removed; the same condition was 
found to exist on the other side, and the same proced- 
ure was adopted. The operation was performed under 
the strictest antiseptic precautions, except that the 
spray was not used during the operation. On the 
thirteenth day after the operatibn the patient was sit- 
ting up in bed, having recovered completely, without 
a bad symptom. The time of one menstrual period 
had passed, and as yet no sanguineous discharge had 
occurred. 

Case 11. was a lady 25 years of age, who had been 
married three years, and was the mother of one child, 
eighteen months old. Her menstrual periods began 
at the age of seventeen, and before her marriage gave 
her no trouble whatever. Nine months after confine- 
ment she was taken with an attack of pelvic inflamma- 
tion, which seemed to have been unquestionably one 
of slight cellulitis or peritonitis. Since the birth of her 
child she had never been well, and suffered from con- 
stant pelvic pain, with occasional accessions of inflam- 
mation. She menstruated irregularly and painfully, 
and suffered from leucorrhoea and difficulty of loco- 
motion. At the operation the ovaries were found very 
slightly diseased, but the tubes were distended by 
large accumulations of pus. Both ovaries and tubes 
were removed. The patient recovered without any 
remarkable rise of either pulse or temperature. 

Case III. was that of an unmarried Udy aged 22 
years, who began to menstruate at fourteen, from which 
time she had suffered from most dreadful dysmenor- 
rhoea until a year ago. Pain was confined to the 
menstrual period, and was agonizing for thirty-six or 
forty-eight hours. Both ovaries and tubes were re- 
moved. The ovaries were found filled with small 
cysts and the membrane lining the tubes inflamed and 
bathed with pus, which was, however, not confined 
within them so as to create dr >psical enlargement. 
The patient recovered without unfavorable symptoms. 
Case IV. was a maiden lady 27 years of age, who 
began to menstruate at fourteen. This was accom- 



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31 



panied with severe pain until two years ago. Her 
case would have been classed as one of those very 
common ones of exceedingly severe dysmenorrhoea. 
At this time she had a short attack of pelvic peritonitis, 
and had ever since been a most wretched invalid, 
having become greatly emaciated, suffering constantly, 
and being almost continually confined to bed. 

An operation being decided upon, owing to her low 
vital condition, an attempt was made to get her into a 
more favorable condition for the operation. This, how- 
ever, proved ineffectual after a fair trial, and it was 
decided to operate at once, which was done on the i ith 
of the present month. The ovaries were not very 
much diseased, but they contained a number of small 
cysts. The Fallopian tubes were dropsical, and through- 
out their whole extent firmly bound down by false mem- 
brane, which had to be torn with considerable force. 
The operation was tedious and difficult, and at its con- 
clusion no one who witnessed- it could avoid making 
an unfavorable prognosis as to the result. Twenty- 
four hours afterwards one of those insidious attacks 
of peritonitis, with Idw temperature and slight pain, 
which so often develop after laparotomy, declared it- 
self, and on the sixth day destroyed the patient's life. 
The ovaries and tubes that were removed from the 
first, second, and fourth cases were presented to the 
Academy, those of the third having accidentally been 
lost. The tubes were greatly enlarged and character- 
istic of the condition described by Tait. 

Dr. Thomas called attention to the fact that the re- 
sults from Mr. Tail's oophorectomy operations had, like 
those of Keith, Wells, and several other European 
surgeons from ovariotomy, been exceedingly gratifying. 
In this country we could present no such glowing ac- 
counts of the results of these operations. It was true 
that surgeons might lull their misgivings to rest by 
listening to the kindly suggestions Of a superior phy- 
sique on the part of patients, a more advantageous 
climate, and the concentration of cases in the hands 
of experts on the other side of the Atlantic, but it was 
unlike the genius of our land to accept such placebos. 
He suggested, therefore, that we look the disagreeable 
truth boldly in the face, and recognize the fact that, 
so far at least, our European brethren in this field of sur- 
gery were for some unkn-)wn reason ahead of us. The 
discrepancy which existed between our statistics to- 
day could not be met by argument ; it must be abol- 
ished by results. 

The President announced that the paper of Dr. 
Thomas would not be discussed independently. 
The next paper was a 

comparison between gastro-elytrotomy (thomas's 
operation) and OOPHORO-HYSTERECTOMY (porro's 
operation), 

by Dr. Henry J. Garrigues. 

The paper consisted of a critical comparison, from 
the surgical standpoint, of the two operations the aim 
of the author evidently being to make a strong plea in 
fovor of Thomas's operation. He considered that the 
latter had various advantages over the Porro or the 
Porro-Miiller operation, and argued that it should, at 
least, be given a fair trial. By operating early, or re- 
fusing to operate upon dying subjects, there could be 
no doubt but that the danger of the operation would 
be shown to be much less than the present statistics 
would seem to indicate. Though the Porro operation 
had an advantage from the standpoint of antiseptic 
surgery, it was nevertheless possible to enforce anti- 
septic precautions to a considerable extent in Thomas's 
operation. One advantage of the Porro-Miiller opera- 
tion was that it could be commenced before the com- 
mencement of labor. 

Dr. Polk being called upon to open the discussion. 



remarked that there was very little to be said upon the 
operation beyond what was contained in the paper, 
except, perhaps, to place the operation, and to disabuse 
the mindj of its opponents as to its difficulties. He 
thought, in placing the operation, it was a mistake to 
put it in competition with Caesarean section and its 
modifications. There were cases in which the Caesa- 
rean operation was the only one that could be per- 
formed. In certain cases, he thought, the operation 
of embryotomy might well give way to gastro-elytrot- 
omy. The latter operation rested between Caesarean 
section and its modifications on the one hand, and 
embryotomy on the other. The laceration incidental 
to embryotomy was infinitely more deirimental than 
that produced by gastro-elytrotomy. This remark re- 
ferred only to cases where there was the minimum 
limit to the deformity. Dr. Polk went on, and de- 
scribed, step by step, in detail the anatomical points 
in the two operations, and thought the evidence thus 
adduced showed that Thomas's operation was the sim- 
pler of the two. 

Dr. Taylor spoke in favor of o5phoro-hysterectomy, 
and was followed by Dr. Skene, of Brooklyn, who 
argued in favor of Thomas's operation. 

Dr. Lusk thought that when there was a dilated 
cervix, no operation was better than gastro-elytrotomy. 
It was also the only operation to be thought of m 
cases where there was a contracted pelvis over the 
head. He was not prepared, however, to say that 
gastro-elytrotomy would supersede all other operations. 

Further remarks were made by Drs. Gillette and 
Emmet, and the discussion was closed by Dr. Gar- 
rigues. 



RHODE ISLAND MEDICAL SOCIETY. 

Semi-annual Meeting held at Providence, December 
SI, i88s. 

(Specially reported for THE MEDICAL News.)' 

The semi-annual meeting of the Rhode Island Medi- 
cal Society was held in Providence, on J)ecember 21st, 
The President, Dr. Job Kenyon, in the chair. The 
attendance was large. 

The Secretary, Dr. George D. Hersey, read the 
records of the last quarterly meeting, which were ap- 
proved. 

Dr. M. Fifield, of Centreville, presented a report of 
the following 

CASE of intra uterine TUMOR. 

The patient is a woman 39 years of age, whose men- 
struation, beginning at 13 years of age, continued very 
profuse and frequent up to six years ago, the periods re- 
curring every two or three weeks during the whole time. 
During the past six years there has been no menstru- 
ation, but very severe uterine hemorrhages have oc- 
curred at irregular intervals. One of these took place 
last July and was with great difficulty checked by the 
use of ergot and viburnum. 

An examination at that time showed the abdomen to 
be greatly enlarged, the tumefaction extending above 
the umbilicus, its upper left side being distinctly rounded 
and hard on p ilpation. On examination per vaginam 
the cervix uteri was found shortened and softer than 
norm.al, with the os so patulous as to readily admit the 
tip of the finger which immediately encountered a 
firm, hard mass completely filling the uterine cavity. 
Since July there had been no recurrence of the hemor- 
rhage until last week, when there was a profuse and 
alarming loss of blood. Walking is painful to the 
patient, but she can ride in an easy carriage in com- 
fort. 

The question is asked. Is the intra-uterine mass a fi- 



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22 



PROCEEDINGS OF RHODE ISLAND MEDICAL SOCIETY. [Mbdical Nbws, 



broid tumor, and if so, what treatment is indicated ? Is 
Battey's operation justifiable in the case ? 

Dr. Lucy R. Weavek said, regardmg a case oper- 
ated on by Dr. A. E. Tyng, and reported two years 
ago that a fibroid existed in that case, and Battey's 
operation was done; that almost immediately the tumor 
began to diminish in size and could now scarcely be felt 
at all and that the woman regarded herself as being 
now in perfect health. 

Dr. J. H. Morgan, of Westerly, read the report of a 
case of 

ANEURISM OP THE DESCENDING AORTA, 

occurring in a Scotch stonecutter, 38 years old, who 
was first seen by the writer April 19. 1882, soon after 
coming from Vancouver Island. Formerly in vigor- 
ous health, he had then become weak and emaciated. 
For fifteen months he had suffered from neuralgic 
pains in the right thigh and leg. A well-marked prom- 
inence existed in the lower dorsal portion of the spinal 
region, in which severe pain was caused by allowing his 
weight to come down forcibly on his heels. Percussion 
and auscultation gave only negative results. Caries of 
the vertebrae being diagnosticated, it was proposed to 
put on a plaster-ol-Paris jacket, but to this measure the 
patient himself objected. The case went on without 
marktd change until May 18th, when, after a day of 
less suflfering than usual, death occurred suddenly. The 
autopsy showed the diaphragm to be prol ipsed, the 
liver pushed downward and to the left, the stomach 
contracted, the spleen and pancreas normal, the heart 
crowded to the left, and the right lung compressed and 
adherent. On the right side of the spinal column and 
behind the kidney was found a ruptured aneurisinal 
sac, communicating by a small oritice with the descend- 
ing aorta. The sac had ruptured into the right pleural 
cavity. The writer emphasized the need of caution in 
the application of the plaster jacket, in face of the pos- 
sibility that, as in this case, the spinal disease may have 
been caused by the pressure of an undiscoyered aneu- 
rism. 
Dr. F. B. Fuller exhibited a specimen of 

ENCEPHALOID OF THE TESTICLE. 

At 12 years of age the man had received a blow in 
the scrotal region which immediately caused acute 
orchitis. This subsided, but the right testicle soon be- 
gan to enlarge, and became painful. The condition 
changed but little for several years when the trouble 
increased rapidly for four months until the growth be- 
came so burdensome and painful that it was excised 
February 10, 1882. The tumor, which was the speci- 
men shown, was the size of a fcetal head at term ; 
its upper two-thirds were fibrous and contained c> sts 
and enchondromatous masses ; the lower third was 
encephaloid carcinoma. The patient recovered well 
from the operation, but very soon began to have severe 
pain in the abdomen which was from time to time 
relieved by the escape per rectum of large quantities of 
clots, blood, and pus. Death occurred in ten months, 
and post mortem there was found in the abdominal 
cavity a mass of encephaloid cancer the size of a man's 
head. 

Dr. W. H. Palmer, of Providence, read a paper on 

CORONERS AND THEIR DUTIES. 

The ancient origin of the system of investigation 
through the office of coroner was alluded to as dating 
back iis early as the year 908 in England, in which 
country the officer, vai iously termed " coroner," " crow- 
ner," and "coronator" — either title signifying a direct 
representative of the crown — enjoyed uncommon au- 
thority and privileges, which the writer described. The 
establishment of the coroner system was said to be one 
of the earliest concessions made by the crown to the 



people — the coroner having first summoned a jury from 
the ranks of the common people. 

In those early days the appointment of coroners was 
naturally hedged with due precaution, and it was di- 
rected that none but loyal and discreet knights should 
fill the position. In 1640 there was published in Eng- 
l.ind a long and explicit summary of the coroner's 
duties. 

Our advancing civilization is unable to dispense with 
the coroner system or its equivalent, notwithstanding, 
from time to time, public di'iapproval demands the 
abolition of the coroner entirely. 

The coroner's office, organized to make inquiry into 
the cause of death, is one of special interest to the 
medical profession. 

The different methods employed in some of the 
countries of continental Europe, where the office of 
coroner does not exist, were described. 

Although the method of appointing coroners differs 
in the various States in this country, there is agreement 
in one direction, viz., coroners are almost universally 
appointed without special qualifications for the posi- 
tion. 

It would be as rational to hand a stopped watch to a 
lawyer for him to investigate the cause of the trouble 
as to expect a non-medical coroner to properly and 
intelligently seek for the cause of the stopping of a 
human life, a machine so manifold more intricate and 
delicate. Now, in England, the office is filled almost 
entirely by medical men. 

The writer claimed that in Rhode Island the author- 
ity and work of the coroner are neither merely sup- 
plementary nor inefficient, as has been alleged in the 
public press. He alone has authority to take charge 
of dead bodies in suspicious cases, to order exhuma- 
tions, examinations, and analyses; to enter houses to 
investigate, to summon juries and witnesses, impose 
fines, etc. 

The system at present employed in Massachusetts, 
whereby the office of coroner is supplanted by that of 
medical examiner, was reviewed in detail, and the fol- 
lowing mentioned as among the most important feat- 
ures of that system : 

1. The best element is that only medical men are 
appointed. 

2. An inquest is held without the intervention of a 
jury, the opinion of one man prevailing instead of six. 

3. At the option of the trial justice, the inquest may 
be held in private. 

In the opinion of the writer, however, it did not seem 
probable that the Massachusetts system would take the 
place of the coroner. 

The coroner system, ai its best, is the best, and the 
defects charged against it are not inherent in the sys- 
tem, but arise from the carrying out of the application 
of the system. 

Dr. a. Ballou thought the medical profession were 
not alive to the importance of having suitable men 
appointed coroners. He expressed his approval of the 
paper just read, and also his belief that the legislation 
in Rhode Island bearing on the subject is not inferior 
to that of other States. The system employed in Penn- 
sylvania is very expensive, and, as managed, is far 
inferior to our own. 

Dr. Caswell expressed his interest in and approval 
of the paper. He had thought, however, that the 
Massachusetts system was excellent and entirely suc- 
cessful. 

Dr. O'Learv asked Dr. Palmer if it was within the 
province of a Rhode Island coroner to inquire beyond 
the proximate cause of death, e. g., in case of drown- 
ing on board ship, shall the coroner investigate as to 
the seaworthiness of the ship, etc. 

Dr. Palmer replied that the jury should not be re- 



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January 6, 1883.] 



PROCEEDINGS OF RHODE ISLAND MEDICAL SOCIETY. 



23 



stricted, and might seek for remote and contributory 
causes of death. 

THE censors' report 

was next in order, and was presented by Dr. S. S. 
Keene for the Board. It simply recommended that 
the applications for fellowship of Dr. Jean Antoine 
Baptiste Tanguay and Dr. George Reuben Smith, 
which were received at the last quarterly meeting, be 
referred to the next meeting. This report was ac- 
cepted. 

Dr. Robert F. Noyes, of Providence, then read a 
paper on 

PERITYPHLITIS AND PERITYPHLITIC ABSCESS. 

The caecum, covered in front and laterally by peri- 
toneum, and posteriorly by cellular tissue, has functions 
that are peculiar and distinct. Its contents pass slowly 
and in a direction opposed to gravitation ; hence the 
liability of the lodgement of fruit seeds and stones, 
bits of epithelial and fibrous tissue from the ingesta, 
etc. It may become enormously distended — even to 
the capacity of a gallon, and its walls greatly hyper- 
trophied. The symptoms of inflammation of the cae- 
cum and its appendages are pain in the right iliac 
fossa, vomiting, pain and numbness in the thigh, fre- 
quent and painful micturition, and the presence of 
regional swelling. 

Regarding the appendix vermiformis caeci, it was 
said that it exists in the ourang and ape alone of the 
lower animals; that its non-uniformity anatomically, 
and in its investments, complicates the diagnosis ; its 
orifice sometimes becomes occluded, causing atrophy ; 
calculi may form in it ; ulceration in the appenaix is 
less apt to be followed by cicatrization than in case of 
ulceration of the caecum, but perforation is more com- 
mon in the appendix. Perforation may occur without 
the previous existence of symptoms severe enough to 
attract the attention of the patient. 

The softening of the caecum renders caution neces- 
sary in the use of copious injections, especially when 
the rectal tube is introduced. In the great majority of 
cases perforation of the vermiform appendix is caused 
by foreign bodies. Reference was made to Dr. Bar- 
tholow's description of cases of idiopathic perforation 
of the appendix. 

Regarmng the symptoms in perityphlitis, the dull 
pain is due to cellulitis, the sharp pain to peritonitis, 
the pain and ntmibness of the thigh to pressure on the 
lumbar plexus ; the vomiting is due to obstruction of 
the intestine. The tumefaction is at first hard, and 
afterwards becomes softer. To diagnosticate perityph- 
litic abscess may be very difficult, but it is very im- 
portant. Examine for swelling, pain, and fluctuation, 
and employ the aspirator needle in doubtful cases. In 
dia^osis the following must be considered in differ- 
entiating : Tumors due to fecal accumulation ; psoas 
abscess ; malignant disease ; inflammation of right 
ovary ; perinephritic abscess ; "movable kidney, with 
suppuration ; abscess of the abdominal wall ; in chil- 
dren hip-joint disease ; and invagination, especially if 
at the ileo-caecal region, when it may be very difficult 
to determine the diagnosis. 

The prognosis in perityphlitis depends largely upon 
the etiology. It is more favorable when the cause is 
exposure to cold or traumatism. In case of abscess, 
the course taken by the pus largely influences the 
result. If it escapes into the intestine or bladder, it is 
more favorable than through the abdominal wall or 
upward through the diaphragm. 

The writer had collected notes on 100 cases, of which 
IS were fatal. Perforation of the appendix is almost 
always fatal, though a few cases have recovered. 

In the treatment of perityphlitis, saline laxatives 



should be used, with enough opium to relieve pain and 
control peristalsis ; turpentine fomentations ; leeches 
may be applied to the ileo-caecal region. There should 
be frequent examinations for abscess, and when found 
it should be opened by an incision parallel to Pou- 
part's ligament. When pus is suspected, but fluctua- 
tion is not present, the exploring needle may be used. 
The needle is valuable in diagnosis, but can not super- 
sede the knife. Out of 100 cases of abscess 31 were 
due to presence of foreign bodies, and in this class of 
cases the knife is fat better than the needle. When 
an incision is made it should be carried down to the 
fascia transversalis, when deep-lying pus is suspected. 
Several authorities were quoted as to the proper time 
for opening the abscess. The sac of the abscess on 
percussion may give a tympanitic sound as tho'ugh the 
intestine lay in front, but the writer had never found 
this condition present. The treatment in case of per- 
foration of the appendix vermiformis should include 
opium, fomentations, and pierhaps the application of 
the ice-bag in the iliac region. 

Dr. a. Ballou cited three fatal cases in point : 

1. The case was seen during the acute inflammatory 
stage. Opium and fomentations were used. A por- 
tion of the caecum became gangrenous and was thrown 
off per rectum. The specimen was preserved. 

2. The case of a woman of 200 pounds weight and 
seven months pregnant. There was no movement 
from the bowels and death occurred from inflamma- 
tion. There was no tendency to abortion. The autopsy 
showed that two inches of the ileum had become in- 
vaginated by the caecum, strangulated and gangrenous. 

5. This case was similar to the second, the ileum 
being invaginated within the caecum and gangrenous. 

Dr. Wm. Shaw Bowen, of Providence, then read a 
paper on a case of 

ulceration of THE LARYNX. 

The patient, Mr. H., is 30 years old, of spare build, 
regular habits, and in comfortable circumstances. Six 
years ago he fell down stairs, striking his face on an 
open door, causing fracture of the nasal bones, and 
displacement of the vomer. A few months later a hard 
pimple appeared near the right ala nasi. It broke 
down and refused to heal. The disease extended up 
the nostril on the mucous membrane, destroying a por- 
tion of the vomer and middle turbinated bone. There 
was but slight involvement of the skin outside the nos- 
tril. A course of hot-iron treatment, in Boston, was 
followed by an apparent cure. 

In December, 1 881, he began to have slight soreness 
of the throat, cough, and hoarseness ; swallowing was 
painful, especially of condiments ; soon no solid food 
could be swallowed. A physiciaiy pronounced it to be 
laryngeal phthisis, and tried the usual remedies, with 
no avail. When first seen by Dr. Bowen the ulcerative 
disease had so far advanced that there had been ex- 
tensive destruction of bone ; oedema and cicatricial 
bands had left only a small orifice between the pharynx 
and the post-nasal space, so small as only to admit a 
fine bougie. There was a mass of mucous polypi in 
the nose, attached to the middle turbinated bone. The 
left tonsil was enlarged. The epiglottis was bare, some- 
what rigid, and sensitive to the touch. There were a 
few nodular masses on its dorsum. It was very diffi- 
cult to obtain a view of the vocal chords. There was 
harassing cough, and the voice was gone. Except 
in carcinoma or throat phthisis, a worse condition of 
the throat is rarely seen. 

No syphilitic history was acknowledged, but it was 
decided to try the mixed anti-syphilitic treatment. 
Mercury, iodide of potassium, cod-liver oil, and sea- 
water baths were employed. Morphia and powdered 
starch were dusted over the raw surfaces, together with 



Digitized by 



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le 



"4 



OBITUARY. 



[Medical Nkws, 



the application of olive oil. This treatment was con- 
tinued three weeks without tnarlced change in the local 
condition. The diagnosis of laryngeal lupus was then 
made. The arytenoideus was involved in the ulcera- 
tion, some of the small nodular masses existing on its 
surface. 

The treatment was now changed. A solution of 
nitrate of silver (480 grains to the ounce) was carefully 
brushed over the ulcerated surface. The first two ap- 
plications caused severe laryngeal spasm, and no 
marked improvement followed the first twenty appli- 
cations. The voice then became a hoarse whisper, and 
the cough was much less troublesome. The treatment 
was continued six weeks, resulting in marked improve- 
ment in all the local conditions. The tincture of the 
chloride of iron and iodoform were also used locally. 
In November, the voice had improved to a hoarse tone, 
and the dysphagia was gone. The silver and iodoform 
treatment was then stopped, and a stimulating inhala- 
tion of benzoin used instead. 

Dr. Daniel O. King, of Pontiac, reported 

A CASE OF PERITYPHLITIC ABSCESS, 

which recently occurred in his practice, in a boy 4)4 
years old. The first symptoms were pain in the right 
iliac region, tympanitis, and vomiting. An injection 
relieved the symptoms, which returned the next day, 
however. Laudanum and chloric ether were given in- 
ternally. The case went on for a week, when the writer 
was discharged. He was recalled to the case ten days 
later, and found the patient in a most critical condition, 
apparently very near death. A soft boggy swelling the 
size of an egg was now found in the right iliac space. 
The swelling was tympanitic on percussion and gave 
no distinct fluctuation. The patient was etherized, and 
by means of a hypodermic syringe a few drops of pus, 
having a fecal odor, were withdrawn. An incision, 
two inches long, was theif made parallel to Poupart's 
ligament and carried down to the fascia transversalis. 
The fascia was punctured by the needle, letting out a 
fluid which the microscope showed to be purulent. A 
warm carbolized dressing was applied. The patient 
improved. Fecal matter oozed through the incision for 
some days, and some fragments of apple pie, eaten by 
the boy contrary to directions, also oozed out. The 
boy is now strong and well. 

In this case the writer thought the abscess was caused 
by perforation of the vermiform appendix, for if the 
abscess had been primary it would have pointed into 
the intestine at once. 

THE APPOINTMENTS OF DELEGATES 

to the annual meetings of other State Societies were 
then named by the Chair, as follows : 

Connecticut. — Drs. O'Leary and Browning. 

New York.—X>r%. Ely and W. O. Brown. 

Vermont. — Drs. Robbins and O. C. Wiggin. 

New Hampshire.— Drs. A. Ballou and W. R. White. 

Massachusetts. — Drs. Miller and Swarts. 

New Jersey. — Drs. Parks and Bullock. 

Maine. — Drs. Anthony and Bowen. 

Dr. Caswell sported two more 

LITHOLAPAXIES. 

The first was a secondary operation on a patient in 
whose bladder a few fragments remained after the first 
operation. The secondary operation was done in Oc- 
tober last, occupied forty minutes, and resulted in the 
washing out of ninety grains of stone. 

Case second, that of a man forty-seven years old, 
who was operated on, in 1876, by the old lithotrity 
method, eleven sessions having been required to free 
the bladder from fragments. He began to suffer again 
last spring. At the recent operation Dr. Caswell, be- 



lieving the stone to be small, made a preliminary wash- 
ing before introducing the lithotrite at all. A small 
stone was at once drawn into the eye of the instrtiment 
by suction, and was removed while so engaged without 
difficulty. The stone was round, •^ of an inch in di- 
ameter, flattened into a disk shape, and perfectly whole 
and symmetrical. It was formed of urates and weighed 
10 grains. Further examination revealed the presence 
of a second stone in the bladder, which was crushed 
and washed out at once, making 31 grains in all re- 
moved. The entire operation lasted half an hour. The 
patient was up and aoout his room the next day, and 
attending to business in a week. 

Dr. Caswell emphasized the great advantages and 
superiority of litholapaxy over all other stone opera- 
tions, and compared it with the far more dangerous 
lithotomy, especially in such a case as he had just re- 
ported. 

He then exhibited Dr. Bigelow's modified evacuating 
apparatus, and explained its application. 

Dr. W. E. Anthony, of Providence, read 

AN OBITUARY NOTICE OFl)R. GEO. CAPRON, 

who died September 21, 1882. It was mentioned that 
in a practice covering sixty years. Dr. Capron had at- 
tended more than ten thousand confinement cases, a 
branch of practice in which he excelled. 

President Kenyon announced the death on No- 
vember 28th, of Dr. George E. Mason, of Providence, 
a Fellow of the Society, and- appointed Dr. J. W. 
Mitchell to present an obituary at the next meeting. 

Dr. E. M. Snow said there had been 109 deaths from 
typhoid fever, in Providence, since September ist. 

Adjourned. 

OBITUART. 

GEORGE FOX, M.D. 

Dr. George Fox died in this city on Wednesday, 
the twenty-seventh day of December, in the seventy- 
seventh year of his age. Although Dr. Fox relin- 
quished his' private practice and his professional 
appointments almost thirty years ago— grande morta/is 
avi spatium — his death will still be felt in the medical 
community of which he was a well-known ^and dis- 
tinguished confrire. 

Dr. Fox belonged to a family in the Society of 
Friends, of high social position and extended influ- 
ence, in the ci^ of Philadelphia. He was graduated 
from the University of Pennsylvania, Bachelor of Arts, 
in 1825, dividing the second honor in his class with the 
late Adolphe E. Borie. The same year he began the 
study of medicine under his brother. Dr. Samuel M. 
Fox and Dr. Joseph Parrish, and received the degree 
of Doctor of Medicine from the University, in the 
spring of 1828. 

During the two following years he was resident phy- 
sician in the Pennsylvania Hospital; Dr. James A. 
Washington being his colleague the first year, and Dr. 
Ralph Hamersly the second. During his term of ser- 
vice as resident he devised the apparatus for fract- 
ured clavicle, still known as the Fox apparatus, and 
of which Sargent well says in his Minor Surgery, "No 
one who has employed it will be disposed to use any 
other as a substitute." In 1848, Dr. Fox was elected 
one of the visiting surgeons to the Hospital, and ful- 
filled all the duties of that position with the greatest 
fidelity so long as he remained in the city. On the 
organization of the Wills Hospital for the indigent 
blind, and lame. Dr. Fox with Drs. Hays, Littell, and 
Isaac Parrish, were elected surgeons, and he diligently 
served that institution until his election to the Penn- 
sylvania Hospital, when he resigned his position at the 



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Wills. After resigning from the Wills Hospital as 
surgeon, Dr. Fox was elected one of the Board of Man- 
agers, and acted as such until his removal to the 
country. 

In 1851, Dr. Fox was elected a Fellow of the College 
of Physicians, and always showed great interest in its 
affairs. He was an active member of its Building 
Committee, and took a leading part in the selection 
and purchase of the site of the present hall of the Col- 
lege and in its erection. He possessed, it may be said, 
peculiar and special qualifications, which enabled him 
to be of great assistance to the College in these trans- 
actions. 

At the time of the formation of the American Medi- 
cal Association, and for several years afterwards, Dr. 
Fox was very prominent in advancing its interests and 
furthering its objects. He attended the meetings as 
one of the delegates from the College of Physicians. 

In the practice of his profession Dr. Fox was emi- 
nently successful in curing kis patients; or, if such 
phraseology be not acceptable, patients were very apt 
to get well under the means he used. As an instance 
of this, of all the cases in which he was forced to am- 
putate a limb at the Pennsylvania Hospital, some twenty 
m number, only one died. He was distinguished for 
good judgment, and he was prompt, energetic, and not 
sparing of himself when his patients needed him. 
Moreover, to use a frank phrase, «/ avait Us opinions 
franc Aus; he was not habitually indifferent as to which 
course to pursue, but he was decided in believing one 
certain thmg was the one thing to do, and that he did. 

Dr. Fox was happily married on September 25, 1850, 
to Sarah D. Valentine, of Bellefonte, oy whom he had 
six children, four sons and two daughters, all of whom 
survive him. One of his sons, Joseph M. Fox, has 
graduated in medicine, and been resident in the Penn- 
sylvania Hospital; thus far following in his father's 
footsteps. Dos magna, virtus parentum ; this is true 
in our profession as elsewhere. 



NEWS ITEMS. 



WASHINGTON. 
(PivM our Sftdal Corrtiptmdent.) 

Special Legislation to continue the Immigrant 
Inspection Service to the National Board of 
Health. — At the semi-annual meeting of the National 
Board of Health held in Washington, D. C, December 
12-14, the following communication was submitted: 
Washington, D. C, December la, i88a. 

At a meeting of representatives of State and other 
boards of health, who have come here to place before 
the National Board of Health the importance of con- 
tinuing the sanitarjr inspection of immigrants for the 
prevention of the mtroduction of contagious diseases 
mto this country, and their spread throughout the 
country, W. M. Smith, M.D., Health Officer of the port 
of New York, was chosen chairman, and Dr. Henry 
B. Baker, Secretary of the Michigan State Board of 
Health, was chosen secretary. 

The subject having been verbally presented to the 
National Board of Health, at its meetmg this day, and 
the Board having requested a summary statement in 
writing of the views of those present, the subject was 
discussed at some length, and - a communication to 
the National Board of Health was formulated as fol- 
lows : 

To the National Board of Health : 

Gentlemen: The undersigned respectfully repre- 
sent that the maintenance, at the principal ports of 
entry in the United States, of an efficient sanitary 



inspection gf immigrants as to their protection from 
smallpox, and as to their liability to communicate that 
disease, is necessary to prevent the frequent introduc- 
tion of smallpox and other contagious diseases among 
the people of this country ; and that such inspection 
is necessary to secure efficient action at ports of de- 
parture and on board ships on the part of the trans- 
atlantic steamship lines engaged in the transportation 
of immigrants. 

There is also urgent need for constant watchfulness 
to detect contagious disease occurring in immigrants 
after they have passed the ports of entry — the disease 
not having appeared when they were examined at the 
port of entry. 

We therefore urge upon you the necessity for con- 
tinuing such inspections as have been established. 

This inspection service is such that its benefits have 
no relations to State boundaries, but its protective in- 
fluences extend widely throughout this country, con- 
sequently expenses therefor should not properly be 
borne by any local or State board of health. We 
believe that it is the duty, and one of the highest 
duties, of the national government to maintain this 
inspection service whenever needed in this country. 

In our opinion, the sum of $25,000 will be sufficient 
for this service during the remaining months of this 
fiscal year. 

Wm. M. Smith, Health Officer, Port of New York. 
John H. Ranch, Secretary State Board of Health of 
Illinois. H. R. Mills, M.D., Henry B. Baker, M.D.,» 
Secretary Michigan State Board of Health. 

This report and the recommendations were concurred 
in by a large number of representatives of State and 
city boards of health who were present. 

This communication was transmitted by the Board 
to Congress, and was referred to the committee on 
Epidemic DiseSses, and on the Public Health in the 
Senate and House of Representatives. 

Senator Conger and Mr. Roch, of ^^ichigan, have 
since introduced bills into the two Houses appropriat- 
ing $25,000 to enable the National Board to continue 
the service during the remainder of the fiscal year. 

NEW ORLEANS. 
( From our Special Correspondent.) 

Present Prevalence of Malaria, and its Clin- 
ical History.— The weather here has been exception- 
ally beautiful. Frosty nights have been followed by 
cloudless days and a bracing atmosphere. Notwith- 
standing this fact, the admissions to the Charity Hos- 
pital have been unusuallv large — averaging nearly fifty 
a day. Almost the whole of these new admissions are 
persons suffering from malarious affections. Although 
the first range of temperature arrests at once the fur- 
ther development of the malarial poison, there can be 
no question that it is liable to determine attacks in the 
persons of those previously exposed to its influence. 

After more than two score years of study of the phe- 
nomena of this class of diseases, your correspondent 
can declare that the most remarkable feature that they 
present to his mind is the difference in symptoms which 
they present in some seasons as compared with other 
seasons. During the present year, diarrhoea and ma- 
larial coma have been the most common and danger- 
ous symptoms. In some former years haematuria and 
congestive chills have been the principal sources of 
danger. This year he has not met with a case of either 
of these forms of pernicious fever. 

Why should these differences obtain in the effects of 
a poison which is commonly looked upon as isomor- 
phous ? 

There appears to be no way of explaining the fact, 
except by admitting differences in toxic qualities of 



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[Medical Nxw$, 



different crops, or by claiming that the systems of 
those exposed undergo some unknown changes which 
determine the variations in the effects of the poison. 
The former appears to be the more rational theory. 

The mortality rate from this class of diseases has 
not been great. The diarrhoeas have in many in-' 
stances been cured by cinchonism. Where this has 
failed, small doses of sulphate of soda and morphia 
have ordinarily accomplished a cure." 

Quite a number of cases have been complicated by 
cardiac troubles. The most common of these has 
been dilatation caused by undue physical exertion in 
that state of innutrition and muscular atony caused 
by chronic malarial toxaemia. These cases recover 
with surprising certaintv and rapidity as repair in the 
nutritive processes and restitution of degraded fluids 
are effected. Of course, rest from physical exertion is 
a sine qu& non to recovery. 

Inflammations of cardiac structures have also com- 
plicated several malarial fever cases. 

Your correspondent has now under observation a 
case of endocarditis associated with intense malarial 
cachexia, and a hypertrophied spleen, but with no his- 
tory of rheumatism. 

We are well satisfied that the malarial cachexia, like 
that of Bright's disease, invites inflammations of both 
mucous and serous structures. 

_We had one patient die of symptoms which he at- 
^buted to ante-mortem vascular clot. A previously 
strong man had two attacks of malarial fever during 
two months preceding the first observation. At this 
date he presented the appearance of alarming de- 
terioration of the systemic fluids, but he was encour- 
aged to hope for a reasonably prompt restitution. 
During a violent fit of vomiting he complained of 
sudden pain at the upper part of the sternum and in 
the precordial region. At our next trisit we found a 
very intermittent heart, with cool extremities and sur- 
face and anxious countenance. A peculiar systolic 
murmur was heard over the heart and quite as dis- 
tinctly over the upper part of the sternum. Death en- 
sued about forty-eight nours afterwards, but no autopsy 
was permitted. 

BOSTON. 
(Prom our Sptcial Corresprndtnt.) 

Dr. Carpenter's Fifth Lecture on Human Au- 
tomatism. — The first subject discussed was the au- 
tomatism of those perceptive processes, by which are 
determined the distance, direction, and notably the 
solid form of external objects. In us this is acquired 
instead of being congenital as in the lower animals. 
Many observations of infants and of adults who have 
recovered sight by means of the removal of the lens 
icatoract) prove the truth of this statement, and show 
that a combination of the impressions received from 
several senses is necessary in order to create the ideas 
we possess of external objects. A person blind from 
birth, upon obtaining vision, will not recognize forms 
like the cube, sphere, and pyramid, notwithstanding 
the sense of 'touch has long since made them fa- 
miliar. Locke doubted this and the question, then 
unanswerable, since his time has received repeated 
answer. For example, a young man whose signt was 
restored in one eye, was unable by vision to distin- 
guish a cat from a dog, both of which he was accus- 
tomed to fondle. He finally taught himself to know 
the cat by handling her frequently, meanwhile looking 
at her intently. A remarkable case was that of a child 
aged 4 years, blind from birth, who recovered sight by 
the operation for cataract. He gave evidence of his 
ability to see. The operation had occurred in a house 
with which the boy had become familiar by feeling his 



way about. After the operation, while going over the 
house, he at first felt and looked as he went, but for 
some time evidently preferred the guidance of touch, 
and eventually began to find his way by sight alone. 
Upon returning to his home, however, he was quite 
unable to discover his way by sight among objects per- 
fectly familiar to him and for a long time closed his 
eyes in going from place to place. But when taken to 
a place entirely strange to him he used his sight with- 
out embarrassment, and finally overcame the difliculty 
in using sight at home. 

In a third case a blind seamstress obtained her sight, 
and when shown a pair of scissors could not recognize 
without touching them. These examples indicate the 
amount of education necessary in the training of our 
automaton, which, once disciplined, subsequently 
makes no mistake unless something is wrong in the 
mechanism. 

Our perception of solid form is the result of a union 
of the effects of two modes of perception, as is proved 
by the stereoscope. In looking through this instru- 
ment two slightly dissimilar pictures, such as are 
thrown upon the retina of the two eyes, when the ob- 
served object is near, by their difference in direction 
form an object in relief and the mind thus perceives 
one solid object instead of two flat ones. This conver- 
sion is an automatic process the. result of education. 
Sir Charles Wheatstone, who invented the stereoscope, 
also investigated the singular fact that a body first held 
at a distance, and then closer to the eyes, always pre- 
sents the same size to the mind, although the image on 
the retina is much larger. By bringing the pictures in 
the stereoscope nearer together, thus causing the eyes 
to converge, the object shown seemed to diminish in 
size, although the images on the retinae were not 
changed in dimension. In a similar manner, if the 
pictures were separated until the direction of the eyes 
was made parallel, the size of the object was made ap- 
parently to increase in size. This proves that the idea 
of the size of near objects and the relative distance of 
their posts depends upon an automatic comparison of 
the size of the image on the retinae and the degree of 
convergence of the eyes. (Dr. Carpenter discussed 
these phenomena more at length in the Edinburgh 
Review about i860.) 

At distances which make the direction of the eyes 
sensibly parallel, we no longer possess this muscular 
aid in determining size and relief, atad our perceptions, 
depending mainly upon light and shade, are accord- 
ingly less distinct. At a distance we cannot distin- 
guish objects actually in relief from carefully painted 
flat surfaces. This is really due to the absence of con- 
vergence, as proved by the fact that a photograph, the 
mountings being concealed, if seen with one eye alone 
appears to be an object in relief. 

Passing to the automatisms of the higher intellectual 
processes, the lecturer discussed those uniformities 
which, some being general in the race, others being the 
result of special training, and already studied under 
the name of " laws of thought," markedly illustrate 
the doctrine of automatism as well as the power of 
the will to devote itself to such processes as may be 
chosen. Wordsworth has testified that his best poetry 
was created by allowing his mind to direct itself in- 
tently upon all the phases of his subject, and then 
waiting for a spontaneous outflow of poetical imagery 
from his mental mechanism. Mozart, whose musical 
faculty had from childhood been trained with most 
assiduous care, had only to think out the general plan 
of a composition, deciding as to the place to be given 
to solo, recitation, duet, quartette, etc., and then allow 
his thought to work of itself and evolve its own results. 
In the same way trained mathematicians solve difHcult 
problems. But most instructive of all is the action of 



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memory. We endeavor to recall some half-forgotten 
fact, name, or date. After fixing the attention upon 
the subject for a certain length of time, and recalling 
every accessible circumstance, we find it better to 
withdraw the attention, to "hang up " the subject, and 
leave the matter to time. The general result will be a 
sudden return of the missing fact to the consciousness. 
In all these cases of " unconscious cerebration," it is 
noteworthy that we must first give direction to the pro- 
cess, and, moreover, that in order to obtain results we 
must previously train the automata. Other instances 
were given. 

Evolutions of the judgment are also common under 
the same conditions of a previous training, antecedent 
fixing of the attention, and, as far as possible, a volun- 
tary development of the process. Thus an executor 
unable to decide as to the best solution of a difficult 
provision in a will, arranged a plan which, though un- 
satisfactory, seemed the most feasible, and then dis- 
missed the matter from his mind. Some days later, on 
waking from a sound sleep, a perfect plan flashed into 
his consciousness and was accepted without change. 
Experience has shown that these automata, once 
trained, work far better when left alone than when the- 
attention is fixed upon them. When we apply the 
theory of automatism to our beliefs, there arises the 
question as to whether we are responsible for them, 
and whether we can believe what we wish to be- 
lieve. The reply is that if we have accustomed 
ourselves to give due weight to all the evidence which 
may affect our conclusions, we are not responsible for 
our belief. We may, however, close our mental eyes 
to certain aspects of the case, just as an unjust judge 
may refuse to admit evidence on one side and unduly 
admit it on the other. In such case we are directly re- 
sponsible for what we believe. 



The Philadelphia Polyclinic and College for 
Graduates in Medicine. — It is proposed to establish 
in this cit^ a Polyclinic, and the faculty, so far as 
arranged, is constituted as follows : Dr. Chas. H. Bur- 
nett, Diseases of the Ear; Dr. J Solis Cohen, Diseases 
of the Throat and Nose ; Dr. Henry Leffman, Clinical 
Chemistry and Toxicology; Dr. Richard H. Levis, 
Operative and Clinical Surgery; Dr. Morris Long- 
streth, Pathology and Post-mortem Examinations ; Dr. 
Chas. K. Mills, Diseases of the Mind and Nervous 
System ; Dr. Thos. G. Morton, Orthopaedic and Gen- 
eral Surgery; Dr. John B. Roberts, Applied Anatomy 
and Practical Surgery ; Dr. Wm. Thomson, Diseases 
of the Eye ; Dr. Jas. C. Wilson, Diseases of the Chest 
and General Medicine ; Dr. John B. Roberts, Secre- 
tary. It is proposed to have a large building devoted 
solely to the purposes of the school. Dispensaries 
will be conducted in connection with each department, 
and instruction will be clinical and demonstrative, in 
series of short courses of from six to eight weeks ; 
studies may be pursued in all branches or on special 
subjects. Demonstrators and assistants, with the pro- 
fessors, will give clinical lessons in each department 
dailv. _ It is also proposed to furnish hospital accom- 
modations for cases which require it. 

Annual Address Before the . Philadelphia 
Academy of Surgery. — Dr. William Hunt will de- 
liver the Annual Address before the Philadelphia 
Academy of Surgery on Monday evening, January 8th, 
at 8 o'clock, in the Hall of the College of Physicians 
— subject, Esmarch and Antisepsis. 

Complimentary Dinner to Prof. Austin Flint, 
Sr. — A number of prominent members of the medical 
profession of Philadelphia will entertain Prof. Flint at 
a dinner on next Friday evening. The chair will be 
occupied by Prof. Alfred Stilli. 



Semi-centennial of the University of Zurich. 
— The University of Zurich will, at the end of the 
current winter term, celebrate the fiftieth anniversary 
of its foundation. 

Lumleian, Croonian, and Gulstonian Lectures. 
— The Lumleian Lectures for 1883, at the Royal Col- 
lege of Physicians, will be delivered by Dr. A. B. 
Garrod, on " Uric Acid ; its Relations to Renal Calculi 
and Gravel." The Croonian Lectures will be delivered 
by Dr. J. E. Pollock, the subject being "Modern The- 
ories and Treatment of Phthisis;" and the Gulstonian 
Lectures, on the " Nature, Causes, and Treatment of 
Sterility in Woman," by Dr. Matthews Duncan. 

Strafford District (N. H.) Medical Society. — 
The 75th annual meeting of the Strafford District, New 
Hampshire, Medical Society was held at Dover, on 
December 19th, with Dr. S. C. Whittier, of Portsmouth, 
Chairman, and Dr. C. A. Fairbanks of Dover, Secre- 
tary. The following officers were elected for the ensu- 
ing year : 

President. — Dr. John R. Ham, of Dover. 

Secretary. — Dr. Charles A. Fairbanks, of Dover. 

Treasurer. — Dr. Charles A. Tufts. 

Porro's Operation. — On Nov. 27, Dr. C. Godson, 
Assistant Physician-Accoucheur to St. Bartholomew's 
Hospital, performed Porro's operation on a dwarf, aged' 
24, whose pelvis was distorted to an extreme degree. 
The patient was returned to her bed one hour after the 
commencement of the operation ; the child was a girl, 
twenty inches in length, and eight pounds and a half 
in weight; the mother being but fifty- two inches in 
height. Up till November 29, the case was reported 
as doing well ; the temperature had not risen above a 
maximum of 99.4° Fahr., and the pulse had never ex- 
ceeded 80 beats per minute. — British Medica/ Journal, 
Dec. 2, 1882. Later accounts report steady progress 
toward cure. 

The Public Health in Connecticut. — Dr. C. M. 
Chamberlain, Secretary of the State Board of Health, 
has just submitted his report for November, from which 
we learn that the record for November is in general 
more favorable than that for several preceding months. 
The ^tivaXenc^ oi scarlet fever uni of diphtheria in- 
creases the death-rates in several places. The proba- 
bility of an increase in the frequency and malignancy 
of scarlet fever, stated in the last report, has become a 
certainty in repeated instances. 

Measles is not reported in the mortality list, nor from 
any part of the State. Its prevalence for the last few 
years would indicate that there were few children left 
that had not had this disease, and in one or two in- 
stances its recurrence for the third time was men- 
tioned. 

Whooping-cough is reported more frequently than it 
has been for several months. Cases are stated to be 
in Simsbury, South Manchester, Haddam,, and in the 
southern part of the State. 

Diphtheria is reported from Avon, Hampton, Water- 
town, and Manchester — a few case^ in each place. 

The same general tendencies in typhoid a.nA malarial 
fevers that have been noted the last few months con- 
tinue. There is not any alarming prevalence of typhoid 
fever, nor has there been any degree of prevalence 
that would have been noticeable in former years, 
except in certain localities where there have been 
localized epidemics. The cases of typhoid fever are 
peculiarly interesting, because they are happening in 
localities where a case has not been reported for years, 
or where there have been very few cases. There has 
not yet been reported, taking the State as a whole, as 



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NOTES AND QUERIES. 



[Medical News, 



many cases as occurred each year on an average be- 
fore the appearance of malaria, although this year 
approaches it. 

There was in many places, and in general every- 
where, as far as reports are received, an unusual 
amount of sickness during the autumn months, more 
marked where the local unsanitary conditfons were 
worst. There is no occasion for a {ianic over the ap- 
pearance of scarlet fever, but it is the part of wisdom 
to prevent its spread as much as possible. The utility 
of a hospital for contagious diseases suggests itself 
strongly when we see child after child in a poor man's 
family attacked by contagion from which he might 
have been saved could the first case have been iso- 
lated, as has been done with success again and again 
by means of such institutions. The idea is not a pop- 
ular one at first, but others less so have proved their 
claims for recognition. 

Lung fever a.pptAxs early, and apparently the mor- 
tality corresponds with that of last year. Above the 
average cases are reported from North Manchester, 
Watertown, Hampton, and Avon, and one fatal case 
from Guilford. 

Review of the Situation. — In comparison with pre- 
ceding months this has been quite a healthful one. 
But the large percentage of zymotic diseases, and the 
amount of sickness indicated, show plainly that there 
.were many agencies at work that could have been 
prevented. 

Health in Michigan. — Reports to the State Board 
of Health, for the week ending December 23, 1882, indi- 
cate that cholera morbus, diarrhoea, typhoid fever, and 
diphtheria have increased, and that intermittent fever, 
pneumonia, dysentery, and remittent fever have de- 
creased in area of prevalence. Including reports by 
regular observers and by others, diphtheria was re- 
ported present during the week ending December 23, 
or since, at 16 places, scarlet fever at 10 places, and 
measles at 4 places. Smallpox was reported at Rich- 
mond, Osceola County, December 27. 

Precautions against Cholera. — Dr. Hampshire, 
the Senior Medical Officer of Penang, India, in his re- 
port for the month of September, intimates that the 
spread of cholera in the East and around the Straits, 
and its gradual extension in a westerly direction have 
caused considerable anxiety to the health authorities. 
To prevent its spread, when it occurs periodically, all 
measures have been taken so far as the legal powers 
permit, but native prejudices do not allow of their being 
carried out as effectually as in European countries. 
Doubts are entertained by the public, under the at 
present necessarily imperfect verification and registra- 
tion of disease, as to whether all cases of cholera that 
have occurred have really been registered as such ; 
but during the past few months the death registers at 
the different town and suburban police stations have 
been frequently examined, with the view of detecting 
any local increase in the mortality, should such occur. 
And in the case of doubtful entries, further inquiries 
have been made at the house of the deceased, among 
relatives and friends, in order to verify the diagnosis. 

Among Chinese, who bury their dead in coffins her- 
metically sealed, with free disinfection as a preliminary, 
no great danger is involved in the burial rites ; but 
among Hindoos and Mahommedans the body is re- 
tainea in a room, crowded with relatives and friends, 
for a period varying from twelve to thirty-six hours, 
no disinfectants being used in the meanwhile. It is 
urged that, as Hindoos and Mahommedans, many of 
whom are aliens, constitute less than fifty per cent, of 
the population, some concession on their part is due 
to the majority of the population. 



Obituary Record. — Died in Munich, on Dec. 5th, 
Prof, von Bischofp in the 75th year of his age. Prof, 
v. B. was bom in Hanover, Oct. 28, 1807, and studied 
natural science and medicine in Bonn and Heidelberg. 
After having served as an assistant in Berlin and Bonn, 
he was called in 1836 to Heidelberg to the chair of 
Comparative and Pathological Anatomy ; in 1843 ^c 
was called to Giessen to the chair of Anatomy and 
Physiology, and 1855 to the same position in Munich, 
which he filled up to the time of his death. 

His reputation rests* on his numerous and valuable 
contributions to the embryology of mammals. 



NOTES AND QUERIES. 



MEDICINiE SPECIALIS MAGISTER. 

To the Editor of THE Medical News. 

Sir : I see it stated in a recent journal that the Faculty of Med- 
icine in Paris proposes creating "a higlier doctorate than the 
simple M.D. It is proposed to confer the degree of " Doctor of 
Medical Sciences," after special examinations, and perhaps only 
after original work. The same journal goes on to say that America 
rapidly adopts European ideas, and that we may perhaps soon hear 
of a similar degree in this country. It has been rumored in the 
recently published accounts of the New York Post-graduate Med- 
ical School that there is a possibility of a degree higher than M.D. 
being conferred by that institution. If this or similar colleges for 
graduates, hereafter established, confer a degree, nothing appears 
to me so appropriate as " Master of Special Medicine." Such 
colleges are especially designed to give instruction in the special- 
ties; hence the title " Medicinse Specialis Magister" (M.S.M.) 
seems a proper designation for one wlio has passed an examination 
in such branches. It corresponds with the present custom of con- 
ferring the higher degrees in arts and surgery, as, for example, 
Artium Magister, Scientise Magister, Chirurgise Magister, and is, 
I think, preferable to " Doctor of Special Medicine," or " Doctor 
of Medical Specialties," which might also be suggested with a 
considerable degree of propriety. 

Yours respectfully, 

John B. Roberts. 

offiaal list of changes of stations and duties 
of officers of the medical department, u. s. 

ARMY, FROM DECEMBER 2$, 1 88 2, TO JANUARY I, 
1883. 

Perin, Glover, Lieutenant-Colonel and Surgeon. — Granted 
leave of absence for one month, from the 19th inst. — S. O. 2tj 
Department of Dakota, December 20, 1883. 

Bill, Joseph H., Major and Surgeon.— Vila report to the 
commanding officer, Fort Omaha, Neb., for duty. — Par. 4, S. O. 
'34. Department of the Platte, Deeemier ai, i88a. 

KlLBOURNE, H. S., Captain and Assistant Surgeon.— OrajsXxA 
leave of absence for one month, with permission to apply through 
Headquarters Military Division of the Missouri for an extension 
of two months.— £ O. 218, Department of Dakota, December ai 
i88a. 

Reed, Walter, Captain and Assistant Surgeon.— Rtiitrted 
from duty as attending surgeon, headquarters Department of the 
Platte, and will report in person to the commanding officer Fort 
Omaha. Neb., for duty.— 5. O. 134, Department of the PlatU, 
December ai, 1883. 

TURRILL, H. S., Captain and Assistant 51i(r«<w».— Upon being 
relieved from duty at Fort Omaha, Neb., will proceed to Fort 
Fred. Steele, Wyoming, and report to the commanding officer of 
that post for duty thereat. — Par. $, •?. O. T34, Department of the 
Platte, December ai, 1883. 

Hopkins, Wm. E„ Assistant Surgeon.— Oraniei leave of ab- 
sence for two months, to commence January i, 1883, with per- 
mission to apply for an extension of two months. — Par. 1, S. O. 
88, Military Division of the Atlantic, December 38, 1883. 

The Medical News mil be pleased to receive early intelli- 
gence of local events of general medical interest, or of matteri 
wkick It is desirable to brtng to the notice of the prefestum. 

Local papers contaisting reports or news Hems sklMeld be marked. 

Letters, whether written for pubUeation or private iirformaiiom. 
must be OMthentieated by the naaius and addresses of their writert — 
of course not necessarily for publication. 

All eommunitations relattsig to the editorial depatrtment of the 
News should be addressed to No. 1004 Wahtmt Street, Pkiladelfkiet. 



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THE MEDICAL NEWS. 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



Vol. XLII. 



Saturday, January 13, 1883. 



No. 2. 



ORIGINAL LECTURES. 



PHILADELPHIA COUNTY MEDICAL SOCIETY 
LECTURES. 

ON THE PHYSICAL EXPLORATION OF THE 

LUNGS BY MEANS OF AUSCULTATION 

AND PERCUSSION. 

A course of thru Ufhires delivered hy invitation iefore the 
PhiladelpTiia County Medical Society. 

By AUSTIN FLINT, M.D., 

nOFSSSOK OP THB PRINCIPLES AMD PRACTICS OP MBOiaNS AMD OP 

CUHICAL HBDia»B IN THS BSLLIVUB HOSPITAL MBDICAL 

COLLBCB, NBW YORK. 



LECTURE II. 

AUSCULTATION. 

Delivered December i6, iSSi. 

The exploration of the lungs by means of ausculta- 
tion divides itself into the study : First, of the normal 
respiratory sounds and their abnormal modifications ; 
second, of adventitious sounds, or rales ; and, third, of 
voc»l sounds, the latter including, with the loud or 
laryngeal, the whispered voice. 

STETHOSCOPES. 

The question whether auscultation should be mediate 
or immediate, is easily disposed of. It should be prac- 
tised in both ways, according to the circumstances in 
particular cases. Laennec, as is well known, employed 
only mediate auscultation. He probably failed to rec- 
ognize the value of immediate auscultation, because 
all bis observations were made exclusively with the 
stethoscope. Some of those present may be interested 
in seeing the kind of stethoscope which Laennec em- 
ployed. His first instrument was a cylinder of paper, 
consisting of three quires rolled together and kept in 
place by paste. He then tried instruments made of 
metal, glass, and wood, instead of the paper cylinder. 
Quoting his words, " In consequence of tnese various 
experiments, I now employ a cylinder of wood an inch 
and a half in diameter and a foot lone, perforated lon- 
gitudinally by a bore three lines wide, and hollowed 
out into a funnel shape to the depth of an inch and a 
half at one of its extremities. It is divided into two 
portions, partly for the convenience of carriage and 
partly to permit its being used of half the usual length. 
The instrument in this form — that is, with the funnel- 
shaped extremity — is used in exploring the respiration 
and the rales ; when applied to the exploration of the 
heart and the voice, it is converted into a simple tube 
with thick sides, by inserting into its excavated ex- 
tremity a stopper or plug traversed by a small aper- 
ture, and accurately adjusted to the excavation. This 
instrument I have denominated the stethoscope." 

The stethoscope which I exhibit has an interest aside 
from the illustration of the kind which Laennec used. 
It not only belonged to Laennec himself, but was un- 
doubtedly made with his own hands. Its authenticity, 
as having belonged to Laennec, is indubitable. It was 
given to me by a former colleague, the late Professor 
Choppin, of New Orleans, and it was given to him in 
Paris, by an old physician, who was Laennec's interne 
in the Hospital Necker, and who received it from Laen- 
nec himself. Laennec, as is known, was accustomed 
to make stethoscopes for his own use and for his friends. 



Moreov^, the instrument bears intrinsic evidence of 
having been made by an amateur mechanic. When in 
the possession of the interne referred to (whose name 
I have forgotten), it was evidently not regarded with the 
same respect which it nqw claims, for the aural end 
has the traces of a penknife, showing that this sort of 
petty vandalism is not exclusively an American trait. 
In connection with the stethoscope made by Laen- 
nec, I exhibit another, which is of interest, as having 
belonged to Valentine Molt, who obtained it in Paris, 
when the stethoscope devised by Laennec was in com- 
mon use. This instrument, as you perceive, was made 
by a true mechanic. It is nicely polished and the ends 
are encircled with ivory. 

In a recent lecture on the " Evolution of the Stetho- 
scope," Samuel Wilks, of London, says, " I know not 
who invented the instruments with flexible tubes, but 
I have no doubt that a s.earch into medical history 
would tell us." The stethoscope, with a single flexible 
tube, was devised by Carter Nestor Pennock. It was a 
great improvement on the wooden cylinders of every 
variety of shape devised by auscultators in different 
countries. Pennock's stethoscope consisted of a bell- 
shaped pectoral portion of metal, connected by a hol- 
low flexible tube with a metallic ear-piece, the latter 
being introduced within the meatus auditorius. A still 
greater improvement was the binaural stethoscope de- 
vised by Cammann, in 1854. The advantages of this 
stethoscope are so great that, after a fair trial by any 
one, it is sure to supersede any other at present in use. 
After nearly Ikirty years from the date of its introduc- 
tion by Cammann, it has come into considerable, but 
not as yet general, use throughout our own country, 
and it is but little used in other countries. I can speak 
of this instrument after ample experience, inasmuch as 
I have used it almost daily since 1855. 

In my work on Physical Exploration, published in 
1856. I stated that it was more difficult to judge of the 
quality and pitch of sound transmitted by Cammann's 
stethoscope, than with the wooden cylinder. This was 
an error, arising from my not then having used that 
stethoscope sufficiently to appreciate it fully. I corrected 
the error in a subsequent edition, but the error was 
quoted by Walshe, and appears in all the subsequent 
editions of his work on diseases of the lungs. Much to 
my regret, therefore, I may unwittingly have done some- 
thing toward retarding the adoption of the instrument 
by our British brethren. Wilks, however, in his recent 
lecture, already referred to, appears to cohslder the 
binaural instrument as the result of the " evolution of 
the stethoscope " up to the present time, on the " prin- 
ciple of selection and the survival of the fittest," and he 
remarks that "the primitive instruments are indeed 
only to be found amongst the fossilized curiosities — the 
relics of former ages — on the antiquated shelves of 
some very old medical practitioner." The advantages 
of the binaural stethoscope relate to a conduction of 
sounds far better than by any uniaural instrument, and 
to gp-eater facility in its employment. But there are 
certain obstacles to be overcome in the way of the ap- 
preciation of the first of these advantages. Want of 
knowledge of these obstacles is, I am persuaded, a 
reason for the fact that, after nearly thirty years, this 
stethoscope, except in some parts of our own country, 
is not in common use. In the first place, many stetho- 
scopes, sold as the binaural stethoscope of Cammann, 
are essentially defective in their construction. Let me 



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ON THE PHYSICAL EXPLORATION OF THE LUNGS. 



[Medical N&ws, 



indicate the points which are often overlooked by in- 
strument makers. Cammann arranged the curves at 
the aural extremities so that when the terminating bulb 
is inserted into the ear, the opening in the bulb should 
have the direction of the external auditory canal. The 
conduction of sound is chiefly by the column of air 
within the instrument. This fact is readily demon- 
strated by obstructing one of the tubes leading to the 
pectoral end ; the sound is prevented from reaching 
the ear on the side of the obstructed tube. 

Another point in the construction is the size of the 
terminating bulb. This should not be too large to 
enter the meatus readily ; and, on the other hand, if 
too small, passing too far into the meatus, it occasions 
discomfort and even pain. If these points be not 
properly attended to in the construction, the instrument 
IS almost useless, and many instruments which have 
come under my notice have been defective therein. 
The flexible tubes should not be stiff. If they be so, 
every movement of the pectoral extremity acts within 
the ear as a lever, and occasions discomfort. The 
flexible tubes should move noiselessly. Sometimes 
the tubing used gives rise to a creaking sound which 
obscures other sounds. The elastic or the spring 
which is to hold the ends of the instrument within the 
ear should be neither too ^veak nor too strong. All 
these are minute points, but they are essential. It is 
proper to state that they are attended to by the instru- 
ment makers who made the first stethoscope under 
the personal direction of Cammann, Messrs. Tiemann 
& Co.. and I have seen stethoscopes made by Ford, of 
New York, with which no fault could be found. I am 
afraid it is not safe to trust to the majority of instru- 
ment makers, and yet I hesitate to make a sweeping 
assertion of this kind. 

Another obstacle applies to all perfectly constructed 
stethoscopes, namely, a humming sound belongs to the 
instrument, and this, for a time, confuses the attention. 
After a little use this obstacle disappears, ttie humming 
ceases to be observed, and the attention is free for the 
chest sounds. Before this, however, the instrument is 
often thrown aside as unsatisfactory. I have had much 
experience in giving practical instruction in ausculta- 
tion to classes, and I have always found that at the 
commencement of a course most members of a class 
appreciate thoracic sounds better with the ear applied 
directly to the chest than by the use of the binaural 
stethoscope, but after a short time the stethoscope be- 
comes so attractive that it is difficult to enforce suffi- 
cient exercise of the ear in immediate auscultation. 

Wilks, in his interesting lecture on stethoscopes, 
refers to a fact first pointed out to him by Andrew 
Clark, which relates to a peculiarity of the binaural 
instrument in the objective appreciation of sounds. It 
is as follows : " If each ear-piece be separately used, 
and any sound be made near the mouth-piece, it is 
heard in the ear itself; but if the two pieces are em- 
ployed together, the sound is heard at the spot where 
It is produced." "This fact," he adds, "corroborates 
the theory as to the value of a double set of senses, 
. . . . the two ears listening to the same sound 
more thoroughly appreciate its objectivity." This fact 
is easily verified. 

I should, perhaps, refer to Alison's differential steth- 
oscope, which I exhibit. It is a binaural stetnoscope, 
but with a double pectoral extremity. Sounds from 
two situations are received simultaneously, but from 
each situation, into one ear. The theory is that the 
sounds from the two situations can in this way be best 
compared with each other. The theory is fallacious. 
If we wish to bring into comparison two sounds which 
are not musical, or if we wish to compare the quality 
of two musical notes, we do not desire to listen to both 
at the same instant, but to each in succession. The 



increased conduction of sounds by means of a binaural 
conductor is not obtained by Alison's stethoscope, and 
a little practice will render it evident that with Cam- 
mann's instrument sounds in different situations, lis- 
tened to consecutively, are much better compared than 
by the so-called differential stethoscope. 

THE NORMAL VESICULAR MURMUR OF RESPIRATION. 

Auscultatory sounds, like those obtained by percus- 
sion, are to be studied analytically with reference to 
their differential characters. They are to be studied 
with special reference to differences in pitch, quality, 
and intensity ; but the other points of distinction which 
have been mentioned already are to be considered ; 
namely, the duration of respiratory sounds, the rhythm- 
ical succession of the sounds of inspiration and expi- 
ration, and the apparent nearness to or distance from 
the ear, especially of vocal sounds. It is needless to 
say that in the study of auscultation, as of percussion, 
the analysis of the normal sound should precede and 
be the point of departure for determining the differential 
characters of the abnormal sounds which are signs of 
disease. Entering upon the consideration of respira- 
tory sounds, the normal pulmonary murmur of respi- 
ration is to be first considered. 

Seeking naturally to give an idea of this murmur by 
likening it to something familiar, Laennec found no 
better comparison than to the sound of a person breath- 
ing tranquilly in sleep. Feeble as is this comparison, 
a better has not been suggested. The comparison by 
Skoda to the sound of air sucked in by the lips, is 
quite as indefinite. It has been compared to the 
sound of the wind passing through foliage. This is 
not an improvement on the comparison by Laennec, 
except that it has something of a poetic savor. From 
this comparison the quality of the murmur has some- 
times been called breezy. Analyzed with reference to 
its component characters, the intensity varies so much 
in different healthy persoQS that nothing distinctive is 
to be derived from this source. The pitch, as com- 
pared with that of the more important of the morbid 
respiratory sounds, is low. Here is one distinctive 
feature. The quality, like that of the normal reso- 
nance on percussion, is sui generis. It cannot be de- 
scribed by words which give any definite idea of it. 
It has no close analogy to any other sound produced 
outside of the body. It can only be correctly appre- 
ciated by direct observation. The quality may be 
called vesicular for the same reason that the quality of 
the normal resonance on percussion is so called ; in 
each of these normal signs the quality is incident to 
the vesicular structure of the lungs. This structure is 
so peculiar that it cannot be fully represented by any 
artificial contrivance by which the movements of air 
within the structure may be imitated ; hence, the fact 
that the quality of the respiratory murmur, as well as 
that of the normal resonance on percussion, is sui 
generis. These characters of pitch and quality relate 
to the inspiratory sound. The relative characters of 
the expiratory sound are of importance in distinguish- 
ing the normal murmur from certain morbid respira- 
tory signs. The expiratory sound is much shorter than 
the inspiratory, and also much weaker. It has no 
vesicular quality. I know of no better way of ex- 
pressing the quality than by calling it simply blowing. 
It is not unlike the sound of the expired breath from- 
the open mouth. 

Laennec's explanation of the vesicular respiration 
was that it is due to the friction of the air in the pul- 
monary alveoli. I need not take time to show that 
this explanation is unsatisfactory. To say, as does 
Skoda, that the murmur is due to the resistance which 
the cells offer to the air, is simply to state a fact with- 
out any explanation. Other explanations, alike un- 



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JANOARY 13. 1883.] ON THE PHYSICAL EXPLORATION OF THE LUNGS. 



31 



satisfactory, are, that it is due to contraction of the 
bronchial muscular fibres in the act of inspiration, as 
held by Blakiston and Leaning; and, as held by 
Zamminer an(] Seitz, that it is produced at the mouths 
of the infundibula, in the same way as sounds by 
blowing over the opening of a hollow key. Eichhorst, 
author of a German treatise on The Methods of Physi- 
cal Investigation in' Internal Diseases, (1881], after 
citing these explanations, assumes that it is a physical 
impossibility for the respiratory sounds to be produced 
by the currents of air within the pulmonary air pas- 
sages, and he considers, therefore, that their source 
must be within the larynx, being there produced by 
the projection of the vocal cords, and conducted 
downward by the air tubes. This is a revival of the 
doctrine of M. Beau, author of a work on Ausculta- 
tion (1856); an author whose fantasticgtheories were 
deemed of sufficient consequence to be always quoted 
by contemporaneous writers, but almost invariably 

auoted in order to dissent from them. This glottic 
leory of the mechanism of the vesicular murmur of 
respiration is rfeadily disposed of by a very simple ex- 
periment. Remove the lungs from the body and 
separate them from the trachea. Now, if respiration be 
imitated by means of the bellows, the nozzle being intro- 
duced into a primary bronchus, or by means of one of 
the flexible tubes connected with Davidson's syringe, 
and the lung be auscultated, either by immediate aus- 
cultation or the stethoscope, the vesicular murmur is 
reproduced, much intensified as compared with the 
murmur in life. This experiment, assuredly, disproves 
the physical impossibility of the production of respira- 
tory sounds within the pulmonary air passages, and, 
consequently, the glottic theory of the production of 
the vesicular murmur. 

For the true explanation (as it seems to me) of the 
vesicular murmur I am unable to give credit to any 
writer. In my work on Physical Exploration, pub- 
lished in 1856, I. submitted the following inquiry: 
" May not the peculiar quality be owing to the separa- 
tion of the sides of the cells and the capillary tubes 
which, to a greater or less extent, come into contact, 
and, owing to the moisture of the tissues, are slightly 
adherent during the collapse of the lung incident to 
expiration ?" And I added, " We shall see hereafter 
that this is the most rational explanation of an impor- 
tant and highly distinctive physical sign of disease." 
Allusion in the latter sentence was made to the crepi- 
tant rale. It is noteworthy that Laennec, in describ- 
ing the differences between the vesicular murmur and 
bronchial respiration, says that the latter loses the 
" slight crepitation " which belongs to the former. The 
expression " slight crepitation " distinguishes more 
accurately than any other term the peculiar quality of 
the vesicular murmur, and, at the same time, it denotes 
the mechanism. The explanation whidi, more than a 
<]uarter of a century ago, I submitted in the form of an 
inquiry, I have ever since taught as the true explana- 
tion. As corroborative of its truth, I submit the follow- 
ing experiment : 

Take the lungs of any animal of sufficient size (a 
sheep or a calf), twelve or twenty-four hours after the 
animal has been killed, and introduce the nozzle of a 
pair of bellows into either the trachea or one of the 
primary bronchi. Imitate respiratory acts by means 
of the bellows. If the stethoscope be placed directly 
upon the lungs, or with a folded napkin intervening, 
with each inflation a crepitating character of the sound 
is apparent. The inflation of portions which contained 
but little or no air, i. e., collapsed portions, gives a 
perfect representation of the crepitant rile. Now if 
the intervening folds of cloth between the stethoscope 
and the chest be sufficiently increased in thickness, 
the crepitating character is modified, and the quality 



becomes hyper- vesicular ; in other words, we obtain an 
intensified representation of the vesicular respiration. 
The lungs from the human body will, of course, answer 
as well as those of the calf or sheep. The crepitation 
may disappear '.after the inflations by means of the 
bellows have been continued for some time. The ex- 
pression by Laennec, "slight crepitation," therefore, 
expresses not only the character of the murmur, but 
the mechanism of its production. 

I refer to an experiment made by Penzoldt, and 
ci|||d by Eichhorst, in his work* on the methods of 
physical exploration, as exemplifying either the dis- 
advantage of not having studied respiratory sounds 
analytically with reference to pitch and quality, or the 
influence of the imagination on the observation of ^ 
sounds, or, perhaps, of both these two sources of error. 
It IS stated that if a portion of a solid organ, the liver, 
fop example, be placed over the larynx of a healthy 4 
subject, the laryngeal respiration is transmitted to the | 
eaj^of the auscultator without change ; but if a portion 
of mflated lung be so placed, the laryngeal respiration 
becomes changed, by its transmission, into a vesicular 
respiration. This latter statement is adduced by that 
author to show that the vesicular murmur of respiration 
is not produced within the pulmonary alveoli, but that 
it is the laryngeal respiration conducted through air 
vesicles. Let any observer, not biased by theoretical 
expectations, and familiar with the distinctive char- 
acters of the vesicular and the laryngeal respiration 
as determined by analytical study, repeat this simple 
experiment, and it will be found that there is no es- 
sential difference between the sounds as transmitted 
through the solid organ and the inflated lung. The 
inspiratory sound does not lose its tubularity, acquir- 
ing in its place the vesicular quality ; and the rela- 
tive pitch of the inspiratory as compared wiih the 
expiratory sound, is the same as when the stethoscope 
is placed immediately upon the integument covering 
the larynx. I make this statement after having re- 
peatedly made the experiment. Whether this state- 
ment or that of Penzoldt is correct, can be readily 
determined by any one who will take the little trouble 
requisite for repeating the experiment, and comparing 
the sounds analytically and impartially. 

BRONCHIAL RESPIRATION, 

Of the morbid respiratory signs, the one which offers, 
in its distinctive characters, the strongest contrast to 
those of the normal vesicular murmur, is the bronchial 
respiration, and there is an advantage, therefore, in 
considering first this sign. Let me enumerate the dis- 
tinctive characters of the bronchial respiration, as de- 
termined by analytical study, although, doubtless, they 
are familiar to those whom I now address. The in- 
tensity of both the inspiratory and the expiratory sound 
is often greater than that of the vesicular respiration ; 
t)ut this is not an essential feature. The inspiratory 
sound has no vesicular quality, but, in place thereof, a 
quality expressed by the term tubular. It is identical 
with the sound of a current of air through a tube. 
The pitch is high. The expiratory sound, usually 
more intense than the inspiratory, has a tubular in- 
stead of the simple blowing quality of the expiratory 
sound in the normal vesicular respiration ; it is higher 
in pitch than the inspiratory sound ; it is prolonged to 
the length of, or more, of the inspiratory sound, and, 
instead of being continuous with the latter, as is the 
case with the inspiratory and the expiratory sound in 
the normal vesicular respiration, the two sounds are 
separated by a brief interval of time. The latter char- 

1 Lehrbuch der Physikalisrhen Untersuchungstnethoden in- 
nerer Krankheiten, von Dr. Hermann Eichhorst, Braunschweie 
1881. * 



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acter is due to the fact that the inspiratory sound ceases 
a little before the cessation of the inspiratory act. 

No one doubts that the sign having the characters 
just enumerated is heard over solidified lung. It 
occurs, therefore, in the second stage of pneumonia, 
over lung compressed into a solid mass by the pressure 
of liquid or air within the pleural space ; also, m cases 
of phthisical exudation and induration, as well as in 
other affections which solidify the pulmonary structure. 
That the sign represents exclusively solidification of 
lung, however, is not universally acknowledged. The 
opinion is held by many that it represents, also, pul- 
monary cavities. When I come to consider the cavern- 
ous respiration, I shall undertake to demonstrate that 
this opinion is erroneous. I believe the bronchial 
respiration to be the respiratory sign of complete or 
considerable solidification of lung, and of no other 
morbid physical condition. The only room for doubt 
as regards this limitation of the significance of the 
sign, is afforded by cases of dilatation of the intra- 
pulmonary bronchi. In these cases, as it seems to me, 
the presence of this sign is due, not to the bronchial 
dilatation, but to the condensation of lung surrounding 
the dilated tubes. The artificial illustration of this 
sign is easy with Davidson's syringe. If the tube con- 
ducting from the central bulb be placed close to the 
ear, and covered with the hand, in order to exclude 
extraneous noises, the current of air produced by com- 
pression of tb« bulb causes a well-marked tubular 
sound. A similar sound is heard when the tube con- 
ducting to the bulb is placed close to the ear, th^ 
sound in this instance being caused by an expansion 
of the bulb. If we attach to the tube conducting from 
the central bulb other tubes of more or less length, and 
varying in size, the tubular sound is heard at any 
point with an equal force of the current of air, and the 
pitch is found to be somewhat higher the smaller the 
size of the tube. Blowing into the tube with the 
mouth will answer as well as Davidson's syringe ; and 
it is not necessary that the current be strong in order 
to produce a tubular sound. I oppose this simple ex- 
periment to the statement by Eichhorst that it is a 
physical impossibility for the movement of air in the 
Dronchial tubes to produce a sound. It seems sur- 
prising that an author should make 'this statement 
when it may be disproved by an experiment which 
can be made at any moment. 

The mechanism of the bronchial respiration, of 
course, involves the passage of air in tubes ; but it is 
a question in what tubes is the sound produced when 
this sign is heard over the chest. Laennec's explana- 
tion was simple, and, in the main, it has not been dis- 
proved. He referred the sound chiefly to the passage 
of a current of air in the larynx, trachea, and the large 
bronchi at the root of the lungs. He accounted for the 
absence of the sign over the nealthy chest, first, by the 
presence of the vesicular murmur, which drowns th^ 
Dronchial sound ; and, second, by supposing that the 
air vesicles containing air conduct sounds less readily 
than solidified lung. The better conduction of sounds 
by solidified lung than by the normal inflated lung was 
denied by Skoda. Skoda based his denial on physical 
principles and on certain experiments relating to the 
conduction of the voice. I shall refer to these experi- 
ments in connection with vocal signs. I will simply 
say here that I have repeated them, and with a result 
the same as stated by Skoda. Another experiment by 
Skoda is easily repeated ; namely, placing successively 
over the larynx portions of solidified lung and of in- 
flated lung, equal in volume, and comparing the trans- 
mission, through each of these media, of the laryngeal 
respiration. This experiment shows, according to my 
observations, that Laennec was in error in supposing 
that solidified lung is a better conductor of sound than 



healthy lung. It has been asserted that if a watch be 
placed alternately beneath portions of solidified and of 
healthy lung, of equal volume, auscultation shows thf 
solidified lung to oe the better conductor of sound. 
This experiment I have repeatedly made, and with a 
result the reverse of the assertion that the solidified 
lung is a better conductor. I may add that up to a 
recent date I had believed, in accordance with the gen- 
eral belief at the present time, that sounds were better 
conducted by solidified than by healthy lung contain- 
ing air. 

Laennec supposed that a current of air within the 
intra-pulmonary bronchi, and even in those of small 
size, cooperated in producing the bronchial respira- 
tion. This supposition has been deemed improbable, 
at least when an entire lobe is solidified, as in cases of 
lobar pneumviia. Skoda and others have main- 
tained that a current of air cannot take place within a 
solidified lobe. This view seems not irrational, con- 
sidering that the lobe is enlarged to the limit of a full 
inspiration, that its volume diminishes very little with 
expiration, and enlarges as little with iflspiration, and 
that the respiratory movements of the chest on the 
affected side are more or less restricted. Experiment, 
however, shows that air passes freely through the bron- 
chial tubes within a lobe solidified by pneumonia. In 
a lung removed from the body, the upper lobe com- 
pletely solidified and the upper two-thirds of the lower 
lobe solidified, the unsolidified portion of the lower 
lobe was readily inflated either by the bellows, or by 
the breath, the current being inserted either into the 
trachea or the primary bronchus. Moreover, in the 
condition just stated, a vesicular respiratory murmur 
was appreciable over the lower third of the lower lobe 
during life, as well as by inflation after death, a fact 
showing the free passaee of a current of air within the 
intra-pulmonary bronchi of the solidified upper two- 
thirds of the lobe. I assume, therefore, that it is incor- 
rect to say that air does not pass into the bronchial 
tubes within a lobe which is completely solidified. 
Assuming this, the question then is, what part does the 
air in the intra-pulmonary bronchi have in the pro- 
duction of the bronchial respiration? That Laennec 
was right in supposin|; a tubular sound to be produced 
by a current of air in these tubes is not irrational. 
Such a sound, in fact, may be produced after death by 
a current of air from the bellows or the mouth directed 
into the bronchus connected with a solidified lobe. 

But there are grounds for attributing the bronchial 
respiration, chiefly, if not exclusively, to the larynx 
and trachea. The fact that in essential characters re- 
lating to pitch and quality, the normal laryngeal and 
the tracheal respiration are identical with those of the 
bronchial respiration, is perhaps suflicient in itself to 
prove that the latter is in reality the former conducted 
into the solidified lung. How can this be, if solidified 
lung be not a good conductor of sound ? The answer 
to this question is, the conduction is not by the solidi- 
fied lung, but b;^ air within the intra-pulmonary 
bronchi. This, as it seems to me, enters into the expla- 
nation of the bronchial respiration. The air in the 
intra-pulmonary bronchi is the conducting medium, 
as it is in the stethoscope. The explanation does not 
conflict with the fact that solidified lung is a poorer 
conductor of sound than healthy lung. For good con- 
duction of sound it is not necessary that the conduct- 
ing column of air be large. The space containing air 
within the tubes of the binaural stethoscope, is not 
larger than that in the medium sized bronchi. The 
explanation is consistent with the absence of bronchial 
respiration when the bronchial tubes are obstructed by 
either an accumulation of morbid products, or by press- 
ure from without. The following experiment illus- 
trates the conduction by the air within the intra-pulmo- 



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January 13, 1883.] ON THE PHYSICAL EXPLORATIOiVr OF THE LUNGS. 



33 



nary bronchi : In a lung from a body dead with acute 
pneumonia, the upper lobe was completely solidified. 
When a current of air from the mouth was directed 
^ into the trachea, and the stethoscope applied to the 
solidified lobe, a well-marked bronchial respiration 
was appreciable. By compressing with the fingers the 
bronchus leading to the solidified lobe, a very feeble 
and distinct respiratory sound only was perceived. A 
well-marked bronchial respiration returned when the 
compression was suspended. Dr. Powell, of London, 
cites an experiment made by MM. Boudet arid Cha- 
veau, as demonstrating the conduction from the larynx 
and trachea of the bronchial respiration. On a horse 
affected with pneumonia, well-marked bronchial res- 
piration over the solidified lung was ascertained. 
Tracheotomy was then performed, and when the 
wound in the trachea was held widely open, the bron- 
chial respiration disappeared, while exaggerated vesic- 
ular respiration over the other lung continued. On 
introducmg a tube within the wound the bronchial res- 
piration over the solidified lung returned. This ex- 
periment illustrates not only the fact of the conduction 
from the larynx and the trachea, but also that the 
conducting mediym is the air within the bronchial 
tubes. 

Experimental observations thus appear to prove 
conclusively that suppression of the vesicular murmur 
and conduction of the tracheal and laryngeal respira- 
tion are the two factors in the mechanism of bronchial 
respiration, admitting that solidification does not ren- 
der the lung a better conductor of sound. This ad- 
mission, however, will be found to be not easily 
accorded with certain clinical facts. To some of these 
reference will be made in connection with vocal signs. 
One difficulty relates to bronchial respiration. If lung 
containing air within the alveoli be a better conductor 
of sound than solidified lung, why is it that we do not 
have bronchial respiration when the vesicular murmur 
is suppressed by emphysema? Here is an evident in- 
consistency. If, however, the explanation which has 
been given of the bronchial respiration be proven, it 
is no» disproved by apparently conflicting facts. The 
proper course to pursue is to seek to reconcile these 
with the explanation. I am not prepared to say how 
this is to be done in the instance just cited. 

The higher pitch of the expiratory, as compared 
with the inspiratory, sound in the bronchial respiration 
accords with what is observed when the stethoscope is 
placed upon the larynx or trachea. The explanation 
is the narrowed orifice at the glottis by an approxima- 
tion of the vocal cords in the act of expiration, when 
compared with the separation of the cords which takes 
place in the inspiratory act. 

CAVERNOUS RESPIRATION. 

From the bronchial I pass to the cavernous respira- 
tion. Laennec recognized the existence of a cavern- 
ous respiration, but he regards it as having the same 
. characters as tl^ bronchial respiration, its distinctive 
feature being a perception as if the air entered a space 
larger than that of the bronchial tubes. He described 
two modifications, in one the air seeming to enter and 
emerge from the ear of the auscultator, and in the 
other the sound giving the idea of a movable veil 
between the cavity and the ear. He called the former 
of these modifications, a blowing respiration, and the 
latter veiled blowing. It must be admitted that Laen- 
nec's account of cavernous respiration is indefinite and 
unsatisfactory. The criticisms of Skoda are un- 
doubtedly just. But Skoda fell into an error greater 
than that of Laennec, with regard to this sign, for he 
denied in Mo the existence of a cavernous, as distinct 
from bronchial respiration. He says (quoting his lan- 
guage), " I consider Laennec's bronchial and cavernous 



respiration to be one and the same murmur ; his blow- 
ing bronchial to be a loud bronchial murmur, and his 
souffle voile to be an unimportant modification of the 
bronchial respiration." So great has been the in- 
fluence of Skoda's teachings, that the most recent 
German writers hold to the identity of the characters 
of the bronchial and the cavernous respiration. The 
individuality of cavernous respiration has been, and is 
acknowledged by English and French authors, but its 
differential characters were not distinctly indicated 
prior to 1852. I believe that I do not assume too much 
m'saying that these characters were first fully pointed 
out in the prize essay published in that year, to which 
I have already referred, and in my work oVi Physical 
Exploration, published in 1856. My description of 
cavernous respiration was based on the analytical study 
of respiratory sounds with reference to pitch and 
quality, conjoined with autopsical examinations. In 
the instances given in my essay, the examinations after 
death were made, and written reports furnished, by 
Prof. John C. Dalton. 

With reference to its distinctive characters, the cav- 
' ernous respiration is to be contrasted, on the one hand, 
with the bronchial respiration, and, on the other hand, 
with the normal vesicular murmur. Contrasted with 
the bronchial respiration, the points of difference are 
not less marked than those which distinguish the bron- 
chial respiration and the normal vesicular murmur. 
•The cavernous inspiratory sound has no tubular 
quality, and is low in pitch ; the expiratory sound is 
usually .more feeble than the inspiratory, its duration 
or length variable, and its pitch is lower. With an 
appreciation of these differential characters, the cav- 
ernous and the bronchial respiration cannot possibly 
be confounded. The quality of the sound in both the 
cavernous inspiratory and expiratory sound may be 
called blowing, in distinction from a tubular quality. 
The quality is like that of the expiratory sound in the 
normal vesicular murmur. The contrast of the cav- 
ernous respiration with the normal vesicular murmur 
is less strong than with bronchial respiration. In both 
the cavernous respiration and the normal vesicular 
murmur, the pitch of the inspiratory and of the expi- 
ratory sound is low, and the expiratory is lower in 
pitch than the inspiratory sound. The essential poini 
of difference relates to quality. The vesicular quality 
is wanting in the cavernous respiration. Given a res- 
piratory sign in which the inspiration is non-vesicular 
and non-tubular, with lowness of pitch, the expiration 
having the same quality but still lower in pitch, the 
sign can be no other than cavernous respiration. 'In 
confirmation of the presence of this sign, clinically, cir- 
cumstances other than its distinctive characters may 
be taken into account. It is limited to a circumscribed 
space ; around this space the respiratory sound is 
either vesicular or the signs of more or less consolida- 
tion are present, the latter being true in a large pro- 
portion of instances; the coexisting vocal signs and 
those obtained by percussion are indicative of cavity, 
and evidence is sometimes obtained by inspection. 

Artificially the cavernous respiration may be illus- 
trated by the following simple experiment : The cavity 
is represented by an India-rubber balloon of the size 
of a large orange, with thin walls, and two openings 
connected with a tube of greater or less length. At- 
taching to one of the tubes a pair of bellows, or, what 
answers equally well, using the breath from the mouth, 
the balloon is inflated and the air withdrawn in imita- 
tion of the respiratory acts. Placing a binaural stetho- 
scope over the balloon, or listening with it close to the 
ear, the movement of the air into it and out of it gives 
rise to a low-pitched blowing sound, the outward lotver 
in pitch than the inward current. These observations, 
identical with those of the cavernous respiration, may 



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34 



ON THE PHYSICAL EXPLORATION OF THE LUNGS. 



[Medical News, 



be contrasted with tubular breathing produced artifi- 
cially in the manner already stated.' 

The sig^n may also be reproduced within A cavity 
with flaccid wsHs in a lung removed from the body. I 
had recently under observation a hospital case in which 
there was well-marked cavernous respiration at the 
summit of the chest. After death, in that situation was 
found a cavity of the size of a large orange, the an- 
, terior wall of which consisted of only thickened pleura, 
and collapsed when the lung was removed from the 
body. The cavity was readily and largely inflated by the 
breath directed into the trachea. With the stethosc<Tpe 
applied upon the lung, over the cavity, a loud, low- 
pitched, blowing sound was perceived when the air en- 
tered and when it escaped from the cavity. It is not 
difficult for those connected with large hospitals to ob- 
tain this demonstration of the distinctive characters of 
the cavernous respiration. 

AMPHORIC RESPIRATION. 

Amphoric respiration is to be regarded as a variety 
of the cavernous, and claims but a few words. As is 
well known, it is a sign par excellence of perforation of 
lung and pneumothorax ; but it is not a very infrequent 
sign of a pulmonary cavity. V^enever present, if 
pneumothorax be excluded, it is diagnostic proof of a 
cavity with rigid walls, that is, walls which do not 
expand notably with inspiration, and collapse with 
expiration. As produced in cases of pneumothorax, 
it may be represented artificially by blowing through 
a small tube into an inflated India-rubber bag of con- 
siderable size. As produced in a pulmonary cavity, it 
is represented by directing a current of air from the 
mouth or a pair of bellows over the opening Into an 
India-rubber ball of the size of an egg or an orange. 
It may be demonstrated to be a sign of a cavity with 
rigid walls in a lung removed from the body. In the 
specimen just referred to, of a cavity with flaccid 
walls, which furnished a cavernous respiration after 
death and during life, a little below this cavity the 
lung was solidified; but within a circumscribed space 
well-marked amphoric respiration was perceived when 
a current of air from the mouth was directed into the 
lung. An incision revealed a cavity of about the size 
of an English walnut, surrounded on all sides by 
solidified lung. 

BRONCHO-VESICULAR RESPIRATION. 

The three signs which have been considered, namely, 
the normal vesicular murmur, the bronchial respira- 
tion, and the cavernous respiration (the first of these, 
a normal sign, and the two others abnormal signs), 
may be said to constitute the simple types of the 
respiratory sounds heard over the chest. Other signs 
consist of the characters of these in combination, and 
may, therefore, be distinguished as compound types. 
Of these signs, the one which is of most importance I 
shall consider under the name broncho vesicular respi- 
ration. This name was proposed in my work on 
Physical Exploration, published in 1856. It has been 
adopted, to some extent, by writers in this country. 
Hrof. Da Costa prefers the term vesiculo-bronchial. 
The pressing need of a term expressive of certain 
morbid auscultatory sounds must, as it seems to me, 
be evident to any one who has given attention to the 
study of these sounds. The morbid physical condi- 
tions represented by the sounds referred to are the 
varying degrees of solidification of lung, falling short 
of a degree sufficient to give rise to a purely bronchial 
respiration. In a purely bronchial respiration, the in- 

I The si^n is not produced by blowing into a balloon with but 
one bpening. I infer, therefore, that for the cavernous respiration 
in life, cavities must have openings for the exit as well as the 
ingress of air. 



spiratory sound is devoid of any vesicular quality ; the 
quality is entirely tubular. In the broncho-vesicular 
respiration, the inspiratory sound is both tubular 
ana vesicular; that is, it consists of these two qualities 
combined. The tubular and the vesicular quality 
may be combined in different proportions; in some 
instances the vesicular, and in other instances the 
tubular, quality predominates. The _ predominance 
of the one or of the other of these qualities depends 
on the degree of solidification ; if the solidification be 
but slight, the vesicular quality exceeds the tubular, 
and, per contra, if the solidification be nearly sufficient 
for the purely bronchial respiration, there is but little 
of the vesicular quality, the tubular being in excess. 
The broncho-vesicular respiration, thus, as a repre- 
sentative sign, covers all the modifications of respira- 
tory sounds, denoting solidification, between the normal 
vesicular murmur and a purely bronchial respiration. 
And by means of this sign it is practicable, not only to 
recognize the existence of solidification which is insuf- 
ficient in degree to give rise to the bronchial respira- 
tion, but to judge of the degree of solidification, that is, 
whether it be very slight, slight, moderate, or closely 
approximating to that requisite for a purely bronchial 
respiration. The combination of the' vesicular and the 
tubular qualities carries with it other characters which 
correspond to the different proportions in which the two 
qualities are combined. In proportion as the vesicular 
quality predominates in the sound of inspiration, the 
pitch of the sound is low; and, conversely, the pitch is 
raised in proportion as the tubular quality predotni- 
nates. The expiratory sound is prolonged, high in 
pitch, and tubular in quality, in proportion as the 
inspiratory sound is high in pitch and tubular in 
quality; in other words, in proportion to the degree of 
solidification ; and, conversely, the expiratory sound 
is less prolonged, less high, and less tubular in pro- 
portion as the vesicular quality in the inspiratory sound 
predominates; in other words, in proportion as the 
degree of solidification is small. 

The name broncho-vesicular is intended to super- 
sede such terms as rude, rough, and harsh respiration. 
These terms are not only inapprnriatj, but they lead 
to error. An exaggerated vesicular respiration with- 
out solidification of lung may be ruder or more harsh 
than the sound which represents the latter condition. 
An imperfectly developed dry bronchial rSle may give 
roughness to the respiratory murmur. These terms, 
thus, do not denote any fixed, definite,'morbid physical 
condition, and erroneous inferences are liable to be 
drawn from them in cases of disease. Still more un- 
satisfactory is the name indeterminate respiratory 
murmurs introduced by Skoda, which embraces the 
abnormal sounds expressed by the term broncho- 
vesicular. Under the name indeterminate Skoda in- 
cludes, quoting his language, "Respiratory murmurs 
having neither the character of vesicular nor of bron- 
chial respiration." He admits-that "No distinct indi- 
cation can in any particular case be drawn from such 
a murmur," and he adds, " All respftratory murmurs 
which give us no information as to the state of the 
parenchyma of the lungs I call indeterminate respira- 
tory murmurs, and any subdivision of them appears 
to me to be useless." The name " indeterminate' with 
the meaning as defined by Skoda, is still in vogue 
with German writers. The name is applied to sounds 
due to simple bronchitis, as well as to phthisis and 
other affections. It must be sufficiently obvious that 
with the confused idea of the sign, a confusion implied 
in the name "indeterminate," it cannot be of much 
practical value in diagnosis. It is far otherwise with 
the broncho- vesicular respiration, its characters having 
been determined by analytical study. The sign is of 
great practical value in the diagnosis of phthisis, in 



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January 13, 1883.] ON THE PHYSICAL EXPLORATION OF THE LUNGS. 



35 



the early stage of pneumonia, and the stage of resolu- 
tion, and in other pulmonary affections involving par- 
tial solidification of lung. The sign represents the latter 
condition, and nothing else. It cannot be produced by 
a simple bronchial affection. It is not less determinate 
as regards its distinctive character^ and its pathological 
significance, than any of the respiratory signs. 

A case of pneumonia during the stage of resolution 
affords illustrations of all the gradations of this sign. 
The sign is present as soon as absorption has removed 
the contents of a sufficient number of air vesicles for 
a vesicular quality to be perceived in the sound of in- 
spiration. The tubular quality now predominates, and 
the respiratory sound is still prolonged, high, and 
tubular. With each successive aay, as absorption pro- 
gresses, the vesicular quality in the inspiratory sound 
increases, and the tubular quality diminishes. With 
these changes in the inspiratory sound, the expiratory 
sound on each successive day is less prolonged, less 
intense, less light in pitch, and less tubular in quality. 
At length, resolution being complete, the vesicular 
quality becomes, for a time, more marked than in 
health, all the characters of the broncho-vesicular res- 
piration having disappeared. 

The characters of tne broncho-vesicular respiration 
may be studied as illustrated in the healthy chest. In 
the infra-clavicular region, especially the sternal por- 
tion, and in the interscapular region, the respiratory 
murmur, as compared with that over other parts of the 
chest, is broncho- vesicular; that is, owing to the prox- 
imity of the larger bronchi, the characters of the bron- 
chial and of the vesicular respiration are combined. 
This is more apparent on the right than on the left side. 
The respiration in these situations has been called the 
normal bronchial respiration. This expression is in- 
exact, inasmuch as the respiratory sounds are not purely 
bronchial. It is more correct to say that in these situa- 
tions there is a normal broncho-vesicular respiration. 
This normal broncho-vesicular respiration may be still 
better observed by auscultation of the lungs removed 
from the chest. With the human lungs or those of the 
calf or sheep, if the nozzle of a pair of bellows be in- 
troduced into the trachea, the respiratory acts imitated, 
and the stethoscope placed either on the lung, or a thin 
layer of cloth only interposed, the mixture of the char- 
acters of the bronchial and the vesicular respiration at 
and near the apex of the lungs, will be rendered very 
marked by contrast with the respiratory sounds over 
other portions. 

BRONCHO-CAVERNOUS RESPIRATION. 

The combination of the characters of the bronchial 
with those of the cavernous respiration, and of the 
cavernous with the vesicular murmur, constitute other 
compound types. Seitz, the editor of the later editions 
of Niemeyer's work on the Practice of Medicine, \ii& 
described a respiratory sign which he calls a " meta- 
morphosizing respiratory sound. " The metanforphosis 
is in the inspiratory sound. Tiie sound atits beginning 
is described as rude, and the last two-thirds as bronchial. 
Bearing in mind that with German writers there is no 
cavernous, as distinguished from bronchial, respira- 
tion, I infer the latter part of the respiratory sound to 
be cavernous. Such a metamorphosis was described 
by me in my prize essay, published in 1852, together 
with the physical conditions found after death. This 
is one variety of a broncho-cavernous respiration. The 
first part of the inspiratory sound is a bronchial respi- 
ration. It takes place before the air has entered freely 
into a cavity. One of the characters of the cavernous 
inspiration is that it is evolved slowly. When the air 
enters freely into the cavity, the bronchial is super- 
seded by the cavernous respiration. The sign thus 
denotes a cavity, with proximate solidification of lung. 



Another variety is an association of a bronchial expi- 
ration with a cavernous inspiration. This variety is 
not infrequently met with. The explanation is simple. 
In bronchial respiration, the expiratory sound, as a 
rule, is more intense than the inspiratory. The inspi- 
ratory sound may be relatively quite feeble, and it is 
sometimes wanting. On the other hand, the expira- 
tory sound in cavernous respiration, as a rule, is feeble, 
and may be quite so, or it may be wanting;. Now, it 
is easy to understand that when a cavity is situated 
near a portion of solidified lun^, the auscultator may 
obtain over the cavity an inspiratory sound which is 
cavernous, that is, low in pitch and blowing in quality, 
associated with an expiratory sound which is bron- 
chial, that is, high in pitch and tubular in quality. 

VESICULO-CAVERNOUS RESPIRATION. 

The characters of the vesicular and of the bronchial 
respiration are combined when the pulmonary struct- 
ure surrounding a cavity remains intact, or but little 
affected. The vesicular quality is then derived from 
the surrounding lung. The recognition of this com- 

Cound type may seem a refinement in auscultation, 
ut that in certain cases it is readily recognized, clin- 
ically, I am well satisfied. It may be called a vesiculo- 
cavernous respiration. 

lUMINISHED AND SUPPRESSED VESICULAR MURMUR, 
AND INTERRUPTED RESPIRATION. 

Diminished vesicular murmur, without change in 
pitch and quality, and suppression of the murmur, 
which are physical signs of much value, taken in con- 
nection with other signs and with symptoms, do not 
here claim consideration. Of the sign called inter- 
rupted, wavy, and cog-wheeled respiration, I will only 
remark that, as an isolated sign, it ha$ but little clin- 
ical importance; it derives whatever value belongs to 
it from its association with other signs. I shall con- 
clude this discourse with some remarks on prolonged 
expiratory sound, either existing without an inspiratory 
sound, or when the latter is too weak in its character 
to be distinctly appreciable. 

PROLONGED EXPIRATION. 

It is remarkable that Laennec should have given so 
little attention to the study of the sound of expiration. 
James Jackson, the younger, was the first to appreciate 
the clinical value of a prolonged expiratory sound. As 
early as 1832 he called attention to the significance of 
a prolonged expiratory sound at the summit of the 
chest in the diagnosis of pulmonary phthisis. He no- 
ticed not only the prolongation, but its resemblance in 
character to the prolonged expiration in bronchial 
respiration. Since his observations this sign has been 
included in the group of signs to be sought after in the 
diagnosis of phthisis. It may or may not have signifi- 
cance in relation to that disease. A prolonged expira- 
tion whi<:h may be more or less high in pitch and 
tubular in quality, is not very infrequently observed in 
healthy subjects at the summit of the chest on the right 
side. It belongs to the normal broncho-vesicular res- 
piration, and may be present when the characters of 
this sign, owing to feebleness of the inspiratory sound, 
are not appreciable. I have known a prolonged high- 
pitched expiration to exist on both sides at the summit 
of the chest, no other morbid signs being therewith 
associated. Absence of other signs of disease is the 
fact to be relied upon in judging that the prolonged 
expiration is a normal peculiarity. But, as a morbid 
sign, prolongation of the expiratory sound is not always 
evidence of phthisis nor of any affection involving 
solidification of lung. It is a sign in cases of pulmo- 
nary emphysema, and may occur whenever the expira- 
tory act is increased in force and length, or whenever 



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36 



AMPUTATIONS, AND THEIR ANTISEPTIC DRESSINGS. [Medical Nkws, 



there is an obstacle to the free exit of air from the 
smaller to the larger bronchial tubes. How is this 
difference in the significance of the sign to be rec- 
ognized clinically ? This question can be definitely 
answered. If the prolonged expiratory sound be high 
in pitch and tubular in quality, exclusive of the in- 
stances in which it has these characters as a normal 
peculiarity at the summit of the chest on the right side, 
the sign denotes lung solidified by a phthisical or some 
other solidi Tying morbid process. It has precisely the 
same significance as when it is associated with a high- 
pitched tubular inspiratory sound in the bronchial 
respiration. If, on the other hand, the prolonged ex- 
piratory sound have characters, as regards pitch and 
quality, the same as in the normal vesicular murmur, 
differing only in length and intensity, it is not a sign of 
phthisis, nor of any other affection involving solidifi- 
cation of lung. This variety of prolonged expiratory 
sound, associated with other signs, is diagnostic of pul- 
monary emphysema. 

These differential characters pertaining to the sign, 
the difference in its significance being correspondingly 
marked, exemplify the importance of the analytical 
study of auscultatory phenomena.. With few excep- 
tions in works treating of auscultation at the present 
time, a prolonged expiratory sound, as a morbid sign, 
is considered without reference to the differences in 
pitch and quality on which depend its diagnostic sig- 
nificance. If these differences be not taken into ac- 
count, the sign is as likely to lead to error as to a 
correct diagnosis. 

ORIGINAL ARTICLES. 



AMPUTATIONS, AND THEIR ANTISEPTIC 
DRESSINGS. 

By J. HENRY C. SIMES, M.D.. 

ASSISTANT SUflGBOM TO THE BriSCOrAL HOSTITAL, rHILADBLPHIA. 

Any experience in any method of treatment, 
whether the result proves favorable or unfavorable, 
is, if carefully noted, a means of assisting the treat- 
ment in similar cases which may occur at a future 
period. More especially is this a fact when applied 
to those methods which from their novelty or theo- 
retical claims are urged by their discoverers. 

Antiseptic surgery, at the present time, can 
scarcely be considered as a new method of treat- 
ment in surgical operations, nor are its claitns now 
based entirely upon theoretical grounds; yet it is 
far from being accepted as a general method of 
treatment ; more particularly is this true of Ameri- 
can surgeons. In this city I know of no hospital in 
which its surgeons have fully and thoroughly car- 
ried out the details necessary to give their treatment 
the name of antiseptic ; that is to say, they have not 
attended to the minute directions, and in many 
cases the principal features have been omitted in 
their operations. For these reasons I have thought 
a brief outline of my experience, during the past 
summer while on duty at the Episcopal Hospital, 
would perhaps aid in assisting to form some conclu- 
sions as to the value of antiseptic dressings when 
applied to amputations. 

My reasons for not continuing the usual mode of 
treatment, viz., non-antiseptic, and adopting the 
antiseptic, was -that upon beginning my term of 
service it was found that there had been for the 
previoias spring and winter months, an almost unin- 



terrupted series of secondary complications (ery- 
sipelas, cellulitis, etc.) following the amputations 
which had been performed in the hospital ; these 
complications were not limited to this hospital 
alone, but upon ftirther investigation it was ascer- 
tained that in most of the hospitals throughout the 
city, similar sequelae to operations had prevailed. 
Therefore, it seemed to me a change of some kind 
was justifiable, in order to endeavor to check the 
unfavorable course taken by the process of healing 
after amputations. The antiseptic dressing had not 
been, during this year, employed in the hospital. 
The opportunity to test its usefulness or not, as the 
case might be, here presented itself, and a trial was 
determined upon. 

The procedure followed, in the cases coming 
under my care, was essentially that recommended 
by Lister, and consisted, in outline, of the car- 
bolized spray; catgut ligatures; close apposition of 
the wound by means of silver sutures; thorough 
drainage, obtained by the use of rubber drainage- 
tubes of large calibre (one-fourth of an inch) ; 
washing the wound with carbolized water ; oil-silk 
protective over the line of incision; carbolized 
gauze wet with carbolized water ; dry caj-bolized 
gauze ; rubber cloth, which was securely kept in 
close relation to the parts by the employment of a 
narrow elastic bandage at its margin ; and, finally, 
the whole held in position by a inuslin roller. The 
instruments used during the operation were placed 
in a tray of carbolized water. 

The results obtained by the employment of the 
above dressing were very satisfactory, as may be 
seen from the following cases. These cases, seven 
in number, are not given in full, but they may be 
summarized by stating that they consisted of two 
amputations of the forearm, two amputations of the 
armi one amputation at the knee-joint, one resection 
of the knee, and one amputation of the female 
breast. In none of the cases was there any sec- 
ondary complication, no erysipelas, no cellulitis, no 
abscess. Certainly here was a change for the better, 
since only a month previous one or all these com- 
plications accompanied similar operations, and the 
questions which naturally presented themselves were : 
Was the favorable change owing to a change in the 
manner of dressing? Was it due to a change in the 
time of the year? or. Was it dependent upon any 
other outside influence ? 

These were all very satisfactorily answered to my 
mind, ind convinced me that there was but one cause 
to account for the results which so very markedly 
differed from those previously obtained. The, to 
me, convincing circumstance exists in the progress 
of other operations performed in the same hospital, 
at the same time and treated in the same wards, 
but under a different method of treatment; the 
dressing was not antiseptic, and the results were not 
so favorable. • These cases were one amputation of 
the forearm, three amputations of fingers, one ampu- 
tation of thumb, and one amputation of toe. In all 
of the above cases there occurred either a compli- 
cation of erysipelas, cellulitis, abscesses, or all three. 
When contrasted with the former cases — those 
dressed antiseptically, there are observed very evi- 



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January 13, 1883.] TOTAL LOSS, BY SLOUGHING, OF BOTH PAROTID GLANDS. 



37 



dent and important differences. Here are two 
series of cases, both placed under the same sur- 
rounding influences, both receiving the same care 
and attention, yet each following a different course. 
A cause for such a distinct and marked difference in 
the course of the two series is to be expected and 
naturally sought after, and the only appreciable one 
is found in the different methods employed in 
dressing the cases. In nothing was there any 
known variation made in treating the two series, 
except in that of the different dressings — the one 
antiseptic, the other not; and it would seem only 
reasonable to conclude that this difference was the 
one which influenced the ultimate results. 

Not only were these differences of secondary 
complications following the operations noticeable, 
but there was also a great variation in the symptoms 
which followed as a result of operative interference ; 
and when comparing the two series one with an- 
other, it was found that the cases dressed antisepti- 
cally presented a much more favorable record than 
those cases in which this method of treatment had 
not been employed. 

A symptom common to both secies, but one in 
which the difference was most decidedly marked, 
was that oi pain. In the cases in which the non- 
antiseptic dressing was used this symptom was always 
present, and habitually demanded anodynes for its 
relief; while, on the contrary, with the antisepti- 
cally dressed cases, the pain was so slight — indeed 
it may be said absent — that in none were anodynes 
indicated, and their administration was omitted 
during treatment.- 

The amount of traumatic fever, in the two series 
of cases, differed in a very appreciable degree. 
In the cases in which the antiseptic dressing was used, 
this symptom was generally very poorly defined, 
and its presence only indicated by the employment 
of the thermometer; while in the non-antiseptic 
dressed cases, there was no exception : each case 
had a distinct and quite evident attack of surgical 
fever. This variation in the relative amount of 
fever was very apparent when the temperature 
records taken during the progress of healing of the 
wounds were contrasted. Thus, the average max- 
iiflum temperature in the antiseptic dressed cases 
was 99 6' Fahr., while in the non-antiseptic it was 
102.5° Fahr. 

The aspect of the wounds in the two series of 
cases was very different. The cases in which the 
antiseptic dressing was used presented a perfectly 
normal appearance of the surrounding parts ; there 
was an entire absence of all redness and tumefac- 
tion, only a very faint red blush was observed 
along the line of incision and surrounding the punct- 
ures produced by the wire sutures. In the cases not 
, treated antiseptically, there were seen, on the con- 
trary, a marked diffused redness and considerable 
oedema of the neighboring tissues. 

The symptom of tenderness upon pressure, in the 
two category of cases, was singularly unlike. In 
the one — the antiseptic dressed, it was so slight as 
scarcely to merit a place as a symptom ; while in the 
other it was a very prominent and always present 
feature. 



The length of time necessary to complete the heal- 
ing of the wounds in the two series of cases varied 
very much. Those cases in which the antiseptic 
dressing was used healed much sooner than those in 
which it was not. This circumstance was, undoubt- 
edly due to the secondary complications which 
interfered with the process of healing in th& latter 
cases. 

There is one point more I wish to speak of, and 
it is in reference to the application of the antiseptic 
dressing. In reading over the directions given by 
the advocates of this method of treatment, it does 
appear a very formidable and extremely tedious one. 
But in its practical application, however, I am quite 
satisfied, from my experience with it, that these 
seeming drawbacks to its use do not exist. It is 
something out of the usual routine, and the first 
trials made with it may, and indeed do, call for a 
little more time and attention on the part of the 
surgeon; yet with a little experience, and the 
assistants and nurses becoming familiar with its ap- 
plication, the dressing can be applied with as great 
facility as that ordinarily employed. A circumstance 
not to be overlooked, and it also bears upon the 
question of tin&e occupied in applying this method 
of treatment, is that the renewal of this dressing b 
not required as often as the non-antiseptic. Most 
of the cases which were dressed antiseptically had 
the dressing renewed two or three times in the 
course of a week, frequently the interval was longer 
— once in four or five days. In the non-antiseptic 
dressed cases, it was generally necessary to renew 
the dressings daily, and they never remained longer 
than two days without renewal. Therefore, it is 
seen that the time actually occupied in dressi ng 
these two series of cases was much longer in the 
non-antiseptic tlian in the antiseptic. 



TOTAL LOSS, BY SLOUGHING, OF BOTH 

PAROTID GLANDS. 

By C. M. RAMSDELL, A. M., M. D, 

OF LAMPASAS, TKXAS. 

On the 26th of August, 1882, my brother, Dr. 
F. R. Ramsdell, was called into the country to see 
a case of fever. The patient was Mr. Lewis C, 
white, carpenter, aet. 29, native of Michigan; 
height, 5 ft. II in.; weight, 150 pounds; family 
history, consumption on the side of the father, 
whom he resembles. For several weeks he had 
been working among the cedar brakes on the Col- 
orado river, where he contracted chills and fever, 
which soon compelled him to quit work. 

Wheli seen, Aug. 26th, he was delirious, very 
restless, with marked opisthotonos, and complained 
of constant and severe pain in the back part of the 
head and neck. His temperature in the axilla was 
106° F., pulse 120, resp. 32, spasmodic. He was 
given potassii brom. gr. x, tr. aconit. gtt. iij, spt. 
ath. nit. fSss, every two hours until fever abated; 
then cinchonia alkaloid gr. xx, in four doses, one 
to be taken every four hours. On the following 
day I saw the patient, and from that time on the 
case was treated by my brother and myself in com- 
pany. 

During the night of the 26th, the fever left him 



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38 



TOTAL LOSS, BY SLOUGHING, OF BOTH PAROTID GLANDS. [Medical Nbws, 



and returned on the afternoon of the 27th; the 
temperature reached 105*", but there was no opis- 
thotonos and but little delirium. The urine was 
scanty and very dark, coffee-colored, and much 
pain was felt in the lumbar region. He was given 
spt. aeth. nit. a teaspoonful every three hours for two 
days, and the same amount every six hours for sev- 
eral days longer, the urine gradually becoming 
normal in quantity and color. During the night of 
the 27th he took quinine gr. xxx, with pulv. doveri 
gr. X. 

There was no return of the fever, but.the patient 
was greatly prostrated so that he could scarcely sit 
up in bed. He was stupid, and talked incoherently 
much of the time during the 28th, still complaining 
of pain in the head. On the morning of the 29th 
his left jaw began to swell, and by noon the whole 
left side of the face and neck was much swollen 
and very painful, especially in the parotid region. 
There was also intense pain in the left ear, and the 
patient was continually turning from side to side 
and crying out. Morphine in doses of gr. ^ to 
gr. j, every four hours, and local applications of 
vinegar and hot fomentations, gave only slight 
relief. On the 30th, the right parotid region be- 
came inflamed, and the swelling on that side was 
soon as great as on the left, reaching an enormous 
extent on both sides, extending down the neck to 
the shoulders and backwards beyond the mastoid 
region, so that the auricles were thrust upwards and 
forwards, giving a very grotesque appearance to the 
sufferer's countenance. 

The prostration was so great, and the rigidity of 
the jaws'such, that food was administered with diffi- 
culty. He was given half an ounce of brandy in 
egg-nog or milk-punch every two hours for three 
days, and at longer intervals, alternating with animal 
broths, for about two weeks. Quinine gr. v was 
also given night and morning from Aug. 28 to Sept. 
8. His tongue was enlarged and heavily coated, 
mouth very dry, and hearing much impaired. On 
Sept. ist there was a discharge of thin, ichorous pus 
from the left meatus auditorius externus. On the 
td, a similar discharge took place from the right,, 
and fluctuation was noticeable just back of the lobe 
of each ear. He also had a slight chill, and night 
sweats set in. for which he was given 20 drops of 
aromatic sulphuric acid three times a day for four 
days. 

On Sept. 3d, the abscess on the left side was 
lanced at a point half an inch below and behind the 
lobe of the ear, and the day following that,on the 
right was opened at a corresponding point, in both 
cases giving exit to a large quantity — an ounce or 
more — of thick yellow pus mixed with a substance 
resembling the white of egg. From this time on 
the pain was much less severe, and the morphine 
was discontinued, but, as the patient kept calling for 
it at frequent intervals, to pacify him a number of 
powders were made out, consisting only of wheat 
flour, labelled "morphine," and after taking one of 
these he always seemed to be greatly relieved. His 
bowels were inclined to be constipated, but an action 
was procured about once in two days by the use of 
small doses of sulphate of magnesia. 



On the 8th, he was put upon the following tonic 
which he continued to use for three weeks. 

B . — ^Tr. nucis vomicae, . . . f 3'iss. 
Tr. cinchonae, . . q. s. ad. fjiv.— M. 
S. A teaspoonful four times a day after eating. 

An attempt was made to apply compresses to the 
sides of the neck in order to secure thorough evacu- 
ation of the abscesses and prevent burrowing of the 
pus, but the patient would not tolerate any kind of 
dressing, pulling them off' as fast as they could be 
applied. 

On the morning of the loth, the openings made 
by the lancet, which had become considerably en- 
larged by sloughing, were found occluded by what 
the attendants thought to be " proud flesh." This 
was removed by pulling it out with forceps, and was 
found to be the parotid glands almost entire, the 
superficial portions having sloughed away so that 
only a few fibres of tissue held them in place. The 
left gland came out easily, the right required a 
little cutting to detach it from its connections. 
Both presented a similiar appearance, being some- 
what spongy and having deep sulci, apparently 
where large bloodvessels or nerve-trunks had passed 
through their substance, and the right gland still 
showed something like the outlines of the natural 
shape, but the left was not larger than the first joint 
of the thumb, and its true character could be made 
out only by its position and its internal structure. 

After the removal of the glands as much as three 
fluidounces of thick pus escaped from each cavity. 
There was no hemorrhage nor has there been any 
paralysis, so that no important nerves or bloodves- 
sels could have been involved. No other glands 
were implicated nor was there any burrowing of 
pus. The discharge from the ears ceased in a few 
days after the glands came away, the only treatment 
directed to them having been a daily syringing out 
with warm water. 

On September 13th, he was given sixty granules 
containing one-tenth of a grain of calcium sulphide 
each, of which he took three per diem until all were 
used. He recovered strength slowly, the wounds 
remaining open until about the middle of October. 

By the loth of November he was entirely well, 
except slight stiffness of the jaws. He then com- 
plained of having more "heart-bum" than he 
used to have, and said that his mouth seemed 
dryer than natural. A carefiil examination with a 
fine probe showed Steno's duct, to be entirely closed 
on the left side, and to consist only of a cul-de-sac 
about one-fourth of an inch deep on the right. 

At the present time, November 25th, his gastric 
trouble has disappeared and his mouth has regained 
its natural amount of moisture, doubtless through 
an increased activity in the remaining salivary 
glands. The loss of the parotid glands has caused 
no deformity beyond a slight depression and cica- 
trix at the site of the openings made by the lancet. 
The hearing is normal. 

This case seems to be unique. Flint, Practice of 
Medicine, p. 401, says that parotiditis is an occa- 
sional complication of typhus and typhoid fever, 
and that in such cases considerable sloughing of the 



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MEDICAL PROGRESS. 



39 



areolar tissue frequently occurs, but neither he nor 
any other writer, so far as I know, mentions loss of 
the gland as a possible result. 



MEDICAL ^PROGRESS. 



Cutaneous Manifestations of Malaria. — Prof. 
Verneuil and Dr. A. Merklen give the following 
conclusions in a paper with the above title : 

I. Herpes is a frequent manifestation of malaria. 

3. It may precede the access of the intermittent 
fever, occur during any one of the three stages of the 
attack, or after the sweat. There is consequently no 
etiological correlation between herpes and the fever, in 
spite of their frequent coincidence. 

3. Malarial herpes possesses no special character- 
istics. Its most frequent seat of occurrence is on the 
face, and while usually discrete, it may occasionally 
become confluent. 

4. The black crusts and vesicles of herpes are asso- 
ciated with the grave and pernicious forms of malarial 
fever. 

5. Exceptionally, malarial herpes occurs under the 
form of zona. 

6. In all forms, malarial herpes may be preceded 
or accompanied by vaso-motor troubles, disturbances 
of the sensibility of the skin in its neighborhood, and 
may perhaps indicate a nervous origin of the com- 

Clication. — Ann. de Dermatol, et de Syphitog., Novem- 
er 25, 1882. 

The Complication of Labor with Ovarian 
Tumors. — Dr. R. Lomer, of Leipzig, contributes a 
paper on the above subject to a recent number of the 
Archiv fUr Gyn&kologie. His conclusions are based 
upon the collections of cases made by Playfair and by 
Jetter. We shall only quote those which relate to 
treatment. But we may remark, first, that the tumors 
in the cases in question are always small, for the rea- 
son that large tumors are commonly found out before 
labor begins ; and it is obvious that only a tumor small 
enough to be contained in the pelvic cavity can obstruct 
labor. Dr. Lomer' s first practical rule is one of which 
the wisdom is obvious. It is, that in labors complicated 
with ovarian tumor, interference should not be too long 
delayed. 2. In all cases an attempt should be made 
to push the tumor out of the way, above the pelvic 
brim. 3. If this cannot be done, the puncture of the 
cyst should be the next alternative. 4. Should the 
contents of the tumor be too viscid to flow through a 
canula, a free incision should be made into the cyst- 
wall. Dr. Lomer remarks that from this measure to 
the pulling down of the cyst, ligature of its pedicle, and 
removal of the tumor — that is, vaginal ovariotomy — 
would seem but a step. Nevertheless, the latter ope- 
ration has never yet been done, lack of time usually 
having been a sufficient obstacle. When the cyst has 
once been emptied, vigorous pains have forced down 
the child, and so put a stop to the operator's further 
proceedings. 5. All further attempts at emptying fhe 
tumor are dangerous, and should not be attempted. 
6. When the tumor can neither be pushed up nor 
diminished in size, the choice must be made, according 
to the peculiarities of each case, between perforation 
and Caesarcan section. — Medical Times and Gazette, 
December 16, 1882. 

A Double Superior Vena Cava. — Dr. H. Rex 
reports such a case in which the right superior vena 
cava was formed by the union of the right common 
jugular and axillary vein, and was joined at the angle 



of union of these two vessels by the right vertebral 
vein. It passed in front of the trunk of the innominate 
artery and pulmonary vessels into the right auricle. 
The left superior vena cava could clearly be separated 
into a vertical and a horizontal portion ; the vertical 
portion was formed by the union of the left common 
jugular, axillary, and vertebral veins, and passed 
backwards in front of the carotid and subclavian 
arteries, and in front of the ligamentum arteriosum 
and pulmonary vessels to the left side to reach a posi- 
tion oehind the left auricle. The transverse portion 
was then bent on itself in the left auriculo-ventricular 
furrow, and entered the right auricle below the left 
pulmonary veins. — Centralbl. f. die med. Wissen., No- 
vember 18, 1882. 

Chorea and Rheumatism. — Dr. Thomas R. 
Frazer, F.R.S., narrates a case of chorea which shows 
in a most marked manner the relations between chorea 
and rheumatism. This relationship has long been 
recognized. First referred to by Bouteille and Berndt, 
it was afterwards acknowledged by Copland, Scuda- 
more, Abercrombie, and more recently stated in the 
exact form of statistical enumeration by Hughes, 
Kirkes, S^, Roger, and many other physicians. Its 
existence is now generally admitted, although occa- 
sionally it is regarded as a mere coincidence, the rela- 
tionship being relegated even to the trivial bond which 
connects any depressing agent with the production of 
a disease. A case such as that which he at this time 
described, undoubtedly affords very strong support in 
favor of a causal relationship. It affords supports 
from two aspects of the case — from its time of occur- 
rence, and from the results of the treatment. The 
former is so significant, in the first occurrence of the 
choreic disease as well as in its subsequent appearance 
during a relapse of the rheumatic fever, that it is im- 
possible to overlook it. The latter has, in addition to 
Its equally clear significance, the further value that it 
constitutes a description of evidence, the quantity of 
which, so far as he knew, was very limited. He re- 
ferred for evidence of probably a similar description to 
the fact that some cases of chorea have been treated 
with success by Dr. Weir Mitchell and Dresch with 
the same remedy that produced such striking results in 
his patient. The details of these cases he has not 
learned, and he therefore cannot tell if they illustiate 
in so clear a manner the relationship between rheuma- 
tism and chorea by showing that the most certain 
remedies for the former disease with which we are 
acquainted — the several compounds of salicyl — may 
exert a like curative action upon chorea. It would be 
important to still further test this point by tre.iting a 
number of cases of chorea by salicyl compounds, and 
especially cases where the chorea does not present so 
close a relationship to the rheumatic affection as to 
suggest the possibility of its being a mere symptom of 
rheumatism. This view is, indeed, one that has been 
already adopted. Its existence led Dr. Frazer to dwell 
upon the importance of avoiding any all-pervading 
opinion in regard to this disease. Nothing will appear 
more obvious, when the known facts in regard to 
chorea are considered, than that it is far from being 
the product of any single pathological condition. 
There is now much evidence to shpw that, at times, it 
is accompanied by a lesion of the corpus striatum, at 
others of^ the mecIuUa oblongata, at others of the me- 
dulla spinalis, at others of some part of the peripheral 
nervous system, at others of the heart, and at others 
by no lesion that can be discovered in any of these 
situations. 

Dr. Frazer can scarcely hazard an opinion as to its 
production in the present case. The embolic theory 
IS here entirely inapplicable, because of the rapidity 



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MEDICAL PROGRESS, 



[Medical News, 



wiih which the disease disappeared on two separate 
occasiuns. The mere existence of cardiac disease, 
of rheumatic origin, seems equally insufficient to 
afford an explanation. It existed before the chorea, 
it has persisted after its disappearance: and, further, 
the chorea was rapidly cured by salicylat' s. whereas 
salicxiates do not directly affect the occurrence or the 
course of cardiac disease in acute rheumatism. A 
rertex influence, originatinjf from the inflamed joints, 
cannot account for the chorea, as it often appears in 
rheumatic patients, while no inflammation of joints is 
present; and, in our case, the joints were on several 
occasions acutely inflamed, without a reappearance or 
an exacerbation of the chorea Such a case would al- 
most indicate that chorea may be a mere manifestation 
of acute rheumatism, in the same sense as the joint or 
heart aflections, a mere complication of that disease, 
produced, it may be, a rheumatic inflammation of some 
porii"ns of the central nervous system, whether true 
nerve- substance or surrounding media. — British Med- 
ical Journal, December 9, 1882. 

Treatment of Diphtheritic Sore Throat. — Dr. 
W. Aluan Jamieso.n has used M. Barff's boro-glyc- 
eride in conjunction with salicylic acid, in the treat- 
ment of this disease, and the results of this combined 
treatment have been highly satisfactory. The saturated 
Solution of boro-glyceride in glycerine causes no pain 
when painted on the inflamed, ulcerated, or sloughy 
mu<.ous membrane, but its use is immediately followed 
by relief to the symptoms. The disease, however, 
causes blood-poisoning, evidenced by ihe fever and the 
albuminuria, and against this the salicylate of sodium 
acts energetically, as- has been seen in the recorded 
cases, which are but examples of what occurred in 
many others. With this treatment there have been no 
recurrences, no formation of abscesses; recovery has 
in all been rapid and satisfactory. In conclusion, he 
recommends a trial ot the boro-glyceride in glycerine 
in ulcers of the mucous surfaces, as of the cervix uteri. 
The treatment has another advantage over any form 
of gargle, that by painting the inflamed surface we 
keep It at rest, instead of, as in the act of gargling, 
causing painful and injurious movement by the un- 
avoidable coniraciiun of the muscles of the palate and 
pharynx. In the case of children, even, little difficulty 
was experienced when they found not pain, but com- 
fort, followed its use. — Edinburgh Medical Journal, 
December, 1882. 

A New Moxa. — Under the name of " crayon Jeu," 
Dr. Moses describes a preparation made as follows: 
Charcoal powder, 30 grammes; nitrate of potash, 4 
grammes ; pulverized iron, 5 grammes ; benzoin, 1 
gramme. The whole to be made up, with some adhe- 
sive substance, into forty crayons. He so obtains a 
hard preparation, which is easily inflamed by a 
match, and which he proposes for the cauterization of 
poisoned wounds, and when the actual cautery is re- 
quired. — Oaz. Hebdnmadaire, Dec. I, 1882. 

Myositis Ossificans — At a recent meeting of the 
Vienna .Medical Society, Prof. Podrazki exhibited a 
soldier affected with the rare condition which has 
been termed myositis ossificans. Four weeks pre- 
viously the man had applied for treatment, on account 
of an intense inflammation of the muscles on the front 
of the right upper arm, apparently set up by severe 
gymnastic exercise. The muacles were large, hard, 
and uneven, and the elbow-joint was fixed in flexion. 
The hardness was removed, and some increased mo- 
bility was obtained, by massage and the application of 
cold. At the end o( 1 wo weeks a hard, round, movable 
tumor developed in the flexor of the elbow, which was 



evidently due to an ossification of the brachialis anti- 
cus. At first it was movable, the upper part appeared 
to be cartilaginous, and it was evidently not connected 
with the periosteum. Podrazki has seen, in the course 
of nineteen years, two. cases in the practice of Pitha 
quite sinular to this in their characters. In those two 
cases neither iodide of potassium, nor any other treat- 
ment adopted, had any influence. In a discussion 
which followed. Prof. Weinlechner stated that he had 
twice seen similar small spots of ossification in the 
muscles on the front of the leg, due, in each case, to a 
traumatic cause. Kundrat expressed the opinion that 
some supposed exostoses on the thigh proceed from 
muscles. Their form and seat correspond to certain 
muscles. 1 heir greater frequency in men, and espe- 
cially in muscular individuals, suggests that their origin 
is traumatic. They constantly become adherent to 
bone in the course of their growth, and hence are 
commonly thought to be primary exostoses. — Lancet, 
December 16, 1882. 

Malignant CEdeha. — Brieger and Ehrlich, 
woiking in Frerichs' clinic, have recorded (Berliner 
kltn. VVochen., No. 44) two cases of an affection asso- 
ciated with typhoid lever in which they recognize a 
disease that in animals has been called "malignant 
oedema." This malady is an infectious one, and de- 
pendent on, or at all events associated with, a bacterium 
which has sufficiently well-defined characters. The 
exciting cause of the malignant oedema in the authors' 
cases was a hypodermic injection of a musk solution 
administered as a stimtdant to overcome the slate of 
profound. collapse into which both patients had fallen. 
Much swelling of the subcutaneous tissue, with em- 
physematous crackling and discoloration of skin at the 
site of the former injection (in the thigh in both ex- 
amples), coming on in forty-eight hours, were the 
features descriptive of the malignant oedema. The 
authors remember to have met with another example 
of the affection in a case of diphtheria, but here there 
was no obvious exciting cause, and the emphysematous 
and oedematous conditions developed about the front 
of the chest. Inoculations of some of the fluid from 
the diseased thigh of the typhoid patients, performed 
on rabbits and guinea-pigs, brought about the usual 
characters of malignant oedema at the focus of vacci- 
nation, and the animals died in a few days. The 
existence of the septic vibrios was proved by the 
microscope (after the usual method of preparation), 
both in the fluids of the patient and in those of the 
animals experimented upon. Brieger and Ehrlich 
regarded their patients as suffering from a mixed infec- 
tion, the virus of enteric fever and that of malignant 
oedema being both present at the same time. There 
are many facts in medicine which might be looked 
upon as demonstrating the predisposition which one 
complaint establishes for another — noma following 
measles and other acute specific diseases, tubetculosis 
after measles and whooping-cough, joint-suppurations 
after typhus, septicaemia after scarlatina, and many 
other examples. In the language of bacterial pathol- 
ogy, the human garden, by the action of one bacillus, 
is prepared and fitted for the growth and development 
of another micro-organism, which in the normal state 
of health would not have found so suitable a nidus. — 
Medical Times and Gazette, December 16, 1882. 

Treatment of Fetid Bronchitis. — Dr. E. Lan- 
CEREAUX recommends the hyposulphite ofsodium in the 
treatment of fetid bronchitis; he combines it with the 
syrup of eucalyptus, 4 grammes of the hyposulphite to 
30 of the latter. He has seen the greatest improve- 
ment in five cases treated on this plan. — Bull. Gen. de 
Titer., November 30, 1882. 



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BACILLUS MALARIA. 



41 



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be made at the risk of the publishers, by forwarding in registered 
letters. 

Address. HENRY C. LEAS SON ft CO., 

Nos. 706 ft 708 Sansom Street, 

Philadelphia, Pa. 

SATURDAI^, JANUARY 13. 1883. 

THE EXISTinO STATE 0? OXra KKOWLEDOE . 
COKCEKKIHG THE BACILLUS HALABI2. 

However erroneous and ill founded were the 
conclusions of- Dr. Salisbury, in the matter of the 
micro organism he announced as the cause of 
malaria, his observations must be acknowledged to 
have become a part of the history of a subject which 
promises to be of vastly greater interest and impor- 
tance than was for a long time anticipated. The 
names of other observers since Salisbury, but before 
the announcement in 1879 of the discovery by 
Klebs and Tommasi-Crudeli of a bacillus which is 
the cause of malarial disease, have been more or 
less associated with a micro-organism of similar 
properties, but no decided impression was made 
until the last-named published their results. 

These observers found in the earth of malarial 
districts, in Italy, numerous shining oval and mobile 
spores, .95 of a micro-millimetre in the longer 
diameter. They were able to cultivate these spores 
in the animal body as well as in culture experi- 
ments, and the animals infected by them exhibited 
not only the clinical course of malarial disease as 
seen in man, but also the post-mortem appearances; 
while the bacillus was also found in the blood of 
such animals, taken after death. The spores de- 
velop in the animal body, as well as in culture ex- 
periments, into long threads, which are at first homo- 
geneous, but later divide, while new spores develop 
in the interior of the segments. The position of 
the spores which are found either at the poles, or 
in the middle of the segment, serves as a mark of 
distinction between this and other pathological 
bacilli. 



Following Klebs and Tommasi-Crudeli, Marchia- 
favaand Cuboni, in \\'a\.'^ {Archiv fur Experimentelle 
Patholngie, vol. xiii.), studied the blood of men 
ill with malaria. In this they found spores and 
bacilli which they declared to be identical with 
those described by the former. The spores included 
in the white blood-corpuscles were sometimes so 
numerous as to seem to fill them completely. Sim- 
ilar studies on malarial patients by Lanzi, and 
again by Peroncito, led to the same conclusions. 

Succeeding these, Marchand published in Vir- 
chow's Archiv, vol. Ixxxviii., p. 104, April, 1882, 
some observations really made in 1876, whence he 
concluded that there exists in the blood, in the cold 
stage of intermittent fever, mobile and flexible rods 
presenting slight swellings at their ends, and some- 
times also at the middle. These end swellings he 
thought also might be of the nature of spores. 

More recent still are the elaborate experiments of 
Prof. Ceri, of Camereno, Italy, published in the 
Archiv fur ExperimentelU Palhologie, vols. xv. and 
xvi., 1882. These consisted of culture experiments 
with organisms found in malarial and other soils, of 
experiments on animals, and culture experiments 
with quinine. They resulted in proving that the 
spores could be cultivated — Ceri applying the term 
natural germs to those found in the atmosphere and 
soil, and artificial germs to those which result from 
their culture; that animals could be infected by 
their injection into the blood, though to a less de- 
gree by the cultivated than by the natural germs, 
the former growing weaker in successive genera- 
tions; and that the infecting properties could be 
retarded by the application of heat to culture fluids, 
and the introduction of quinine into them, certain 
degrees of the former, and strengths (i:8oo) of the 
latter making the culture of the spores impossible 
and arresting the putrid fermentation induced by 
them. The practical application of these facts is 
self-evident. 

Finally the opportunity has recently been pre- 
sented to Dr. Franz Ziehl to test these results clin- 
ically {Deutsche Medizinische Wochenschrift, Nov. 
25, 1882) in three typical cases of malaria, in all 
of which the spleen was enlarged. In all three 
the bacilli above described were found in the blood 
taken from any part of the body by the prick of a 
needle, aiid examined in the fresh state, or dried in 
a thin layer upon a cover glass, by simply passing 
the latter over a flame. These have been preserved 
by Dr. Ziehl for three months without undergoing 
any change. 

The bacilli thus observed were of different lengths, 
but usually were from one-fourth to the entire diam- 
eter of a red corpuscle. The majority of those 
measured were about 4 micro-millimetres long and 
.7 broad. Their ends were swollen and roundish. 



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THE MEANING OF NYCTALOPIA AND HEMERALOPIA. 



[Medical News, 



The ratio of the diameter of the former to the 
latter varied, being sometimes as i to 2, sometimes 
more and sometimes less. They presented active 
flexions and movements among the red corpuscles, 
their motion being so slow that they often remained 
for half an hour in the field of view afforded by a 
Zeiss's objective F, and ocular I (about 410 diam- 
eters). With the same amplification there was pres- 
ent for the most part but a single bacillus in one 
field, and never more than three. In two of these 
cases the use of quinine was followed by prompt relief 
and the disappearance of the bacilli from the blood in 
seven and nine days respectively. The third case 
improved under the use of Fowler's solution but, 
unfortunately, no further examination of the blood 
was made. 

Subsequently, Dr. Ziehl examined the blood of 
twenty- five persons, healthy or ill of other condi- 
tions than malaria. In only one of these twenty-five 
did he find bacilli, and these in considerable num- 
bers. The man was a diabetic, in whom the disease 
clearly succeeded upon exposure. There was no 
history of malaria, but Dr. Ziehl, remembering that 
diabetes mellitus has been occasionally traced to 
malaria, put his patient upon quinine. The daily 
excretion of sugar, which had been reduced by 
opium and diet to one-half the quantity noted on 
admission, was not further reduced, but the bacilli 
disappeared from the blood in eleven days after the 
treatment was instituted. It would seem, therefore, 
that quinine acts as a parasiticide, in some way de- 
stroying the bacillus, or, at least, interfering with 
its development. 

Should these observations be confirmed, and it 
must be admitted that the whole chain of evidence 
is much more conclusive than that adduced in favor 
of a bacillus tuberculosis, the whole mystery of the 
efiicacy of quinine in the treatment of malaria would 
be solved. It is evident, also, that the question is 
one of much easier solution than that of the bacil- 
lus tuberculosis, and we predict a speedy settlement 
of it. 

With a view of completing the presentation of 
the matter, we must mention a microbe claimed to 
have been discovered in the blood of persons suffer- 
ing from malarial fever by Richard {ComptesRendus, 
vol. xciv. p. 49), a French investigator, and named 
by Laveran oscillaria malaria. This infests the 
red-blood disk, and its development is said to 
be analogous to that of a parasite in the lentil. 
We condense from our contemporary, the Phila- 
delphia Medical Times, the annexed description 
of the microbe. In the blood of malarial subjects 
will be found some corpuscles presenting on their 
periphery a minute light and perfectly round spot, 
but which are otherwise exactly like the normal 
corpuscles. In a further stage of development the 



spot is larger and surrounded by a wreath of fine 
black nodules; around them haemoglobin — recog- 
nized by its yellowish-green color — is deposited in 
the form of a ring, which diminishes as the microbe 
grows, until nothing is left of the cell except a 
marginal zone, whence the haemoglobin is com- 
pletely absent. Thus the microbe completely oc- 
cupies the corpuscle, being still surrounded by the 
ring of black nodules. Finally, the fully developed 
oscillaria, which possesses several scarcely visible 
prolongations, perforates the membrane and escapes 
into the liquor sanguinis. Occasionally the pro- 
longations, or fibres, which have a power of motion, 
alone perforate the membrane, and the microbe 
itself remains within the cell wall. Sometimes, 
ako, the fully-grown microzyme is seen to move, 
and its fibres oscillate rhythmically, as "thin twigs 
would when held by their thicker ends and rapidly 
shaken . " This movement continues about an hour, 
when it ceases, and only the dead body of the par- 
asite is left. The dead parasites lose their shape, 
the ring of pigment is dissolved, and the whole ap- 
pears as a gray mass, including a few black nodules, 
which are subsequently liberated and rapidly ab- 
sorbed by the leucocytes. 

Such is the somewhat fanciful description by 
Richard of the oscillaria malariee yrhich, he says, 
he was able to demonstrate in the blood of all per- 
sons suffering from malarial infection who came 
under his charge, while the severity of th'e disease 
was proportionate to the number of microzymes 
found in the blood. Kelsch and "a few other ob- 
servers" are referred to as having noted these same 
phenomena. We have no critical comment to make 
upon these organisms other than that the changes 
described are strikingly similar to certain ones un- 
dergone by the red -blood corpuscles in the process 
of crenation and drying. 



THE KEAHIHO 07 HTCTALOPIA AND HEMEBAIOPIA. 

Medical terminology, and particularly that of 
ophthalmic surgery, is often accused of being for- 
midable, and it is not too much for those who 
undergo the labor of mastering it to expect that 
they shall be in possession of terms that are at least 
definite, if not etymologically correct. 

Unnecessary changes are of course to be avoided, 
and if the name given to a disease or symptom can 
claim the universal consensus of medical writers, if 
it involves no absurdity and is free from ambiguity, 
the wisdom of tampering with it may be doubtful, 
even if it cannot be defended on either scientific 
or literary grounds. But if its etymology is more 
than questionable, its application absurd, and its 
use confusing, certainly the sooner it is consigned to 
the limbo of obsolete words the better. Nyctalopia 
and hemeralopia seem to be much in this position. 



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January 13, 1883] AN IMPORTANT DECISION AS TO QUARANTINE FEES. 



43 



If we wish to record the fact that a patient's right 
leg is paralyzed, we do not do so by stating that his 
left is vigorous, and though we may indicate that 
the right half of his field of vision is gone by sta- 
ting that the left half remains (». e., that he has left 
hemiopia, or half vision) ; the term hemiopia is 
usually translated as "half blindness," and of lafe 
we have the choice of the more rational expression 
hemianopia or hemianopsia, which is coming into 
general use. Not so with the writer who wishes to 
state, in one rather learned looking word, that his 
patient cannot see at night, or that he cannot see 
so well in daylight as at dusk. He is not allowed 
the benefit of a translation " by contraries," or the 
choice of another word, but must, perforce, commit 
a verbal absurdity and write down " hemeralopia" 
or " nyctalopia." 

Among modem authors the use of the former 
term to express night-blindness and of the latter to 
express day-blindness is almost universal. How- 
ever inconvenient and confusing these terms may 
have been, we have consoled ourselves with the 
belief that their etymology was settled, and their 
use sanctioned by an antiquity extending back into 
the mythical ages of medicine. Elaborate articles, 
however, by Drs. Greenhill and Tweedy, in the last 
two numbers of The Royal London Ophthalmic 
Hospital Reports, show that the etymology of these 
words admits of an amount of learned philological 
discussion sufficient to bring doubt to the most 
conservative mind, and that the use of them in 
their present sense is a comparatively modern and 
probably accidental innovation. 

These authors say that Oribasius, Palladius, 
Aetius, Alexander Trallianus, Paulus .^ginata, 
Joannes Actuarius, and a host of others use nycta- 
lopia in the sense of night-blindness. Galen, who 
distinctly explains nyctalopia to mean night-blind- 
ness in one of his works, has been accused of tak- 
ing the opposite side in two others, but the latter 
are apocryphal. In fact, up to the middle of the 
seventeenth century, Hippocrates only can be cited 
as using nyctalopia in the sense of night-sight. 
About this time, the Hippocratic works were more 
generally consulted, and the passage— ^" Those who 
see at night, whom we call nyctalopes," etc., de- 
termined the meaning of nyctalopia, while hemer- 
alopia came into use to indicate the opposite kind 
of sight. It is shown, however, that the descrip- 
tion of the etiology, history, and treatment of the 
disease, which follows this passage, corresponds to 
night-blindness rather than to day-blindness; and 
a revised edition of Hippocrates is produced in 
which the word m>x is restored, making the passage 
read : "Those who do not see at night," etc., and 
undermining the faith that has inspired many gen- 
erations of medical authors. 



Drs. Greenhill and Tweedy have done a great 
service to medical literature by determining, at the 
expense of much labor and learning, the true lean- 
ing of these words ; but we fear that it will hardly 
be possible while they remain in use "to put an 
end to the confusion which has existed for consid- 
erably more than a thousand years. ' ' It would prob- 
ably be easier to change the terms than to reverse 
their accepted meaning. As hemianopsia and 
hemiachromatopsia have definite and unmistakable 
meanings, might not some such words as nyctanop- 
sia and hemeralanopsia be made equally useful ? 



UX nCFOSTAlTT DBCISIOff A8 TO (tirAKAIITnrS TSXB. 

A DESPATCH dated New Orleans, January 3, states 
that a perpetual injunction restraining the Board of 
Health of that city from collecting quarantine fees, 
has been granted by the District Court on the ap- 
plication of the Morgan Railroad and Steamship 
Company. Judge Monroe, in delivering the opinion 
of the Court, concluded as follows: "It is remark- 
able, in view of the fact that the convention which 
adopted the Constitution of the United States dis- 
tinctly determined, after the most elaborate and 
earnest discussion, that the States should not be al- 
lowed without the consent of Congress to levy 
duties on tonnage for any purpose whatever, that it 
should still be considered a matter of discussion as 
to whether such duties may not be imposed for the 
support of a police or quarantine established by a 
State for the protection of the health of its citizens. 
There is no reason for requiring that the quarantine 
service should be supported by those who are under 
no legal obligations to do so." 

As the quarantine fees are the chief source of 
revenue of the New Orleans Board of Health, 
which receives no appropriations from the city or 
the State, this decision to a large extent deprives it 
of funds. The opposition of the New Orleans 
Board of Health to the National Board, and espe- 
cially to the Ship Island Quarantine, has been no 
doubt influenced to a certain extent by the fear 
that its revenue from quarantine fees might be di- 
minished if vessels were allowed to perform quaran- 
tine elsewhere than at its own station, but it may 
now be able to take a more impartial view of the 
matter. This decision, if sustained by the superior ' 
courts, before which it will no doubt be brought in 
some way, affects all ports of the United States 
where quarantine fees are charged, and it would 
seem as if under it one or two things must follow : 
t. e., either the States or cities must appropriate 
the necessary funds for maintaining these quaran- 
tine inspections, or the general Government will be 
asked to assume the expense, and take charge of 
the matter. • 

Not having the full text of the decision before us. 



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44 



INFLUENCE OF ARSENIC ON THE FORMATION OF SUGAR, [Medical News, 



it does not seem worth while to comment further 
on the matter at present, but it is possible that this 
is the first step towards a really national system of 
quarantine. 

THE HmtlEKCE 07 ABSENIC ON THE EOBK&TIOH 
OF 8U0AS. 

This subject has been studied by M. le Dr. 
LoNGEviALLE, both by physiological experimenta- 
tion and by clinical observation. He has ascer- 
tained that the saccharine condition of the urine 
produced by puncture of the floor of the fourth 
ventricle, is very greatly diminished by the simul- 
taneous administration of arsenic. He has further 
observed that in cases of diabetes the quantity of 
sugar is equally diminished by the administration of 
Fowler's solution. This medicine he administers 
in doses which, to our notions, are rather extreme, 
giving from ten to thirty drops daily, and increas- 
ing the quantity up to the tolerance of the stomach. 
The result is striking. Not only is the quantity of 
sugar greatly reduced, but the simultaneous waste 
of the nitrogeneous materials in the form of urea 
is also much diminished. With the diminution in 
the quantity of urea and of sugar, a notable decline 
in the quantity of the urine passed also takes place. 

We are able to confirm these observations as 
regards the power of arsenic to check the formation 
of sugar, and the excessive production of urea, in 
cases of glycosuria. Although Longevialle has re- 
duced to scientific expression the utility of arsenic, 
it must be admitted that it has long been known 
that arsenic is a useful remedy in diabetes. The 
clinical fact now receives scientific confirmation, 
but the fact has, nevertheless, long existed. 



The Pseudo-bacillus Tuberculosis of Schmidt, 
we feel, should be the term applied to the object 
of the studies of Dr. Schmidt, of New Orleans. 
That this object is a fat crystal derived from the fat 
so abundantly present in the sputum of tuberculosis, 
as well as in tubercle itself, there is every reason to 
believe. But that this is the object which has been 
called the bacillus of tuberculosis by Koch and 
others is not at all likely. No further proof of this 
ought to be required than the demonstration by Dr. 
J. Gibbons Hunt, at the College of Physicians of 
Philadelphia, last Monday night. That the pseudo- 
bacillus is a crystal, is proved by the fact that it 
Polarizes under the microscope, while the true ba- 
cillus does not polarize. These different properties 
were sho"wn side by side. Otherwise the two objects 
are similar, but Dr. Schmidt has mistaken the crystal 
for the real thing, which it closely resembles. 



It is important to publish widely the fact that 
in Illinois one Lambrecht has recently been detected 
in an attempt to personate Dr. Heinrich Andreas 



LOders, a graduate from the University of Gottin- 
gen in May, 1866, who died in November, 1878. 
Lambrecht, who is a barber by trade, became in 
some way possessed of the diploma of the dead man, 
and attempted to register under it ; and although, 
by reason of suspicious circumstances connected 
with the application, the required certificate was 
held back for some time by the Illinois State Board 
of Health, it was finally obtained in two years from 
the date of application, and he began to practice in 
CoUinsville, III. The fraud was discovered by cor- 
respondence with the dean of the medical faculty 
of Gottingen, but not until the man had sacrificed 
a mother and infant in the attempted rdle of obste- 
trician. The scoundrel escaped, however, before 
he could be arrested, and may attempt the same 
game in some other State, where requirements of 
registration are less rigid, or do not exist at all. 

Attempts at personating others through diplomas 
acquired by theft or otherwise are not infrequent, 
and suggest a rigid examination as to the identity 
of the individual with the name on the diploma. 
In this instance, the unscrupulousness of the man in 
forging letters of recommendation enabled him to 
deceive the Secretary of the Board. Had an affi- 
davit before a justice of the peace, properly ex- 
ecuted, been required in addition to the letters of 
recommendation, another obstacle to the success of 
the fraud would have been interposed. 



The new year has brought with it the usual num- 
ber of alterations in our exchanges. 

The New York Medical Journal has been con- 
verted from a monthly to a weekly, of 28 octavo 
double-columned pages, with the usual diversity of 
matter. The first number contains for its leading 
article Dr. W. B.* Carpenter's initial lecture on 
Human Automatism, a full abstract of which was 
laid before our readers in our issue for December 
2d. The journal remains under the editorial con- 
trol of Dr. F. P. Foster. 

The Sanitarian likewise becomes a weekly publi- 
cation, and the first number consists of sixteen 
handsome double-columned quarto pages. It re- 
mains under the able editorial control of Dr. A. N. 
Bell, who is assisted by Dr. T. P. Corbally. The 
opening number contains papers by Drs. Cabell, 
Bowditch, Peters, and others. 

The Medical Record, with the new year, appears 
in new type, a greatly improved dress, and a length- 
ened page, and it announces its intention of avail- 
ing itself of all the resources of modern medical 
journalism. 

The Detroit Clinic and The Michigan Medical 
News pass under the control of Mr. George S. Davis, 
and win be combined and published hereafter under 
the title of The Medical Age. 



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January 13, 1883.J PROCEEDINGS OF COLLEGE OF PHYSICIANS OF PHILADELPHIA. 45 



The cost to the Government of the star route 
trials has just been made public, and we learn that 
Mr. George Bliss has been paid up to December 1st 
^40,660.34, and the total sum paid to special 
counsel at that date was about 170,000. Judge 
Porter and Mr. Davidge each received for his ser- 
vices in the Guiteau trial Jio,ooo, and Mr. Edwards 
Pierrepont was paid 13,099.35 in the past year for 
his services in the discontinued Tilden income-tax 
suit. These sums have been paid without eliciting 
a word of comment from the same Congress which, 
with considerable appearance of virtue as well as 
economy, denounced the extravagance of the sum 
it was proposed to pay the four surgeons who were 
in attendance upon President Garfield, and then 
created the Board of Audit which subsequently 
awarded them the total sum of 120,500. We com- 
mend these figures to the thoughtful consideration 
of the profession and the public. 



SOCIETY PROCEEDINGS. 



COLLEGE OF PHYSICIANS OF PHILADELPHIA, 

Stated Meeting, January 3, i88j. 

The President, W. S. W. Ruschenberger, M.D., 
IN THE Chair. 

Dr. John B. Roberts read a paper on 

HEART- PUNCTURE AND HEART-SUTURE AS THERAPEUTIC 
PROCEDURES. 

It is more than probable that in a few years punct- 
ure of the heart-wall (cardicentesis), with direct ab- 
straction of blood by aspiration, will be recognized as 
the best treatment in cases of greatly dilated or much 
distended right heart, with intense pulmonary engorge- 
ment ; and that incision of the pericardium, with suture 
of the heart muscle, will be accepted as proper in car- 
diac wounds. Hence these latest novelties in cardiac 
surgery deserve the attention of the Fellows of the 
College. 

That punctures of the heart are comparatively harm- 
less has been well known to many for some years. In 
1872, Roger, while performing pericardicentesis on a 
child with pericardial efTusion, thrust the needle into 
the right ventricle and withdrew about 6% Troy ounces 
(200 grms.) of pure venous blood. The boy, who was 
aged five years, became pale, sweated, and had an 
imperceptible pulse. The withdrawal of the pericar- 
dial flu'd, accomplished prior to the heart injury, was 
beneficial : and the cardiac puncture did no permanent 
mischief, for the patient recovered. Death occurred 
five months later from long existing dilatation and 
valvular disease of the heart (Bull, de rAcadimie de 
Medecine, 1875, P 1276). 

In Hulke's case ( Trans. Clinical Society of London, 
viii. p. 169), a woman with pleuro-pneumonia was sup- 
posed to have large pericardial effusion, and a trocar 
was introduced through the fourth left intercostal space. 
Nothing escaped except a drachm of venous blood, 
after which the patient seemed relieved of dyspnoea. 
She died four weeks later from a complication of dis- 
eases, and the autopsy revealed cardiac dilatation and 
valvular changes. 

I have said elsewhere ( Ptracentesis of the Pericar- 
dium, 8vo., Philadelphia, 1880), in commenting upon 



this case : " The abstraction of blood seemed to relieve 
the distended heart much better than phlebotomy would 
have done, as was evinced by the diminution of threat- 
ening symptoms and the decrease of the area of dul- 
ness." 

Cloquet, Bouchut, Legros, and Onimus have also ob- 
served the apparent innocuousness of wounds of the 
heart made by capillary trocars. Steiner found, ten 
years or more ago, that eleciro-puncture needles could 
be quite safely introduced into either ventricle, pro- 
vided they were at once withdrawn (Med. Tim^s and 
Gazftte, May, 1873, p. 492, from Langenbeck's Archiv 
fiir klin. Oiirurgie). 

It has been considered less safe to puncture the 
auricles; but the interesting paper of Ur. Benj. F. 
Westbrook, just published in the Medical Record for 
December 23, 1882, seems to show that our fears are as 
unfounded as were those of our predecessors in regard 
to ventricular puncture. It is, in truth, to call attention 
to his case of harmless intentional cardicentesis and to 
his researches in the surgical anatomy of the operation, 
that I have been led to refer to the corroborative 
evidence of the cases mentioned above. , 

I have with much satisfaction, as have many others, 
done venesection at the bend of the arm for the tem- 
porary relief of the distressing symptoms of dilated 
heart, and for the dyspnoea due to thft pulmonary en- 
gorgement of acute pneumonia. If, however, a few 
drachms of blood drawn directly from the heart give 
the relief that could only be afforded by taking a 
similar number of ounces from the veins of the arm, 
it seems proper to adopt the former measure. The 
subsequent circulatory dfpression from anaemia would 
undoubtedly be less than after the latter operation. 

It is manifestly necessary, however, to determine 
that cardicentesis is innocuous before it can take the 
place of venesection. The above-mentioned cases 
and Dr. Westbrook's experience tend to show that 
such is the fact. 

Dr. Westbrook believes that the proper place to 
perform the operation is in the third costal interspace 
close to the right «.A%t of the sternum. This situation 
enables the operator to tap the right auricle without 
injuring the right internal mammary vessels, and with 
little danger of striking the tricuspid valve. My own 
preference would be to perforate the ventricle of the 
right heart by introducing the needle through the 
fourth interspace, about one and a half or two inches 
to the left of the median line of the sternum. Dr. 
Westbrook's opinion, however, is entitled to more 
deference than mine, because he has studied the sub- 
ject with special reference to cardicentesis, while my 
special investigations have been limited to the consid- 
eration of pericardicentesis. 

Further experimentation in heart-puncture for the 
relief of cardiac distention and pulmonary engorge- 
ment is requisite, but it is probable that it will soon 
become a well- recognized surgical procedure in selected 
cases. Pericardicentesis has alre.idy taken that posi- 
tion, and there is no reason to believe that cardiac 
surgery will stop its march with the demonstration that 
the pericardium can be tre.^ted as the pleura. 

In October, 1881, I read a paper before the Ana- 
tomical and Surgical Society of Brooklyn { The Sur- 
gery of the Pericardium ; Annals of Anatomy and 
Surgery, December, 1881), in which I advised resection 
of the costal cartilage and incision of the pericardium 
for removal of foreign bodies in the pericardial sac ; 
and at the same time said: "The time may possibly 
come when wounds of the h^art itself will be treated by 
pericardial incision, to allow extraction of clots, and 
perhaps to suture the cardiac muscle." 

It seems as if this time had now almost arrived, for 
Dr. Block has not only expressed a belief that death 



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PROCEEDINGS OF NEW YORK ACADEMY OF MEDICINE. 



[Medical News, 



can be averted in many cases of heart-wounds by 
simple incision of the pericardium to allow escape or 
extraction of the clots which cause pressure and aeath, 
but has also undertaken to demonstrate by vivisectal 
experiments that suture of the heart is a simple opera- 
tion ind reauires but three or four minutes (Amer. 
Journal of the Afed. Sciences, January, 1883. p. 276 ; 
from Journal de Med. de Paris, Oct. 28, 1882; from 
Caz. Med. de Strassbourg, Oct. 18, 1882). He finds 
that opening of the right and left ventricles, and entire 
compression of the heart for the application of sutures, 
can be supported by rabbits for several minutes. 
During suturing he seizes the apex of the heart and 
draws the organ forward until the traction prevents 
the escape of blood from the wound. Sutures are then 
introduced, or the orifice closed by ligation. Even if 
cardiac pulsation and the respiration stop during this 
mechanical interference with the heart's movement, 
death, he asserts, does not necessarily ensue. 

Thesef experiments are even more important than 
the researches spoken of in regard to heart-puncture. 
I regret that as yet I have not been able to consult 
Dr. Block's original memoir, but I hope at a future 
time*to do so, and perhaps to be able to report some 
investigations of my own which I desire to make in 
the same direction. 

The following Fellows were then elected 

OFFICERS FOR THE ENSUING YEAR. 

President.— Mind StilM, M.D. 

Vice-President.—]. M. Da Costa, M.D. 

Secretary. — R. A. Cleemann, M.D. 

Treasurer. — Chas. Stewart Wurts, M.D. 

Curator. — Thomas Hewson Bache, M.D. 

Honorary Librarian. — ^James H. Hutchinson, M.D. 

Recorder. — J. Ewin^ Mears, M.D. 

Censors. — Drs. Lewis Rodman, Edward Hartshorne, 
William Goodell. and Samuel Lewis. 

Councillors (to serve three years). — Drs. S. Weir 
Mitchell and W. S. Forbes. 

The following resolution complimentary to 

THE RETIRING PRESIDENT 

was unanimously adopted. 

'•"Resolved, Inasmuch as the term of the retiring 
President of the College, W. S. W. Ruschenberger, 
M.D., has just been completed under the limit pre- 
scribed by the by laws, the Fellows of the College 
hereby respectfully and cordially congratulate him 
upon the very successful termination of his official ser- 
vices, and upon the long-continued, constant, and 
faithful administration which has distinguished those 
services not only in the Presidential Chair, but in his 
unremitting, wise, and watchful attention to the in- 
terests of the College. 

" They take especial pleasure in expressing the 
grateful appreciation of the College, and in recording 
the fact that throughout his nearly four years of service 
as Vice-President, and his subsequent four years of 
service as President, Dr. Ruschenberger, while holding 
always the pleasantest relations with his Fellows of the 
College, has never been obliged by ill health or other 
cause to absent himself from his post, either at the 
meetings of the College or of the Council." 

NEW YORK ACADEMY OF MEDICINE. 
Stated Meeting, January 4, i88j. 

The President, Fordvcb Barker, M.D., LL.D., 

IN the Chair. 
The result of the 

ANNUAL ELECTION 

of officers for 1883 was as follows : 
President. — Fordyce Barker. M.D. 
Vice- {Resident.— H. P. Farnham, M.D. 



Recording Secretary. — W. H. Katzenbach, M.D. 

Corresponding Secretary. — ]. G. Adams, M.D. 

Treasurer. — William F. Cushman, M.D. 

Trustee.— G. M. Smith, M.D. 

Treasurer of Board of Trustees.— Charles Wright, 
M.D. 

Mem. of Com. on Admission. — E. L. Partridge, M.D. 

Mfm. of Com. on Ethics. — H. E. Crampton. 

Mim. of Com. on Education — ]. C. Dalton, M.D, 

Mem. of Com. on Library. — F. R. Sturgis, M.D. 

The scientific work of the evening consisted in the 
reading of a paper by Dr. Francke H. Bosworth, on 

TUMORS IN THE NASAL PASSAGES. 

By nasal passages, he said, was meant the whole of 
the physiological air tract from the nostrils to the lower 
part of the soft palate. 

The most frequent form of growth is the adenoid in 
the vault of the pharynx. It consists simply in a hy- 
pertrophy of the glands normally found in that region. 
It is a rather common belief that adenoid tumor in 
the vault of the pharynx is a rare and obscure disease, 
whereas Dr. Bosworth had found it a most common 
affection. The point from which he wrote was that 
this was one of the conditions which gave rise to so- 
called nasal catarrah. Nasal catarrh, however, was to 
him a meaningless term. There were a number of dif- 
ferent conditions which gave rise to discharge from the 
nose. In a very large number of instances the dis- 
charge is the result of a definite morbid condition, the 
removal of which results in radical cure of the disease. 

Among the common causes or sources of nasal ca- 
tarrh were mentioned in passing rhinitis hypertro- 
phica, deviated septum, adenoid growths in the vault of 
the pharynx, nasal polypus, presence of foreign bodies, 
syphilitic ulceration or necrosis, and strumous ulcera- 
tion. These were diseases which generally presented 
to the physician for treatment as nasal catarrh. 

During the last twelve mofiths seventy-five cases of 
these growths (adenoid) had come under Dr. BoS- 
worth's observation. Five were in patients under the 
age of ten, forty-three between ten and twenty, twenty- 
three between twenty and thirty, two between thirty 
and forty, one between forty and fifty, and one in a 
patient over fifty. Of these, forty nine were females 
and twenty-six males. These cases all presented for 
treatment of nasal catarrh. We thus find the largest 
proportion of these cases occurring in patients below 
the age of twenty. The deduction from this is that the 
disease is essentially one of childhood, and that with 
the development which occurs at puberty, these growths 
gradually disappear. 

The existence of these growths has long been recog- 
nized, but was first accurately described -by Luschka, 
from whom the disease received the name of Luschka's 
tonsil. Woakes, of London, describes adenoids as 
consisting of a papillomatous structure; Meyer, of 
Copenhagen, and Loewenberg, of Paris, described them 
as being glandular. The analogy between these and 
the faucial tonsil seems complete, both in an anatomi- 
cal, physiological, pathological, and clinical point of 
view. 

Symptoms. — The most prominent symptom to which 
these growths give rise is that of an abnormal secretion, 
which is composed of mucus or muco-pus. The 
morbid process giving rise to the hypertrophy does not 
destroy the secreting function of the glands, but rather 
increases it. The secretion makes its way out through 
the nostrils or down the throat. 

Another symptom is a change in the voice. Their 
presence gives rise to what Meyer calls the dead voice, 
the nasal resonance being destroyed as in an ordinary 
cold, so that il/and W become Eb and Ed. The fact 
of even a small adenoid growth in the vault of the 



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47 



pharynx upon a singing voice offers many points of 
interest The conversational voice does not tax the 
full capacity of the larynx. A person with a consider- 
able_ degree of laryngeal disorder will experience no 
special difficulty in an ordinary conversational use of 
the voice. Singing, however, taxes the very highest 
capacity of the larynx, and demands that not only the 
latrynx, but the pharynx and the nasal passages shall 
be in a state of perfect health. In the lower or chest 
register a healthy larynx of course is essential, and 
notes in this register are taken with ease and clearness 
even when disease may exist in the nasal cavity. The 
vocal cords regulate the pitch tension of the voice, but 
the quality of the voice is governed or depends upon 
the nasal cavity,' largely ; so that while it is a matter of 
common observation among singers that it is the head 
register that first gives out, this illustrates what Dr. 
Boswoith has always urged, that the so-called catarrhal 
laryngitis is, in the majority of instances, a secondary 
affection and depending on the catarrhal disease of the 
nasal cavity. The laryngitis therefore becomes merely 
a symptom of the nasal disease. The method by 
which the sihgin^ voice becomes affected from the 
presence of adenoid growths in the vault of the phar- 
ynx is quite simple. The prominent function of the 
pharynx is that of a sounding-board, and in order that 
this sounding-board function shall be exercised, the 
pharynx must necessarily present a smooth, rounded, 
dome-like cavity against which the vocal waves may 
strike and be reflected. If, then, this region is the seat 
of an adenoid growth, the voice becomes mufHed, and 
loses something of its proper resonance and quality. 
The singer becomes conscious of this loss of tone and 
unconsciously, perhaps, makes a renewed effort to 
overcome this obstacle. In doing so he ruptures some 
of the capillaries in the larynx or muscular fibres, thus 
bringing on secondarily a laryngitis. A strained voice 
is the result. 

Impairment of hearing is not an infrequent accom- 
paniment of adenoid disease in the vault of the 
pharynx. It is a common belief that this symptom is 
due to an extension of catarrhal disease into the Eus- 
tachian tubes. Dr. Bosworth was disposed to regard 
this as a very infrequent occurrence. In making an 
examination by inspection of the orifices of the Eus- 
tachian tubes, it is exceedingly rare to find any evi- 
dence of catarrhal inflammation in them. 

Dr. Bosworth also said that it was commonly believed 
that the ear symptoms were due to pressure upon the 
Eustachian orifices. Adenoid tumors are soft, pulpy 
masses, having very little resistance, and, as the 
Eustachian orilices are composed of hard, dense, car- 
tilaginous, or horny tissue, they could not likely be 
affected by pressure of soft adenoids. The real ex- 
planation of impairment of hearing, urged by Dr. 
Bosworth, was that it was due to interference with the 
renewal of air in the middle ear. The constant and 
ceaseless impulse of vocal waves upon the tympanum 
necessarily acts to rarefy the air in the middle chamber. 
To counter-balance this, we have the movement of the 
faucial muscles. The presence of an adenoid growth 
very markedly interferes with the free pl-iy of the leva- 
tor palati muscles, and, therefore, interferes with the 
renewal of air function. The growth, of course, does 
not oppose any obstacle to the levator palati mUscle 
itself, but the elevation of the palate. Moreover, any 
cause which interferes with free nasal respiration, acts 
to produce a certain amount of rarefaction of air in the 
pharyngeal vault. It is thus that nasal stenosis, to 
which the presence of an adenoid growth gives rise, 
acts still fiirther to rarefy the air in the middle cham- 
ber, thus causing impairment of hearing. 

Ret urring attacks of earache were present in a cer- 
tsun number of cases, and in two cases there were 



attacks of otitis medii. In one case, tinnitus aurium ex- 
isted, with impairment of hearing, which was markedly 
relieved, though not cured, by the removal of the 
growth. 

Nasal stenosis is a prominent symptom in the pres- 
ence of an adenoid tumor. It is due to the mechanical 
interference with the to-and-fro flow of currents of air. 
It is a very noticeable fact in these cases that under 
the influence of damp weather these growths become 
swollen and turgid to such a degree that they are very 
markedly larger on inspection at one time than at 
another. The point examined will sometimes appear 
very small ; a^ other times puffed up. In this feature, 
the disease presents some of the characteristics of 
nasal polypi. 

The disease is purely a local one, the inflammatory 
affection ini^olving these glands always manifesting 
itself in a hypertrophy, and never in an atrophy. The 
morbid process confines itself to these glands. 

In four of Dr. Bosworth's cases, disease occurred in 
connection with atrophic rhinitis, but in by far the 
larger proportion of cases it occurred in connection 
with rhinitis hypertrophica. In about one-half of the 
cases it occurred independently of any other morbid' 
process. 

Diagnosis. — The diagnosis is made by means of a 
rhinoscopic examination. Loewenberg and Meyer dir 
rect that digital exploration should be made in all' 
cases. This, Dr. Bosworth did not consider to be 
necessary. It was only accomplished with discomfort 
to the patient, and unnecessarily excites more or less 
terror and apprehension on the part of the child. A 
better and clearer conception of the size and position 
of the tumor can be obtained by means of the rhino- 
scope. To make an examination, sunlight should be 
used in all cases, as the ordinary gas jet is not sufficient 
to thoroughly illuminate the parts. That there is any 
difficulty in making a rhinoscopic examination of chil- 
dren is an entire mistake. The confidence of the child 
is easily gained, and with a little adeptness of manipu- 
lation and patience, a satisfactory inspection can be 
obtained. Dr. Bosworth recalled no single instance 
where he had not been able to make this examination 
in children. 

Treatment. — ^The treatment consists in the removal" 
of the growths. The question arises whether an opera- 
tion is demanded, in view of the fact that they some- 
times disappear with the development that occurs at 
puberty. Dr. Bosworth claimed that their presence 
always gave rise to symptoms sufficiently prominent to 
demand their removal without regard to this feature. 
Not only should the existing .symptoms be relieved 
before removal, but the threatened dangers of disorder 
lower down as a result of their presence. The presence 
of this growth undoubtedly gave rise to a tendency to 
weak throats, and bronchial troubles as the result of 
the habitual mouth breathing which they induce. 

Various devices have been used for extirpating these- 
tumors. Meyer, of Copenhagen, uses a ring knife. 
This consists simply of a ring with the cutting edge on 
the inside, mounted on a straight rod. The instrument 
is passed through the nose, and manipulated by means- 
of the finger passed in the mouth behind the palate, 
and the growth shaved off. He follows this operation 
by passing a long curved instrument, having a rasp on 
its convex surface, by means of which instrument passed- 
into the mouth he rasps the base of the tumor. Finally, 
he cauterizes the surface. Meyer unquestionably does- 
his work very thoroughly as his record shows. He 
has operated upon between three and four hundred 
cases. 

The question arises, cannot this work be done by 
much simpler means? Woakes, of London, Cohen, of 
Philadelphia, and others recommend a pair of curved' 



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PROCEEDINGS OF NEW YORK ACADEMY OF MEDICINE. [Medical News, 



forceps with a cutting bite, which is passed behind the 
palate, and the growth seized and torn away. This 
seems to be a rude and harsh procedure. Loewenberg, 
of Paris, Michel, and Voltalini use the gal vano- cautery. 
There are two methods by which this device may be 
■used : Either by the heated wire severing the mass, or 
by destroying it by the flat electrode. The first method 
is not feasible. As a directly destructive agent, Dr. 
Bosworth believes the gal vano-cautery to be immensely 
■over-estimated. It is an expensive and ponderous in- 
strument, and always getting out of order; and, more- 
over, for the p jrposes of destruction it does not accom- 
plish what has been claimed for it. If a-cold electrode 
is placed upon the growth, and the current closed the 
loss of heat is so great that it is impossible to develop 
even a dull red heat. The destruction of tissue is 
therefore limited. If heat be developed in the electrode 
before entering, it is almost impossible to pass it with- 
out burning healthy tissue. MacKentie recommends 
the use of the curette. This instrument Dr. Bosworih 
formerly used, but found it difficult to remove any but 
simple growths with it. 

The instrument which the aathor of the paper made 
■use of was an adaptation of Jarvis's snare. In his 
hands it had answered a most admirable purpose in 
the removal of these growths. The dis al end of the 
tube is bent to a quadrant of a circle, with the radius 
of one and a quarter inches. The instrument is fitted 
with a loop of No. 5 piano wire, of a sire which it 
is judged will embrace the growth. The loop is now 
bent forward to a right angle with the distal orifice of 
the instrument. The wire is then drawn out about 
one-eighth of an inch, and the whole of the loop is 
now bent backward toward the hand. The wire now 
has two kinks in it. The instrument with the loop in 
this position is readily passed behind the palate and to 
the vault of the pharynx with the extremity of the tube 
lying immediately behind the tumor. As the screen at 
the proximal end of the instrument is slowly turned, 
the loop is made to swing up and embrace the growth, 
which is slowly severed. The rigidity and firmness of 
the steel wire render this procedure an exceedingly 
■simple matter. By this simple device even a broad 
sessile growth can readily be removed. The operation 
is attended with but little pain and trifling hemorrhage, 
and is not difficult to perform. The growth is either 
drawn out with the instrument or blown into a hand- 
kerchief through the nose. Dr. Bosworth has never 
had the slightest inconvenience from these growths 
■dropping into the air passages. He has. however, oc- 
■casionally lost a specimen by its being swallowed. No 
anaesthetic is required.- The operation of course neces- 
sitates a certain amount of faucial control on the part of 
the patient, as the loop cannot be passed unless the 
palate is entirely relaxed. Occasionally, Dr. Bosworth 
lias been compelled to operate through the nose in 
young children on account of an irritable throat. In 
these cases an anassthetic has been given, and the 
operation performed with the ordinary straight Jarvis's 
■snare. The method by which.this has been done is as 
follows : The snare is fitted with steel wire as before, 
•the loop being of proper size to embrace the growth. 
The loop is then bent downward, and to a right angle 
with the orifice of the tube. Having done this, it is 
drawn into the tube until sufficiently small to pass 
readily through the nares. It is then passed in a ver- 
tical position until it reaches the pharynx, where it is 
turned in such a manner that when the wire is pulled 
out through the txihe, the kink which has been given 
it, will turn the loop downward. When in this position 
the end of the instrument is pressed firmly against the 
pharynx, and the loop drawn home by means of the 
screw at the proximal end of the tube. The same 
jM-ocedure is repeated in each nostriL Complete anaes- 



thesia is not necessary, as the operation is completed 
in from one to two minutes, the child being imme- 
diately aroused and directed to blow its nose. 

Nasal PolvpuK. — The next class of nasal tumors to 
which Dr. Bosworth called attention was nasal polypi. 
This disease has been recognized since the days of 
Hippocrates, and is treated of in all text-books to the 
present day. The morbid condition consists of the 
presence in one or both of the nasal cavities of one or 
more soft gelatinous bodies which block up the pas- 
sages, and give rise to more or less profuse secretion 
or discharge. 

Properly speaking, the term polypus means peduncu- 
lated tumor. As a clinical fact, the only pedunculated 
tumors met with in the nose are nasal polypi. In 
structure these tumors are pure myxomata. A proper 
cta^isification would demand that these tumors be rec- 
ognized as such. Fibromata never become peduncu- 
lated. They are always sessile growths. In current 
literature a fibroma of the nasal pharynx is usually 
spoken bf as a naso-pharyngeal polypus. During the 
last year there were treated at Dr. Bos worth's clinic at 
Bellevue Hospital 1641 cases of throat and nose affec- 
tions. Of these, there were 19 cases of nasal polypus. 
During the same time he saw and operated upon 16 
cases in private practice. Of these 35 cases, 2 were 
under 20 years of age, namely, 11 and 15 years; be- 
tween 20 and 50 years of age there were 9 cases ; be- 
tween 40 and 50, 12 cases; between 50 and 60, 6; 
between 60 and 70, 4 cases ; 20 were males, 15 females. 
In a large number of cases the disease occurs in both 
nostrils. In those cases in which they are fouird only 
in one nostril the tumors are few in number and small 
in size. This fact would argue that the disease com- 
mences in one nostril and subsequently develops in 
the other. They spring from the under surface of the 
middle turbinated bone in a large proportion of the 
cases. Dr. Bosworth recalled but two cases in which 
they sprang from the septum. They are pear-shaped 
bodies attached by a narrow pedicle. Their shape_ is 
probably due to their soft consistency. Under the in- 
fluence of gravity and the to-and-fro movements of 
inspired air they are drawn out and hang in the cavity 
They rarely assume much size, simply from the fact 
that they have no room for development in the narrow 
nasal passages. Occasionally they develop near the 
posterior nares and drop into the pharynx, where they 
have more abundant room for growth, and therefore 
attain a larger size. Dr. Bosworth showed two polypi 
nearly of the size of hens' eggs, which were removed 
by operating through the nares. We were generally 
taught that this disease was the result of nasal catarrh. 
Dr. Bosworth thought that nasal polypus is a disease 
by itself, having no special connection with nasal 
catarrh or chronic rhinitis. In a majority of his cases, 
after the removal of the polypi, the nasal mucous 
membrane was found healthy. In a certain proportion 
of cases there was chronic hypertrophic rhinitis. In 
four cases there was atrophic rhinitis, which would 
seem to argue that there is no connection between 
these affections and hypertrophic catarrh. In two in- 
stances the writer had removed polypi from the borders 
of syphilitic ulcers in the nose. This would indicate 
no connection between syphilis and nasal polypi, the 
growths being simply the result of local morbid 
changes. 

Ordinary symptoms were briefly referred to. They 
consist in a watery discharge, the hydroscopic char- 
acter of the tumors, a nasal stenosis, etc. Sneezing 
was referred to as a prominent symptom of nasal 
polypus, and one whose importance is usually under- 
estimated. The irritability of the nasal mucous men\- 
brane in chronic rhinitis is impaired, and sneezing is 
not a symptom of ordinary chronic nasal catarrh. In 



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49^ 



the early stages of nasal polypus, repeated and violent 
attacks of sneezing are very common. This symptom 
is always suggestive of the disease, and when it exists 
without apparent cause, the nasal cavity should be 
explored. 

In three Cases asthma was present, and depended 
upon the existence of these growths. The asthma 
presented all the characteristics of ordinary spasmodic 
aithma, the physical signs, together with nocturnal ex- 
acerbations, being present. In two cases the asthma was 
entirely cured by the removal of the pol) pi without the 
administration of remedies. In one case in which it 
had existed for two years, the asthma was only relieved 
by the administration of iodide of potassium for three 
months after the polypi were removed. This reflex 
syntpiom of nasal polypus (asthma) was first noticed 
by Volialini, in 1871. Since then additional testimony 
has been adduced by Daly, Frankenkel, Rumbold, 
Spencer, Todd, Porter, and Holden. 

Treatment. — The earliest treatment recommended 
for the removal of these growths was that by Hippoc- 
rates. This consisted in passing a string through the 
nar€S, to the end of which a large piece of sponge was 
■ tied, which was then drawn back through the nasal 
passage, bringing out with it some of the growths. It 
IS a strange fact that this procedure is still recommended 
in some books. 

Injections with acetic acid, tincture of iodine, per- 
sulphate of iron, and corrosive sublimate have been 
recommended. The result of the use of these injections 
into the growth is its necrosis. The polyp sloughs 
away after from three to five days, during which time 
the patient suffers from offensive, watery, and fetid 
discharge from the head. It is impossible to inject 
more than one or two polypi at a time. Hence, for the 
eradication of all the growths, a long course of treat- 
ment is necessary, during which time the patient is 
practically suffering from an offensive form of ozsna. 
All works on general surgery recommend the u^e of 
forceps for the removal of these tumors. This method 
is perhaps the one most universally resorted to. We are 
directed to pass the forceps in and seize the pedicle of 
the polyp, and drag it out. Dr. Bosworth said that he 
had never seen a pedicle of the polypus until after it was 
removed. Hence this procedure is impossible by in- 
spection. If it is meant to pass the forceps in and feel 
for the pedicle, the result is that a harsh instrument's 
passed mto an exceedingly sensitive cavity, and made 
to grope about, until something is seized upon, whether 
it be healthy or diseased tissue, and is dragged forth. 
Healthy parts, in all cases^are bruised and mutilated. 
Violent hemorrhage is the result of the first introduction 
of the forceps, and all subsequent procedures are en- 
tirely in the dark. It is one of the most unsurgical 
proceedings that Dr. Bosworth knew of. Moreover, 
all the tumors cannot be removed by the forceps. We 
are, therefore, directed to remove a portion of the tur- 
binated bone. The healthy mucous membrane Upon 
the turbinated bone has a certain function to perform 
in the economy, and its removal is unjustifiable without 
sufficient cause. 

The galvano-cautery recommended by Middledorphf 
is probably efficient. Dr. Bosworth's objection to this 
was that it was a bungling instrument. Moreover, the 
use of a heated wire in the nasal cavity is liable to do 
a great deal of injury to healthy tissue. The introduc- 
tion, by Hilton, of the snare was the first thoroughly 
surgical method of removing these growths. The snare 
was mounted with the soft wire, which was passed 
around the growth, tightened, and the pol) p evulsed. 
This procedure was liable to leave a portion of the 
polyp tissue in the nose. 

Jarvis's snare fcraseur furnishes us with an instrument 
which leaves nothing to be desired. The steel-wire 



loop with which it is provided being firm and resisting, 
can be carried in any direction in the nasal cavity, and 
easily manipulated so as to embrace the smallest 
growth. This difference should be noted between the . 
action of the snare and the action of the 6craseur. In 
the snare the growth is seized and evulsed, in the ^cra- 
seur the growth is embraced and severed by a slow pro- 
cess of 6crasement. With this instrument, when the 
operation is done deftly, a long shred of fibrous tissue 
is easily dragged out from the healthy mucous mem- 
brane. Dr. Bosworth was not a believer in roots, but 
if there was a root of a polypus this is the root, and 
another polypus does not develop at this spot. In the 
specimen shown,, this fibrous shred was easily recog- 
nizable. The only objection to the ordinary snare is 
that in deeply seated growths the hand of the operator 
obscures inspection of the nasal cavity. To overcome 
this. Dr. Bosworth made a combination of Jarvis's 6cra- 
seur and wire snare. 

As to the recurrence of these growths Dr. Bos- 
worth expressed the opinion, that if they were thor- 
oughly relieved they would not occur. The operation, 
it should be stated, is done with but little pain and no 
hemorrhage, and can be continued from day to day 
until all the growths are removed. He had not found 
it necessary to apply a cautery to the base in order to 
prevent the recurrence of the growths. They were 
to be treated as you would weed a garden. 

Dk. Lefferts was called upon to open the discus- 
sion. In doing so,he said that there were many points 
in Dr. Bosworth's excellent paper that needed no dis- 
cussion. On the other hand, there were some state- 
ments made by Dr. Bosworth which he thought it 
would be well to consider. First among these was that 
adenoid tumors of the naso-pharynx were generally 
believed by the profession to be rare. Dr. Lefferts- 
declared that any one who had read the journals could 
not help having noticed this subject treated of almost 
ad nauseam. The speaker, however, had not found 
these adenoid vegetations so comparatively common 
as the statements of Dr. Bosworth and the numerous 
pathological specimens presented by him this evening 
would seem to indicate. 

The fact that a large number of these growths were 
exceedingly small and could hardly be considered as- 
an abnormality, should not be overlooked. The author 
of the paper had not laid sufficient stress upon this 
point. The question was asked, is it always necessary 
to remove tliese growths ? Dr. Lefferts believed not. 
His reasons were that at a certain age, namely, that of 
puberty, these growths disappear by a gradual process 
of atrophy. Hence, he thought it was desirable not to 
operate in any of these cases unless the symptoms 
were of an aggravated character. He agreed that 
there were cases causing a certain amount of interfer- 
ence with a child's voice, and giving rise to other dis- 
agreeable symptoms which required attention. The 
majority of children that were brought to him having 
these growths, were brought on account of having nasal 
catarrh. There was usually found a condition of 
hyper-secretion. In these cases it was his practice not 
to operate; but to wait until the time had passed for the 
atrophy of these tissues to take place. Hence, he 
would not advocate their treatment by removal. 

As to treatment. Dr. Bosworth had run over the 
various methods in use, and summed up by recom- 
mending the method of removal by means of Jarvis's 
snaie, which instrument, the speaker said, had figured 
largely in the author's writings of late. This instru- 
ment answers the purposes of removal very well, but 
it has not met with general approval on the part of the 
profession. The speaker stated that it was not gener- 
ally used by those engaged in this special practice. 
While in Europe, Dr. Leffert's attention had been called 



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to a new form of forceps which answered every pur- 
pose, and did not require for their use so much skill as 
Dr. Jarvis's snare. These forceps had been used by 
him extensively, and with gratifying results. 

Two forms of nasal tumor, not mentioned by the 
author of the paper, were alluded to. First, that of 
-cystic tumors of the nasal passages. This was a rare 
affection, but was worthy of notice, being of diagnostic 
importance. The speaker had met with but one case, 
and knew of but one in literature. Cystic tumors re- 
sembled exactly in their appearance gelatinous polypi. 
They differ from the latter in that in operating after 
seizing with the forceps, they are ruptured, and their 
contents escape. Under these circumstances, ordinary 
operators would continue to grasp for growths which 
did not exist, and hence might do harm. Dr. Lefferts 
stated that he himself had committed this error. The 
second form of nasal tumor sufficiently common to 
justify its mention was that of papilloma. These grew 
far forward. In several cases the speaker had seen 
them give rise to persistent attacks of epistaxis. It was 
a simple matter to put such a patient in a suitable 
light, and make an examination of the growth, upon 
detecting; which, it could be readily removed by means 
of the forceps or scissors. He did not agree with Dr. 
Bosworth's statement, that interference with the sing- 
jng voice was usually first noticed in the upper register. 
His experience had been that the middle register was 
the first to be affected. This, however, was a subject 
the discussion of which the limits of his remarks would 
not permit him to enter into. 

Dr. Brandeis wished' to take issue with the author's 
statement regarding the use of the galvano-cautery. 
He had used it for a number of years past, and had 
'thus far not met with any of the evil consequences 
-described by authors. He had never had any affec- 
tions of the middle ear resulting from its use, nor suf- 
.ficiently extensive cicatrices to cause malposition of 
normal parts. The offensive discharge which was in- 
cidental to this method of operating was of only tem- 
porary duration, and of trivitil annovance. He had 
removed tumors by this means through both the nasal 
and pharyngeal cavities. The removal of growths by 
means of the galvano-caustic loop was considered good 
practice for two reasons: it not only removed the 
growth at its base, but, by virtue of its intense heat, 
reduced the probability of a recurrence of the trouble 
to a minimum. 

Dr. Lincoln thought there were many growths in 
the nasal passages, especially anteriorly, the evil re- 
sults of which might be far-reaching. In regard to 
those in the posterior region, the necessity for opera- 
tion depended entirely upon whether the consequences 
of their continuance were sufficiently great to impair 
the health or produce great discomfort. The discom- 
fort would depend upon the size of the tumor, and the 
■discharge in consequence thereof. A case of reflex 
asthenia, due to one of these smalt growths, was cited. 
The growth was so insignificant that its removal was 
only finally resorted to as a matter of experiment, and 
the result which followed its abolition was an entire re- 
lief from asthmatic symptoms. 

Another evil effect which might arise from the pres- 
ence of these growths was that of malformation of the 
chest produced in childhood. The speaker had seen 
a number of instances where no other explanation by 
which the production of this deformity could be ac- 
counted for than that it was due to faulty respiration, 
incidental to the presence of growths in the nasal pas- 
sages. Children thus afflicted would have short breath- 
ing, and breathe with their mouths open, causing a 
sucking movement, and consequently an insufficient 
expansion of the chest. 

He believed that the author of the paper intended 



to infer that no method other than the use of the 
snare afforded satisfactory results. Upon this point he 
must take issue with Dr. Bosworth. He had published a 
series of cases some years since, in which caustics were 
used, and where the results were eminently satisfac- 
tory. The Vienna paste was a substance which could 
be applied by any one, and was most certainly a suc- 
cessful method of removing growths from the nasal 
passages. He had often applied it to the tonsils in 
cases of their enlargement, and with satisfactory re- 
sults, reducing the tonsils to their normal size in a 
short time. 

Jarvis's snare was certainly a most excellent and 
serviceable instrument. For certain cases, he believed 
that there was nothing else that could be devised to 
take its place. It was the most useful instrumem in 
his office. He, however, recognized that in many cases 
there were other means of obtaining satisfactory re- 
sults. The tonsils, as a rule, become atrophied at 
puberty. In cases of enlarged tonsils, he applied 
boracic acid, and with the result of diminishing the 
size of the growth. 

Dr. Robinson remarked that most of the points 
which had occurred to him during the reading of the 
paper had been touched upon by those who had pre- 
ceded him in its discussion. In regard to Jarvis's bnare 
and the warm advocacy of its use by Dr. Bosworth, 
the fact remained that it was not the only instrument 
we could use for the removal of these growths. It was, 
however, undoubtedly the best instrument which could 
be selected for that purpose when the growths were of 
any considerable size. Of course, when they were 
small, flat, and sessile — and such cases were very nu- 
merous — they could be removed by the galvano-cau- 
tery, or- scarification with Myer's knife, or a sharp 
curette. But for the large growth, as he had already 
stated, there was no method that could at all compare 
with Jarvis's. In two cases, where other methods had 
failed entirely, he had used the snare and readily re- 
moved the growth without great pain or much trouble. 

There was one point which he thought was not suf- 
ficiently emphasized by the author of the paper, and 
that was -that when these adenoid growths were of 
considerable size, a certain amount of air was sucked 
out of the Eustachian tubes during each act of degluti- 
tion. He believed that the extension of the inflam- 
matory action up the tubes was the explanation of 
imperfect hearing following the development of these 
growths. It was a curious fact, however, that in some ■ 
instances the hearing was notably affected, while in 
others it remained g'ood, notwithstanding the existence 
of growths of considerable size. 

Dr. Jarvis being called upon by the Chair, it was 
learned that he was absent in consequence of sickness. 

Dr. Bosworth, in closing the discussion, com- 
mented upon the question as to whether it was desirable 
to operate for the removal of these growths in children 
under the age of puberty. He stated that these chil- 
dren were brought to us in a morbid condition. They 
were brought on account of the existence of permanent 
and annoying symptoms, from which they wished to be 
relieved. It seemed to him that it was our duty to re- 
lieve these symptoms if we could. There was an ad- 
ditional reason for such a practice, as he had already 
stated. These growths naturally have a tendency to 
involve the parts below, giving rise to throat and bron- 
chial troubles. Furthermore, we were not at all sure, 
that they would disappear upon the patient reaching 
the age of puberty, inasmuch as one of the patho- 
logical specimens presented this evening was from a 
patient sixty years of age. 

As to the question of the forceps or the snare, he 
would say that if one or two of the growths which he 
had presented this evening were carefully inspected, it 



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January 13, 1883.] PROCEEDINGS OF NEW YORK NEUROLOGICAL SOCIETY. 



51 



would be seen that they bear the marks of the forceps. 
In fact, one of the growths which he presented had 
been chopped at with the forceps for three months by 
an expert, and had afterwards been removed by him 
by means of the snare. He had never seen a pair of 
forceps that could be made to reach the whole of one 
of these adenoid tumors. As to extension of catarrhal 
disease through the Eustachian tube, he could say that 
he had very rarely seen any evidence of catarrhal in- 
dammation at the Eustachian orifices when inspecting 
them. His explanation of the interference of hearing 
due to the presence of these growths was not that they 
pressed upon the orifice of the Eustachian tubes and 
thus occluded them, but that, when of considerable 
size, they interfered with the action of the levator palati 
muscles which were concerned with the entrance of 
air into the middle ear. 



NEW YORK NEUROLOGICAL SOCIETY. 

Stated Meeting, January 2, 1883. 

The President. E. C. Spitzka, M.D., in the Chair. 

PRESENTATION OF A SPECIMEN OF OCCLUSION OF 
BASILAR ARTERY. 

Dr. Leonard Weber first read the history of a 
patient who bad died m consequence of occlusion of 
the basilar artery, which was, in brief, as follows : 

The patient, a male, 42 years of age, and a mer- 
chant by occupation, had been, for a few weeks pre- 
vious to his visit to Dr. Weber, feeling unnecessarily 
tired and weak. His appetite was dimmished, he had 
occasional liausea, irregular action of the bowels, and 
frequent headacnes of the nature of painful pressure 
on the top of the head ; also, disturbed sleep. He 
came under observation November 9, 1878. On Nov. 
31 he bad not improved. He complained of vertigo 
and of a constant roaring noise in both his iears, and 
of increased pressure on the top of his head. In 
walking, he now dragged the right leg a little. The 

Eatient looking quite ill, a carriage was ordered for 
im, and he was taken home. Short>y afterward, he 
was found with paresis of the right upper and lower 
extremities, also right half of face and tongue. Eye- 
sight was normal, as far as ordinary tests were con- 
cerned. He complained of vertigo, sickness, and 
increased pressure on the top of the head; no pain 
elsewhere. The patient gave a history of having had 
a primary sore on his penis twelve years previous, 
which, however, was not indurated, and was not fol- 
lowed by any secondary symptoms. He also gave a 
history of having subsequently had an ulcer upon his 
heel, which came without apparent cause, and re- 
mained open for a long time. Fmally, under the in- 
fluence of Iodide of potassium, this ulcer healed. From 
these facts, it was supposed that his trouble now was 
probably due to syphilis, there being no other evidence 
of other organs bemg diseased which might cause em- 
bolism or cerebral apoplexy. At 2 p.m., Nov. 22, the 
patient was taken with a terrible fit of general convul- 
sions, lasting several minutes. After the first attack 
the patient lost consciousness. These attacks were 
repeated every half hour, and the patien^ died in deep 
coma at 10.30 A.M. 

A post-mortem examittation twenty-four hours after- 
wards revealed no evidence of disease of the larger 
arterial branches until coming in contact with the 
basilar artery. This vessel was found completely filled 
with a firm clot extending from the place of union of 
the two vertebrals, about half an inch upwards. Upon 
making a longitudinal section, a small dense tumor 
growing from the inside of the walls of the right verte- 
bral was cut through just at the junction with its fellow. 



and almost completely obstructing the lumen of the 
basilar artery at its very commencement. A micro- 
scopic examination revealed the fact that the tumor was 
composed of small cells and connective tissue, corre- 
sponding in its character to similar gummatous affec- 
tions of cerebral vessels as described by several 
authors. 
Dr. William A. Hammond then read a paper on 

ALLOCHIRIA, ITS NATURE AND SEAT. 

The case reported was one which Dr. Hammond 
saw in November in conjunction with Dr. L. A. Stim- 
son. It was asserted that the patient had received a 
serious injury to the spine. In a day or two after the 
accident, symptoms indicating spinal trouble began to 
develop. Some time afterwards a physician was con- 
sulted, who diagnosticated Pott's disease. A plaster 
jacket was applied. Several months elapsed, during 
which he was at times better, and at other times worse. 
Upon the whole, there was no decided improvement. 
The fact that he had brought an action for heavy 
damages against the city was the immediate cause of 
Dr. Hammond's examination. Dr. Hammond was of 
(he opmion that the patient had never suffered from an 
injury of the vertebral column or of subsequent Pott's 
disease. "This opinion was concurred in by Drs. L. A. 
Stimson, Hamilton, and Clymer. The patient com- 
plained however of pain throughout the whole spine, 
and of excessive nervous irritability. He had had 
contractions of the muscles of the lower extremities, 
and on causing him to walk about the room, it was 
evident that his limbs were stiff and that he lifted his 
feet with difficulty. His gait was not that of locomotor 
ataxia. Up to this time, no experiments had been 
made with a view of testing the sensibility of the lower 
extremities. These were now denuded of their cloth- 
ing, and the patient was told to shut his eyes. The 
touch of a finger, the scratch of a pin, or a deep punct- 
ure with the blade of a penknife, was equally unfelt in 
the right leg. On making the like experiments on the 
left leg, he complained of pain when the knife was 
stuck into it and automatically carried his hand to the 
place where he supposed the puncture had been made, 
but instead of touching the spot injured, he indicated 
the exactly corresponding situation on the other leg. 
Repeated experiments led to like results. The conclu- 
sion was reached, that the patient was suffering from 
antero-lateral or lateral sclerosis, with the implication 
of the posterior horns of gray matter, and probably of 
the membranes of the cord to a slight extent. 

It was with reference to this cross sensibility which 
the patient exhibited that Dr. Hammond's paper was 
concerned. To this condition the name of allochiria 
has been given by Prof. Obersteiner, of Vienna, who 
was the first, so far as Dr. Hammond knew, to call 
especial attention to the phenomenon, though it had 
been incidentally alluded to by Leyden and Ferrier. 
In a post-mortem examination of one of Obersteiner's 
cases it was found that there had been inflammation of 
the first, second, and third lumbar vertebrae, menin- 
gitis, and extensive transverse inflammation of the 
cord. The posterior columns for a considerable dis- 
tance above the seat of the injury were in a state of 
sclerosis, and the posterior horns of gray matter in 
portions of the cervical enlargement were transversely 
divided by a peculiar, structural, transparent mass in- 
tensely colored by carmine, and very similar to the 
mass which is found around the larger vessels in in- 
flammatory processes in the cord. 

Dr. Hammond was of the opinion that the lesion 
above described of the posterior horns of gray matter 
was that to which the phenomenon of allocheria is to be 
ascribed. Obersteiner and Furrier had declared their 
inability to give an explanation of the mechanism of 



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52 TRANSACTIONS OF PATHOLOGICAL SOCIETY OF PHILADELPHIA. [Medical News. 



the production of allochiria. Preparatory to an ex- 
planation of this symptom, Dr. Hammond referred to 
the fact that the posterior tract of gray matter was 
probably the only channel by which sensory impres- 
sions reached the brain, the posterior columns having 
in their normal condition nothing whatever lo do with 
the transmission of such impressions. But, before 
reaching the posterior horns, the posterior roots of 
the spinal nerves pass through the columns of Bur- 
dach, and when these are the scat of inflammation, 
as they are in locomotor ataxia, disturbances of sensi- 
bility, such as hyperxsthesia, parsesthesia, and anaes- 
thesia are produced in the parts below by the pressure 
exerted upon the roots. It was quite certa'n that there 
is an almost complete decussation of the sensory fibres 
within the gray matter. We were taught these facts 
not only by experimental physiology, but also by the 
instruction we derive from the study of cases of disease 
or injury of the cord. A diagrammatic representation 
of a section of the cord was then displayed and an ex- 
planation given of the method by which the peculiar 
symptoms alluded to arose. Dr. Hammond stated that 
in those cases of disease or injury of the posterior horns 
of gray matter, whether they be primarily involved or 
secondarily, as in locomotor ataxia, in which allochiria 
exists, either the lesion must be unilateral, or, if both 
horns are involved, the lesions must be at difi°erent 
levels. 

In the only case of allochiria in which a post-mortem 
examination has been made, and which has been re- 
ferred to above, Obersteiner found, among other ab- 
normal conditions, disease of both posterior horns of 
gray matter. The morbid process was not continuous, 
as it is stated that it was not perceived in all the sec- 
tions. It was situated at the narrowest part of the 
posterior horns, being so placed as to interrupt the 
decussation of all the nerve fibres, and hence to cause 
a transmission of sensory impressions upward on the 
same side in which they entered — a condition whidh, 
equally with that which Dr. Hammond described, 
would give rise to allochiria. 



PATHOLOGICAL SOCIETY OF PHILADELPHIA. 

Slated Meeting, Thursday Evening, Dec. 14, 1883. 

The President, Dr. James Tyson, in the Chair, 
a case of mitral obstruction, with sequential 

LESIONS. 

Dr. E. T. Bruen presented this specimen, in which 
the auriculo-ventricular opening of the left heart is 
nearly occluded by an epiglottic- shaped enlargement 
of one of the leaflets of the mitral valve. The valve 
is very much thickened, and thefocusof a considerable 
calcareous deposit. The orifice during life permitted 
a reflux of blood from the ventricle into the auricle. 
The left auricle is dilated and hypertrophied, so that 
its cavity is about twice as large as normal. The right 
ventricle is very much dilated, the walls of this cavity 
are less than half the normal thickness, and the ven- 
tricle must have had'during life twice its physiological 
capacity. The tricuspid valves were insufficient. The 
Considerable cardiac enlargement, occasioned an in- 
crease of the area of dulness on the level of the third 
and fourth ribs, and to the right of the median line of 
the sternum. In children, the heart with similar en- 
largement encroaches upon the left pleural cavity to 
such an extent that the physiological inflation of the 
left lung cannot occur. Bronchial breathing is pro- 
duced, audible posteriorly, while anteriorly, below the 
second interspace, no respiratory murmur is audible. 
In these cases when the complication of bronchitis 
occurs, the physical signs suggest a pleural effusion. 



Enlargement of the right ventricle, both in children 
and adults, causes a pronounced impulse at the epi- 
gastrium and occasions serious pain and inconvenience. 
The murmur heard during life, in the case from which 
this specimen was taken, indicated this lesion, both 
presystolic and systolic murmurs being audible. The 
second sound at the pulmonary artery cartilage was 
also much accentuated, owing to the repletion of that 
vessel with blood. The first sound over thit right ven- 
tricle was very clear and distinct, as is common in these 
cases, but the first sound at the apex was obscured by 
the murmur. The patient from whose body these 
specimens were removed was a woman, aged 46 years, 
who had been subject to heart disease since 20. The 
immediate cause of death was pulmonary repletion 
with blood, which induced right-heart failure. 

PERICARDIAL EFFUSION AND ADHESION OF THE PERI- 
CARDIUM TO THE APEX OF THE HEART MISTAKEN FOR 
HEART RUPTURE. 

Dr. J. T. EsKRiDGE presented the specimens, and 
said that in this case the physician making the autopsy 
actually considered the specimen to be one of heart 
rupture. The patient was an athletic young man, and 
had been perfectly well until a few days before he 
sought medical advice. He was under treatment for 
only twenty-four hours, suffering from cardiac pain 
and great prostration. He died suddenly and unex- 
pectedly, when no one was near him. The attending 
physician, who made the post-mortem examination 
with no professional assistance, reported effusion in 
both pleural cavities, the pericardium distended with 
thin, non-coagulated blood, and a rupture of the left 
ventricle. Dr. Eskridge said that a careful examina- 
tion of the heart, pericardium, adjacent glands, and 
portions of the larger bronchi, showed marked evi- 
dences of pericarditis and pleuro-pericarditis. The 
pericardium was adherent to the lower third of the 
heart, but the adhesions were recent and easily sev- 
ered. The heart was not much enlarged, its valves 
were nearly normal, and its muscle firm. No rupture 
was found. He believed that the case was one of 
pleurisy and pericarditis with efifusion, death taking 
place suddenly from mechanical interference with the 
heart and lungs. He thought that the most plausible 
explanation of the doctor's mistake in calling it a case 
of cardiac rupture was that, when severing the blood- 
vessels around the heart, blood flowed into the peri- 
cardium and mingled with the serous effusion. He 
did not think that a firm, non-fatty heart could rupture 
itself by its own contractions. If the pericardium was 
filled with effusion in that instance, it taught a lesson 
of far more practical value than a case of cardiac rup- 
ture under similar circumstances would. It was evi- 
dent, if the pericardium should be attached to the apex 
of the heart in a case of pericardial effusion in which 
operative interference was determined upon to free the 
heart's action, ar thrust of the trocar into the pericar- 
dium would greatly endanger the ventricular walls. 

SEVERAL SPECIMENS OF EYES ENUCLEATED ON ACCOUNT 
OF SYMPATHETIC IRRITATION IN THE OTHER EYE, OR 
FROM FEAR OF ITS DEVELOPING, 

were exhibited by Dr. Little, who said that sym- 
pathetic irritation and sympathetic ophthalmia are the 
only two forms of the sympathetic diseases of the eye 
that afford an opportunity for pathological study, and 
in these cases only the enucleated eye can be investi- 
gated. Just what are the conditions in the remaining 
eye must remain uninvestigated. If full restoration of 
the function of vision is attained, great satisfaction 
only is felt. Less and less opportunity is being af- 
forded of studying the condition of an eye enucleated 
for sympathetic ophthalmia in the other eye, since 



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January 13, 1883.] TRANSACTIONS OF PATHOLOGICAL SOCIETY OF PHILADELPHIA. 



S3 



merely the sympathetic irritation of the sound eye 
impels the surgeon to enucleate the primarily affected 
eye before true sympathetic ophthalmia asserts itself. 
The portion of the eyeball which renders liable the 
development of this affection when diseased is so well 
known that not even sympathetic irritation should 
be allowed to develop, as an early enucleation will 
prevent it. Enucleation of the primarily diseased eye 
when true sympathetic ophthalmia is present in the 
other eye is now questionable, as after all inflamma- 
tion has subsided under treatment, surgical procedures 
upon the primarily affected tyi may afford the best 
results for visual purposes. A recent experience will 
bear out this statement, the patient refusing the advice 
of a former medical attendant, and also my own, after 
two months suddenly developed sympathetic ophthal- 
mia of the sound eye. Enucleation was then too late; 
now both eyes are becoming quiet, and I am in doubt 
which in the end will be the more available eye. A 
physician recently under treatment for a severely trau- 
matized eye has refused the advice of two surgeons 
and is now doing well, b'ut the danger of a sympathet- 
ically irritated eye is constantly before him. The 
pathological investigation is, then, mainly restricted 
to eyes enucleated before or after sympathetic irrita- 
tion has developed in tWe other eye, as results show 
that under such circumstances full protection to the 
remaining eye is afforded. Investigation of eyes enu- 
cleated when sympathetic ophthalmia of the other eye 
is present may explain the cause of the trouble in the 
remaining eye, but there is so much damage done to 
both that our knowledge only makes us the more de- 
sirous to prevent these conditions from arising, and in 
the multiplicity of conditions the principal cause is 
lost. When enucleation to forestall sympathetic irri- 
tation is done, or when the operation is performed with 
sympathetic irritation just beginning or» present, the 
eyeball removed is in a much better state to examine, 
and niore light can be thrown upon the cause of sym- 
pathetic irritation, since severe inflammatory processes 
cloud the change from sympathetic irritation to that of 
sympathetic ophthalmia, and the pathological study is 
more difficult. My collation contains only one speci- 
men enucleated when sympathetic ophthalmia was 
present, and in this case there was a double acute 
glaucoma, with sympathetic iritis. 

At this time I only desire to place before you some 
specimens of eyes enucleated for the protection of the 
fellow eye from sympathetic irritation, or in which it 
was already beginning or developed ; and in these 
cases good and permanent results have been attained. 
Four of these cases were due to traumatism; the fifth 
was of an inflammatory character. All but one of the 
traumatic cases had the fellow eye affected, and the 
examination of the enucleated eye in the exceptional 
case justified the operation. In two cases the sound 
eye became affected shortly after the infury to the enu- 
cleated eye. In one case, no irritation until forty years 
had elapsed since the accident tp the enucleated eye. 
In one non-traumatic case, there were repeated at- 
tacks, for a series of years, of irritability in the sound 
eye, until the pain in the diseased eye, and the disturb- 
ance of the sound eye, compelled operation. In the 
remaining traumatic case, for twenty years the unin- 
jured eye was unaffected, except rendering the myopia 
more progressive, which made an operation more in>- 
perative for its arrest, and to prevent the outbreak of 
sympathetic ophthalmia later in life. The patients were 
agea respectfully, three years, forty years, forty-seven 
years, fifty years, and seventy years. Three of the 
patients were males, and two females. In four cases 
the left eye was enucleated, in one case the right. In 
every case the injury or disease involved directly or 
indirectly the ciliary body ; and where the crystalline 



lens remained in situ, or the sclerosed tissue infringed, 
most markedly on the ciliary region, the irritation most 
rapidly in the other eye. Where the crystalline lens 
was dislocated with weakening of the sclerotic tissue, 
no irritation appeared for forty years in the other eye. 
In one case with dislocation of the lens, and detach- 
ment of the retina and choroid, no irritation had ap- 
peared at the end of twenty years in the other eye. In 
those cases where the iris became entangled in the cic- 
atrix, sympathetic irritations of the other eye developed 
most rapidly, in one instance the lens becoming cata- 
ractous in the sound eye, while that of the injured one 
was either absorbed or lost at the time of the accident. 
In short, is it not to injury of the ciliary nerves, with 
their varied function, and to the damage done to the 
tissue in which they are imbedded in the different di- 
visions of iris, ciliary body, and choroid, that we are 
to look as the cause of sympathetic irritation in the 
fellow eye ; and of these, the ciliary body and nervous 
structures in it, with or without the involvement of the 
iris as the prineipal part involved ? When sympathetic 
ophthalmia arises in the sound eye, can it not be traced 
to inflammatory processes added to the irritation of the 
ciliary nerves, and involving the iris, ciliary body, and 
choroid ? How far the retina and optic nerve participate 
in the sympathetic irritation, it is difficult to say, only 
we find that in sympathetic enucleation for sympathetic 
irritation, the fellow eye regains the full function of 
sight. In sympathetic ophthalmia, however, the in- 
volvement of the nerves and retina is a more important 
factor, and the fellow eye is not so likely to be restored 
to full function of sight, as the conditions in the enu- 
cleated eye and in the one affected are more serious on 
account of marked inflammatory processes. 

STAB OP PERICARDIUM, DIAPHRAGM, AND LIVER. 

Dr. Stkittmatter exhibited three specimens, which 
were removed from a German laborer aged sixty-two, 
a patient in St. Mary's Hospital under Dr. Mears. He 
had been laboring for some ddys under a mental delu- 
sion, and after writing a clear, intelligible letter to his 
wife and family in Germany, stabbed himself with a 
clasp knife in the right side of the chest several times. 
He was at once admitted to the hospital. He was 
much excited, with a rather flushed face, and but little 
shock. Examination showed two wounds — one over, 
^nd reaching down to the cartilage of the sixth rib of ! 
the right side, about one and a half inch from the 
sternal border, and about two inches in length ; the 
other, half an inch from the border of the sternum, 
and severing from it the cartilage of the seventh and 
eighth ribs. Closer examination of this wound showed 
that there were two openings through the costal carti- 
lages about a line apart, the outer passing downward, 
outward, and backward, the inner in a direction in- 
ward, downward, and backward. Through these 
openings air occasionally passed when the patient 
respired violently when struggling, causing a high- 
pitched sucking and blowing sound. None but slight 
bleeding took place, and that from the integument. 
Physical signs everywhere normal except over the 
lower part of the right lung, where increased reso- 
nance was noted, and on heavy perc^sion a kind of 
"cracked-pot sound" was elicited. Auscultation re- 
vealed diminished breathing sound over the upper 
part of the right lung, while respiratory sounds were 
entirely absent over its lower portion. Heart's action 
rapid and irregular; heart sounds feeble, especially 
the first; pulse, 112; respiration 42, and shallow. 
There was no sign of internal hemorrhage. Both 
during inspiration and expiration, when the head and 
shoulders were raised, and he inspired deeply, a pecu- 
liar high-pitched blowing sound was occasionally 
heard a little to the left and below the ensiform carti- 



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S4 TRANSACTIONS OF PATHOLOGICAL SOCIETY OF PHILADELPHIA. [Medical News, 



lage. It did not resemble the sound produced by gas 
in the stomach or bowels. Antiseptic dressings were 
used and morphia given, but he slept little, although 
nothing was complained of beyond a burning sensa- 
tion beneath the sternum. The next morning he was 
calmer, rational, felt pain only du^ng inspiration, and 
altogether breathed more easily than during the night, 
although the physical signs remainf d the same. The 
abdomen was tympanitic ; the pulse full and moderately 
strong, 92 per minute ; respirations 32, and expiration 
labored. During the next night grew worse. Friction 
sounds over the whole of the left chest, and on the 
right side from the apex to the fourth rib. Pericardial 
friction sounds were also heard. Pulse 100, full ahd 
hard ; respiration 48, with rapid jerky inspiration, ab- 
ruptly terminating, to be followed by a free, prolonged, 
groaning expiration ; temperature, 103.2°. During the 
next twenty-four hours all the symptoms, physical as 
well as rational, of effusion into the pericardium and' 
both pleurae developed, but although the abdomen was 
tympanitic, no signs of effusion were detected. Pulse 
in evening 126, irregular and intermitting; respirations 
40; temperature 101.8°. Had a bad night, and next 
morning appeared much prostrated, with a feeble, oc- 
casionally intermitting pulse of 120 per minute ; tem- 
perature 102.8°; respiration 40, labored and shallow. 
Low, muttering delirium now set in ; he sank rapidly, 
and died at 2 p.m. of the 20th, with a temperature of 
105.5°. 

Sectio cadaveris. — Brain : pia mater adherent, thick- 
ened in patches and opaque, especially on either 
side of the vessels, which were filled with dark blood 
over the upper convex surface of the left hemisphere. 
There was a slight amount of serous effusion in the 
subarachnoid space. The ventricles contained a small 
amount of serum. Chest : on raising the sternum the 
right pleural cavity was seen filled with a thick, fatty- 
looking effusion, with some bands of recent lymph, 
extending from the lung to the chest-wall. The apex 
of the lung was quite firmly adherent to the chest-wall. 
The anterior surface of the lung was covered to the 
depth of one-fourth of an inch with soft, grayish-yel- 
low lymph. A portion of the back part of the inferior 
lobe was consolidated. The left pleural cavity was 
only about half filled with the same thick layer of 
lymph and adhesions of the apex that were noted in 
the right lung. No part of the left lung would sink in* 
water. The pericardial sac was distended with fluid, 
and both upon its inner surface and upon that'of the 
heart was abundance of lymph, connecting the two 
surfaces by drawn out bands of the same. There was 
a large chicken-fat clot in the left ventricle, extending 
about six inches into the aorta. The right ventricle 
was filled with blood, with a small clot extending into 
the pulmonary artery. Examination showed that, 
while there were but two penetrating wounds exter- 
nally, the knife must have been thr\ist in repeatedly 
after partial withdrawal, as there were three openings 
through the diaphragm, penetrating the liver to the 
right of its suspensory ligament, and one traversing 
the lower part of the pericardial sac, and entering the 
left lobe of the liver for about one inch. The other 
liver wounds \|pre one-fourth, one-half, and one-sixth 
of an inch deep. There were no traces of peritonitis, 
although about two ounces of serum were present, hav- 
ing probably escaped from the pericardial sac through 
the wound. The liver wounds did not gape; were 
united and surrounded for about an inch in every direc- 
tion by a brownish-yellow discoloration. The liver 
weighed sixty-two ounces. Spleen enlarged and soft; 
other organs healthy. 

Dr. Mears said he was much interested in this case. 
During life the symptoms of wound of the diaphragm 
and of the liver were markedly absent, whilst those of 



injury of pericardium and pleura developed as the in- 
terval after the receipt of the wounds increased. The 
external wounds gave little indication as to the direction 
taken by the knife after puncturing the thoracic cavity, 
and, as shown by the post-mortem examination, no in- 
formation as to the extent of injury inflicted. The ab- 
sence of symptoms of injury of the diaphragm may 
be explained by the fact that the wounds were in the 
tendinous portion of that muscle, and being small 
did not interfere to any great extent with its function 
in respiration. In injuries causing laceration of the 
muscular fibres attached to the ribs dyspnoea occurs 
as a prominent symptom, by reason of the impairment 
of the respiratory duty of the muscle. Moreover, the 
symptoms may have been masked by those referred to 
the injury of the pericardium, as in wounds of both of 
these structures dyspnoea is a prominent symptom. 
The knife in one of the thrusts passed through both, 
and involved them in a common injury. The only 
explanation I can offer of the production of the blow- 
ing or rather suction sound which was heard under 
the ensiform cartilage, is that it was occasioned by the 
passage of air during respiration through the openings 
m the diaphragm — the air entering primarily the lung 
cavity through the external wound. The fact that the 
air did not pass in and out of the external wound 
during the act of respiration afforded good evidence 
that the lung was not wounded. ' The wounds of liver 
were of such character as to make little or no impres- 
sion beyond what might occur as the result of injury 
to the coverings and superficial portions. Puncture of 
the liver with a trocar is infrequently performed with a 
view of evacuating fluids. Instances are reported in 
which no fluiB has been found, and no harm has been 
inflicted by the tapping. Extensive laceration, the re- 
sult of gunshot wounds or rupture following falls, pro- 
duce characteristic symptoms of shock and internal 
hemorrhage. 

SECONDARY SARCOMA OF HEART, LUNGS, AND GALL- 
BLADDER, FOLLOWING PRIMARY AMPUTATION FOR ^ 
DEPOSIT IN THE FEMUR. 

Dr. Willard exhibited trie heart, lungs, and gall- 
bladder of a female aged 21, whose right thigh had 
been amputated four months previously for a spindle- 
celled sarcoma of the lower end of the femur. The 
apex of the right ventricle was infiltrated with a sar- 
comatous mass which extended into a cavity among 
the columnae calrieae, forming an irregular shaped body 
occupying one-fifth of the space. The walls were 
softened. The diseased tissue was very soft and easily 
detachable, rendering its propulsion into the lungs a 
matter of exceeding probability at each heart-beat. 
The walls above the mass were natural in appearance 
and in thickness; the valves showed no evidence of 
disease on ei.ther side of the heart. The left ven- 
tricular and both auricular walls were healthy. The 
disease had not reached the visceral layer of the peri- 
cardium, and there was no abnormal effusion in the 
cavity of the sac. The septum ventricularum was not 
involved. That numerous particles had been swept 
into the lungs was very evident when these organs 
were examined. At a large number of points in either 
lung were to be seen white masses, varying in size from 
that of a pin's head to that of an English walnut. 
Some of these were dense, others were undergoing 
softening, and in nearly every instance the lung sub- 
stance surrounding was so disintegrated that the mass 
seemed to be in a cavity containing a drachm or more 
of sanguinolent fluid. A very moderate degree of 
pressure would cause a nodule near the surface to burst 
its pleural covering and give rise to an accident similar 
to the one which was found to have occurred near the 
right apex. At this point a large sarcomatous mass 



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January 13, lisj.] 



CORRESPONDENCE. 



55 



bad excited a degree of inflammation sufficient to 
fasten the lung to the parietal pleura, and one week 
before the patient's death, ulcerating through the 
serous covering, had given rise to an internal hemor- 
rhage that was well-nigh fatal, and gave the symptoms 
of sudden collapse note^ iii the history. This escaped 
blood was found in the right pleural cavity confined by 
adhesions chiefly to the upper portion of the chist. In 
the week which elapsed between the hemorrhage and 
death, it had coagulated, formed chicken-fat clots and 
other coagula weighing fully two,pounds. The pleural 
cavity below the adhesions contained about two quarts 
of bloody serum. There was no consolidation of the 
lungs save around the diseased foci. The lungs had 
evidently acted as a complete strainer and had pre- 
vented the passage of emboli, for liver, kidneys, spleen, 
and all other organs were healthy save one small spot 
in the gall-bladder. The brain was not examined. 
The primary disease in the femur had apparently 
resulted from traumatism, since no difficulty had ex- 
isted previous to a severe fall upon the knee. From 
this time the pain on walking was continuous, and four 
months later there was decided enlargement of the ex- 
ternal condyle and swelling in the popliteal space. 

The chief points of interest in the case were : First, 
the traumatism acting as an exciting cause. Second, 
that the physician who first saw her detected neither 
fracture nor luxation, nor anything beyond contusion 
of the joint Third, the appearance at the end of four 
months of a pulsating tumor in the popliteal space, 
which presented. a decided bruit, but no thrill. This 
was due to the lifting of the artery from its bed by the 
sarcomatous mass. Fourth, the non-involvement of 
the knee-joint, although the nodules had pushed for- 
ward the synovial membranes between the condyles 
posteriorly. The articular cartilage of the femur was 
intact, although the bone tissue immediately beneath 
it was extensively diseased. Fifth, the return of the 
disease, not in the stump- in the right ventricle, and 
the failure in circulatio;i and great prostration which 
came on frofti four to six weeks after the amputation-, 
and without anything in the condition of the stump to 
warrant such depression. The patient seemed in ar- 
ticulo mortis, yet there was no pain and no dyspnoea, 
only a feeble rapid heart action accompanied by low 
delirium and weakness. There were no valve sounds 
audible. These symptoms were due, as shown post- 
mortem, to the deposit and development of the sar- 
comatous m^s in the heart. Nature, however, grad- 
ually accommodated herself to the new growth, and 
the patient rallied for a time, so as to be able to walk 
on crutches, eat heartily, and consider herself in good 
health. She got fatter, and only slight dyspnoea on 
exertion, with three or four coughs a day, remained to 
indicate recurrence of the disease. Sixth, a sudden, 
causeless as to exertion, profuse hemorrhage, from the 
collapse incident to which she rallied and lived one 
week, with respiration 30-36, pulse 130-140. Seventh, 
the primary and consecutive growths showed a pre- 
ponderance of spindle-cells, while the secondary nod- 
ules were composed chiefly of round cells. Eighth, 
the post-mortem examination throws great light upon 
the clinical symptoms, while the great •rarity of sar- 
coma of the heart makes it important to note that there 
was never any angina pectoris. In Dr. Ingham's report 
of a case called carcinoma of the heart in the Trans- 
actions of this Society for 1877, the o"ly case ever pre- 
sented to this Society, angina pectoris was indicated as 
one of the diagnostic points. In the report of the 
Committee on Morbid Growths, Dr. Ingham's specimen 
was shown to be really an alveolar sarcoma. Second- 
ary sarcomatous growths of the heart are mentioned 
by various authors, but the histories give no clinical 
signs of the growth. 



Dr. Barton said that in regard to traumatisms caus- 
ing morbid growths, he considered that they probably 
had no more causative effect than acting as exciting 
causes. 

Dr. Formad asked if the exact nature of the pri- 
mary growth was known ; whether it consisted of round 
or spindle-cells, since it has been stated that the 
spindle-celled variety never form metastasis. 

Dr. Seiler replied that the primary growth con- 
sisted of both round and spindle-cells. 

Dr. Shakespeare agreed with Dr. Barton as to the 
origin of the primary growth. He did not believe that 
injuries were anything more than exciting causes in 
those predisposed to such growths. The case pre- 
sented a typical example of the method of metastasis ; 
we have the growth first developing at the knee, 
whence particles were carried by the veins to the heart, 
becoming there lodged, and developing into a tumor, 
which formed a new centre from which microscopic em- 
boli were carried by the blood-current into the lungs, 
where they lodged and grew into the nodules seen in 
the specimen. Metastasis of sarcoma occurs by 
means of the blood-current, while that of carcinoma 
takes place through the lymphatics. 

Dr. Formad could see no other cause for the tumor 
than the injury of the knee, previous to which the pa- 
tient had never shown any symptoms of disease of the 
joint, while shortly after receiving the injury the tumor 
appeared. The tumor may not necessarily be malig- 
nant ; there is an inflammation and the formation of 
cells ; the malignancy will depend upon the looseness 
of the cells, and the facility with which they can be 
transported. 

Dr. L. R. Mills then read a paper on the Brain in 
Epilepsy. 

Dr. Brubaker presented a specimen of Tumor of 
the Brain, which, with the accompanying paper, was re- 
ferred to the Committee on Morbid Growths. 



.CORRESPONDENCE. 



COLOR-BLINDNESS, 

To the Editor of The Medical News. 

Sir: On page 712 of your December 23d number 
you have quoted a notice from the British Med. Joum. 
of November i6th, in relation to the examinations of 
Dr. Kolbe and other Russian physicians for color- 
blindness. The article speaks of the very great varia- 
tion in the percentage found by different observers 
among railroad employes, varying from 0.85 to 5.00. It 
does not, however, include Dr. Kolbe's explanation, 
which he gives in reporting the Russian statistics in the 
St. Petersburgh Med. Wochenschrift, October 23, 1882. 
This is important for us just commencing the testing 
on the railroads of this country. It seems that the three 
gentlemen who found so few color-blind were "sold " 
by the defective empIoy6s getting some normal-eyed 
to personate them during the examination. Dr. Kolbe 
wrote me that he had heard this from these gentlemen, 
and as it has now been proved he publishes it. Thus 
all criticism as to extraordinary variation in percentage, 
and consequent doubt as to the observer's skill or the 
reliability of the method used, falls to the ground. The 
great value of Holmgren's test is shown by the very 
uniform results experienced and competent examiners 
obtain by its use. It and all other methods are useless 
in the hands of the laity or the inexperienced phy- 
sician. 

Respectfully yours, • 

B. Joy Jeffries, M.D. 

Boston, 15 CHRSmuT St., 
December 30, tSte. 



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POLYGONUM HYDROPIPEROIDES. 

To the Editor of The Medical News. 

Sir: In the Medical News of December 9, I find 
a short notice of Polygonum hydropiperoides, as given 
in Eberle's Materia Medica. 

Dr. Eberle says it was brought to his notice by a 
country practitioner who made it his thesis subject. 
Thii was while Dr. Eberle was Professor of Theory 
and Practice in the Medical College of Ohio, and the 
country doctor was one Bud Eastman, then practising 
in the village of Paris, Jennings County, Indiana. 

The writer wsts personally acquainted with Dr. East- 
man, and has frequently heard the doctor speak of his 
thesis upon " smart weed." If there is any credit due 
any one for its introduction into our therapeutics, it is 
to Dr. Eastman, who was a man of more than ordinary 
ability in the profession — a safe, careful practitioner. 
He finally fell m with Millerism or second adventism, 
became a noted lecturer, drifted south, and died in 
Texas some twenty years ago. 

The writer has practised medicine thirty-three years, 
and during this time has prescribed the Polygonum 
many hundred times, and has ever found it an emmena- 
gogue of rare virtue. J. W. Conway, M.D. 

Madison, Iho., December 15, iSSa. 



A CARD FROM MESSRS. W. H. SCHIEFFELIN 
& CO., OF NEW YORK. 

To the Editor of The Medical News : 

Sir: In your issue of Dec. i6, 1882, you publish 
an article giving the results obtained by " an expert 
analytical chemist" (name and fame to us unknown) 
in the analysis of ({uinine pills. 

We wish it distinctly understood, at the outset, that 
we are in favor of a most rigid examination of all 
chemical and pharmaceutical productions, whether of 
our make or of others, and we do not doubt that your 
wish is to do justice to all. But we assert that the 
value of analyses of complex organic mixttires, like 
pills, depends very largely upon the previous training 
and experience, as well as the good name and reputa- 
tion, of the analyst. An analysis not accompanied by 
the name of the analyst as a pledge of good faith, has 
no more value than has an unsigned bank check. It 
is worthless. 

Before criticising in detail the methods and results 
upon which you base your charge, that we, among 
others, are either careless or dishonest, and are furnish- 
ing the trade with short weight quinine pills, we wish 
to state that the charge is not true, so far at least as we 
are concerned, and we have positive proof to substanti- 
ate our statement. 

We ask now that we may be allowed to correct some 
of the erroneous statements which appear in your 
article, as well as to record some of our objections to 
the methods of analysis. For convenience of refer- 
ence we will classify our remarks. 

I. A faulty method of analysis. 

Twenty pills were taken for analysis. They should 
contain 40 grains of sulphate of quinine (CmH„N,0,),.H, 
S04.7H,0, equivalent to 29.725 grains of anhydrous qui- 
nine (C„H„N,0,), or 1.486 grain per pill of anhydrous 
quinine. The analyst recovered 1.420 and 1.424 (aver- 
age, 1.422) grain of anhydrous quinine from each of 
our pills ; he failed to recover 0.004 grain of anhydrous 
quinine from each of our pills, a quantity equivalent 
to 0.086 grain %( sulphate of quinine. Failing, there- 
fore, to recover 1.28 grain of anhydrous quinine in a 
total amount (in 20 pills) of 29.725 grains, you see fit 



to charge us with not putting in the full amount. In 
reply we would say that the method of assay which was 
used is not one which will allow all the quinine present 
to be recovered, 

1. The use of excess of ammonia as the precipitant 
was unfortunate. It has been repe itedly shown that 
quinine is nearly insoluble in solution of soda, more 
soluble in solution of potash, and very soluble in am- 
monia. Because of this greater solubility in ammonia 
the Pharmacopoeia (p. 160) directs the use of solution 
of soda in the assay process for quinine in the scaled 
salt, Ferri et Quinince Cilras. Again, Kerner's test for 
the purity of sulphate of quinine, now prescribed by 
the U. S. Pharmacopoeia (p. 279), depends upon this 
very solubility of quinine in ammonia. It is certainly 
very difficult, if not practically impossible, to remove 
quinine completely from a solution containing excess 
of ammonia. In this method of "shaking out" an 
alkaloid by means of some solvent, the wider the dif- 
ferences in solvent power of the liquids present the 
more complete the extraction ; hence soda would have 
been a very much better precipitant than ammonia. 
This statement is corroborated by our own frequently 
repeated laboratory assays of the scales referred to 
above. 

2. The use of ether as a separative solvent was also 
unfortunate. In selecting a solvent for " shaking out " 
methods of assay two points must be carefully guarded. 

a. The substance should be very much more soluble in 
the new solvent than in the alkaline liquid from which 
it is to be extractrd. 

b. The new volatile solvent should itself be as nearly 
insoluble as possible in the alkaline liquid. 

Neither of these conditions is fulfilled by ether. Pure 
stronger ether is soluble, according to Dr. Squibb, in 
eight times its volume of water. Therefor^, in any 
"shake method" of assay, the lower aqueous layer 
will surely be fully saturated with ether, which latter, 
in turn, will hold in solution a very perceptible amount 
of quinine. For this reason many experienced analysts, 
And notably the U. S. Pharmacopoeia (p. 160), favor the 
use of chloroform. 

For the evtraction of quinine from uncomplicated 
aqueous solutions containing excess of soda, no solvent 
which we have used can compare with chloroform ; it 
is a better solvent for quinine than is ether, and is 
more nearly insoluble in alkaline solutions (see arti- 
cles iCther Fortior, Chloroformum Purificatum, and 
Quinina, U. S. Pharmacopoeia, 1880). 

3. The test with potassio-mercuric iodide, as here de- 
scribed, could not fail to give a false indication as to ex- 
traction of the'quinine. Quihine is precipitated by this 
reagent only in neutral or acid solutions ; the precipi- 
tate so produced is soluble in ammonia. This test, 
therefore, applied to the "remaining aqueous" (am- 
moniacal) "liquid" is absolutely worthless as regards 
the quinine present. On the other hand, gelatine, if 
present, could hardly fail to be precipitated by Mayer's 
solution whether qumine were present or not. ( Vide 
Prescott's Proximate Organic Analysis, pp. 139, 140.) 

4. No allowance is made for experimental errors. We 
have shown that the analytical process is one subject 
to several serious errors, and that, with the most con- 
scientious attention to details of manipulation, the 
analyst cannot fail to leave unextracted a notable 
quantity of quinine. 

A proper regard for the rights of the parties accused 
should have prompted the analyst to determine exactly 
the limits of error to which his process was subject. 
We can only account for this oversight upon the sup- 
position that the difficulty of extracting quinine from 
complex mixtures was not fully appreciated by the 
"expert" employed. 



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January 13, 1883.] 



CORRESPONDENCE. 



57 



II. MATHEMATICAL ERRORS. 

,You have seen fit to condemn various firms, and, in 
our case, the analyst's failure to extract ^Sv grain of 
quinine from each /wo-grain pill, is his reason for 
charging us with dishonesty or inexcusable negligence. 

In matters of this importance, where every -rirr K''*'?* 
has great weight in determining our honesty or dis- 
honesty, we have a right to demand that simple mathe- 
matical calculations shall be correct. And if we shall 
show that the analyst has made several errors, we have 
a right to infer that he himself has been careless. 

We beg to point out the following errors : 



Maiiu£u:tunn. 


1 


•5 

1 

< 




Analyst's 

Equivalent 

Sulphate of 

Quinine. 


Correct 

EquivaKnt 

Sulphate of 

Quinine. 


li 

< 


W. H.SchieJrelin&Co.. 
W. H.Schieffelin&Co., 
Keasbey & Matlison, 


I 

II 
III 


VII 

III 
II 


1.43 

1.424 

1.42 


I.9I 
I.9I 
1.93 


I.9I 
1.92 
I.91 


0.00 

O.OI— 

0.01+ 



It is very peculiar that 1.42 grain of anhydrous 
quinine should in one case be equivalent to 1.9 1 grain 
of sulphate of quinine, and in another case to 1.92 
grain, while 1.424 grain of anhydrous quinine repre- 
sents only 1. 9 1 grain of sulphate of quinine. 

We do not care to quibble over li^ grain, and we 
would not, were it not that we are judged by hundredths- 
grains, but we refer to the above to show that the 
a$talyst has been careless in making calculations. 

III. MISLEADING COMPARISONS. 

We wish to call attention to a singular and very 
unfair comparison of one sample of pills containing 
bisulphate of quinine with six samples containing sul- 
phate of quinine. 

In speaking of " quinine pills " it is always, and very 
properly, understood that the pills contain the ordinary 
medicinal sulphate (C„HmN,0,),.H,S04.7H,0, a salt 
containing 74.31 per cent, of antiydrous quinine. Bi- 
sulphate of quinine is quite another salt, as appears 
from its chemical formula, Cj,HmN,0,.H,S04.7H,0. 

Now, bisulphate of quinine contains only 59.12 per 
cent, of anhydrous quinine, and the injustice of your 
comparison appears m this, that, to those not chemists, 
you apparently afBrm that 1.24 grain of anhydrous 
qufnine represents more "sulphate of quintne ' than 
does 1.42 grain of anhydrous quinine (Table, p. 690). 
1.24 grain of anhydrous quinine is in reality equivalent 
to 1.67 grain of ordinary sulphate of quinine, as ap- 
pears from the following proportion : , 

74.31 : 100=1.24 '• "*■ x=i.67 
In your conclusions (I., p. 691) you speak of seven 
samples of pills, five of wnich " have not in them the 
amount 0/ SVLVHA.TB OF QUININE which they are repre- 
sented to contain." Any competent chemist knows 
that a comparison of pills containing salicylate of qui- 
nine with those containing the ordinary sulphate would 
be no more unfair and misleading than the comparison 
of bisulphate with sulphate. 

And now, it is due to our friends in the drug trade 
who have so unhesitatingly recommended our pills to 
the physicians, and due also to the great number of 
the medical profession who have become accustomed 
to administer them with implicit confidence, that ive 
repudiate the imputation which has been put upon us 
of either carelessness or dishonesty. We do deny em- 
phatically that the pills tested were short weight. We 
have shown how the analysis might have failed in find- 
ing a true result from imperfections in its method. We 
now assert that the analyst was at fault in regard to 
our pills. 



1st. Because we know that the full weight of sul- 
phate of quinine was put in them. 

2d. Because, since the publication of your article, we 
have examined the record of our production of them 
as far back as the ist of July, and find that the varia- 
tion between the quantity of sulphate of quinine used, 
and the corresponding number of pills produced 
amounts to a mere fraction of one per cent., a degree 
of accuracy unattainable in extemporaneous dispensing. 
Pills made to order on physicians' prescriptions can be 
divided with only approximate exactness, and to make 
correctly only a few granules at a time in minute sub- 
divisions is an impossibility. With us the liability to 
error is reduced to a minimum, for the chances of mis- 
take in one skilled person making 5,000 pills at once, 
as against one hundred persons making collectively 
the same number, are as one to one hundred. 

3. We have repeatedly had them analyzed by Mr. 
H. B. Parsons, who is not unknown as a chemist, and 
they were found by him to contain sulphate of quinine 
in full weight. 

In regard to the comparison of prices, we care 
nothing, and only refer to it in order to show where the 
compiler seems to be weak, and that is in exactness 
or in carefulness. A slight examination of the table 
will show that, whil« purporting to give retail prices, 
it has, in some cases, given wholesale long prices, 
and in others wholesale net prices, and is as mislead- 
ing as are the analyses. 

In conclusion we desire to call your attention to the 
fact that the injury which such a publication as the one 
under consideration is calculated to inflict on parties 
whose names are used in such a connection is not 
likely to be overcome by any reply which may be 
made, as in many cases the persons who may have 
read the first article will never see the reply, and, if 
they do, will perhaps not read it carefully ; we trust, 
therefore, that your sense of justice will induce you to 
give this reply as general and wide a circulation as 
that accorded the original article. 
Yours truly, 

W. H. SCHIEFFELIN & CO. 
New York, December 30, i8Sa. 

[In reply to the above card, it seems almost un- 
necessary to state that the report of the results of our 
analyses of quinine pills was not put forth anony- 
mously, but was publisned as the work of The Medical 
News Commission, and "the|;ood name and reputa- 
tion "of The Medical News is the guarantee of the 
trustworthiness of the results obtained. 

It is unfortunate that Messrs. Schieffelin & Co.'s 
general denial of the accuracy of our analyses is not 
accompanied with that " positive proof" which they 
assume to furnish. Apart from a general assertion as 
to the quantity of quinine issued since July ist — an 
assertion which we of course do not presume to ques- 
tion — their card resolves itself, when examined, into 
criticisms reflecting upon the analysis, and objections 
to the method employed. The several points of objec- 
tion will, therefore, be considered seriatim. 

As regards the statement that " the method of analy- 
sis was faulty " because : I. " The use of an excess of 
ammonia as the precipitant was unfortunate." 2. 
"The use of ether as a separative solvent was also 
unfortunate;" the simple fact is that, by this means, 
the amount of quintne contained in a solution may 
practically h^ fully recovered. 

That quinine is more freely soluble in ammoniacal 
liquids than in pure water, or in solutions of soda or 
potassa, and that it is more freely soluble in chloroform 
than in ethef-, are facts which were considered to be so 
well known as to render any allusions to them unnec< 
essary. 



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NEWS ITEMS. 



[Medical News, 



That ether is soluble in water to the extent men- 
tioned was not overlooked in the making of our 
analysis. It is, however, plainly evident that the 
amount of quinine held in solution by the ether dis- 
solved in the water must of necessity be reduced to 
an inappreciable amount, when the relative volumes 
of the aqueous liquid and ether employed are con- 
sidered, and when the aqueous liquid is repeatedly 
shaken with fresh portions of ether and the ethereal 
layer in each instance is carefully separated. That the 
quinine is thus as completely recovered as is possible 
by any method of assay, is believed to be satisfactorily 
proven by the application of the test with potassio- 
mercuric iodide. 

To the statement that " the test with potassio- mercuric 
iodide, as here described, could not fail to give a false 
indication as to extraction of the quinine," the answer 
is that the conditions attending the application of this 
reagent as a test for alkaloids were perfectly well 
known to our Commission, and the statement was not 
made in the report that the ammoniacal liquid was di- 
rectly subjected to the test. The " remaining aqueous 
liquid," as stated in our report, was, indeed, tested ; 
but not, however, without having been previously 
supersaturated with an acid; a condition which was 
considered so well known to chemists as not to require 
specific description. 

The Messrs. Schieffelin further state that " for the ex- 
traction of quinine from uncomplicated aqueous solu- 
tions containing excess of soda, no solvent which we 
have used can compare with chloroform ; it is a better 
solvent for quinine than is ether," etc. etc.; and further, 
the supposition is expressed " that the difficulty of ex- 
tracting quinine from complex mixtures was not fully 
appreciated by the ' expert ' employed." Now, it must be 
conceded that an aqueous solution of quinine contain- 
ing considerable amounts of sugar, gelatine, etc., can 
not be considered an "uncomplicated solution," and 
that an amqunt of chloroform which would be suffi- 
cient readily to abstract the quinine from a pure solu- 
tion, or one containing simple inorganic salts, would 
form, in the case of a solution thus complicated, a very 
viscid mixture. 

The exactitude of the methods, and the avoidance 
of what Messrs. Schieffelin & Co. call " experimental 
errors," are sufficiently proved by the close coinci- 
dence of results arrived at in successive analyses, 
without any knowledge on the part of the operator as 
to the source of the specimens on which he was at 
work. 

As considerable prominence has been given by 
Messrs. Schieffelin & Co. to the subject of " mathe- 
matical errors," and as they "demand" that "the 
mathematical calculations shall be correct," we pre- 
sume that they will be satisfied when they see that 
such has been the case. 

The discrepancy of ^^ grain in the tabulation of 
the result, which they supposed they had discovered, 
is attributable to the fact that in the second series of 
analyses, in stating the amount of anhydrous <}uinine, 
Uie third decimal was inserted) which was omitted in 
those of Series I. and III. The amounts of anhydrous 

auinine obtained by our Commission, extended to the 
lird decimal, were as follows : 



Manufacturers. 



W.H. Schieffelin & Co.. 
W. H. Schieffelin &Co.. 
Ke<-isbey & Mattison 







a 




M 


is 


i 


s. 


'1 








X, 


o 


50' 


(/) 


< 


< 


I 


VII 


142a 1 


II 


III 


1.424 1 


HI 


II 


1.436 i 




I.ei4 
1.^16 
I.919 



The statement criticised was, therefore, as correct as 
was possible within two decimals. 

The Messrs. Schieffelin & Co. call attention to wh&t 
they consider " a singular and very unfair comparison 
between bisulphate and sulphate of quinine pills," 
which, as stated by them, would mislead the reader into 
supposing that we had compared the amount of anhy- 
drous quinine in these respective pills. It seems almost 
unnecessary for us to deny that we made any such com- 
parison. The investigation by our Commission was 
solely to ascertain if the quinine pills on the market con- 
tained the amount of qumine sulphate, or bisulphate, 
as the case may be, which they were represented to 
contain, and the cleair view of the result is not to be 
clouded by any extraneous issue. The reason why 
in the case of one house the bisulphate pills were ana- 
lyzed was because that house sells and advertises to 
sell the bisulphate whenever quinine pills are called 
for, since they are believed to be more readily soluble 
than the sulphate. 

As regards the comparison of prices, it is sufficient 
to remark that the Commission simply reported the 
prices whi,ch it paid, like any other retail purchaser. 
This is all that the profession and their patients are 
interested in ; the questions of " wholesale long prices," 
and ' ' wholesale net prices," are trade mysteries with 
which The News has nothing to do. — Ed.] 



NEWS ITEMS. 



BOSTON. 
(From our Sftcial Corrtspandtnt,) 

Dr. Carpenter's Sixth Lecture on Human 
Automatism. — This lecture, which concluded the 
course, considered automatism in morals. The lect- 
urer began by stating the theory of pure automatism, 
as distinguished from his own theory of automatism 
controlled by the will, as follows: Man cannot be an 
exception to the general uniformity of nature ; all his 
action is the result of what has gone before ; choice is 
as absurd as in the case of a bar of iron between two 
magnets ; " I cannot be other than I am ; I cannot do 
otherwise than I do," is the automatist's creed. This 
position was then criticised as not taking account of 
human nature, which does not work in sequences as 
material forces do. The theory of a limited choice 
on the part of the human agent will explain all the 
facts brought forward by the automatists and many 
which their theory will not explain. A large body of 
moral experiences is utterly inconsistent with the au- 
tomatist view. Now moral experience is determined 
by the original constitution and acquired habits. The 
habits are formed in ^outh, and the most important 
part of early training is that which relates to control 
of the bodily appetites and passions, as well as of the 
intellectual powers. As a proof of the freedom of the 
human agent, the lecturer dwelt upon the power ot 
fixing the attention. He next considered the several 
motives which excite human action. First of all is the 
desire for air, which is so intense that persons never 
take their own lives by suspension of the breath, but 
by direct act of the will. But they overcome this de- 
sire by a flank movement, by means of muscles' over 
which the will has more powerful control. Thus indi- 
viduals commit suicide by holding the face in a basin 
of water, or by hanging when they could easily save 
themselves by touching the feet to the floor. Next 
ranks the desire for food. The influence of alcoholic 
drink was discussed, the lecturer saying that alcohol 
seriously modifies the constitution and its effect is 
hereditary. 



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59 



Coleridge was cited as the most remarkable ex- 
ample of intellectual antomatism of the brightest 
type. But he lacked power of self-direction and was 
put under the control of a guardian. His son Arthur 
mherited his father's weakness, and was irresponsible 
for his unhappy end. Moral motives were considered, 
the dominant motive, according to the lecturer, being 
the desire to do right. But this motive varies greatly 
in clearness. In the case of street children, they ap- 
parently think that which they like is right, and that 
which they do not like is wrong. As an instance in point 
the Feejee Islanders were mentioned. Their morals 
have been regarded as nearly or wholly lacking, but 
an experienced observer has found that the Feeiees 
have a strict sense of the weight of the nomas or law, 
and on their plane are rigid in their actions. In re- 
gard to morals the lecturer quoted the words which 
have been said to embody all morals : " I am, I 
ought, I can, I will." The first implies power of in- 
trospection. The second directs our attention to the 
consequences of our acts, and leads us to intensify 
their force by keeping the mind upon them. We 
possess the power of self-regulation in the power of 
control over our fixed character. By fixing our minds 
upon a lofty motive a flank movement may be made 
which shall defeat a base motive. No human power 
can be so strengthened by practice as this power of 
self-control. Every successful moral conflict leaves 
the victor so much the stronger — with so much the 
more good — for the next struggle. The best means to 
conquer temptation is to fix the mind upon some other 
object. It is bad policy constantly to say . " 1 will not 
yield to this," for then the object is kept before the 
mind; but the mind should resolutely be turned to 
some other thing. Instead of brooding over wrongs 
and the slights inflicted upon us by friends, the remedy 
is not to say: " I will not think of'^it," but to direct the 
mind into some other channel. Morose feelings, fre- 
quently, are the result of some bodily derangement, 
often of the liver. Nothing is worse than brooding. 
In periods of depression the lecturer had found much 
relief in reading Scott's novels. He concluded by 
saying that the moral automatism is largely under the 
control of the will. 

The Appropriation to the Army Medical Mu- 
seum AND Library.— We are glad to be able to an- 
nounce that the House of Representatives, in the debate 
on the Army Appropriation Bill, has restored the ap- 
propriation for the Army Medical Museum and Library 
to the usual amount. The following is an extract from 
the Congressional Record of Jan. 4th : 

Mr. Butterworth. — In regard to that item, I will 
state to the Committee that it was reduced by the sub- 
committee on Appropriations from |io,oooto 17,500, 
and we bad such a storm raised about our ears because 
of the fact that this is the pet of the whole medical 
profession, that after we had reduced it to that sum I 
moved to restore it to the amount of the estimate. 
The Committee on Appropriations, the whole com- 
mittee, instructed, however, that this should be restored 
to $5,000. It has heretofore been $10,000. It relates 
to the collections made during the war, and stored in 
the Army Medical Museum, and for works of reference 
for the Surgeon-General's ofiice ; and I believe it is the 
finest collection possibly in the world. They insist 
that a larger sum is necessary. How it is necessary, 
however, was not made to appear, and the Committee 
instructed this reduction to be made. 

Mr. Townshend, of Illinois. — Let me ask the gen- 
tleman, if any consideration was given to the construc- 
tion of a fire-proof building for the museum ? 

Mr. Butterworth.— Yes. I will say to my friend 
this, that a part of the public building proposed to be 



erected for a library, would be devoted exclusively to 
this museum, and to the articles there gathered, to- 
gether with the library. 

Mr. Townshend, of Illinois. — I have received com- 
munications from many persons, who speak of the 
library and museum as of great value, and of the ne- 
cessity for the erection of a fire-proof building for their 
preservation. 

Mr. Butterworth. — There is no doubt of it. The 
gentleman is correct. It is asserted by many doctors 
to be one of the most valuable collections in the world; 
and it is now stored in what you might almost say is a 
mere tinder-box, liable to be\lestroyed by fire at any 
time. That is one of the reasons the committee deemed 
it unnecessary to add materially to the collection while 
it is in that building, but deemed it proper to withhold^ 
appropriations until a more suitable building was se- 
cured. 

Mr. Townshend, of Illinois. — Do the committee 
make any recommendations Upon the subject ? 

Mr. Butterworth. — The committee believe that a 
part of the new library building might be necessary 
for this museum. 

Mr. Townshend, of Illinois. — Does the gentleman 
think that it would be wise to separate the library from 
the museum ? In my judgment they ought to be to- 
gether. 

Mr. BirrrERWORTH. — ^The proposition was, to set 
apart a section in the new library build.ing, to be de- 
voted to the museum and its library. 

Mr. Hewitt, of New York.— Permit me to say that 
the amount, |io,ooo, appropriated last year was not, 
in the judgment of many eminent in the medical pro- 
fession, sufficient. That, I suppose, the gentleman 
from Ohio understands. Five thousand dollars is en- 
tirely inadequate. This library is the most complete 
library in the world on medical subjects. The object 
is to complete it, and to keep it complete. Five thou- 
sand dollars a year will not purchase the new publi- 
cations necessary to keep it up to its present standard. 
I think this is perhaps the wisest expenditure of money 
we can possibly make with reference to disease. 

Mr. Butterworth. — If the gentleman from New 
York will yield to me, I beg to state that I will move 
to increase the appropriation to 1 10,000. 

Mr. Hewitt, of New York. — That is right. 

Mr. Townshend, of Illinois. — I desire to say a word, 
unless the gentleman from New York (Mr. Hewitt) 
wishes to retain the floor. 

Mr. Hewitt, of New York. — I have finished what I 
had to say. 

Mr. Townshend, of Illinois. — I think true economy 
would require we should make provision for the preser- 
vation of the library and museum, and that a mere 
increase of the appropriation is not sufficient. I would 
suggest to the gentleman from New York (Mr. Hewitt) 
or the gentleman from Ohio (Mr. Butterworth) to bring 
in a provision here for the erection .of a fire-proof 
building for the preservation of the museum and li- 
brary. 

Mr. Butterworth. — I do not think that would be 
proper in this bill, although I agree with my friend 
from Illinois it is something which ought to be done. 

The question being taken on the amendment offered 
by Mr. Butterworth, to strike out "$5,000," and insert 
"$10,000," it was agreed to. 

Citizens' Auxiliary Sanitary Association of 
New Orleans. — According to the New Orleans papers 
a sanitary war is in progress in that city. It appears 
that the Auxiliary Sanitary Association, which was 
called into being by the sufferings of the city during 
the epidemic of 1878, and which since that time has 
labored to improve the sanitary condition by securing 



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dean streets, and the removal of all nuisances which 
are so apt to accumulate in an unsewered city, has re- 
cently made an effort to prevent the spread of small- 
pox by representing to the City Council the danger at- 
tending upon the usual burial service in cases of death 
from this disease. The association in the first instance 
offered to cooperate with the board of health to obtain 
appropriate legislation, but it does not appear that any 
action was taken by that body to meet the views of the 
citizens. One gentleman complained that a fatal case 
of smallpoK occurred in the house which adjoined his 
own, and that jio.warning, was given by the board of 
health. His first knowledge of the existence of the 
disease so near to his own household was conveyed by 
the funeral of the deceased. At a meeting of the board, 
a few days later, it decided that the association, instead 
of remaining "auxiliary," was becoming " suptrsid- 
iary," and forthwith passed a resolution for its suppres- 
sion. Nevertheless the SjSsociation yet lives, and has 
tendered its support in the work of sanitation to the 
City Councilmen in an address, in which it adverts to 
some of the most important permanent works which 
have been accomplished by it. 

Smallpox in Virginia. — A telegraphic despatch 
from Lynchburg states that smallpox has made its ap- 
pearance at Salem, Roanoke County, and that thirty 
cases have already been reported. The neighboring 
towns of Roanoke and Wythville have quarantined 
against Salem, and other southwestern towns are con- 
sidering the question of doing likewise. Roanoke 
College has suspended, and the students have gone- 
home. The public schools have also closed, and busi- 
ness is at a standstill. 

Trouble in McGill University. — A telegram from 
Montreal states that trouble has arisen in McGill Uni- 
versity between the medical students and Dr. Wright, 
Instructor in Materia Medica. One hundred and forty- 
seven students demand the resignation of Dr. Wright, 
and threaten to leave the university if their demand is 
not complied with. 

Complimentary Dinner to Prof. Austin Flint, 
Sr. — Prof. Flint, who completes to- night his course of 
lectures before the Philadelphia County Medical So- 
ciety, was entertained last evening at dinner at the 
Hotel Bellevue by a number of the prominent mem- 
bers of the medical profession of Philadelphia. Covers 
were laid for forty, and Prof. Alfred Stille, President of 
the College of Physicians, presided, with Prof. Flint 
on his right and Prof. Gross on his left. Among those 
who participated were Dr. John L. Atlee, President of 
the American Medical Association, Drs. D. Hayes 
Agnew, Da Costa, Goodell, Bartholow, Austin Flint, Jr., 
S. Weir Mitchell. E. Wilson, A. H. Smith, W. V. Keat- 
ing, Wm. Thomson, John Ashhurst, Jr., J. H. Brinton, 
I. M. Hays, and others. The arrangements bf the 
dinner were under the charge of a committee consist- 
ing of Drs. Alfred Still6, J. M. Da Costa, Wm. Pepper, 
S. W. Gross, James Tyson, Horace Y. Evans, and J. 
Ewing Mears. Towards the close of the dinner, the 
chairman proposed, in a few graceful remarks, the 
health of the distinguished guest, which was responded 
to by Dr. Flint in a feeling manner. 

Election of Officers of the Philadelphia 
County Medical Society. — The annual meeting of 
the Philadelphia County Medical Society was held on 
January 3d, and the following officers were elected for 
the ensuing year : 

./V«/V/<-«/.— William M. Welch, M.D. 

Vice-Presidents. — Drs. William R. D. Blackwood and 
Addinell Hewson. 



Recording and Reporting Secretary. — Henry Leflf- 
man, M.D. 

Corresponding Secretary. — H. Augustus Wilson, M.D. 
Treasurer. — L. K. Baldwin, M.D. 
Librarian.— C. M. Seltzer, M.D. 

Prof. Henle, the eminent anatomist, has been 
elected, in the place of the late Prof. Wohler, as per- 
manent secretary of the Royal Academy of Sciences, 
at Goitingen. 

The New York Society of Medical Jurispru- 
dence. — The newly organized New York Society of 
Medical Jurisprudence held its first public meeting last 
Thursday evening at the Academy of Medicine. Dr. 
J. S. Wight, Professor of Surgery m the Long Island 
College Hospital read a paper on the " Bearing of Illu- 
sions and Hallucinations on Testimony." 

This society was organized last month. Its object is 
the " advancement and study of the science of medical 
jurisprudence and the attainment of a higher standard 
of expert testimony." It has a membership of more 
than one hundred physicians and lawyers. Among 
the prominent medical members are Drs. Meredith 
Clymer, T. E. Satterthwaite, Clinton Wagner, T. C. 
Finnell, C. S. Wood, W. A. Hammond, Nathan Boze- 
man, T. A. McBride, J. S. Wight, and L. C. Gray. The 
society will hold monthly meetings. 

Abolition of the Graduation Thesis. — The Sen- 
ate of Toronto University has abolished the statute 
which requires candidates for the degree of M.D. to 
write a thesis. 

New York Polyclinic. — The attendance at the 
New York Polyclinic during its first course of six weejcs 
has been such as to assure the success of the institu- 
tion. Fifty-nine practitioners took out tickets, twenty- 
seven of these being in the Gynecological Department, 
and 1089 new patients were treated in the dispensary. 

Health in Michigan. — Reports to the State Board 
of Health by observers of diseases in different parts of 
the State, for- the week ending Dec. 30, 1882, indicate 
that intermittent fever has considerably increased, and 
that scarlet fever, consumption, membranous croup, 
^measles, and remittent fever have increased in area of 
prevalence. 

Compared with the average for the month of De- 
cember in the preceding five years, neuralgia, tonsil- 
litis, and dysentery were more prevalent, and remittent 
fever, intermittent fever, diphtheria, bronchitis, con- 
sumption, and pneumonia were less prevalent during 
the month of December, 1882. 

Including reports by regular observers, and by 
others, diphtheria was reported present during the 
week ending Dec. 30, and since, at 18 places, scarlet 
fever at 12 places, measles at 7 places, and smallpox 
at 2 places, as follows: at Richmond, Osceola Co., 
Dec. 27 ; at Ionia (one case), Jan. 3, 1883. 

Three cases of scarlet fever are reported at Mar- 
quette among immigrants just arrived from England. 
The disease was contracted on the steamer. 



offioal list of changes of stations and duties 
of officers of the medical department, u. s. 

army, from JANUARY I TO JANUARY 8, 1883. 

McKee, J. C, Surgeon. — To report, on or before Jan. 1, 1883, 
to the commanding officer Fort Winfield Scott, Cat., for assign- 
ment to duty as Post Surgeon. — Par. i, S. O. 797, Department of 
California, December aS, i88a. 

GORGAS, W. C. Assistant Surgeon. — Relieved from the tem- 
porary duty to which he was assigned under par. iv., S. O. 137, 
Department of Texas, and will report to the commanding officer 
Fort Brown, Texas. — Par. 3, S. 0. 140, Department of Texas, 
December a6, iSSi. 



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THE MEDICAL NEWS. 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. • 



Vol. XLII. 



Saturday, January 20, 1883. 



No. 3. 



ORIGINA L LEC TURES. 

PHILADELPHIA COUNTY MEDICAL SOCIETY 
LECTURES. 

ON THE PHYSICAL EXPLORATION OF THE 

LUNGS BY MEANS OF AUSCULTATION 

AND PERCUSSION. 

A touru ef three lectures delivered by invitation before the 
Philadelfhia County Medical Society. 

BY AUSTIN FLINT, M.D., 

fBorassoit or ma mMarLBS amd fracticb of Maoicna ads o* 

cumcAi. MBDicnn iic thb bbllbvvb hostitai, mbdical 

COLLBOB, MBW TOBX. 



LECTURE III. 

AUSCULTATION, CONTINUED AND CONCLUDED. 

Delivered January ij, ttSj. 

The adventitions sounds or r^es produced by acts 
of respiration, and the vocal signs, will furnish the 
topics to be considered in this lecture. 

MOIST and dry BRONCHIAL RALES. 

The bronchial r&les, moist and dry, were studied and 
explained by Laennec so completely and accurately 
that they need at the present time, in these regards, no 
modifications nor additions. Diversified as are the 
sounds, he reduced them to three signs, namely, the 
mucous (more correctly called the moist bronchial or 
bubbling rales), the sonorous, and the sibilant rales. 
These are distinct from the crepitant, the subcrepitant, 
and the crackling rales, which require separate notice. 
The crepitant and the crackling rales are distinguished 
as not bronchial but intra-l^sicular in their source. 
It is interesting to contrast this simple division by 
Laennec with toe over-refinement by Foumet. That 
author describes five varieties of intra- vesicular r&les, 
five varieties of extra-vesicular rales, and four varieties 
of bronchial rales. Skoda aimed at simplicity in his 
division, but it is in striking contrast to the simple ar- 
rangement by Laennec. Skoda divided the riles which 
have been referred to, into : ist. A vesicular r&le ; 3d. 
A consonating rile ; 3d. A dry crepitating rile ; and, 
4th. Indetermmate riles. The effect of Uiis division 
and nomenclature is to substitute confusion and error 
for clearness and correctness. It is needless to men- 
tion here the physical conditions which the moist and 
dry bronchial riles represent. I will make one practical 
remark respecting the clinical significance of the mobt 
or bubbling (or, as called by Laennec, the mucous) 
riles — namely, they are often wanting in bronchitis af- 
fecting the larger and medum-sized tubes, for the 
reason that adhesive mucus and solid sputa are not 
suited for bubbling. These rales occur when the bron- 
chial tubes contain pus, serum, blood, or liquefied 
tuberculous deposit. 

It is pleasant to find in Skoda's treatise a statement, 
with respect to these riles, of an important practical 
fact. I quote the statement referred to as follows : 
" The pitch of a rile generally corresponds to that of 
the respiratorjr murmur which is either replaced by or 
accompanies it." Again, "The acute, large, or un- 
equal bubbling thoracic riles indicate the same con- 
dition of the lung tissue as bronchophony and bronchial 
respiration." The importance of this fact is perhaps 
not always appreciated by auscultators. It enables 



the auscultator to determine by the riles alone, if 
respiratory sounds be, as they sometimes are, absent, 
whether solidification of lung exists or not. For ex- 
amples, the bubbling riles in capillary bronchitis and 
pulmonary oedema are always low in pitch, denoting 
non-solidification of lung. These riles are hiKh in 
pitch in a lobe solidified by pneumonia or by a phthis- 
ical affection. It does not seem to me easy to explain 
this effect upon the pitch of riles by solidification of 
lung, but it IS not less true, on that account, as a clinical 
fact determined by observation. 

The moist bronchial riles are easily illustrated 
artificially as follows : Attach to a Davidson's syringe 
a long India-rubber tube, or a series of tubes differing 
in size. After passing a little water through the tube 
or tubes, bubbling sounds are produced by a current of 
air for several hours. To observe these the tube should 
be held close to the ear, and other sounds excluded by 
covering the ear and the tube with the palm of the 
hand. This experiment shows that a very little liquid 
is sufficient to produce much bubbling, and therefore 
the abundance of moist bronchial riles is not evidence 
of much liquid. 

The dry riles, sibilant and sonorous, can be illus- 
trated with India-rubber tubes, either attached to 
Davidson's syringe or using the breath, by contracting 
the tubes at certain points. This may be done by 
either applying ligatures or compression with a forceps. 
It requires, however, some pains to secure the precise 
amount of contraction of the tubes necessary for the 
production of whistling and snoring sounds. The 
experiment, thus, while it demonstrates the mechanism 
of these riles, is defective in some accessory physical 
conditions which are involved in their production in 
cases of asthma and bronchitis. 

SUBCREPITANT AND CREPITANT RALES. 

Laennec described a moist crepitant rale, a subcrepi- 
tant rile, and a dry crepitant or crackling rile. His 
descriptions, as far as they go, are exact, but he failed 
to draw a sharp line of distinction between the riles 
now well known as the crepitant and the subcrepitant. 
Ttte error of attributing the crepitant as well as the 
subcrepitant rile to the bubbling of liquid, probably 
occasioned perplexity. The fact that the crepitant ' 
rile is heard with inspiration and never with expiration, 
would not occur to him as probable if both were bub- 
bling sounds; hence he failed to recognize this im- 
portant distinctive point. That he confounded the 
crepitant and the subcrepitant rile, seems certain ; 
yet he regarded the crepitant rale as the pathogno- 
monic sign of pneumonia. In this respect ne was in 
advance of his commentator, Skoda, who declared 
that the crepitant rile is only occasionally limited to 
inspiration, and that " no distinctive Une can be drawn 
between crepitating, subcrepitating, and mucous riles." 
This must seem a remarkable statement to the auscul- 
tators of to-day ; at all events, to those of this country. 
Not less remarkable is Skoda's statement that he has 
not often observed, in cases of pneumonia the crepi- 
tant rile as described by Laennec. 

The true explanation of the mechanism of the crepi- 
tant rile was first given by an American writer, the 
late Dr. E. A. Carr, of Canandaigua, New York, in a 
communication published in the American Journal of 
the Medical Sciences, in 1842. This explanation attrib- 
utes it to the separation of the walls of air vesicles in 



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ON THE PHYSICAL EXPLORATION OF THE LUNGS. 



[Medical Nkws, 



the act of inspiration, more or less of the walls having 
become adherent at the end of the act of expiration, 
from the presence of adherent mucus. It is probably 
more accurate to say that the sides of the ultimate 
bronchial tubes or bronchioles adhere at the end of 
inspiration, and are septraied by the act of inspiration ; 
hence, it is not strictly correct to call the crepitant rale 
a vesicular rile. It is not a bubbling sound, and the 
application to it of the term moist, is one of the few 
instances in which Laennec's observations were in- 
fluenced by his reasoning. A true crepitant rale is 
characterized by dryness ; but it is to be considered 
that Laennec did not discriminate sharply the crepi- 
tant from the subcrepitant, the latter bemg a moist 
or bubbling sound. After the lapse of forty years the 
explanation by Carr has made considerable headway 
as regards its general adoption. The explanation is 
so simple, it accounts for the peculiar characters of 
the sign so completely, and its correctness may be ren- 
dered so demonstrative by artificial illustrations, that 
it would seem as if it should at once have been adopted. 
Carr's im itation of the rale was by moistening the thumb 
and forefinger with a littie mucilage, and alternately 
pressing them together and separating them, h-ld 
close to the ear. As already stated, a crepitant rile 
may be obtained by auscultating directly a healthy 
lung after its removal from the body. The illustration 
is better after twenty- four hours than shortly after the 
lungs are removed. But the most perfect illustration 
was by means of an article made ten or twelve years 
ago, of India-rubber, to serve as a substitute for a 
sponge. This article was in structure like a very fine 
sponge; when compressed and then allowed to ex- 
pand, holding it close to the ear, the representation of 
the crepitant rale was as perfect as possible. This 
illustration furnished demonstrative proof that the rile 
is not a bubbling sound, and that it is produced by the 
separation of adherent surfaces, for in using the ar- 
ticle to illustrate the sign, not the least moisture was 
required.' 

The subcrepitant rale may be illustrated with the 
lungs of the calf or the sheep. Aft^r having obtained, 
by application to the lungs of the binaural stetho- 
scope, the crepitant rile, which, as has been seen, 
may be in this way illustrated, a certain quantity of 
liquid (water or glycerine) is to be poured into the 
trachea. Now, imitating respiration by inflating with 
the bellows, the subcrepitant rile is beautifully repre- 
sented. The bubbling is extremely fine, and is asso- 
ciated with crepitation. It is heard with the current 
of air which represents expiration as well as that rep- 
resenting inspiration. A similar association of the 
crepitant with the subcrepitant rile is by no means 
uncommon in pneumonia, and is, perhaps, the rule in 
the resolving stage of that disease. It is probable that 
this fact contributed to Laennec's confusion as regards 
these two rales. 

A recent theory attributes the crepitant, the sub- 
crepitant and, indeed, other bubbling riles, to intra- 
pleural exudation and adhesions. The experiment 
just stated demons-rates the fact that each of these 
riles may be produced within the lungs removed from 
the body. Autopsical examinations in cases in which 
these rales have been observed during life, show the 
existence of physical conditions analogous to those in 
that experiment. The riles are found in cases in 
which examinations after death show no pleural ex- 
udation or adhesions. On these data may be based 
the assertion that the intra- pleural theory of the pro- 
duction of these riles is, to say the least, purely gratui- 

• A similar .irticle is now made and used by artists. Something, 
however, is combined with the India-rubber, making it better 
adapted for its use as a sponge, but impairing very much its 
fitness to illustrate the mechanism of the crepitant r&le. 



tous. This is not saying that the stretching of fibrin, 
or of newly formed tissue between the pleural surfaces, 
may not sometimes produce sounds which simulate 
these riles. I cannot, however, think that the ear of 
an experienced auscultator can be thereby often de- 
ceived. 

The pleural friction sounds with which every practi- 
cal auscultator is familiar, have characters which are 
sufficiently distinctive. They are expressed by such 
terms as grazing, rubbing, creaking, grating, rasping, 
and not by bubbling or crackling. They are irregular 
in their connection with the respiratory acts, occurring 
with some and not with other successive acts; now 
heard in inspiration and now in expiration ; sometimes 
at the beginning and at other times near the end of 
either inspiration or expiration; in some instances 
being continuous, in othei; instances interrupted or 
jerking, and not infrequently disappearing temporarily 
after repeated forced respirations. These are not char- 
acters in common with the crepitant or the subcrepitant 
rile. A highly distinctive feature is their apparent su- 
perficial seat. They seem to be produced directly be- 
neath the ear applied to the chest, or the stethoscope. 
Rales produced within the air tubes or vesicles differ 
in this regard. Of the clinical significance and impor- 
tance of pleural friction sounds, it is unnecessary to 
speak. 

Laennec described a rile under the name "dry 
crepitant, with large bubbles or crackling" (r&U crepi- 
tant sec it grosses bulles ou craguement). He stated, as ■ 
a distinctive feature, that it is limited to the inspiratory 
act. He supposed it to be a diagnostic sign of pulmo- 
nary emphysema. There is an obvious incongruity in 
calling the sign a dry rile, with large bubbles. The 
term crackling is more defiiiite. At the present day 
this rale is not generally recognized as a distinct sign. 
Skoda admitted its existence, but remarked, somewhat 
flippantly, that they who had failed to recognize it had 
not lost much. A rile such as Laennec described is 
the crackling at the summit of the chest,' which is one 
of the accessory signs 14 the early stage of phthisis. 
It is sometimes heard at the summit of the chest on 
both sides in healthy persons at the end of a very deep 
inspiration. It is certainly not of much diagnostic value 
in pulmonary emphysema, but I have sometimes met 
with it occurring in connection with that affection. It 
has seemed to me to originate in the portions of lung 
not having become emphysematous. I have regarded 
it as an abnormal exaggeration of the vesicular quality 
of the inspiration in the normal respiratory murmur. 

Metallic tinkling, a sign with characters so distinc- 
tive that it is recognized at once from a description of 
them, has given rise to diversity of opinion and much 
discussion m regard to its mechanism, there being no 
lack of agreement in respect of its clinical significance. 
Jacob Bigelow, in 1839, demonstrated by a few well- 
devised experiments that the dropping of liquid in 
a space containing liquid and air gives rise to the 
sign. This was Laennec's explanation. Bigelow, how- 
ever, demonstrated that the sign was also produced by 
the explosion of bubbles on the surface of a liquid, 
within a cavity containing both liquid and air. This 
was the explanation given by Beail, Dance, and Spittal. 
These two explanations require the presence of liquid 
as well as air within either the pleural cavity or a pul- 
monary excavation. A third mode of production is 
the bursting of bubbles of air at the mouth of a fistu- 
lous opening into the pleurah cavity, or at the point of 
communication of a bronchial tube with a pulmonary- 
excavation. It is easy to demonstrate the correctness 
of each of these explanations. The sign may be pro- 
duced by either of the three modes, and, clinically, 
each is applicable to certain instances. For this de- 
monstration we may employ the India-rubber bag be- 



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longing to the modern foot-ball, which has been found 
serviceable in illustrating tympanitic resonance on 
percussion, and amphoric respiration. If the opening 
into this bag be connected with an India-rubber tube 
of sufficient length, the bag partially filled with a liquid 
and inflated, metallic tinkling may be produced by 
holding the bag so that the opening is dependent, and 
causing bubbles at the surface of the liquid by intro- 
ducing air through the tube from the mouth. It will 
be found that the quantity of liquid within the bag 
must not be large, otherwise gurgling is produced in- 
stead of the tinkling sounds. Tinkling sounds may 
be produced by making the other end of the bag de- 
pendent, and thus causing drops to fall from above to 
the surface of the liquid. Shaking the bag will also 
produce the sounds. Now, if the liquid within the bag 
be allowed to escape, and a few drops remain in the 
tube, on blowing into the latter and holding the bag 
close, to the ear, excellent examples of this sign are 
obtained. This last experiment gives the best illustra- 
tion, and it is probable that it exemplifies the most 
frequent of the modes in which the sign is produced 
clinically. 

We are now to consider vocal signs, and, first, the 
signs which are incident to the lary/igeal or loud voice. 

The names bronchophony, pectoriloquy, and aego- 
phony, applied by Laennec to vocal signs, are still, and 
will probably always remain, in common use. It is, 
however, conceded on every side that in the descrip- 
tion and interpretation of the first two of these signs 
(bronchophony and pectoriloquy) Laennec's treatise is 
defective. It is evident, in reading that portion of his 
treatise which is devoted to these signs, that his mind 
was biased by the desire to establish pectoriloquy as 
a cavernous sign. According to his description of 
bronchophony, " the voice seldom traverses the steth- 
oscope.* In pectoriloquy, on the other hand, the voice 
traverses the stethoscope either wholly or in part. By 
this language he means, doubtless, that the voice in 
pectoriloquy seems to be more or less near the ear of 
the auscultator. The distinction is a just and good 
one, but, as will presently be seen, it is not character- 
istic of a cavernous sign. The confused idea in Laen- 
nec's own mind is shown by his division of pectoriloquy 
into three varieties, namely, perfect, imperfect, and 
doubtful. The last variety, as he admits, is not to be 
distinguished by its intrinsic characters from broncho- 
phony. A doubtful physical sign can hardly have 
much clinical value, and, quoting from an essay by 
Oliver Wendell Holmes, " To speak of the tones of 
the voice being heard a short distance up the stetho- 
scope, is to present to the student a distinction of such 
tenuity as must seem beyond the reach of his facul- 
ties."* The vulnerability of this part of Laennec's 
treatise did not, of course, escape the critical eye of 
Skoda ; but, if it be correct to say there is confusion °in 
the account of bronchophony and pectoriloquy by Laen- 
nec, there is "confusion worse confounded" in Skoda's 
description. Skoda, after distinguishing the normal 
variations of the thoracic voice by the terms, loud, 
clear, and humming (terms which are not very sharply 
distinctive), and after concluding that bronchophony 
and pectoriloquy are identical, makes the following 
abnormal varieties: " I. The voice, accompanied by«a 
concussion in the ear, completely traverses the stetho- 
scope — loud bronchophony, which may be either clear 
or aull. 2. The voice, unaccompanied by concussion 
in the ear, passes incompletely through the stethoscope 
— weak bronchophony, 3. An indistinct humming, 
with or without a barely appreciable concussion in the 
ear." 

I Vide Prize Dissertation. Published by order of the Massa- 
drasetts Medical Society, Boston, 1836. 



It will be observed that there is no provision for 
ascertaining these modifications by immediate auscul- 
tation — ^the stethoscope is essential. I can sympathize 
with the student or the practitioner who attempts to 
grasp the distinctions set forth in this quotation, and 
to apply them at the bedside. The perplexity is not 
diminished by reading all that the author has to say 
with a view to their elucidation in the pages which 
follow. Adopting Skoda's account of vocal signs, it is 
not to be wondered at that a late German author, to 
whom I have repeatedly referred — Eicbhorst — thus 
introduces a chapter on auscultation of the voice : " Its 
diagnostic value has been much over-estimated. It 
hardly ever furnishes original diagnostic results, and, 
almost without an exception, its object is to confirm 
conclusions obtained by previous methods of investiga- 
tion." ' I am sure that this quotation does not express 
the estimate in which the vocal signs are held in our 
country, as bearing on the diagnosis of pulmonary 
diseases. 

How are we to determine the signs which are inci- 
dent to the loud voice and their differential characters ? 
There is but one way, and that is by means of the' 
analytical method of study. This method requires, as 
the point of departure for determining the morbid signs, 
study of the thoracic voice in health. This study shows 
that if we except characters which in some healthy 
persons belong to the voice as transmitted over the 
extra-pulmonary bronchi, especially on the right side 
of the chest, the normal vocal resonance is low in pitch, 
the voice seems diffused and distant from the ear, and 
it is accompanied by a perception of more or less 
vibration, thrill, or fremitus, which is not an acoustic 
but a tactile sensation. It is important to discriminate 
the fremitus from the resonance. 

BRONCHOPHONY. 

Proceeding, now to morbid signs as determined by 
analytical study, it is a highly distinctive abnormal 
deviation from the lowness m pitch, the distance and 
the diffusion of the normal vocal resonance, when the 
thoracic voice is raised in pitch, seemingly concentrated 
and near the ear. These characters are present when 
the voice is transmitted through solidified lung. 
Calling the sign distinguished by these characters 
bronchophony, it always denotes a certain degree of 
solidification of lung, if we except the so-called normal 
bronchophony sometimes ^found on the ri^ht side of 
the chest, and in rare instances on the left side, at the 
summit, over the extra-pulmonary bronchi in healthy 
persons. The abnormal sign is rarely wanting if the 
requisite degree of solidification of lung exist. It is 
not necessary, for the production of this sign, that the 
solidification be complete. It is obtained in pneumonia 
and other affections which involve solidification of 
lung, when the associated respiratory sign is not the 
bronchial, but the broncho vesicular respiration, and, 
of course, the normal bronchophony is heard over lung 
not solidified, its production being evidently due to the 
proximity of the large bronchial tubes. Observe that 
intensity of sound is not included among the distinctive 
characters of bronchophony. The voice may be either 
loud or weak. If the voice be concentrated, near the 
ear, and high in pitch, no matter how feeble the sound, 
it is not less bronchophony than if the sound were ever 
so loud, and the diagnostic significance is the same. 

INCREASED VOCAL RESONANCE. 

The vocal resonance may be abnormally loud, with 
no marked alteration either in concentration, nearness 
to the ear, or pitch. A simple increase of the resonance, 
therefore, it remaining low, distant, and diffused, is a 
vocal sign distinct from bronchophony, and which, 
as clinical observations in connection with examina- 



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tions after death show, represents solidification of lunp;. 
The solidification thus represented is not sufficient in 
degree to give rise to bronchophony. Increased vocal 
resonance, as distinct from bronchophony, is also a 
cavernous sign. This statement is based exclusively 
on my own observations. If a cavity of considerable 
size be situated near the superficies' of the lung, and 
not surrounded by solidified pulmonary structure, the 
Tocal resonance is notably increased, and may be ex- 
tremely intense, without the characters which are dis- 
tinctive of bronchophony. The sign is often associated 
with cavernous respiration, and out rarely with am- 
phoric respiration, the latter sign requiring solidified 
lung around the tuberculous cavity. 

PECTORILOQUY. 

Pectoriloquy, from its derivation, signifies thoracic 
speech as distinguished from thoracic voice, bron- 
chophony having the latter signification. . Strange to 
say, Laennec, who introduced these terms, did not em- 
ploy them in accordance with this etymological distinc- 
tion. His description of pectoriloquy embraced only 
the transmission of the voice. The confusion which 
has always existed, and still exists^ in the use of the 
terms pectoriloquy and bronchophony, is readily and 
completely done away with by the use of these terms 
in the true etymological sense of each. Bronchophony 
should be considered as meaning transmission of the 
voice, together with the characters which are distinc- 
tive of mat sign. Pectoriloquy should be limited to 
the transmission of speech, that is, of articulated words, 
through the chest. 

With this definition, Is pectoriloquy to be rejected as 
a superfluous sign, as is done by Skoda? By no 
means. There is no sign better individualized than 
this. It is easy to decide, in any instance, whether or 
not the speech, that is, articulated words, is perceived. 
There is one liability to error, namely, the auscultator 
may hear the words from the mouth of the patient, 
and fancy that he hears them through the chest. In 
order to avoid {his error, if immediate auscultation be 
employed or an uniaural stethoscope, the ear which is 
not to receive the chest sounds should be effectually 
closed. This, by the way, is a precaution to be ob- 
served in listening to any of the vocal signs. To make 
assurance doubly sure as to the existence of pectorilo- 
quy, the auscultator should not know beforehand the 
words which the patient sfieaks. I have been accus- 
tomed to use this precaution in giving practical lessons 
in auscultation, and I have been led to notice that some 
persons seize much better than others, words trans- 
mitted through the chest. 

Is pectoriloquy a cavernous sign ? It is, and it is not. 
Articulated words may be transmitted through a pul- 
monary cavity. It is then purely a cavernous sign. 
They may be transmitted through solidified lung; it is 
then, of course, a sign not of a cavity, but of solidified 
lung. Now, is it practicable to determine clinically, 
whether the sign denotes a cavity or not ? I answer in 
the affirmative. The discrimination is easy. If the 
thoracic voice which accompanies the pectoriloquy 
have the characters which are distinctive of broncho- 
phony, the transmission of speech is through solidified 
lung. The two signs, pectoriloquy and bronchophony, 
are conjointly present If, on the other hand, the bron- 
chophonic characters are wanting, and the pectoriloquy 
is accompanied by merely an increased intensity of the 
transmitted voice, the transmission of speech is through 
a pulmonary cavity. The two signs, pectoriloquy and 
increased vocal resonance, are then conjoined. There 
is, therefore, a cavernous pectoriloquy, and there is a 
bronchophonic pectoriloquy, the differential characters 
being well marked ai^d easy of recognition. 



iEGOPHONY. 

^gophony claims but a few remarks, not meaning 
to imply that it is a doubtful sign, as regards either its 
distinctive characters or its significance, but because, 
owing to correlative signs, it might easily be dispensed 
with in diagnosis. In fact, now when the exploratory 
puncture of the chest is employed in diagnosis without 
reserve, the auscultatory signs of pleuritic effusion are 
of much less practical importance than heretofore. 
Recently cases have been reported and papers pub- 
lished to show that, by means of the transmission of the 
whispered voice, it may be determined whether liquid 
within the pleural space be purulent or serous ; but 
why waste time in observations and discussions relative 
to this point of inquiry, when by means of a hypo- 
dermic syringe in less than a minute the character of, 
the liquid can be ascertained demonstratively ? 

It is a curious fact that in Laennec's treatise more 
than one-sixth of the portion of the work occupied 
with the consideration of the physical signs obtained 
by auscultation, is devoted to ae^ophony. In the greater 
part of this space, however, he discusses the mechanism 
of the sign. No one has found fault with or improved 
upon his description of the sign, and the name is well 
applied to it in certain instances, although the cry of 
the goat is less familiar to the people of this country 
than to the citizens of Paris. I believe that Laennec's 
interpretation of the sign is the true one, without re- 
gard to his views of the mechanism. The sign denotes 
a certain amount of pleuritic effusion. From Skoda's 
statement that he has heard segophony in cases of 
simple pneumonia, 1 infer that either the pneumonia 
was accompanied by the requisite amount of liquid 
within the pleural space, or that he confounded aego- 
phony with bronchophony. Analytically studied, aego- 
phony has the same characters as bronchophony, minus 
the nearness to the ear, added to which is the tremulous 
or bleating quality. The sound is more or less distant 
from the ear, and is rarely accompanied by fremitus. 
I believe the sound to be essentially a bronchophonic 
*voice, rendered more or less distant, the fremitus sup- 
pressed, the other modifications being due to its trans- 
mission through a stratum of liquid. Hence, the 
physical conditions for its production, in a case of 
pleurisy, are, the presence of a certain quantity of 
serous or purulent effusion, and condensation of a por- 
tion of the compressed lung sufficient to give rise to 
bronchophony. The latter condition is likely to exist 
with a moderate amount of effused liquid when the 
upper third of the lung is adherent to the chest wall by 
either recently exuded lymph or old adhesions, and the 
compressing force of the liquid as a consequence is 
brought to bear on the lower two-thirds of the lung. 

I have repeatedly endeavored to connect broncho- 
phony with aegophony by placing between the chest 
and the stethoscope an India-rubber bag containing 
varying quantities of liquid, in a situation where the 
bronchophonic voice was marked, in cases of pneu- 
monia. The pitch, of course, is that of aegophony, 
and the voice is distant, but the tremulous, nasal, or 
bleating characters of the sign are wanting. The modi- 
fications expressed by these terms, therefore, depend 
«n conditions not embraced in this experiment. Laen- 
nec attributed these modifications to flattening of the 
larger bronchi by the pressure of liquid, together with 
movements of the latter .caused by the vibration of the 
lung. If this explanation be not satisfactory. It is cer- 
tain that none better has been proposed. A bag of 
liquid interposed between the larynx and the stetho- 
scope, occasions none of the characters of aegophony, 
and for a good reason, to wit, laryngophony is not 
bronchophony. The vocal sound from the larynx is 
characterized by intensity, concussion, and firemitus. 



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without that elevation of pitch which is essential in 
order to reader it bronchophonic. 

Reverting to bronchophony and to increased vocal 
resonance, while the clinical significance of these im- 
portant signs admits of no doubt, the mechanism of 
their production is open for discussion. Laennec con- 
sidered that an essential element in the mechanism is 
a better conduction of sound by solidified than by 
healthy lung. Skoda's experiments prove the reverse 
of this. If the lungs be removed from the chest, after 
death from pn<'Umonia, a lobe or more being com- 
pletely solidified, and an assistant speak through a 
tube, the end of which is applied first to a solidified 
and aiterward to a healthy lobe, it will be found on 
auscultation with the binaural stethoscope that the 
voice is conducted further by the healthy than by the 
solidified lung.' Other experiments referred to in my 
last lecture also show that lung containing more or less 
air within the alveoli conducts sound better than either 
solidified lung or portions of the liver. The same re- 
sult obtains if the voice of the assistant be directed 
into the larynx or trachea, and the experimenter aus- 
cultate in alternation a healthy and solidified lung. 
Laonnec's explanation of the mechanism is, therefore, 
not tenable. To meet the difficulty, Skoda resorted to 
the theory of consonance. The adequateness of this ex- 
planation has been sufficiently disproved, and 1 need 
not take any time for the discussion of it. Here, then, 
is an apparent incongruity between an acoustic fact 
and clinical experience. We must admit that healthy 
lung conducts sound better than solidified lung. Per 
contra, it cannot be doubted that the thoracic voice, in 
cases of disease, is often louder over solidified than 
over healthy lung. Observations during life conjoined 
with examinations after death prove this incontesta- 
bly. Which, then, is to give way, the acoustic fact or 
clinical experience ? I answer, neither the one nor the 
other is to give way. The incongruity is, if possible, 
to be removed. The acoustic fact is not, for an instant, 
to be considered as invalidating the significance of the 
signs. Their significance rests on clinical and autop- 
sical data which are not to be put aside in conse- 
quence of anv apparent antagonism by physical facts. 
It is certain that such an antagonism must be only 
apparent, not real, and the object of inquiry should be 
to reconcile the apparently antagonistic facts with the 
truths of clinic U experience. 

It is to be considered that we cannot artificially com- 
bine all the physical conditions involved in the thoracic 
voice of either disease or health, nor even by means 
of the lungs removed from the body. The difficulties 
connected with artificial respiration are such that this 
method of experimentation is entirely out of the ques- 
tion ; but something can be done to ward a reproduction 
of the vocal signs by transmitting the voice through 
the larynx or trachea into the lungs after death. The 
contrast in the degree of conduction when the voice is 
transmitted through the trachea or a primary bronchus 
into a solidified lobe, wuh the transmission when the 
end of the speaking tube is placed upon the surface of 
the same lobe, proves that in the former instance the 
sound is conducted, not exclusively by the lung sub- 
stance, but by air within the pulmonary bronchi. The 
agency of air within the bronchi is also demonstrated 
by the following simple experiment : Insert the end of 
the speaking tube into the trachea, the lungs remain- 
ing attached, removed from the body and artificially 
inflated. The lungs of the calf or sheep will answer 
as well as those from the human subject. An assistant 
speaks into the tube, and the vocal resonance over the 
lung is obtained by means of the binaural stethoscope. 

■ Holden's resonator makes an excellent speaking tube in these 
experiments. 



Now, introduce a plug of cotton-wadding into the 
trachea, and compare the vocal resonance with that 
produced when the trachea is not thus obstructed. The 
intensity of the resonance is diminished, at least one- 
half, by plugging the trachea. The question, there- 
fore, as to solidified or healthy lung being a better 
conductor of sound, has really not very much to do 
with the explanation of the well-established clinical 
truth that when the lung is solidified, often but not in- 
variably, the thoracic voice is abnormally intensified. 
The explanation of this fact has more to do with the 
air contained within the bronchial tubes than with the 
solidification of lung. It is easy to account for the 
transmission of voice sounds from the larynx or trachea, 
as well as of the laryngeal and tracheal respiratory 
sounds, if we assume that a column of air extends into 
the bronchi within the lungs. We have only to in- 
stance the stethoscope and the speaking tubes in our 
houses, for familiar illustrations of the conduction of the 
voice by the medium of air contained in tubes. 

The distinctive characters of bronchophony can be 
reproduced after death over solidified lung by speak- 
ing into the trachea. The voice, transnu^ed through 
a solidified lobe, the binaural stethoscope being applied 
to the lobe, is raised in pitch and near the ear, whereas 
it is diffused and comparatively distant when trans- 
mitted through a healthy lobe. An effect of solidifica- 
tion is thus to modify the vocal resonance as in life. 
I do not attempt to give an explanation of the manner 
in which these modifications are produced. The in- 
tensity of the thoracic voice, transmitted after death 
through a solidified lobe, is not increased; but in- 
creased intensity, as has been seen, is not to be con- 
sidered an essential element of bronchophony. The 
bronchophonic voice may, or may not, be louder than 
the normal vocal resonance. But we have to inquire, 
why is it that bronchophony is ever more intense than 
the normal thoracic voice, and how is to be explained 
an abnormal increase of vocal resonance without the 
bronchophonic modifications whenever this is a sign 
of partial solidification of lung ? The rationale must 
have to do with the air contained within the bronchial 
tubes. I submit the following explanation : Suppose 
a case of pneumonia in the second stage, one lobe, at 
least, being completely solidified. The solidified lobe 
is enlarged in volume nearly or quite to the limit of the 
expansion at the end of the inspiratory act. Its volume 
does not diminish .with expiration, but remains the 
same in the inspiratory ana the expiratory act. The 
respiratory movements on the affected side are more 
or less restricted. Now, the voice is produced by the 
breath in the act of expiration, that is, it is produced 
when the current of air is passing from the bronchial 
tubes of the healthy lung, m consequence of the dimi- 
nution of the volume of this lung by the contraction of 
the thoracic space. It seems fair to assume that, under 
these circumstances, the bronchial tubes on the affected 
side contain more air than on the healthy side, and 
that there is less of a current of air in the expiratory 
act toward the trachea and larynx. Do not these 
points of difference account for a better conduction of 
the voice by air within the bronchial tubes on the 
affected side ? 

The following experiment has some bearing on this 

Question : A hospital patient under my observation, 
ied with acute pneumonia, the physical signs during 
life showing solidification of the entire left lung. In 
order to compare the transmission of the voice before 
and after the removal of the contents of the chest, the 
larynx was exposed and within it the end of the speak- 
ing tube inserted, the chest walls remaining intact. 
Blowing into the tube with the bellows and with the 
mouth produced over the upper solidified lobe a high- 
pitched tubular sound, and over the right upper lobe a 



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vesicular murmur. Moist bronchial riles were heard 
on both sides, but their presence did not drown the 
tubular and the vesicular sounds. Speaking through 
the tube and auscultating with the binaural stethoscope, 
well-marked bronchophony was heard at the upper 

fiart of the chest on the left side, over the solidified 
ung, and on the healthy side, in the same situation, a 
resonance corresponding to the normal. The broncho- 
phony, although well marked, was much less intense 
than during life. Exposing now the lungs, by remov- 
ing the sternum, and applying the stethoscope upon 
the upper solidified lobe, bronchophony was still heard, 
but notably less marked than before the chest was 
opened. I infer from this comparison that the bronchi 
within the solidified lung when in si/u, the chest un- 
opened, contained more air than when exposed directly 
to atmospheric pressure. But in this experiment only 
one of the physical conditions underlying the thoracic 
voice in life is represented. The production of the voice 
with the current of air in expiration, and the thoracic 
respiratory movements are, of course, not included. 

Granting that the explanation which has been given 
of an increas|d intensity of vocal resonance over solidi- 
fied lobe or looes in cases of pneumonia be satisfactory, 
it remains to endeavor to explain an increased inten- 
sity of the thoracic voice when the solidification is not 
sufficient to give rise to bronchophony; when, for ex- 
ample, in cases of phthisis, the increased resonance of 
the voice represents a greater or less number of tuber- 
culous nodules. Here it cannot be said, in explana- 
tion, that the lung-remains permanently expanded, nor 
that the movements of the chest are notably restricted. 
The bronchial tubes in the vicinity of the nodules may 
be dilated, but I am not prepared to state that this is 
the rule. It is intelligible that these tubes may be 
prevented from collapsing by the proximity of solidi- 
fied nodules These physical conditions, however, 
seem hardly adequate to explain the sign. It is still 
more difficult to explain increase of vocal resonance 
when portions of lung are partially condensed by the 

Eressure of liquid or an extrinsic tumor. There must 
e physical conditions involved which, as yet, are not 
understood. But, I repeat, to accept this conclusion is 
not to throw a shadow of doubt upon the diagnostic 
value of increased vocal resonance as a sign of solidi- 
fication of lung, wherever associated with other signs 
denoting that condition. 

The increase of vocal resonance. over cavities is suf- 
ficiently intelligible. If a cavity be superficially seated ; 
if it be not surrounded with lung completely or consid- 
erably solidified ; if it be empty, and there be free com- 
munications with unobstructed bronchial tubes, we" 
have a combination of physical conditions favoring the 
conduction of the voice, so as to give rise to more or 
less intensity of resonance, with fremitus, but without 
the modifications of bronchophony. In a lung removed 
from the body, this combination of physical conditions 
existing, notable intensity of vocal resonance, as dis- 
tinct from bronchophony, may be produced by trans- 
mitting the voice into the trachea. 

It did not occur to Laennec to study the thoracic 
sounds produced by the whispered voice. Many years 
ago, impressed with their value, I was led to institute 
a series of signs derived from this source. The sounds 
thus produced have, of course, characters correspond- 
ing to those belonging to the expiratory act in respira- 
tion; but they are brought out in -tronger relief, and 
are better observed, in connection with whispered 
words. As these signs are correlative to those pro- 
duced by the loud voice, it seemed appropriate to des- 
/ignate them by corresponding names. Whispering 
pectoriloquy was a term which had already been u-ed. 
Applying to the sounds in health the name noimul 
bronchial whisper, the morbid signs were named as 



follows: Increased bronchial whisper, bronchophonic 
whisper, cavernous whisper, whispering pectoriloquy, 
and- amphoric whisper. The differential characters, 
following the same order in enumeration, are those of 
the expiratory sounds in broncho-vesicular respiration, 
bronchial respiration, cavernous respiration, pectoril- 
oquy with the loud voice, and the amphoric voice. 
It would be superfluous, and therefore tedious, to enter 
into further description of these signs, and to consider 
more fully their significance. I would remark, how- 
ever, that an abnormal increase of the bronchial whis- 
per has often, in my experience, been of much service 
as one of the signs of incipient phthisis. But with 
reference to its significance in the diagnosis of that 
disease, it is essential to take into account the normal 
points of disparity between the two sides of the chest 
at the summit. In the infra-clavicular and in the inter- 
scapular regions, the normal whisper on the right side 
is louder than on the left side, but the pitch is a little 
higher on the left side. Consequently, if the whisper 
on the left side be louder than that on the right, or 
even equally loud, it is abnormal ; and if the whisper 
be higher in pitch on the right side, it is abnormal. 

Another practical remark relates to whispering>ec- 
toriloquy. Here, as with the loud voice, articulated 
words may be transmitted through solidified lung as 
well as through a cavity. Here, too, it is not less easy 
to determine in any instance whether the transmission 
be through solidified lung or through a cavity. If the 
pectoriloquy be associated with the characters of the 
bronchophonic whisper, it is the sign of solidification ; 
but it is the sign of a cavity when associated with the 
characters of the cavernous whisper, that is, if it be 
low in pitch and non- tubular in quality. 

CONCLUDING REMARKS. 

Mr. President and Members of the Philadelphia County 
Midii al Society : In concluding these lectures, I beg 
to recall the objects which were stated at the outset 
I was desirous of showing that Auscultation and Per- 
cussion, divested of theories, speculations, non-essen- 
tial discussions, and needless refinements, may be so 
simplified as to be made generally available in medical 
practice. The number of signs obtained by these 
two methods of physical exploration need not much 
exceed thirty. In a considerable proportion the char- 
acters of these signs are so plainly distinguished, that 
even their names suffice for a description and their 
recojjnition. I desired to show that in order to secure 
definiteness and clearness as regards the distinctive 
characters of different signs, and a ready differentiation 
of them, they must be studied by means of the analyt- 
ical method. I cannot too strongly express my sense of 
the importance of relying upon this method of study 
for our practical knowledge of the signs obtained by 
auscultation and percussion. I have submitted, as I 
hope with becoming modesty, the fruits (if I may vent- 
ure to use that term) of my own studies in this field of 
medicine for many years — studies relating to the dis- 
tinctive character of signs, their significance, the intro- 
duction of some new signs, and the names by which 
they are to be designated. 

Not ignoring the interest belonging to inquiries con- 
cerning the mechanism of the signs, I have entered in 
these lectures somewhat into a consideration of them 
in this aspect. My purpose has been chiefly to show 
that most of the more important of the signs may be 
produced out of the body, either by simple artificial 
means, or by using for this end the lungs, healthy and 
diseased, from the human subject and from inferior 
animals. The attention which I have of late given to 
the experimental illustrations to which I have referred, 
has led me to appreciate, more than hitherto, their 
usefu.ness, not only as explanatory of the mechanism 



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67 



of signs, but as affording valuable aid in teaching prac- 
tically auscultation and percussion. The production of 
signs out of the body in the class-room, before bringing 
students to the bedside for the actual illustrations, must 
be of much service in facilitating the acquirement of 

fractical knowledge of their distinctive characters, and 
commend this exercise to the consideration of in- 
structors in physical exploration. 

I need not remind this audience of the inestimable 
value of the results of the inspired thought which 
prompted Laennec to improvise a stethoscope by roll- 
ing together a few quires of paper. Have these results, 
after half a century, reached their termination? Is 
nothing to be expected in the future, in the way of im- 
proved means of auscultation? Does the binaural 
instrument represent the perfection of stethoscopy ? I 
trow not. When we reflect upon the recent develop- 
ment in practical acoustics, as exemplified by the tele- 
phone, the microphone, and the phonograph, may we 
not expect that some inventive genius will dev^op 
similar marvels in auscultation ? Lontj before the time 
of Laennec, a quaint English writer uttered these quasi 
prophetic words : " Who knows but that one may dis- 
cover the works performed in the several offices and 
shops of a man's body by the sounds they make, and 
thereby discover what instrument or engine is out of 
order." This prediction has been fulfilled. And now, 
after the manner of Robert Hook, who wrote in 1705, 
who knows but that the time may come, and perhaps 
ere long, when the only use of the stethoscope of to-day 
will be to illustrate, by contrast, an immense improve- 
ment in the means of discovering "the works per- 
formed in the several offices and shops of a man's body 
by the sounds they make ?" 

Treating, as I have done in these lectures, of auscul- 
tation and percussion in a purely didactic fashion, I 
have had to deal with dry topics, which must have been 
dull to those who have not felt any special interest in 
the subject. This was unavoidable. The conscious- 
ness of the fact enhances the thanks which, under any 
circumstance, would be due to those who have honored 
me with their attendance and attention. And in clos- 
ing, as at the beginning, let me say that I could not 
adequately express my sense of the honor involved in 
the invitation to inaugurate a plan of annual lectures 
which, as I hope, will hereafter be committed to abler 
hands. 

ORIGINAL ARTICLES. 



THE MICROCOCCUS OF GONORRHCEAL PUS- 
INFECTIVE VIRULENCE NOT DUE TO THE 
PRESENCE OF THIS PARASITIC 
MICRO-ORGANISM. 

By GEO. M. STERNBERG. M.D.. 

SUMMON, U. S. A. 

Modern scientific research having demonstrated 
that a number of infectious diseases are due to the 
presence in the infective material — blood, etc. — and 
multiplication in the bodies of infected animals, of 
parasitic micro-organisms, having definite and dis- 
tinct — specific — characters, it is not surprising that 
many physicians are inclined to make the general- 
ization that all infectious diseases are parasitic, and 
it must be admitted that there is much to be said 
in favor of this hypothesis. A proper scientific 
conservatism, however, requires that the list shall 
be considerably extended before such a generaliza- 
tion can be considered safe ; and it is evident that 
if a single infectious disease is shown to be inde- 



pendent of all micro-organisms, the generalization 
will be impossible, and the etiology of each specific 
disease of this class must be worked out separately. 
But such a demonstration cannot rest upon nega- 
tive evidence, for no one will venture to claim that 
failure to discover parasitic organisms in animal 
tissues and fluids is sufScient proof of their non- 
existence, especially since Koch's discovery of a 
bacillus in material which had previously been ex- 
amined by numerous competent microscopists with- 
out success, at least so far as the demonstration of 
this particular organism is concerned. 

On the other hand, a positive demonstration that 
infective virulence is due to something else than a 
living ferment, as, for example, to a peculiar albu- 
minoid product elaborated in the body of an in- 
fected animal, would make the hypothesis of an 
undiscovered "formed ferment" — living organism 
— unnecessary and unreasonable; for we do not 
require two efficient causes to enable us to account 
for the same phenomenon. But I am not aware 
that such demonstration has been made in any one 
of the infectious diseases, and I have no evidence 
of this kind to offer in the case of gonorrhoea. 

The question, then, as to the cause of the viru- 
lence of gonorrhoeal pus remains exactly where I 
found it when I commenced the experimental study 
recorded in the following pages, for my researches 
show that — 

Tite micrococcus which I have found in a certain 
number of the pus-celts in every specimen of gonor- 
rhceal pus examined by me is an accidental parasite 
which has nothing to do with the special virulence of 
this fluid. And — A careful search with a first-class 
objective (Zeiss' 1-18 in.) and by the use of staining 
reagents (methyl violet and other aniline colors) has 
not revealed the presence in this fluid of any other 
micro-organism than this micrococcus. 

This being the case, it may be thought that there 
is nothing more to be said. But it has seemed to 
me that a somewhat extended account of the ex- 
periments which have led me to the above-men- 
tioned result may be uscfiil in the present stage of 
inquiry (a) to substantiate the statement made, {b) 
to clear the way for others who may undertake a 
like investigation, and {c) more especially as a con- 
tribution to the study of micrococci. 

My researches show that differences, morpholog- 
ical and physiological, exist among these lowiy 
plants which make it possible to establish specie.-., 
having characters quite as well defined as have 
many plants much higher in the scale. 

This is in accordance with the views of Cohn 
and of Koch, and opposed to those of fiillrotli, 
Nageli, and others, who consider all the bacteria as 
constituting a single species (^Billroth), or at least 
but a small number of species, each including a 
variety of forms, designated micrococcus, bacterium, 
vibrio, etc. (Nageli), which pass constantly the one 
into the other, being merely different phases in the 
life-history of the same plant. 

That the life-history of some of the bacteria does 
include a variety of forms can not be questioned. 
Thus we have in the case of bacillus anthracis short 
rods, in the blood of an infected animal, which 



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grow into long filaments, in a culture-fluid, in the 
interior of which are developed oval spores, which 
are afterwards set free, and might be mistaken for 
micrococci, but for the fact that they again develop 
into rods. The life-history of other species also 
includes a motile form. But there is nothing in 
such facts to preclude the idea that a large number 
of distinct species exist in nature, and a somewhat 
extended study has convinced me that such is the 
case. Many of these species have, possibly, been 
independent of each other, and rivals in the strug- 
gle for existence, from the earliest period of the 
earth's history. But as among higher plants, these 
lowly organisms are subject to variations as to size, 
rapidity of development, etc., due to circumstance;; 
relating to their environment — abundance and kind 
of pabulum, temperature, etc.; and we already have 
ample proof that varieties possessing different phys- 
iological characters may be produced by special 
methods of cultivation — attenuation of virus in 
anthrax and fowl-cholera (Pasteur). The fact that 
well-defined species do exist, even among the 
smallest and simplest of the bacteria, will be en- 
forced in the present paper by contrasting two 
species of micrococcus, which the writer has had 
under almost daily observation for many months 
past, and which have been cultivated side by side, 
in hermetically sealed flasks,* without even seeing 
one form pass into the other, or either develop into 
anything else than a micrococcus. 

One of these sp^ecies is the micrococcus of gonor- 
rhoeal pus, which turns out to be Micrococcus urea, 
Cohn, and which has been shown to be the cause of 
the alkaline fermentation of urine (Pasteur). 

The other is the micrococcus found in human 
saliva, which has been proved to be a pathogenetic 
species so far as rabbits are concerned.' 

In my paper upon a fatal form of septicaemia in 
the rabbit, published in Studies from Biological 
Laboratory Johns Hopkins University, I devote con- 
siderable space to the morphology of the septic 
micrococcus which is also illtistrated by photo- 
micrographs (heliotype prints) ; a photo-micrograph 
of the micrococcus of gonorrhoeal pus is also intro- 
duced, and at the close of this paper is referred to 
in the following words. 

" Fig. S is introduced to show that there are micro- 
cocci and micrococci. The species (?) here represented 
was obtained in the first instance from gonorrnoeal pus. 
A little of this pus, obtained from a case of two weeks' 
duration, showed upon microscopical examination, in 
a few of the pus corpuscles, an invasion by micrococci, 
while the majority of the corpuscles, as well as the 
liquid in which they were suspended, were free from 
organisms. A culture-tube containing sterilized bouil- 
lon (from rabbit), was inoculated with a little of this 
pus, and an abundant development of micrococcus re- 

> Vide paper ia Studies from Biological Lalxiratory Johns Hop- 
kins Univeisity, vol. ii.. No. a, p. 164, for metliods employed. 

* Vide papers by the present writer. National Board of Health 
Bulletin. April 30, 1881 ; also Studies from Biological Laboratory 
Johns Hopkins University, vol. ii.. No. a, p. i8a; Philadelphia 
Medical Times, September 9, i88a ; American 1 oumal of the Medi- 
cal Sciences, July, 1883, p. 69-76; Philadelphia Medical Times, 
1883 ; also a paper by Dr. Claxton, Philadelphia Medical Times, 
July 17, 1883, p. 637. 



suited. A second tube was inoculated from, the first, 
and a third from the second. The organism was found 
in abundance in all of these solutions (kept in a cult- 
ure-oven at 37° Cent.), unchanged in appearance and 
unmixed with any other forms of bacteria. One cubic 
centimetre of the liquid from culture No. 3, was injected 
under the skin of a small rabbit with an entirely nega- 
tive result. It is evident, then, that physiologically, 
this micrococcus differs from the deadly septic micro- 
coccus which we have been studying. . . . 

The question will naturally be asked as to the possi- 
ble relation of this organism to the peculiar virulence 
of gonorrhceal pus. f have not yet found time to study 
this question experimentally, but think it quite prob- 
able that this organism will be found to be identical 
with the micrococcus found in pus from other sources, 
'• g-) open wounds, inflamed mucous membranes, etc. 
Whether this common and widely distributed micro- 
coccus is capable under special conditions of cultiva- 
tion of developing into various pathogenetic micrococci ; 
whether it is a distinct species from our septic micro- 
coccus, or whether the latter is a pathogenetic variety 
developed from it, are questions which can only be 
settled by extended and painstaking experimental in- 
vestigations." 

The questions above suggested, I have since at- 
tempted to settle by the experimental method, and 
the object of the present paper is to place upon 
record the results of my researches. 

These results may be summarized as follows : 

{a) Microscopical examination of numerous speci- 
mens of gonorrhoeal pus, from a number of cases, 
has demonstrated the constant presence of the mi- 
crococcus first observed in Baltimore in the summer 
of 1881. 

(J>) Upon inoculating a sterilized culture-fluid 
(beef-tea, or rabbit bouillon) with a small quantity 
of gonorrhoeal pus at the moment of its escape from 
the meatus urinarius, and placing this in a culture- 
oven for a few hours, an abundant development of 
micrococci takes place. 

(r) These micrococci present in all cases the same 
morphological characters, and no other micro-or- 
ganisms than these make their appearance in a her- 
metically sealed culture-flask,* inoculated as above 
indicated. 

(//) These micrococci, introduced beneath the 
skin of a rabbit, produce no noticeable result. 

{e) Culture-fluids containing these micrococci 
introduced into the healthy male urethra do not 
give rise to specific urethritis, or to any other no- 
ticeable result. 

(/) A culture-fluid containing this micrococcus, 
upon being added to acid urine recently passed and 
free from micro-organisms, causes it to undergo the 
alkaline fermentation. 

(^) Urine which has spontaneously — that is, 
without resort to experimentol inoculation — under- 
gone alkaline fermentation, contains a micrococcus 
identical in appearance with that obtained by culti- 
vation from gonorrhoeal pus. 

The deduction from these facts is evident. It 
has already been formulated, and is included in the 
title of the present paper. 

I The writer's method of conducting cultiue-experiments is 
described in vol. ii.. No. 3, of Studies from the Biological LiU>o- 
ratory Johns Hopkins University, p. 164. 



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69 



RECORD OF EXPERIMENTS. 

At the outset of the investigation the idea nat- 
urally suggested itself that the question as to the 
possible causal relation of the micrococcus to the 
infective virulence of the fluid containing it, could 
best be answered by culture-experiments, carried 
far enough to exclude everything but the living or- 
ganism, and by inoculation experiments upon sus- 
ceptible animals. 

The following experiments were therefore made 
with a view to ascertain whether the animals most 
easily obtainable for such a purpose were susceptible 
to the action of the virus. 

Experiment No. I (May 6th). — Inoculated dog (male) 
in urethra and in right eye with gonorrhoeal pus ob- 
tained from urethra of a patient in the post hospital, 
Fort Point San ]os€. In this and the following ex- 
periments the pus was obtained from the urethra of the 
patient by means of a silver probe having a little cotton 
twisted about its extremity. This was then introduced 
into the urethra, conjunctival sac, or vagina of the 
animal experimented upon, and rotated vigorously to 
make sure that a portion of the pus was detached. 

Result of above experiment entirely negative. 

Experiment No. a (May 8th). — Inoculated female 
dog in right eye and vagina from same patient as in 
preceding experiment. 

Result negative. 

Experiment No. j (July 28th) — Inoculated puppy, 
two months old, in right eye and in vagina with gonor- 
rhceal pus from a patient in post hospital. 

Result negative. 

Other experiments were made upon rabbits, but 
the notes have been mislaid. Noa* of these experi- 
ments afforded any encouragement to the idea that 
the test could be made upon the lower animals, atfd 
I accordingly determined to seek an opportunity to 
make it upon man. My first efforts, by the offer of 
a bribe, to find a willing subject, were unsuccessful, 
bpt fortunately my friend, Prof. Hirschfelder, came 
to the rescue and offered to introduce my culture- 
fluids into the urethrse of certain patients in his 
wards in the San Francisco City and County Hos- 
pital. These patients consented to the operation 
with a full knowledge of the possible results, from a 
desire to please their doctor, and under the promise 
of speedy cure and a suitable recompense in case of 
successful inoculation. 

The pus from which the cultures used in these 
experiments were started was taken from cases in 
the acute st^ge of the disease, and which had not 
been subjected to any local treatment. 

Experiment No. 4. (July, 1882). — Made by Dr. Hirsch- 
felder with material furnished by the writer. A culture- 
fluid, fifteenth, containing the micrococcus of gonor- 
rhoea! pus was introduced into the urethrs of three 
patients in the city and county hospital, upon small 
wads of cotton which were thoroughly moistened with 
the fluid and left in situ for fifteen minutes. 

Case J, J. D., has been in bed for about nine months ; 
caries of the vertebrae. 

Case 3, J. B., colored ; syphilitic paralysis. 

Cases, D. M., in bed some time; aneurism of the 
abdominal aorta. 

The result was entirely negative. 

Experiment No. s (Aug.). — A fresh culture, four- 
teenth, firom another, and recent case, was introduced 



in the same manner into the urethra of J; D., subject 
of previous experiment. 
Result negative. 

The culture-fluid, rabbit bouillon, used in the 
above experiments was neutral. In the following a 
slightly alkaline culture-fluid was used. 

Experiment No. 6 (Aug.). — A fresh culture, thir- 
teenth, was introduced into the urethra of W. B. 

Result negative. 

As already stated, the injection, in Baltimore, of 
one cubic centimetre of the third culture from 
gonorrhoeal pus produced no perceptible result. 
This experiment I have since several times repeated. 

Experiment No. 7 (June loth). — Injected thirty 
minims of sixth culture from gonorrhoeal pus beneath 
the skin of a small rabbit. 

Result negative. 

Experiment No. 8 (July 17th). — Injected thirty 
minims of second culture from gonorrhoeal pus into 
subcutaneous connective tissue of small rabbit. 

No result. 

Experiment No. g (July 26thJ. — Injected ten minims 
of sixtk culture from blood of septicamic rabbit con- 
taining the septic micrococcus (Fig. 6) beneath the 
skin of the rabbit used in last experiment (No. 8). 
The animal died at 10 A. M., July 29th, and a micro- 
scopical examination made at once demonstrated the 
presence in the blood, and in the effused serum in sub- 
cutaneous connective tissue of the septic micrococcus 
in great abundance. 

Remarks. — This experiment shows very plainly the 
difference between a pathogenetic micrococcus and 
one which is harmless. These organisms, although 
having distinct morphological characters (see Figs. 
2 and 6), do not differ greatly in size, and both 
multiply freely in the culture-fluid used. This fluid, 
with the contained micrococci, proved to be in- 
nocuous in the dose of thirty minims in the one 
case, while one-third of this amount kills the satne 
animal by reason of the presence of the other mi- 
crococcus in a subsequent experiment. 

Experiment No. 10 (July 29th). — One drop of gon- 
orrhoeal pus from a recent case was introduced beneath 
the skin of a small rabbit. 

Result negative. 

This experiment is given for what it is worth. I have 
not yet had the opportunity to repeat it with a larger 
quantity of material. 

The possibility that the micrococcus from gonor- 
rhoeal pus might acquire pathogenetic properties by 
being cultivated in blood-serum having occurred to 
me, the following experiment was made. 

Experiment No. 11 (September isth). — Injected ten 
minims of culture of micrococcus from gonorrhoeal pus 
in blood-serum beneath the skin of a guinea-pig. 

Result negative. 

Remarks. — A single experiment of this kind has 
of course but little value, and I have not yet found 
time to follow up this line of inquiry. The ques- 
tion is however an important one, and well worthy 
of the attention of experimenters in this line of in- 
vestigation. Here is a micrococcus which is harm- 
less under ordinary circumstances. May it develop 
pathogenetic properties as the result of special condi- 
tions as to temperature, pabulum, etc., artificially 
maintained for a length of time, and in the course 



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WHEN IS A PHYSICIAN LEGALLY EXEMPT FROM TESTIFYING? [Medical News, 



of successive generations produce a physiological 
variety having different vital reactions from those 
which marked the parent stock ? 

To test the question as to a possible local patho- 
genetic action of this micrococcus in aji open wound, 
the following experiment was made. 

Experiment No. 12 (August 4th). — An incised wound 
was made with scissors, removing a fragment of skin, 
upon each thigh of a half-grown rabbit. The wound 
upon right thigh was moistened with a culture-fluid 
(twentieth culture) containing the micrococcus from 

fonorrhoeal pus. The wounds were then dressed with 
ry tow and a bandage applied. Both healed kindly 
without any undue inflammation, and no difference 
was observed between the two. 

Remarks. — In the recent work on Antiseptic 
Surgery, by Watson Cheyne, the statement is 
made that micrococci, which, from his illustrations, 
may well be the same as these, are often found be- 
neath the dressing in the discharges from wounds 
treated antiseptically, and that no harm seems to 
result from the presence of these micro-organisms, 
all of which shows that there are micrococci and 
micrococci.^ 

Having determined that the micrococcus of gon- 
orrhoea! pus does not give to this fluid its specific 
virulence, and having observed its morphological 
identity with the micrococcus found in urine under- 
going alkaline fermentation {Micrococcus urea, 
Cohn), the next question was as to the functional 
or physiological identity. The following experi- 
ments establish this : 

Experiment No. 13 (July 26th). — Acid urine, drawn 
from the bladder with precautions to prevent contam- 
ination with micro-organisms located at orifice of the 
urethra,' was inoculated with the eighteenth culture 
from gonorrhceal pus. The urine, in a hermetically 
sealed flask, was placed in the culture-oven, and the 
following day was found to be pervaded with micro- 
cocci in pairs (Fie. 2), and to be highly alkaline. 

Experiment No. 14 (September 3d). — Urine was 

&assed into a test-tube, sterilized by heat, the first flow 
eing rejected (as this contains micro-organisms washed 
from the mouth of the urethra, vide paper above re- 
ferred to), and was then divided into three portions in 
three sterilized tubes. 

No. I was inoculated with the thirtieth culture from 
gonorrhoea! pus. 

No. 3 was inoculated with the ninth culture from urine 
which had spontaneously " broken drown " — alkaline 
fermentation — and which contained Micrococcus urea 
in abundance. 

No. 3 was retained for comparison — temoin. 

The urine was transparent and acid. The external air 
was excluded from the test-tubes by covering each one 
with a bit of sheet rubber tied fast about the neck. The 
tubes were placed in the culture-oven at ioo° Fahren- 
heit, and the following morning Nos. i and 2 were 
found to be clouded, to be pervsuied by the micrococ- 
cus, and to have an alkaline reaction. No. 3 remained 
transparent and acid. 

Remarks. — I have made many other experiments 
of the same kind as those above given, ■ but these 

> I have not the work referred to at hand, and consequently 
cannot give the exact reference, but believe that my memory is 
not at fault with reference to the statement made. 

* Vide paper by writer in Studies from Biological Labora- 
tory, loc. cil., p. 177. 



will suffice to show (a) that the micrococcus of gon- 
orrhoea! pus causes urine to under^jo alkaline fer- 
mentation ; and (3) that it does this by virtue of 
its own vital activity, and not as a mere carrier of a 
chemical ferment present, in the first instance, in 
the gonorrhceal pus used to inoculate culture No. i, 
for this hypothesis would require that such a fer- 
ment should be as active when diluted to an incred- 
ible degree (thirtieth culture) as when present in an 
appreciable amount — e. g., in the first culture. 

In my method of conducting culture-experiments 
the amount of material taken from one culture-tube 
to inoculate the sterilized bouillon in a similar tube, 
for the succeeding culture, is less than the fiftieth 
part of the contained fluid. The amount of dilution 
to which the original material, introduced into cul- 
ture No. I, was subjected in the alwve experiment 
may therefore \x estimated by raising 50 to the 
thirtieth power. It is hardly necessary to introduce 
the array of figures which would result from this 
computation in order to convince the reader that 
the original material is practically excluded, and 
that only the remote descendants of the living or- 
ganisms which were present in it are likely to be 
found in our thirtieth culture. 

I may mention here, incidentally, that I have 
ascertained in the course of my experiments that 
Micrococcus urea is not the only organism which 
has the power of transforming urea into carbonate 
of ammonium— CH,N,0-|-2H,0=(N.H,)C0,.' 

(To bt coHtvuud.) 

WHEN IS A PHYSICIAN LEGALLY EXEMPT 

FROM TESTIFYING TO CONFIDENTIAL 

COMMUNICATIONS MADE TO HIM 

BY HIS PATIENT? 

By FRANCIS W. SHAIN, M.D , 

OF PHILADBLTHIA. 

What is a confidential communication or privi- 
leged communication in the eye of the law? It is 
a communication made bond fide, upon any subject- 
matter in which the party communicating has an 
interest, or in reference to which he has a duty, 
and as the occasion is an absolute privilege, the 
only questions are whether the occasion existed, and 
whether the matter complained of was pertinent to 
the occasion. 

In a degree, the law extends this privilege to the 
lawyer, clergyman, and physician — but not equally, 
and this we would like to see remedied. 

At common law such privileged communication 
extends only to the lawyer, and naturally, as the 
profession constantly brought into relation with the 
accused ; it was conceded on the ground of public 
policy, because greater mischief would probably 
result from the requiring or permitting of such 
testimony than from wholly rejecting it ; and further, 
as a fundamental right for the sole and exclusive 
protection of the client either in person or property, 
by whom and through whom the obligation can 
only be removed. It is made perjietual. Does 
not end or cease with the completion of any par- 

• Schutzenberger, Fermentation. D. Appleton & Co., New 
York, 1879, P- *o3- 



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JANWARY 20. 1883.] WHEN IS A PHYSICIAN LEGALLY EXEMPT FROM TESTIFYING? 71 



ticular business, the seal of the law once fixed re- 
mains forever ; and it is generally comprehensive, as 
implied in the language of the distinguished jurist. 
Lord Chancellor Brougham : " If the privilege 
were confined to communications connected with 
suits, begun, or intended, or expected, or appre- 
hended, no one could safely adopt such precautions 
as might eventually render any proceedings success- 
ful, or all proceedings superfluous. ' ' To the lawyer, 
therefore, by the common law the privilege is uni- 
versal. 

What is the position of a clergyman in this re- 
spect ? Is he or is he not exempt from testifying 
to communications made to him in his professional 
capacity ? This question has been the subject of a 
warm debate on the ground of conscience and gen- 
eral good to society, in that the guilty conscience 
may unfold itself, and ask for spiritual advice and 
guidance, and to seek pardon and relief. 

The law of Papal Ronfte has declared that such 
communications are privileged, and has gone so far 
as to punish her priests who reveal them, holding 
to her unchanging doctrine that the confessions are 
not made to the priest as a man, but in his profes- 
sional character as the representative of the Deity. 
In Scotland, if a prisoner confesses his crimes to a 
clergyman in order to receive spiritual advice, the 
clergyman is not required to give such communica- 
tions in evidence. 

The English law encourages a penitent to confess 
his sins for the purpose of unloading his conscience ; 
the clergyman is only exempt from presenting his 
penitent to the civil magistracy (that is not to turn 
State's evidence voluntarily) "under pain of irregu- 
larity," but must make a full and perfect statement 
of the communication or confession so received by 
him in his professional character, whenever required 
by the law so to do, as it made no distinction be- 
tween clergymen and laymen. The citizens of New 
York, through their legislature, passed a statute 
which has forever, as far as they are concerned, set 
this vexed question at rest. It is as follows : "No 
minister of the gospel, or priest of any denomina- 
tion whatsoever, shall he jdlowed to disclose any 
confessions made lo him in his professional char- 
acter, in the course of discipline enjoined by the 
rules or practice of such denomination." (2 Rf- 
vised Statutes, xai%e ^06, § 72.) The Courts of New 
York have held to the principles of this statute 
whenever required or requested so to do. It is a 
pleasing fact to notice that the same protection has 
been accorded to penitents and clergymen in the 
following States: lliissown {Revised Statute 1845, 
c. 186, § 19 ; Wisconsin {Revised Statute 1849, ^• 
08, § 75); Michigm {Revised Statute 1846, c. 102, 
§80); and in Iowa {Code 1851, art. 2393). In 
States other than those above mentioned the com- 
mon law principles prevail. 

In regard to the communications between a physi- 
cian and his patient : 

The physician under the common law has no status 
granting privileged communications, nor can the 
common law be subject to amendment ; relief must 
therefore be looked for by statute law, granted by 
the legislatures of the respective States. 



In several States such statutes now exist, almost 
rendering unnecessary an argument to prove the 
right and propriety of extending the privilege to 
physicians. 

The Legislature of the State of New York comes 
to the relief of tl\e citizen while living, and to his 
reputation when dead, by a statute of the following 
character, viz : 

"No person, duly authorized to practise physic or 
surgery shall be allowed to disclose any information 
which he may have acquired in attending any patient 
in a professional character, and which information was 
necessary to enable him to prescribe for such patient 
as a physician, or to do any act for him as a surgeon." 
[Revised Statutes New York, vol. ii. page 406, § 73.) 

The following named States have likewise passed 
statutes to the same effect: Missouri, Wisconsin, 
Michigan, and Iowa ; but five States in the United 
States have conceded this wise privilege. 

The Courts of New York have been called on for 
an interpretation of this statute in the only two 
ways in which si^ch- a statute could by any possi- 
bility bar justice. 

The first was in the case of Hewett vs. Prime (21 
Wend., page 79), where the Court held that a con- 
sultation as to the means of procuring abortion in 
another is not privileged by the statute; that if A 
should apply to a physician for a prescription for 
B who was pregnant, or as to the use of instruments 
or drugs on the person of B, such communication 
is not privileged, and the physician would be obliged 
to testify to the fact. 

The second was in the case of Johnson vs. John- 
son (14 Wend., page 637), in which the Court held 
the patient himself may waive this ' privilege, and 
the physician could then testify, as the privilege, 
said the chief-justice, was the patient's and not 
the physician's. He considered it analogous to an 
attorney and client in this respect ; but no statute 
touching this question exists in Pennsylvania, and 
in bringing the subject to the attention of the phy- 
sicians of this Commonwealth, it may be well to 
cite some illustrative cases, showing the importance 
to the citizen that he should be able to state the 
" whole truth " to his medical adviser without ap- 
prehension of self-commitment. 

An erring and unfortunate citizen presents him- 
self to his physician with a sore upon his genital 
organs or elsewhere, obscured by previous treat- 
ment; and, by a candid confession of exposure, he 
aids in the diagnosis of syphilis, and is at once 
properly treated ; to his own great advantage, and 
to the protection of his wife or others from con- 
tamination, and so far restraining the spread of this 
loathsome and grave disease. Now, if this citizen 
was familiar with the fact that his medical attend- 
ant could be compelled in court to convict him of 
adultery or any other crime arising from illicit in- 
tercourse, he would hesitate to take counsel, to his 
own destruction and to the detriment of public 
policy. 

Again, a man in attempting a burglary, is met by 
an excited and outraged opponent who strikes to 
kill, and receives a blow in the temporal region. 
There' exists really a fracture of the bone and 



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laceration of the middle meningeal artesy. The 
real condition is obscured by the swelling of the 
superficial tissues, and the patient knowing he 
must not commit his story of crime to the physi- 
cian, and not feeling the gravity of the injury, tells 
the story of being struck by a s;iow-ball, or by a 
fall or some such slight cause; the physician is 
misled, and hours afterwards the patient dies from 
hemorrhagic compression of the brain. Had the 
whole trouble been told to the physician, knowing 
the provocation and probable force of the blow, his 
investigation would have been more thorough, he 
would have kept the patient under observation and 
been able to give him the hope of a trephining 
operation. Other cases suggest themselves, but 
these are sufficient to illustrate how necessary it 
may be for the patient to tell his story unreservedly 
and without fear to his medical adviser. 

Such is the history of the law of the present day, 
and we trust its presentation will awaken the medi- 
cal profession to take such action as may secure the 
passage of a similar statute in Pennsylvania, and in- 
deed in every State in the Union. 



HOSPITAL NOTES. 



PENNSYLVANIA HOSPITAL. 
(Service of Dr. J. M. Da Costa.) 

A CASE OF DIABETES INSIPIDUS TREATED SUCCESS- 
FULLY BY ERGOTIN. 
(Reported by FRANK Woodbury, M.D.) 

The followin|; clinical note is worthy of record, not 
merely as furnishing an instance of the successful 
treatment of a disorder which had resisted many reme- 
dies during a long course of hospital treatment, but 
also because of the history of the acute beginning, and 
the progressively downward tendency of a purely func- 
tional (vaso-motor?) disease; unaccompanied, so far as 
could be ascertained, by organic lesions at any stage 
of its development. The treatment of diabetes insipi- 
dus by ergot is, of course, no longer a novelty ; but it 
is still of interest to add an additional case to those al- 
ready reported by Dr. Da Costa in The News (Jan. 7, 
1882), where a discussion of the therapeutic method 
may be found. 

Charles L., 28 years of age, bom in Ireland, a farm 
laborer, was admitted August 14, 1882, into the ward 
under the charge of Dr. Arthur V. Meigs. 

An interesting point in his family history which was 
elicited, was a possible hereditary tendency to renal 
disorder — his father had died of dropsy about three 
months before the patient's birth. His own health was 
usually good ; he has served in the British army for 
three years; and had been in this country for eight 
years. He had spent the most of his time here in 
living on a farm, but had never had ague nor an attack 
of rheumatism. He acknowledged having had gonor- 
rhoea, from which, however, he had entirely recovered ; 
but he positively denied all other venereal infection. 
He never had received an injury or blow upon the 
head, nor a severe fall ; he was equally positive on this 
point. In August, 1881, while in his ordinary health, 
he was working hard upon a farm, where he was ex- 
posed to cold and wet. About this time he stated that 
he had come into the city to buy a summer suit of 
clothing, which he wore on his return to the country ; 
the clothes were thin, and on his way home the weather 



changed, and a cold rain commenced to fall, so that he 
became wet through before he reached there. The 
next day he felt as if he had taken a severe cold ; he 
was dull and heavy ; he had irregular chilly sensations 
and aching in his bones, which obliged him to remain 
in the house. Shortly after this, within the week, he 
noticed that he was passing more water, and that he 
had to rise several times in the night ; he stated, how- 
ever, that the aggregate quantity passed each day then, 
though more than normal, was not so great as it was 
a month later. 

The malady continued ; he urinated frequently, and 
was very thirsty all the time. In September, he was so 
ill that he was sent to the Philadelphia Hospital, where 
he remained under treatment for two months; then 
becoming dissatisfied, he left the institution, as he said, 
" worse than when he went in." He then sought ad- 
mission into a hospital at Trenton, where for ten months 
he received medical care, but still he got worse rather 
than better, and as they had given him up to die, he 
left there, though very sick at the time and reduced 
almost to a skeleton. In this miserable condition he 
was found at the gate of the Pennsylvania Hospital 
about two weeks after leaving Trenton, and was taken 
at once into the ward. He was so very weak that, 
although he was passing eight pints of water per 
diem, it was thought better to give restoratives for a 
time before attempting to place him upon special treat- 
ment for diabetes insipidus- His urine, which was 
repeatedly examined, had a specific gravity of 10 to, 
it was faintly acid in reaction, almost colorless, and was 
perfectly free from sugar and albumen. At the time 
the disorder was at its beginning, in September, 1881, 
he passed eight pints of urine, and again in January, 
1882, he had passed a like quantity, as also he had 
after entering the ward, but he had never exceeded this 
to the best of his knowledge. Tincture of chloride of 
iron, quinine, and nux vomica, were given in succession 
for a short time, and with these, aided by a diet of 
milk and eggs and a small amount of stimulants, he 
revived considerably. In the course of a week after 
coming into the ward Dr. Arthur V. Meigs began the 
administration of ergot, of which twenty minims of the 
fluid extract were g^ven three times a day. He took this 
small quantity for more than a month, but as it did 
not have any apparent effect upon the amount of the 
urine, it was stopped September 19th. No more ergot 
was given until October 17th, when the administration of 
ergotin hypodermically was begun ; he at first received 
daily one injection, and afterwards two, of five grains 
(dissolved in fifteen minims of a solution of equal parts 
glycerine and water), therefore much larger doses than 
before. The effect of this treatment was promptly 
manifested. Under its use the urine had decreased to 
four pints by the end of the month ; but on the remedy 
being then suspended for a few days, it increased 
again to six pints. He had greatly improved by Octo- 
ber 30th. He had gained eleven pounds in weight in 
two weeks, his skin was not dry and harsh, he ate and 
slept well, and although he had been very thirsty 
before, he was much less so since he had been under 
the ergotin treatment. He still felt very weak, and 
was obliged to remain in bed, but his improvement 
was very manifest. 

At this time the ward passed under the care of Dr. 
Da Costa, who decided to keep up the treatment, only 
giving the remedy by the mouth instead of hypoder- 
mically. The punctures had not given rise to abscesses, 
but the spots were tender and painful for a time after 
each injection. 

On November 4th he had passed six pints during the 
preceding twenty-four hours. Five grains of ergotin, 
using the same solution, were now directed to be given 
by the mouth, morning and evening, and the succeed- 



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JANI'ARY 20, 1X83 1 



MEDICAL PROGRESS. 



73 



ing day the quantity of urine was again reduced to 
only four and a half pints. On November 6th the er- 
gotin was directed to be given three times a day. The 
next day he was allowed to get out of bed ; but as a 
result, he was not feeling so well on November 8th, 
and was passing five pints. As he complained of in- 
digestion he was allowed to have a drachm of the com- 
pound tincture of gentian before meals, the ergotine 
being continued. After this he steadily improved : it 
was noted on the 13th, that "for the last three days the 
urine has measured three and a half pints daily." The 
tincture of cascarilla was now substituted for the gen- 
tian, as the later did not agree with his stomach. On 
the i6th, the man was brought before the class ; he was 
still passing three and a half pints ; the ergotine was 
now mcreased to four doses daily, his general strength 
and physical appearance had very greatly improved. 
On the 19th, the remedy was reduced one-half, and the 
next day discontinued entirely. The cascarilla was 
continued for a few days longer, but on the 24th strych- 
">'* (gf- <\r) was given in its place. The urine now 
ranged between three and three and a half pints daily, 
and he only occasionally had to rise at night. On the 
2 1 St of November, he took a long walk outside of the 
hospital, but there was no increase in the amount of 
the urine in consequence, and he slept better that 
night. As he was anxious to be discharged, he was de- 
tained but a few days longer under observation, and 
was allowed to go on the 30th, when he was apparently 
strong and well. While under the ergotin treatment 
he reported that he gained in six weeks the surpris- 
ing amount of thirty-two pounds in body weight; he 
weighed in the middle of October but 126 pounds, 
when he was discharged he weighed in the same 
clothing 158 pounds, and appeared in sound, vigor- 
ous health. He considered that the tre»tment had 
saved his life. 

MEDICAL PROGRESS. 



The Treatment of Puerperal Eclampsia with 
Chloral in Large Doses. — Dr. George Rocnt re- 
ports a case of puerperal eclampsia occurring in a 
woman, aged 21, in the eighth month of pregnancy; 
the face was oedematous, and the urine loaded with 
albumen. The patient was first bled, cold compresses 
applied to the head, inhalations of chloroform and 
ether administered, and rectal injections of chloral in 
doses of 60 grains — in all 470 grains of chloral were 
given in 24 hours. Recovery took place. — L' Union 
Mid., November 28, 1882. 

Forty Inches of Bowel Passed per Rectum, 
with Recovery. — At the meeting of the Baltimore 
Academy of Nfedicine, held December 5, 1882, Dr. 
Christopher Johnston exhibited a specimen of forty 
inches of intestine passed by a lady in Charles County, 
Maryland, per rectum. The patient was thirty-two 
years of age, married, and had one child about four 
years old ; her health had always been delicate, and 
she had been subject to indigestion, constipation, and 
colic pains. The attack during which the present 
specimen was passed began with acute epigastric pain, 
at first supposed to be due to cramp colic. There had 
been no action from the bowels for six or seven days, 
and a circumscribed hardness could be easily felt 
through the abdominal parietes. After three days, 
stercoraceous vomiting set in, and continued three or 
four days ; it was accompanied by some relief. At the 
end of the three or four days the sphacelated bowel, 
together with some of the omentum, was passed, fol- 
lowed by loose operations. Part of the specimen re- 
tained its tubular shape, and contained feces ; another 



part passed mixed with feces. The prostration during 
the attack was very great, and death seemed imminent. 
She began to imftrove slowly, and to regain her appe- 
tite after the discharge of the bowel, but had still oc- 
casional pains in the bowels, especially in connection 
with her evacuations. Six weeks after the attack she 
was able to sit up a little, and though still feeble, was 
cheerful, and expressed herself as feeling very well. 
The treatment pursued was cathartics, enemata, in- 
flation, anodynes, etc. — Maryland Medical Journal, 
January I, 1883. 

Extraction of a Cataract without Excision of 
the Iris. — At the meeting of the Society de Chirurgie, 
held November 22d, M. Galezowski read a paper in 
which he urged the advantages of abandoning the in- 
cision of the iris in the extraction of cataract. He 
thinks that iridectomy does not prevent inflammatory 
accidents, and that it predisposes to secondary cata- 
ract. M. Galezowski advises making an ellipsoidal 
flap, making the incision at the edge of the sclerotic. 
In forty operations made without iridectomy since the 
month of July, he has hid no ocular phlegmons. Iri- 
dectomy is, however, indispensable if the iris falls 
spontaneously under the knife, if there is posterior 
synechia, or if the border of the iris has been contused 
during the operation. — Gaz. Hebdom., Dec. i, 1882. 

Disseminated Polypi of Colon. — At the meeting 
of the London Pathological Society held Dec. 19, 1882, 
a specimen of diffused polypoid growth of the colon 
was shown by Mr. Bowlby. The case differed from 
others of the same kind in the absence of constriction 
of the intestine. The growths extended from the cae- 
cum to the sigmoid flexure; the polypi had long ped- 
icles, and consisted of fibrous tissue, covered by normal 
mucous membrane. He also showed a specimen of 
large polypoid growth of the rectum, removed by ope- 
ration from a young woman ; it was attached to the 
wall of the rectum, and was extruded from the anus 
during an effort at defecation ; it had given rise to no 
symptoms. Mr. Bowlby also exhibited a specimen of 
polypus of the small intestine. The patient was a 
child, who suddenly experienced severe pain in the 
abdomen ; when admitted into St. Bartholomew's Hos- 
pital the vermiform appendix and caecum protruded as 
a gangrenous mass from the anus. The child died 
subsequently of congenital syphilis, and at the post- 
mortem examination it was found that there was some 
limited peritonitis of old standing, and a large polypus 
of the small intestine; the whole of the colon was 
absent, having apparently sloughed away ; about three 
inches and a half above the anus was a constriction, 
which appeared to mark the point where the continuity 
of the gut was re-established. — British Medical Journal, 
December 23, 1882. 

Treatment of Typhoid Fever with Carbolized 
Camphor. — M. Dujardin-Beaumetz recommends the 
treatment of ataxic forms of typhoid fever with carbol- 
ized camphor. His mode of administration is by the 
rectum, in the form of injections, with I gramme of 
camphor to 5 decigrammes of crystallized carbolic 
acid, dissolved in 30 grammes of alcohol and 170 
grammes of water. He claims the constant result of 
these drugs in low forms of typhoid fever has been a 
reduction of the fever and the disappearance of the 
nervous symptoms. — Bull. Gen. de Thirap., November 
30, 1882. 

Extirpation of the Spleen. — D. G. Zesas extir- 
pated the spleen in six rabbits under antiseptic pre- 
cautions, and all recovered. The autopsies showed 
that there was in all cases an increase in size of the 



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liver and lymphatic glands, the increase being propor- 
tional to the time elapsing between the operation and 
the death of the animal. Two examinations of the 
blood, fpur and eight weeks after the extirpations, 
showed that at first the red corpuscles and then the 
white were diniinished in number. — Centralb. f. die 
med. Wissen., Dec. 2, 1882. 

Oxygen and Disease Gekms. — Mr. K. I. Faraday 
calls attention in the Times to certain remarkable facts 
communicated by M. Pasteur to the recent Hygienic 
Congress at Geneva. Starting with the suggestion by 
Dr. William Roberts, F.R.S., Uiat disease germs might 
be "spores" from harmless saprophytes which had 
acquired a parasitic habit, it has been argued that such 
"spores" might be developed by cultivation in the 
presence of noxious gases, or in confined places in 
which the propK>rtion of free oxygen present in good 
air did not exist. The hypothesis has been specially 
applied to the evolution of^ the tubercle bacillus, but it 
is obvious that it is equally applicable to the evolution 
of the germs of other diseases, such as typhoid fever. 
The process described by M. Pasteur at Geneva; as 
having enabled him to convert the virus of the form of 
typhoid fever which caused great mortality among 
horses last year in Paris into its own vaccine, has a 
noteworthy bearing upon this hypothesis. M. Pasteur 
first tried to "attenuate" the virus by cultivating the 
specific microbe, which he had already discovered as 
associated with the disease, in contact with air. But 
experiments showed that the culture retained its fatal 
attributes for a certain period, when it suddenly became 
absolutely sterile, or, in other words, the microbe died. 
M. Pasteur then adopted a method which can only be 
described as a process of nursing the microbe, so as 
gradually to adapt it to a new mode of life, or, in other 
words, to modify it without destroying its fertility. 
Taking a virulent culture from the blood of a rabbit 
which, through inoculation, had died of the disease, he 
sowed fresh portions of this culture in veal broth on 
successive days, and kept the series in contact with air. 
He had thus a graduated series of cultures from viru- 
lent stock in process, each of these cultures having 
been subjected to the modifying influence of oxygen 
for a different period. M. Pasteur was thus able to 
seize the moment when the culture which had been ex- 
posed the longest to aeration became sterile, and to 
select a culture on the eve of sterility, which he trans- 
ferred to a fresh infusion already found to be specially 
suitable to the microbes, and which consisted of two 
parts of veal broth with one part of pure rabbit's blood. 
Having, in fact, reduced the microbe to the verge of 
sterility, or death, he subjected it at this critical moment 
to an invigorating regimen, and thus protracted its vi- 
tality and made it the stock of a new series of cultures. 
By repeating this process again and again in all its de- 
tails, M. Pasteur ultimately evolved a race capable of 
serving as the vaccine of the original virus, oxygen 
having been the modifying influence throughout. 

There is a striking analogy between the treatment 
thus described and that by means of which, about six 
years ago, Fraulein Marie von Chauvin evolved am- 
bfystoma, a land salamander, from the water-breathing 
Mexican axolotl. She selected healthy animals, and 
first kept them in shallow water, so that they were not 
quite covered by the water. When their health declined 
she restored them to deep water. Gradually she accus- 
tomed them to shallow water, and eventually kept them 
on land in deep moss. She was obliged to force them 
to eat by compelling earth-worms to wriggle down 
their throats ; and feeding them well at the critical stage 
of metamorphosis seems to have been the main con- 
dition of success. When the change from gills to lungs 
was perfected, they fed themselves with avidity. But 



Nature herself, notwithstanding the difficulties experi- 
enced by Fr&ulein von Chauvm in transforming her 
axolotl (some of which died under the treatment), ap- 
parently succeeds sometimes in evolving amblystoma 
from the Mexican newt ; therefore, assuming the varia- 
bility of specific microbes under the influence of oxy- 
gen, there is nothing unusual in the idea of the para- 
sitic germs of epidemics being spontaneously evolved 
from Harmless saprophytes under peculiar conditions 
of culture, such as the presence of various gases instead 
of free oxygen. In that case, ill-ventilated sewers, 
stagnant pools, and other places where aeration is not 
efficiently carried on, may continually evolve new crops 
of specific disease germs. Moreover, no embryologist 
will object to the attribution of the characteristics of 
species to the infinitely little, and the resistance to re- 
transformation under artificial conditions displayed by 
M. Pasteur's typhoid microbe is only what we might 
expect, on the assimiption that it is a confirmed new 
species. Fr&ulein von Chauvin's' axolotls had to be 
forced to eat under the new conditions which she pro- 
vided for them, and they would certainly have died if 
they had been left to themselves. 

The behavior of M. Pasteur's typhoid microbe, 
which retained its specific or virulent character even 
under the influence of oxygen, until it suddenly died, 
is singularly like that of the axolotls. Does it not 
also explain the often sudden disappearance of epi- 
demics? The typhoid germs, having acquired a para- 
sitic or virulent habit, say in the sewer, are conveyed 
to the bodies of human beings. Though subsequently 
exposed even to the abundant oxygen of a healthy 
locality, they resist its influence for a certain period, 
spreading death meanwhile, and then, under the in- 
fluence of sanitary conditions, they suddenly become 
sterile and^ the epidemic disappears. — Knowledge^ 
October 13*1882. 

Extirpation of the Sub-orbital Nerve. — At the 
meeting of the Soci6t6 de Chirurgie held Nov. 29, M. 
Pozzi read a memoir by M. Blum on this subject. A 
woman, aged 68 years, had for two weeks suffered from 
severe neuralgia of the left side of the face ; all treat- 
ment proved unavailing, even the extraction of all the 
teeth of the upper jaw. M. Blum therefore cut down 
upon the sub-orbital nerve and tore it out ; the pain 
then ceased, and has not returned. M. Pozzi states 
that this procedure has only been employed in three 
instances ; one was followed by cure, and the other 
two were unsuccessful in relieving the pain. — Gat, 
Hebdomadaire, Dec. 8, 1882. 

SuBorrANEOus Injection of Ether in Imminent 
Death from Hemorrhage. — ^At a meeting of the 
French Academy of Medicine, held December 19, 
1882, Dr. Hayem read a paper with the above title, 
of which the following is an abstract. When a dog 
has been bled to the extent of causing convulsions, 
and death is imminent, injections of ether are of no 
service : transfusion of blood may, however, in such 
cases save the animal's life. The results of the sub- 
cutaneous injection of ether are also negative when an 
amount of blood equal to one-nineteenth the weight of 
the animal has been withdrawn and the animal brought 
into a condition where the chances for life or death are 
about equal. In this state also, life may be assured by 
transfusion or the injection of serum obtained from 
blood of an animal of the same species. These re- 
sults show that transfusion cannot be replaced by the 
stimulant effects due to subcutaneous injection of 
ether, which only increases the number and vigor of the 
heart's pulsations, and does not augment the blood- 
pressure or rectal temperature. — L Union MedicaU, 
December 21, 1882. 



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JAITOAEY 20, 1883.J RESECTION OF THE TARSUS FOR INVETERATE CLUB-FOOT. 



75 



THE MEDICAL NEWS. 

A WEEKLY JOURNAL 
OF MEDICAL SCIENCE. 



ComnmiCATloNS are invited from all parts of the world. 
Oiiginal articles contributed exclusively to THB Medical News 
will be liberally paid for upon publication. When necessary to 
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Address, HENRY C. LEA'S SON & CO., 

Nos. 706 & 708 Sansom Street, 
Philadelphia, Pa. 

SATURDAY. JANUARY 20, 1883. 

BESECTIOH OF THE TAB8TT8 FOB IKVETSB&TE 
CLTTB-FOOT. 

Especially in the treatment of deformities, osse- 
ous surgery, if we may so designate it, has made 
rapid progress during the last ten years, and opera- 
tions formerly unthought of, or deemed inadmissi- 
ble, are now of frequent occurrence. 

As a rule, club-foot is amenable to less heroic 
measures than bony resection, but occasionally 
cases occur that resist all other modes of treatment, 
and so long ago as 1853 Little proposed, and in 
1854 Solly performed, an excision of the cuboid. 
Since 1874, however, chiefly owing to the operations 
of R. Davy and E. Reid, the systematic resection 
of portions of the tarsus have been undertaken. 
But while in England and Germany the operation 
has been known and accepted, in France and in 
this country but little has been done. Erskine 
Mason, Stephen Smith, Porter, Bradford, and other 
American surgeons, however, have done a few 
operations. 

In the Archives GiniraUs, we find an excellent 
paper on these operations by Chauvel, of Val-de- 
Grace, which well repays perusal. Three different 
methods exist. In the first or "anterior," the cu- 
boid only is removed ; in the second or "posterior," 
chiefly or wholly the astragalus, and in the third, or 
"total cuneiform resections," a wedge-shaped piece 
is removed, involving chiefly the cuboid and its 
neighboring bones, but extending, if need be, even 
to the inner border of the foot, though in ankylosis 
Reid has applied it to the ankle proper. 

The first operation hds been done, according to 
the statistics of Chauvel, eight times on six patients. 



Recovery has followed in all cases. The immediate 
results have been good, but the ultimate results were 
satisfactory in only one-half of the cases. 

The second operation was done thirteen times; 
six of these were resections of the astragalus Jand 
bones of the leg in wedge-shaped pieces, followed 
by six successful ankyloses ; seven were resections 
of the astragalus, either alone or combined with 
removal of the external malleolus, followed by two 
definite successes, four cases in doubt, and one bad 
result. 

The third method was practised thirty-seven 
times. Three deaths resulted, one on the tenth 
day from an old cardiac valvular insufliciency with 
recent endocarditis, one from hospital gangrene, 
and the third from septicaemia. The operation 
should be held responsible only in part for the 
first two. Of the ultimate results in the thirty-four 
cases that recovered, in twenty-four it was satisfac- 
tory, and in ten undetermined, some of which cer- 
tainly would have been counted among the successes. 

The deformities to which the operations are ap- 
plicable are otherwise incurable varus, equino-varus, 
and equinus. In varus and fquino-varus un- 
doubtedly the total cunieform resection is the best 
operation, and has been oftenest done. Removal of 
the cuboid only has deservedly met with but little 
favor. I f the case be one of pure varus, the wedge has 
its base at the cuboid, the width of the base and the 
length of the wedge being proportioned to the degree 
of the deformity to be corrected, and without special 
regard to the articular surfaces of the cuboid or 
other bones involved. Indeed it is less important 
that exactly this or that bone be removed than that 
the wedge be well placed, and of proper size. Not 
seldom indeed more than one subsequent slice has 
to be taken off the bone, in order to obtain good 
apposition of the bony surfaces. In equino-varus 
the excised portion must be wedge-shaped in two 
ways — (a) the base as before at the cuboid externally, 
and apex internally to correct the varus, and (J>) the 
base above and apex towards the sole to correct the 
equinus. In equinus proper, the anterior operation 
or resection of the cuboid, and the total cuneiform 
method will not remedy the deformity so well as 
the posterior operation at the ankle-joint. This 
should consist not so much in the removal of the 
astragalus or of the astragalus and external malleolus, 
as of a wedge-shaped piece or pieces involving both 
the upper and lower articular surfaces of the ankle 
of such size and shape as to correct the deformity, 
or a wedge-shaped piece may be removed just in 
front of the joint involving the head and neck of 
the astragalus, and the calcaneum if necessary. 

So far as possible these operations should be sub- 
periosteal and antiseptic. Because they are delib- 
erate and designed, they are none the less severe 



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76 



BACILLUS LEPR/f;. 



[Medical News, 



compound fractures, involving also, in most cases, 
the neighboring articulations, and in the part of the 
body most distant from the centres of nutrition. 
Hence, every possible precaution must be taken to 
insure the least risk and the quickest healing. This 
at best, if we obtain bony union, must be slow, and 
cover some weeks or even months. 

The operative procedure is simple. The inci- 
sions in L or J[ at suitable places and of suitable 
length give easy access to the bones. The saw'inay 
be used, but the chisel and bone-forceps are prefer- 
able, and in children a stout cartilage knife will often 
suffice. The arteries are well known and avoid- 
able, and serious hemorrhage is rare. The dorsal 
tendons and, also, especially that of the peroneus 
longus should be carefully preserved. Tenotomy 
will be required occasionally, either at the time of 
the operation or subsequently. Antiseptic dressings 
and a suitable splint, with a foot-piece, are to be 
immediately applied. The splint in some form or 
other, according to the prefference of the particular 
surgeon, is indispensable in order to retain the foot 
in its proper position. 

If the results have been so good in these the 
earlier operations, we have every reason to believe 
that still better are in store for us within the next 
decade. American surgeons certainly should not 
be behind in working out so favorable a result. 



B&CIIXITS lEPBX. 

Among the infectious diseases which have recently 
been ascribed to a micro-organism is leprosy. A 
close examination of the studies which have from 
time to time been made upon the bacillus lepra 
show a better foundation for such a view than would 
at first be expected, though the same examination 
will also show that the evidence in its favor is much 
weaker than in the case of the bacillus malarice. 

The first observations on this subject appear to 
have been made in 1873, ^y Dr. G. A. Hansen, of 
Bergen, Norway, and published in Norsk. Mag. f. 
Laga<idensk, 1874, and more fully in Virchow's 
Archiv for January, 1880. He found constantly in 
the nodules of leprosy, both rod-shaped and granu- 
lar bacteria, enclosed in certain brown-colored celb. 

Dr. Albert Neisser, then of Breslau, now of Leip- 
zig, extended these observations of Hansen's in a 
study of leprosy pursued in Granada in the winter 
of 1880-81, employing, for the first time, the stain- 
ing methods of Weigert and Koch. Neisser claims 
to have been the first to declare that there exists in 
leprosy a specific form of bacteria which is the direct 
cause of the disease, while Hansen had originally 
merely suggested that such relation might exist. 
Neisser also made a culture of the bacillus. 

In May, 1881, Dr. I. Bermann, of Baltimore, 



succeeded in demonstrating the bacillus leprae in 
the "lepra cells" in sections of skin removed from 
a leprous patient. Recently (Dec, 1882) Hansen 
has published another paper in Virchow's Archiv, 
confirming and extending his original results by 
culture experiments. The names of Klebs and 
Ecklund have also been associated with studies on 
bacillus leprce. 

The bacillus lepra is a peculiar one, being very 
attenuated and further characterized by black dot- 
like nodosities, sometimes at one end, at others 
at both, while sometimes there are found two or 
three intermediate dots, in which event the bacillus 
is always longer. These granules have probably 
something to do with spore formation, and may 
entirely replace the bacilli, which then appear to 
break up into them. 

As to their occurrence, the bacilli, at least in the 
tuberculous form of leprosy, are found wherever the 
leprous productions occur, be they recent or old. 
This is especially true in the nodules of the external 
integument. Hansen has never seen the involve- 
ment of the liver, spleen, testicle, lymphatic glands, 
and nerves in its early stage ; but when he has found 
these organs diseased, the bacilli were present in 
them. Nor has he ever seen the latter in the blood, 
though Kobner claims to have found them there in 
his patient. Nor did Hansen find the bacilli in the 
anaesthetic form of the disease, although his oppor- 
tunities for the study of these have been limited. 

An important link in the argument is, however, 
wanting, in that none of the attempts at inoculating 
leprosy in the lower animals, either by the intro- 
duction of pieces of leprous tissue or by the injec- 
tion of the culture fluid swarming with bacilli, have 
been successful. It is true, Neisser claims to have 
communicated leprosy to dogs by inoculation, but 
both Kobner and Hansen, who acknowledge to have 
themselves failed to inoculate monkeys, consider 
Neisser's results doubtful and unsatisfactory. Of 
course, until more uniform success results from 
inoculation experiments similar to those which have 
followed the inoculation of bacillus malarice, the 
existence of a specific bacillus cannot be admitted. 
In the above, however, we present our readers with 
what may be considered the present state of the 
question. 

CHIIDBEH'S FOOD. 

We remember once going to see a respectable 
mechanic's child who had just recovered from an 
attack of cholera morbus. We found the boy of 
three years sitting at the tea table wrestling, and 
successfully, too, with a dozen fried oysters, a good- 
sized bowl of pretty strong tea, and a mug of beer. 
Thanks to our subsequent, but, we also regret to 
add, our unrequited, skill, he escaped the dangers 



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EXPERT UNEXPERTNESS. 



77 



of a relapse, to fall a victim a year later to similar 
parental indulgence. Such an incident, together 
with many another drawn from late Christmas ex- 
perience, may well point a moral as to the food of 
children. 

Up to two years of age, little besides milk should 
be given. Before this age the stomach cannot bear 
stronger food. Even after it, and up to adolescence, 
great care is required in the choice of the diet. It 
should be simple in quality. Milk, oysters, eggs, 
plain farinaceous foods, easily digested and simply 
cooked meats, these should constitute the staple. 
Even if the children eat at the family table — an 
American habit we most heartily commend, be- 
cause of its happy influences on both parents and 
children — they should be restricted to the simpler 
foods. Indeed, it is to be hoped that the very diffi- 
culty of enforcing such restrictions may lead to the 
abandonment of the richer dishes rather than to the 
exclusion of the children. 

But it is especially the villanous but delightful 
concoctions at dessert that we must condemn. Pies 
and doughnuts are bad enough, but the wonderful 
combinations in various "sweets," to tempt an al- 
ready satisfied appetite, are well-nigh a dietetic Pan- 
dora's box to all — except the doctor. Like St. 
John's little book, they are sweet in the mouth, but 
bitter in the belly. Children should never touch 
them any more than the rich ragouts or the highly 
spiced dishes of the rest of the meal. Fruit, ripe 
and wholesome fruit, varied so happily in this 
country from month to month, should be the usual 
dessert, with occasionally simple puddings and the 
plainer cakes. The hot biscuits and various forms 
of breakfast cakes we would not austerely exclude 
the whole year round from the older children, but 
let them be enjoyed as rarities. 

The quantity of food eaten is not nearly so im- 
portant as its quality. Children in good health 
will not often overeat if the food be simple. It is 
the enticing superfluities that do the mischief. Fear 
not only "gift-bearing Greeks," but gift-bearing 
cooks as well. If the appetite flag, and too little 
food be eaten, a little beef tea, tid-bits, and varie- 
ties may be used, which need not be unwholesome 
because uncommon ; for a time a little stimulant 
may do good. 

Many children, like many horses, thrive well on 
but little food. Personal idiosyncrasies must be 
taken into account. The scales are the best test. 
So long as a child gains in weight, even only 
slightly, parents need not, as a rule, have any 
anxiety. 

The regularity of children's diet is also of prime 
importance. The stomach needs its periods of rest 
as much as the brain or the muscles. Feeding be- 
tween meals, even if the food be wholesome, is 



noxious; not but that occasionally some good bread 
and butter, or a little fruit may be proper for a 
growing, romping child, but the rule should be the 
other way. To give candy, doughnuts, cakes, pie, 
etc., between meals, is unintentional cruelty. It 
not only cheats the stomach of its needed period of 
rest, but destroys the appetite for the succeeding 
meal. Candy in moderation, and as a dessert, may 
be allowed as a venial sin — certainly a winsome 
one. But it should be well chosen, and bought 
only of reliable dealers. Not a little arsenic or 
other poison sometimes lurks there. 

When we say " between meals " we do not mean 
that the meals shall only be three in the day. 
Growing children need at least one lunch, especi- 
ally if the interval between breakfast and dinner 
be a long one. Very often children in private 
schools do not get dinner until two or three o'clock. 
Six or seven hours between meals is too long an 
interval without food, and every child so situated 
should be supplied with a hearty lunch at recess. 

The general tenor of the above remarks applies 
equally to children'? drinks. Milk or water may 
always be given. In winter, when somethfng hot at 
breakfast is desirable, chocolate and its allies may 
be used with advantage. Tea and coffee should 
never be given to young children, and only in 
moderation, if at all, before twenty years of age, 
except x>ccasionally in cases of sickness. Among 
the poor especially, as our opening story shows, the 
vicious habit of giving tea in large quantities to 
young children is common, and it cannot be too 
strongly condemned. Beer, wine, and all the 
stronger forms of stimulants are, ipso facto, the more 
to be condemned. Apart from the moral dangers 
they are harmful physically. The parent who gives 
them commits well-nigh a crime. 



EXPEBT TTHEXPSBTNESS. 
In a recent issue of one of the journals devoted 
to specialties in medicine, we find a case recorded 
under the title of "post-scarlatinal insanity," in 
which the author expresses himself as having ex- 
perienced serious doubts whether the case should 
be regarded as post-epileptic or post-scarlatinal 
insanity. Our readers who are not neurological 
experts, but who do know something of general 
medicine, would not be surprised to encounter a 
case of convulsions in a girl of nine years, during 
the desquamative period of scarlatina, or that a 
joint affection had supervened in the same case. 
But by an expert these ordinary complications 
are narrated with an impressive gravity befitting 
an account of unprecedented phenomena. The 
forms assumed by the delirium are described with a 
pompous formality of sounding epithets. Thus, the 
girl of nine " manifested rudimentary delusions of 



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78 A GRIEVANCE OF PASSED ASSISTANT SURGEONS IN THE NAVY. [Mbdical N«ws, 



grandeur strongly tinged with imbecility." In 
another place, "there is evident amnesic aphasia 
with word deafness," because, forsooth, "in answer 
to questions she invariably responds 'flees.' " 

We learn further that "to anticipate several ques- 
tions which are sometimes asked, I will say that no 
sphygmographic, electrical, or craniometrical ex- 
aminations were made." Our readers will surely 
regard our statement as incredible when we say that 
the account contains not one word of the state of 
the urine. Notwithstanding the fanfaronade of 
technical phrases, there is not a word in respect to 
the condition of uraemia, which was, doubtless, the 
true explanation of the convulsions and of the 
delirium. Surely it does not require an extraordi- 
nary expertness to diagnosticate the ursemic com- 
plications of scarlatina, but it would appear that the 
psychiatric expert can find no organ diseased except 
the one with which he is concerned, and that all 
others are of little importance, in causing any form 
of symptomatic disturbance. 



A OBIEVAKCE OF PASSED ASSISTANT SUSOEOHS 
IS THE HAVT. 

Many passed assistant surgeons now in the navy 
have been recently deprived of their seniority, fairly 
assigned them after competitive examination in ac- 
cordance with a custom prevalent since 1824, which 
is recognized in legislative Acts of 1828 and 1835, 
through a literal construction by the Attorney-Gen- 
eral, on February 25, 1881, of a law of March 3, 
1871, as epitomized and presented in the Revised 
Statutes of the United States in 1877. 

In brder that they may have restored to them 
the seniority in their class of which they have been 
thus unjustly, though legally, deprived, they have 
petitioned Congress to enact, "That Passed As- 
sistant Surgeons in the Navy shall be arranged 
upon the Navy Register according to merit, as de- 
termined by the system of competitive examination 
which has heretofore prevailed ; and that this Act 
shall apply to the Passed Assistant Surgeons now 
borne upon the Navy Register, and all future as- 
signments to positions on said Register shall be 
made pursuant to such competitive examination." 

The appointment and promotion of assistant sur- 
geons in the navy in accordance with the results of 
competitive examinations have had, it is universally 
admitted, the effect of procuring for the naval ser- 
vice better qualified practitioners than it could 
have obtained otherwise. This competitive ex- 
amination presents the strong motive of personal 
interest to induce the competitors to strive zeal- 
ously to obtain seniority by increasing their profes- 
sional acquirements, because the higher the seniority 
the earlier is the promotion to the grade of surgeon. 



The measure asked for is surely proper, and it is 
therefore hoped that it will be speedily granted. 



THE OABFIELD BOASD OF AITDIT. 

The award of 120,500 to the four surgeons sum- 
moned to attend President Garfield has been re- 
ceived by them. In response to the question of a 
newspaper interviewer. Dr. Hamilton is reported to 
have said that he accepted his cheque in much the 
same spirit as he would a dividend froni a bank- 
rupt corporation. 

We are informed that the report of the Board of 
Audit has been called for in the House. This will 
again bring up the whole subject, and, in reaching 
a conclusion. Congress will have the aid of the 
light thrown upon the value of professional services 
as shown by the sums recently paid, without de- 
mur, by the Government to the lawyers in the 
Guiteau and Star Route trials. Congress will then 
also have it in its power to do tardy justice to the 
surgeons who are compelled to accept whatever 
may be awarded them, since, generously confiding 
in the justice of the Nation, they, by request, 
signed away all claim upon the estate of President 
Garfield, as a prerequisite to the case being brought 
before Congress for settlement. 

Members of Congress, who are for the most part 
lawyers, have shown, perhaps not unnaturally, a 
willingness to make liberal compensation for legal 
services rendered to the Government, and we hope 
that they will now embrace this last opportunity to 
make, at least, a just remuneration to the eminent 
surgeons whose professional services were unspar- 
ingly given to our late President, under particu- 
larly trying circumstances. 

The new contribution to cardiac therapeutics, 
Cofwallaria maialis, has been carefully studied by 
Dr. Desplats, and his results are given in a special 
memoir. He concludes that convallaria is practi- 
cally useless in ascites due to cirrhosis, and is of 
doubtful utility in albuminuria, and in cardiac ic- 
terus (nutmeg liver). 

In cases of obstruction or regurgitation at the 
mitral orifice, with visceral congestions, dropsy, 
etc., convallaria lessens the number and improves 
the strength of the cardiac contractions, increases 
the urinary discharge, and thus removes the con- 
gestions and dropsy. It is, therefore, distinctly 
useful in this group of diseases. In his treatise on 
the diagnosis and treatment of heart diseases. Prof. 
G. S6e reaffirms his original opinion in regard to 
the utility of convallaria, which was strongly ex- 
pressed in favor of its use in the group of cases for 
which it is advised by Dr. Desplats. Ste regards 
it as superior to digitalis in cardiac dyspnoea, in 
which he combines it with the iodides. 



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79 



SOCIETY PROCEEDINGS. 



NEW YORK SURGICAL SOCIETY. 

Stated Meeting, December 26, 18S3. 

The President, T. M. Markoe, M.D., in the Chair. 

EXCISION OF THE ARTICULAR EXTREMITIES OF THE 
PHALANGES. 

Dr. Post presented a patient upon whom he had 
operated for the relief of an angular deformity, of 
about fifty degrees, of the index finger of the left haad. 
It was one of a class of cases in which he had operated 
a considerable number of times within the past few 
years, by excising the end of the phalanx. About four- 
teen years ago this patient had his finger dislocated 
while playing base-ball. The dislocation was not re- 
duced, and the terminal phalanx remained flexed at 
about the angle mentioned. For some time before he 
came under Dr. Post's observation there had been sup- 
purative disease, £tnd on examination there were found 
two sinuses leading down to rough bone. The opera- 
tJoHj therefore, was performed not merely for the cor- 
rection of the deformity, but for the removal of the 
carious portion of bone, and in this instance instead of 
excising the distal end of the proximal bone, he ex- 
cised the diseased portion of the ungual phalanx. The 
operation had been performed a little more than three 
vreeks, during which time the finger had been sup- 
ported by a splint. Three days ago the splint was re- 
moved, and the parts were supported by , adhesive 
plaster. The wound healed readtly, and the deformity 
had been corrected. Dr. Post said that the operation 
in his experience had not been attended by so much 
irritation as had amputation of the phalanx. ' He had 
applied the same operation to the phalanges of the 
toes. He had not met with a case in which there had 
been any considerable amount of irritation following 
the operation. He believed that the wounds healed 
quite as readily as after amputation. He had not suc- 
ceeded, of course, in securing a perfect joint, although 
there had been in nearly all the cases some motion. 
The after-treatment consisted in keeping the parts sup- 
}>orted until they became sufficiently firm to sustain 
themselves. 

The President then read a paper on 

tripier's hedio-tarsal amputation. 
During my residence at the New York Hospital, in 
the years 1839, '4"' '4i> '^"^ of our best surgical nurses, 
a man named George Compton, had lost both of his 
feet by amputation through the tarsus by Chopart's 
method. He wore on each foot a shoe, not very in- 
geniously contrived, nor very neatly constructed, but 
one which, nevertheless, by much forbearance and not 
a little suffering, he was able to wear occasionally, and 
to stump about his ward with considerable agility, which 
certainly was the reverse of graceful. I remember that 
he used to pad his shoes very carefully with layers of 
old blankets, cut to fit the stump, and then lace them 
very tightly around the ankle and part way up the leg. 
Thus provided, he was able to get about with some 
comfort for a certain time, but soon the pressure upon 
the cicatrices gave rise to pain and soreness, fre^ently 
terminating in most intractable ulceration, and it must 
be acknowledged that, brave as he appeared in his 
shoe toggery on Sunday mornings, as he walked down 
the front avenue leading to Broadway, he would com- 
monly come back in the evening wearied and limping, 
and glad enough to get rid of his uncomfortable shoes, 
and only too happy to be allowed to stump about on 
his knees. Of course, he was not at all times equally 
disabled. Several of the surgeons of the hospital tried 



to improve his stumps by various operations and modes 
of treatment, but without any permanent benefit, and 
to the last his active and useful life was rendered 
miserable by the constant irritation of ulcerated and 
tender stumps, and his intelligence and courage and 
endurance only showed what a prize he might have 
won in life's race if he had not been so heavily handi- 
capped. I did not then study the position and relation 
of the bones, as I should be only too happy to do now; 
but this I remember, that his chief trouble arose from 
the frequent and intractable ulcerations of the face of 
the stump, showing that the cicatrix bore the chief 
weight of the body when he walked, and was, there- 
fore, constantly suffering from the effect of pressure 
directed immediately upon it. 

This unfavorable behavior of the stump left by 
Chopart's amputation has been noticed by all the sur- 
geons who have had much to do with this operation, 
and much thought and ingenuity have been expended 
in endeavoring to explain and to obviate it. In re- 
gard to the cause, all seem to be agreed that it depends 
upon a change in the position of the stump whereby 
the heel being forcibly drawn up, the front part, or the 
cicatricial face, is thrown downwards, so that, instead 
of resting on the natural plantar cushion of the in- 
ferior surface of the stump, this anterior face receives 
the whole weight of the body. It is somewhat remark- 
able that so wide a diversity of opinion should exist 
among really good observers as to the reason of this 
change. It would seem to be a simple and adequate 
explanation of the deformity to say that it is due to the 
unopposed contraction of the gastrocnemial muscles, 
but I find that, at a recent meeting of the Soci6t6 de 
Chirurgie in Paris, a M. Larger read a paper on the 
causes of the tilting of the heel after partial amputa- 
tions of the foot, and arrives at the conclusion that it 
is due solely to the atrophy of the anterior muscles of 
the leg, and not at all to the action of the calf mus- 
cles, which, he asserts, take no active part in the 
change of the position of the heel. Acting upon this 
theory, he applies electricity to the weakened muscles, 
and insists that any other treatment is entirely un- 
philosophical, and therefore useless. The report of 
the committee to whom this paper of M. Larger was 
referred, did not accept the exclusive vieWs of the 
writer, and while they acknowledged" the possible oc- 
currence of the atrophy in question, thiy felt that they 
could not ignore the powerful influence of the muscles 
of the calf. In the course of the discussion which fol- 
lowed, M. Verneuil contended that both the anterior 
and the posterior muscles of the leg undergo atrophy 
after these amputations, and that therefore neither of 
them have anything to do with the displacements in 
question. 

By all the older, and by far the larger number of the 
best modern authorities, the calf muscles are fully 
recognized as the active agents in producing, or at 
least in perpetuating, the deformity. The main practi- 
cal question, it seems to me, is what other vital or 
mechanical conditions favor, though they may not 
originate, the undesirable position which the fact is so 
apt to assume. That there are other causes which at 
least contribute to this undesirable result would seem 
to be proved by the fact that division of the tendon has 
been recommended by many of the best operators, 
and yet it is universally acknowledged that this pro- 
cedure does not by any means always prevent the de- 
formity, and still less cure it when it has occurred. 
Let us look now at one of these accessory causes, to 
my mind a very important one, and see what practical 
relations it may have to the main cause, and to the 
prevention of the trouble. 

While the patient is in a standing posture, the ten- 
dency of strong contraction of the gastrocnemi^tl muscles 



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PROCEEDINGS OF NEW YORK SURGICAL SOCIETY. 



[Mbdical News, 



is to draw up the heel, and thereby extend the foot upon 
the leg. This movement is resisted by the lone lever 
of the foot pressing upon the ground, and thereby 
preventing the extension from taking place. The only 
effect then of moderate action of the sural muscles is 
to keep the foot firmly planted on the ground, and at 
the same time to prevent the body from falling for- 
wards. If now the action of the calf muscles be much 
increased, the ball of the foot remaining in contact 
with the ground, the effect will be to raise the posterior 
part of the foot, and with it the whole body, which rises 
as the act of extension of the foot on the leg is accom- 
plished. The action results from the power A acting 
on the short arm of the lever moving the resistance B 
on the fulcrum C, which is at the end of the long arm 
of the lever (Fig. i). 

Fig. I. 




Now let us suppose, as happens in Chopart's ampu- 
tation, that the long arm of the lever is removed by sec- 
tion between the scaphoid and astragalus ; and then 
we should have the power A unopposed by the fulcrum 
C, and therefore unable to counteract the resistance B, 
which would force the astragalus downward until it 
came in contact with the ground. This becomes plain 
by glancing at Fig. 2. 

Fig. 2. 




If now the unopposed power A continues to act, its 
only further effect, after the astragalus has reached the 
ground, must be to raise higher the heel and thereby 
roll the astragalus in its mortise between the malleoli, 
so that its anterior face looks more and more down- 
ward, until finally it comes to press directly on the 
ground. It must not be forgotten, however, in thus 
estimating the action of the sural muscles, that if their 
influence should be entirely eliminated (as by tenotomy, 
for example) there would still remain in the obliquity 
of the under surface of the bones remaining after a 
Chopart's amputation a mechanical reason why the 
heel should rise and the astragalus descend as soon 
as tha weight of the body is brought to bear, as in the 



act of standing. These two causes, then, it seems to 
me, conspire to produce the result we are considering, 
viz., 1st, the unopposed contraction of the gastrocne- 
mial muscles; and, 2d, the oblique surface, in refer- 
ence to the level of the ground, presented by the in- 
ferior surface of the bones which constitute the stump. 
When now we add to these statements the fact that the 
ligamentous tissues around the ankle-joint soon be- 
come so contracted and so rigid in their changed posi- 
tion that, even when the tendons are cut, they will 
obstinately maintain the displacement, we have re- 
lated the chief, if not the only, causes which produce 
or perpetuate the deformity now under consideration. 
A review of these different causes shows also why it is 
that the deformity is not in every case relievable by sec- 
tion of the tendo Achillis ; and particularly why that 
operation, performed after the lark heel has become 
established, does in many cases so little to improve the 
usefulness of the medio-tarsal stump. 

The study of the causes of the deformity of the 
Chopart stump has led surgeons to seek some plan by 
which it might be avoided, and various suggestions 
have been offered in that direction. The one to which 
I wish to call the attention of the Society is one which 
was first brought forward by M. Tripier, of Lyons, and 
which has since gone by his name. It may be con- 
sidered as a modification of Chopart's amputation in 
so far that the astragalus and calcaneum are left ; but 
it differs from it in this, that a segment is sawed off from 
the lower part of the os calcis in such a way as to leaye 
the lower or plantar surface of the bone showing a line 
parallel with the surface of the ground on which it 
bears in standing or walking. This section is made at 
the level of the sustentaculum tali in such a direction 
as to bring the line of the saw-cut at right angles to 
that of the tibia, leaving therefore a bone surface 
which, when the weight of the body is brought to bear 
on the stump, will have no tendency to change its rela- 
tion parallel to the ground on which it rests. This is the 
principle of the operation, and its originator claims for 
It a great success. The cases in which the operation 
has been tested, thus far, are very few in number, and 
time enough has not yet elapsed to enable us to reach 
a final verdict as to its merits. In the British Medical 
Journal, of February 26, 188 1, Dr. P. J. Hayes, of 
Kingston, Surgeon of the Mater Misericordiae Hospital, 
reports a case in which he operated by this method, the 
man making a good recovery, and walking without a 
crutch in a month. He has since repeated the opera- 
tion with a like satisfactory result. Mr. Wagstaffe, ii» 
the London Medical Record, discusses the merits of this 
operation and approves of it as likely to prevent the 
tilting heel. He contrasts the operation with the sub- 
astragalar, and gives preference to the method of 
Tripier. He does not say that he has ever done the 
operation. 

Tripier's amputation is performed by an incision 
which commences on the outer border of the tendo 
Achillis, on a level with the outer malleolus, passes 
downward and forward, skirting the malleolus about 
one inch below it, passes then along the outer border 
of the foot, rather more toward the dorsal than the 
plantar surface, till it reaches the base of the meta- 
tarsal bone of the little toe. The line of incision here 
turns fipward and inward, passing across the dorsum 
of the foot till it reaches the base of the metatarsal 
bone of the great toe, and then turning downward 
and forward into the sole is continued across the sole, 
making a convex flap at least an inch longer than the 
dorsal. When it reaches the outer border of the sole, 
it turns backward and upward, and joins the original 
incision at an oblique angle on the outer side of the 
foot. The flaps thus marked out are raised so far as 
may be necessary to disarticulate between the astraga- 



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81 



lus and the scaphoid and between the os calcis and 
the cuboid, leaving behind the astragalus and os calcis, 
as in Chopart's amputation. Then the plantar flap is 
carefully dissected from the lateral and lower surface 
of the OS calcis, so that it can be exposed as high as 
the sustentaculum tali, this part of the operation resem- 
bling the dissection round the heel in Syme's amputa- 
tion at the ankle-joint. When the lower part of the 
calcaneum is thus fully exposed, it is to be sawn 
through just below the level of the sustentaculum, so 
as to make the line of saw-cut as near as may be at 
right angles to the line of the tibia when the patient is 
standing, and therefore parallel to the line of the 
ground on which it is to be placed. The section of the 
bone is recommended to be made from within outwards, 
thereby more surely avoiding any injury to the posterior 
tibial artery, which, from its important bearing on the 
life of the plantar flap, is to be most carefully guarded. 
Having made sure that the section of the bone has 
been made in the desired line, the sharp edges and 
comers of the bone are to be removed with cutting for- 
ceps, and the flaps brought into place and united by 
many sutures. Proper drainage-tubes being placed, 
and a supporting dressing applied, which shall hold 
the lower nap well in its place, the operation is com- 
pleted. 

I performed the operation in the following case: 
John Ohmer, a German, set, 33, a waiter by occupation, 
was admitted to the New York Hospital April 18, 1882. 
His health had been good until about four months pre- 
vious, when, without any known cause, his left ankle 
became swelled and painful. The trouble rather slowly 
increased, he continuing to walk about for nearly a 
month, when his ankle oecame so distressing to him 
that he took to his room and finally to his bed. The 
further course of the disease was one of steady increase, 
with increasing and finally severe and constant pain. 
On admission the tarsal region was recognized as the 
seat of the disease, the swelling, however, extending 
up to the ankle-joint. The swollen parts were very 
hard and tender to the touch, and the whole region 
was hot and painful, but without much redness of sur- 
face. After a time obscure, deep fluctuation could be 
discovered, and some crepitation could occasionally 
be elicited by moving the metatarsal bones on the 
tarsus. Deep incisions were made, letting out a great 
deal of pus. The part was poulticed, and everything 
was done that we could think of to improve his general 
nutritive condition, but without result. The abscesses 
did not heal ; fistulse remained ; pain was not mitigated ; 
in short, the carious disease was making constant prog- 
ress. 

On the 20th of May the actual cautery was applied 
at several points on the dorsum of the foot, but, be- 
yond relieved pain, no benefit could be traced. The 
question of amputation soon decided itself, and inas- 
much as we felt confident that disease was confined 
to the anterior row of the tarsal bones, it was regarded 
as a suitable case in which to make a trial of Tri pier's 
method. The amputation was done on the 7 th of 
June, precisely in accordance with the description 
given above. Particular care was taken to make the 

{tlantar flap as liberal as possible. All the fistulae 
eading down to carious bone were included in the 
part removed, except one which remained on the inner 
side of the stump. When the disarticulation was ac- 
complished the remaining bones were carefully ex- 
amined, and were considered to be free from disease, 
and the section of the os calcis revealed bone tissue 
softened, indeed, from the atrophy of disuse, but as 
far as we could judge, free from present disease. The 
flap fitted exceedingly well, and covered the bone 
without the slightest tension. Everything proceeded 
to our entire satisfaction during the first few days after 



the amputation. The wound healed almost entirely 
by the first intention, and he improved very greatly in 
his general condition as soon as he was released from 
the irritation caused by the carious bones. The local 
conditions, however, did not long continue favorable. 
Part of the wound broke open and gave issue to pus, 
which, it was soon evident, came from a deeper source 
than the surface granulations. The stump became 
swollen and painful and it became clear that carious 
disease had -attacked the astrag^alus, and probably the 
OS calcis. His general condition began now pretty 
rapidly to depreciate, and though the operation wound 
was for the most part soundly healed, we were con- 
vinced that there was hopeless local disorganization 
of the bones, and that reamputation was the only 
thing that could save his life. The limb was accord- 
ingly amputated through the lower part of the leg on 
the 8th of August, just two months after the previous 
operation had been performed. He made a rather 
slow, but ultimately a perfect, recovery. 

As far as the cure of the disease was concerned, 
Tripier's amput^ion, in this case, was not a success ; 
the mischief spreading to the bones left in the stump, 
and requiring another operation for its eradication. 
This feature has, however, no particular bearing on 
the operation itself, which is the subject we are now 
considering, and it may be said generally that in all 
these partial operations on the foot and also on the 
hand, some uncertainty must exist — first, as to whether 
any disease of the bones has been left behind; or, 
secondly, whether the bones, now healthy, may not 
take on diseased action in th6 future. As a rule, I 
think this point ought, with care, to be determined 
with substantial accuracy, and, in point of fact, recur- 
rence of disease has been found to be rare. I am 
aware that Mr. Syme says, " In this operation the 
astragalus and os calcis are left, and though they 
appear sound at the time of operation, yet the disease 
frequently 'recurs, as you may learn from the fact that 
I once performed three secondary operations within 
the period of twelve months upon stumps in which 
Chopart's operation had been practised." On the 
other hand, Mr. Hancock replies : " This objection, 
thus forcibly urged by Mr. Syme, is, I am aware, 
maintained by other surgeons, but it is not supported 
by the statistics of the operation ; since, of 104 cases, 
exclusive of those mentioned by Mr. Syme, I find only 
two followed by secondary amputation, and this for 
retraction and painful cicatrix, and not for recurring 
disease." 

The new operation seems to me to offer a satisfactory 
substitute for a very unsatisfactory one, such as in 
many cases Chopart's amputation is conceded to be. 
It is an operation not yet proved, scarcely fairly tried, 
and it would therefore be unwise to pronounce too 
positively on its merits. That it is feasible, that it 
makes a good stump, is settled by the few cases in 
which it has been done. That it certainly and perfectly 
obviates all the disadvantages of the amputation which 
it is proposed to displace, we cannot be sure. I can 
only say that, as far as theoretical considerations go, 
arid as far as a very few cases can be trusted, it seems 
to promise well, and I challenge for it the careful con- 
sideration of those who may have occasion to perform 
a medio-tarsal amputation. 

Dr. Post referred to another operation which fur- 
nished better results, so far as usefulness of the limb was 
concerned, than did Chopart's — namely, that performed 
by Dr. Quimby, also claimed by Dr. Turnipseed, of 
South Carolina. It consisted in a niodification of Piro- 
goff 's operation, but differed from' it in the fact that 
the lower extremities of the tibia and fibula were left 
entire, the cut surface of the os calcis being brought in 
contact with the cartilage covering the lower extremity 



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82 PROCEEDINGS OF COLLEGE OF PHYSICIANS OF PHILADELPHIA. [Medical Nkws, 



of the tibia. Dr. Quimby had performed the opera- 
tion three times and Dr. Post had performed it twice, 
and in all the cases there had been a good stump and 
no inconvenience had resulted from want of homo- 
geneity of the parts brought together. The wounds had 
healed kindly, the stumps had been firm, and the oper- 
ation had been attended by only a moderate amount 
of shortening. • 

Dr. L. a. Stimson said the idea of the operation re- 
ferred to by Dr. Post was not novel. It had been con- 
sidered by Pirogoff himself, and, he believed, also by 
the English surgeon Ure, who devised the operation at 
about the same time as Pirogoff. The suggestion has 
been frequently referred to and generally condemned. 
The lower end of the bone is sawn off in Pirogoff's 
amputation, not because surgeons do not know that 
bone and cartilage can unite, but mainly because of 
the difficulty of otherwise keeping the end of the cal- 
caneum from being drawn up by the tense tendo 
Achillis, the same reason that has led to its modifica- 
tions in the direction of the line of section of the cal- 
caneum or of both bones. Dr. Stimson asked if it had 
been found difficult to perform Tripier's operation. 

The President remarked that there was no greater 
difficulty in the performance of the operation than ob- 
tained m Syme s or Chopart's, except with reference 
to following the line of the incision. 

Dr. McBurney had performed Chopart's operation 
in one case, in which there was ankylosis of the ankle- 
joint, not produced by disease, but by long confinement 
in one position. The patient made an excellent re- 
covery and had a useful stump. That fact suggested 
to him the question as to whether sufficiently strict 
attention had been paid to retaining the stump in 
proper position for a sufficient length of time after 
Chopart s operation had been performed. The idea 
was to retain it in position for a sufficient length of 
time to allow a certam loss of muscular power to take 
place, so that there would not be a marked antagonism 
between the anterior and posterior groups. He could 
easily imagine that the stump after Chopart's opera- 
tion might bend downward within two weeks if allowed 
to follow its own course. He asked Dr. Markoe if he 
was able to give any information upon that point. 

The President replied that, so far as he recollected, 
none of the authorities had directed attention to the 
question raised by Dr. McBurney. It seemed to him, 
however, to be a reasonable suggestion, and it also 
seemed to him that the mechanical factor, even with 
atrophy of both sets of muscles, the os calcis touching 
the ground first, was the great factor of the operation. 
Contraction of the muscles was probably another im- 
portant factor. 

Dr. Sands believed that the neglect to prevent this 
extreme extension of the foot after Chopart s operation 
had been recognized by European continental sui^eons 
as perhaps the main cause of the subsequent difficulty 
in locomotion. He believed it had been claimed that, 
if extension of the foot was duly prevented during 
the course of the treatment immediately following the 
amputation, it would not subsequently take place to 
such a degree as to bring the cicatrix in contact With 
the ground, provided the former was not placed too 
near the plantar surface. He believed that the verdict 
given by American surgeons against Chopart's ampu- 
tation had not been sustained by statistics. The statis- 
tics given by Max Schede proved that the limb, after 
Chopart's operation, was no more frequently useless 
than after oUier partial amputations of the foot; there 
were only ten per cent, of useless limbs after Chopart's 
operation. He thought that Chopart's operation was 
entirely legitimate, provided the astragalus and os 
calcis were both sound. There was an objection to 
both of these operations, Chopart's and Tripier's, 



namely, that when carious disease invaded the tarsal 
bones, it was apt to implicate, sooner or later, all of , 
them, and thus there might occur, as in the case re- 
lated, extension of the disease after performance of 
the operation, so as to render necessary amputation at 
a higher point. Some years ago, Mr. Hancock pro- 
posed, in cases of partial amputation, to regard the 
foot as a whole, and to operate without reference to 
the articulations, forming the flaps and sawing the 
bones as might be expedient. Dr. Sands thought that 
the suggestion made many years ago was particularly 
useful in these days of antiseptic surgery, when opera- 
tion wounds, whether of bones or joints, were so likely 
to pursue a favorable course. 

Dr. Weir supplemented Dr. Sands' remarks by 
the statement that Hancock also suggested the removal 
of a small section of bone, so as to counteract the 
contraction of the posterior gn"oup of muscles. 

Dr. Briddon said that within the last two weeks a 
patient came under his observation who had had 
Chopart's operation performed two years ago. Since 
that time he had been incapacitated m going about on 
account of painful ulceiation in the line of the cica- 
trix; the whole of the anterior surface of the stump 
was covered with cicatricial tissue, and a spot about 
the size of a quarter of a dollar was in a state of 
ulceration. He thought the ulcerated condition was 
not attributable entirely to the operation, inasmuch as 
the operation had probably been performed in appar- 
ently healthy tissues. The original injury, however, 
was a railroad accident, and he, therefore, presumed 
that, as was commonly the case in railroad accidents, 
the vitality of the tissues was, to a greater or less ex- 
tent, destroyed to a point higher than that at which the 
amputation was made, as some sloughing of the flaps 
took place, making them scanty and tense, and ulcera- 
tion occurred after repeated cicatrization. As a further 
operation, he had recommended Syme's amputation. 



COLLEGE OF PHYSICIANS OF PHILADELPHIA. 

Staled Meeting, January j, i88j. 

The President, W. S. W. Ruschenberger, M.D., 
IN THE Chair. 

Dr. James C. Wilson made some 

OBSERVATIONS ON THE MANAGEMENT OF ENTERIC 
FEVER ACCORDING TO A PLAN BASED UPON THE SO- 
CALLED SPECIFIC TREATMENT, 

which he has employed during the past year, and which, 
tested by such uncertain but not necessarily fallacious 
means as are available for a limited series of cases, 
has yielded satisfactory results. 

The Plan of Treatment. — The management by me- 
dicinal means, super-added to the so-called rational and 
expectant method in general use in this communit)-, 
differs from the common practice, and constitutes the 
plan in question. So soon as the patient's symptoms 
warrant a reasonable suspicion that he is about to de- 
velop enteric fever, he is put to bed, ordered a diet 
consisting of milk, animal broths, jelly and simple 
custards, in small amounts and at intervals of two or 
three hours. At night he is given a dose of calomel. 
This dose varies in amount from 7)^ to 10 grains, and 
is repeated every second evening until three or rarely 
four doses have been administered in the course of the 
first six or eight days. It is given alone or in connec- 
tion with sodium bicarbonate. There is commonly a 
slight increase of diarrhoea, if it be present, without 
aggravation of the other symptoms, and in some in- 
stances the tendency of the temperature at this time to 
steadily rise appears to be controlled. If, as is fre- 
quently the case, spontaneous diarrhoea has not re- 



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January 20, 1883.] PROCEEDINGS OF COLLEGE OF PHYSICIANS OF PHILADELPHIA.. 83 



curred in the first week, the calomel usually brings 
about two or three large evacuations on the day follow- 
ing its administration, not more. In either case, the 
tendency to frequent passages in the later stages of 
the* attack is favorably influenced by the repeated 
administration of this drug during the first week. If 
the case does not come under observation until after 
the tenth day, one only, or at most two doses of calo 
mel are given. No further doses of it are, however, 
given during the course of the attack unless constipa- 
tion occur. In this event, if the evidences of extensive 
or deep implication of the intestinal wall, such as ab- 
dominal pain, tenderness, of marked tympany are 
absent, calomel in 7>i-grain doses is given at intervals 
of three or four days. If there is reason to suspect 
serious intestinal lesions, the lower bowel may be more 
safely emptied of its contents every third or fourth day, 
by en^mata of moderate size (8 to 10 fluidounces). It 
is necessary to bear in mind that the gravest lesions of 
the gut, leading even to hemorrhage and perforation, 
have occasionally been observed in cases character- 
ized, not only by constipation, but also by an entire 
absence of pain or tenderness, and very moderate 
tympany. The danger of salivation from calomel in 
these doses in enteric fever appears to be slight. In 
only one case in sixteen were the mercurial fetor and 
slight swelling of the gums observed. 

Excessive diarrhoea has been controlled by the use 
of opium, in suppositories or by the mouth, often asso- 
ciated with bismuth. It is an invariable rule that the 
patient be kept in the horizontal position and to the 
use of the bed-pan and urinal, from the time of the 
recognition of the disease until defervescence is rom- 
]>leted. He is, however, turned upon his side from 
time to time, and made to maintain that position for 
twenty or thirty minutes, if necessary, being supported 
by the nurse. 

From the beginning of the attack the following 
mixture is regularly administered in doses of one, two, 
or even three drops in a sherryglassful of ice-water 
after food, every two or three hours during the day 
and night. 



B. — Tinct. iodinii. 

Acid, carbolici liq., 



f3ij. . 
f3j.-M. 



Unless some unusual circumstance occurs to render 
a change necessary, this medicine is not suspended 
until the attack draws to a close. It is well borne by 
the stomach, and in one case only has it been neces- 
sary to omit the carbolic acid on account of the disgust 
caused by its odor. 

Partly for the sake of its favorable influence upon 
the skin and for the sake of cleanliness, partly because 
of its favorable though slight influence upon the tem- 
perature, the patient is to be sponged twice a day with 
equal parts of aromatic vinegar or alcohol, and cold 
water. If it is more grateful t^ him, this sponging 
may be done with tepid water. 

When the evening axillary temperature reaches 104° 
F., quinifie in massive doses, 24 to 30 grains, is given 
upon a falling temperature. I usually direct 8 to' 10 
grains to be given in solution at 5, at 5.30, and at 6 a.m. 
the following morning. Administered thus at the de- 
cline of the temperature in its diurnal revolution, these 
large doses of quinine depress it from 2.5° to 3.5° F. 
After the lapse of forty-eight to seventy-two hours, if 
necessary the dose may be repeated. If these doses 
be rejected by the stomach — an unusual circumstance 
— half the quantity of quinine may be administered 
hypodermically. For this purpose a citric acid solu- 
tion is to be preferred. Since the adoption of the plan 
of treatment under consideration, I have not encoun- 
tered cases attended with such hyperpyrexia as has 



rendered attempts to control it by col^ baths necessary 
or even advisable. 

The minor nervous symptoms are best held in check 
by skilful nursing. For the relief of the headache of 
the first ten days absolute quietude, a dim light, etc., 
are often sufficient; occasionally the bromides alone or 
in combination with chloral are required. Later in the 
course of the disease chloral is unsafe. From the end 
of the first week the patient cannot be left unattended 
even for a few minutes, without risk. Persons in whom 
delirium was only occasional and transient, have in 
many instances destroyed themselves during the mo- 
mentary absence of the nurse. 

Alcohol is not often indicated prior to the beginning 
of the third week. It is commonly administered, 
usually in small amounts, towards the close of sick- 
ness. Some patients do well without taking it at all. 
It is, of course, administered in accordance with well- 
understood indications upon 'the supervention of de- 
lirium, ataxic symptoms, and the evidences of failure 
of the'forces of the circulation. The patients arecare- 
fully watched well into convalescence, and cautioned 
against too soon regarding themselves as restored to 
health. 

The dangers of the establishment of a focus of con- 
tagion are guarded against by the systematic, thorough 
disinfection of the stools immediately after they are 
voided. 

The considerations which led Dr. Wilson to adopt 
this plan of treatment are : 

1. A feeling of dissatisfaction regarding the expect- 
ant method of treating enteric fever, based upon the 
high death rate. 

The percentage of fatal cases rarely falls below 15. 
per cent:, and often exceeds 25 per cent. Jaccoud, 
with a collection of 60,000 cases, observed a mortality 
of 20 percent.; Murchison, in 27,051 cases, 17.45 per 
cent. ; Liebermeister, in 1,718 cases at Basle, under an 
expectant plan, records 27.3 per cent, of deaths. But 
turning from broad generalizations to personal ex- 
perience, who is there here that, many times elated by 
the happy issue of mild or average cases treated by 
the expectant plan, has not realized the sense of utter 
powerlessness attending it when he has stood face to 
face with cases in which to do, rather than to wait, has 
been necessary to save life ? 

2. Enteric fever is the very type of the general dis- 
eases, of affections tolius substantia. The tissues are 
universally implicated in the morbid processes; no 
function of the body wholly escapes perturbation. For 
this reason plans of treatment suggested by the promi- 
nence of certain groups of symptoms, or by the known 
lesions of particular organs, even though of undoubted 
benefit as far as they go, are in theory un.satisfactory, 
because they are directed in effect against conspicuous 
manifestations of the cause of sickness rather than 
against the cause itself. 

Whilst in actual practice the treatment by turpen- 
tine, by alcohol, by opium with lead, or the silver 
nitrate, or by agents capable of controlling the febrile 
movement, as quinine, digitalis, salicin, and the salicy- 
lates, even the cold-water treatment itself, although at 
times and in the hands of certain clinicians showing 
favorable results — all these have failed of general ac- 
ceptance on the part of the profession. 

3. The general character of the disease, the specific 
nature of its cause, the unsatisfactory results alike of 
an expectant and of a symptomatic plan of treatment, 
or rather of the two combined, have united to render 
the idea of a specific treatment, a true cute for enteric 
fever a most attractive one, to stimulate thoughtful ob- 
servers to renew again and again the disappointing 
search for it. To this idea may be traced the treatment 
by the mineral acids, by chlorine water, by carbolic 



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CORRESPONDENCE. 



[Mkdical Nxws, 



acid, by quinine ^alone, by auinine and digitalis, by 
iodine, by the po&ssium iodide, by calomel. 

4. Not only is the conception of a specific treatment 
for specific diseases a most attractive one, and the 
attainment of such a treatment for enteric fever brought 
within the bounds of a reasonable hope by the analogy 
of syphilis and the malarial diseases, but the search 
after it with due caution and judgment has also the 
warrant of the very highest medical authority. 

The treatment advocated consists of the use of the 
two remedies that are proved to exert a favorable in- 
fluence upon the disease, iodine and calomel, with the 
addition of carbolic acid in minute amounts. The 
results of this treatment encourage Dr. Wilson to hope 
that they will lead to its trial on a more extended scale. 
That it amounts to a specific treatment in the narrow 
sense is not affirmed. 

The total number of cases treated by Dr. Wilson by 
this plan is sixteen ; all recovered, one being now in 
the second week of convalescence. Of these, eight 
were severe, the temperature reaching or exceedmg 
104° F. Of these, one was characterized by uncon- 
trollable vomiting in the third week. The padent 
retained no food taken by the mouth for five consecu- 
tive days. One case was very irregular in its course, 
and was complicated by an obscure abdominal abscess 
which discharged by the bowel. The temperature in 
this case on two occasions attained 105° F. A third 
case was prolonged by a severe relapse. 

Of the eight cases in which the observed temperature 
did not at anv time attain 104° F., one was complicated 
by crural phlebitis, and anoUier by the occurrence of 
intestinal hemorrhage. 

The average duration of the eight severe cases was 
about thirty-one days; that of the eight mild and 
medium cases was about twenty-five days. 

Of the whole number, ten were treated in hospital, 
six in private practice. 

In two cases the special plan of treatment was aban- 
doned about the beginning of the third week on 
account of the supervention of unusual symptoms of 
great gravity. Tnese related respectively to gastric 
irritab^ity and an obscure abdominal abscess. 

These sixteen cases are unfortunately not a consecu- 
tive series. During the year in which Dr. Wilson has 
had the opportunity of observing them, two other cases 
of enteric fever occurred in his hospital praptice in 
which this plan of treatment was not employed. One 
was previously greatly reduced, and was not regarded 
as a suitable subject for a special treatment, the efficacy 
of which was not yet established. The other, with an 
obscure history of a sickness of many weeks, and a 
very irregular temperature, developed the typhoid 
eruption, and within forty-eight hours had general 
peritonitis. These two fatal cases have, however, no 
bearing upon the result of the treatment. 

In private practice several cases of mild continued 
' fever of long duration were treated upon this plan. 
They are believed to have been anomalous cases of 
enteric fever, but as the rose spots of that disease were 
absent, and their departure from the typical disease 
was wide, they were not included. They all recov- 
ered. 

The result of this plan of treatment has not only 
been satisfactory in respect of the recovery of all the 
cases treated, an accidental circumstance not liable to 
mislead persons familiar with the disease, but it has 
also been satisfactory in respect of the general course 
of the attack, and the appearance of the patient. 
These were in the main, despite the severe type of the 
disease in several of the cases and despite the occur- 
rence of grave complications, favorable. Dr. Wilson 
made this statement with due regard to the personal 
equation, and with no willingness to permit the ob- 



served fact to differ from the actual fact, for he desires 
any who may make trial of this plan to be more favor- 
ably impressed with the results of it, than with bis 
account of it. 

Dr. Roberts Bartholow said that this plan of 
treatment is in part the so-called " specific " method. 
The administration of calomel in full purgative doses 
during the first week serves a double purpose : it has 
an effect on the range of temperature, and it acts on 
the typhoid germs present and multiplying in the intes- 
tinal canal. The use of iodine — usually Lugol's solu- 
tion — throughout the disease, is also one mode of the 
specific treatment By the use of this medicine, it is 
attempted to prevent the multiplication of germs in 
the intestine, to check fermentation, and to maintain 
an antiseptic action in the blood. Although the exist- 
ence of typhoid germs has not been proved, it must be 
regarded as possible. Klein, a few years a^o, an- 
nounced the discovery of the specific organism of 
typhoid in the affected intestinal glands, but Creighton, 
of Cambridge, showed that the supposed gei^ns were 
produced by the mode of preparation. This fiasco 
threw great discredit on the whole question of germs. 
Nevertheless, the course of treatment directed against 
supposed germs — the antiseptic method — has had a 
most favorable influence on the progress and mortality 
from typhoid. Whilst the specific plan has been ad- 
vocated in Germany, the Montpelier school has brought 
forward carbolic acid as the remedy, and the success 
which has attended its use has been really remarkable. 
Quite a different complexion has been put -on the 
statistics of mortality since they began the use of car- 
bolic acid. It is probable that the combination of car- 
bolic acid and iodine gives better results than the use 
of either singly. According to my observation, this 
method of treatment diminishes the diarrhoea, lowers 
the fever, and renders the disease much less violent, 
consequently lessening the mortality. Dr. Wilson has, 
therefore, rendered us a real service by drawing atten- 
tion anew to this plan of medication, and especially by 
supporting his position with valuable cases and sta- 
tistics. Besides this use of medicines, Dr. Wilson's 
treatment contains many valuable suggestions and 
practical methods, which, no doubt, contribute materi- 
ally to his success. 

Dr. J. M. Da Costa spoke of the purgative treat- 
ment in enteric fever, as that which had been tried in 
the French hospitals, and for a time sanctioned by 
Louis. As regards calomel, it was partly by its purga- 
tive action that it was supposed to be beneficial. In 
his hands the calomel treatment had not yielded favor- 
able results. He had found carbolic acid useful in 
controlling diarrhoea and in lowering the temperature. 
He had also employed thymol in one-half to one-grain 
doses. He suggested the use of this remedy in the 
place of carbolic acid, as more acceptable to the 
stomach. 

Dr. Wilson called attention to the fact that carbolic 
acid and like drugs probably exert a favorable influ- 
ence upon the course of enteric fever by their power 
to stay the rapid decomposition of the intestinal con- 
tents, which, for lack of the antiseptic influence of the 
intestinal juices, the bile, etc., all of which are changed, 
is a secondary cause of irritation, diarrhoea, and tym- 
pany. Calomel also, he thought, probably exerted an 
indirect beneficial influence in the same direction. 



CORRE SPON DENCE. 

THE APPROPRIATION FOR THE ARMY MEDI- 
CAL MUSEUM AND LIBRARY. 

We have received from Dr. A. B. Isham, of Walnut 
Hills, Cincinnati, the following note addressed to him 



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by the Honorable Mr. Butterworth, in relation to the 
note relative to the appropriation for the Army Medical 
Museum and Library, given in the number of this 
journal for December 30th, page 738. 

We are very glad to learn that we have been misin- 
formed as to the attitude of Mr. Butterworth I'elative 
to this interest. In the last number of this journal, 
January 13th, page 59, the full debate in the House 
relative to this appropriation was given, and Mr. But- 
terworth's remarks as there reported fully sustain the 
statements in his letter. 

House of RspRisBHTATnrBS U.S., 

Washington, D. C, January 6, 1883. 

My Dear Doctor: Your letter of the 3d is received. 
The Medical News was not possessed of accurate 
information. So far from reducmg the appropriation, 
I moved its increase over what the Committee had 
allowed. I am aware of the great value of the 
Museum, and am only sorry that no suitable fire- 
proof building has been provided for it. 

I thank you for the kind expressions contained in 
your letter, and with best wishes, I am 
Very truly yours, 

Benjamin Butterworth. 

A. B. IsRAH, M.D., 
(Walnut Hill*; Cincinnati, Ohio. 



MUSCLE-READING. 
To the Editor of The Medical News. 

Sir : A recent issue of your journal contains a re- 
port of some of my more recent experiments in muscle- 
reading, which, together with the comments made 
thereon, are founded on a misunderstanding of the 
nature of my experiments. 

I understand you to say that there is in these experi- 
ments danger of being deceived. This is precisely not 
the case. Muscle-reading experiments are as accurate 
as anything in mathematics ; they are indeed a part of 
mathematics itself. The beauty and the power of 
these experiments in muscle-reading consist in their 
precision, in the impossibility of being deceived, in 
the certainty of the results, and in the firm knowledge 
which the experimenter has that he has not been 
cheated by anybody, not even by himself. 

It is quite true that mai)y of the phenomena of arti- 
ficial trance or hypnotism can be simulated ; but the 
phenomena of muscle-reading, whether done by a 
person in trance or out of trance, cannot be simulated, 
as all authors all over the world who have studied the 
subject agree ; even a non-expert can understand this 
after a snort process of experimentation. If those 
who have not an opportunity of experimenting them- 
selves on this subject, or of witnessing the experiments 
of others, will read what I have published on the sub- 
ject years ago in The Popular Science Monthly (Feb- 
ruary and July, 1867; and Journal of Science, July, 
1881, London), and in other journals, or will read the 
reports of the members of the Royal Society of Eng- 
land (Francis Gallon, Ray Lankester, M. Romanes, 
and Prof. Robertson), who experimented in the same 
direction {Nature, ]\xrA 23 and July 14, 1881), and who 
obtained results precisely -similar to mine so far as 
they went, they will find that there is nothing in 
science more accurate than the results obtained in 
these experiments. The special object of these later 
experiments was to determme the extreme minuteness 
of the localities that can be found by means of arti- 
ficial appliances. The details will soon be published 
in a scientific journal. 

I hope, however, that the readers of your journal 
will not content themselves with the experiments of 
others on this subject, but experiment for themselves 
independently ; subjects can be obtained everywhere. 



and they will find results as hertofore stated. I trust 
also they will do what is possible to enlighten the 
public, as well as professional and scientific men, on 
this theme. The strongest friend of quackery of all 
kinds, and the strongest enemy of our profession, in 
this country especially, but more or less in all coun- 
tries, is ignorance of the action of mind on body. The 
best single answer to the delusions that sustain 
quackery that I know of is found in these muscle- 
reading experiments ; in the rapidity, the precision, the 
delicacy, the certainty to which they can be carried on 
they show more piowerfully than anything else I know 
of in science the interdependence of body and mind, 
and suggest the true explanation of the success of 
nearly all the forms of charlatanism in all ages. 
Withal, these experiments, which when they were first 
made were an original contribution to science, have a 
direct and positive value for physicians who rightly un- 
derstand them ; the suggestions they give are of prac- 
tical as well as scientific service to our profession, and 
especially to psychologists. 

It is now eight years since I made my first experi- 
ments in this department of science. . The interest in 
the subject has increased to such a degp'ee that there is 
already quite a literature on the subject, particularly, 
in England, and in the past year the German psycholo- 
gists are beginning to look into the matter. There is 
no danger that physicians will study it too much; 
there is much danger of studying it too little, and giv- 
ing too little heed to the important practical suggestions 
which it offers. George M. Beard. 

New York, January lo, 1883. 



NEWS ITEMS. 



NEW YORK. 
(J'rom our Special Correspondent^ 

A Number of Supposed Cases of Typhus Fever 
were discovered in a Hester Street tenement house by 
the Board of Health, and it was found that there had 
been no less than six deaths in a few weeks. The dis- 
ease was typhoid, and not typhus fever. The locality is 
one of the worst in New York, and this outbreak should 
be a warning to the authorities. 

A New Society of Medical Jurisprudence has 
been established by the' dissatisfied seceding members 
of the Medico-Legal Society ; among them Drs. Ham- 
mond, Spitzka, Morton, and a number of Brooklyn 
physicians. Dr. Wight, the Professor of Surgery at the 
Long Island Hospital Medical College, read a paper 
upon " Illusions and Hallucinations as Affecting Testa- 
mentary Capacity," at the inaugural meeting. 

The New Code. — There is much sharpening of 
knives and burnishing of armor upon the part of the 
delegates who are to go to the State Society. The out- 
side County Societies are repudiating the action of their 
delegates who went to Albany last year. Several medi- 
cal men, not entirely unknown in medical politics and 
post-graduate instruction, are determined to make a 
titter fight for the New Code. 

The Illness of Miss Lillian RXjssell, a popular 
comic opera singer, brought forth a column of inter- 
view in the New York World the other day. Miss 
Russell seems to have been treated in sections by a 
dozen or more of the regular physicians and homoe- 
opathists, all of whom pursued a different plan of treat- 
ment, and abused each other roundly. The stage 
manager of Miss Russell objected because one of these 
gentlemen gave her 120 grains of quinine /«r diem. 



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The Government's Medical Experts in the 
GuiTEAU Case, many of whom gave a month of their 
time to the- trial, have not been compensated yet, 
although over a year has elapsed. The lawyers have 
been paid, and it is difficult to see why an exception 
should have been made entirely in their favor. 



POUGHKEEPSIE, N. Y. 
{J'i-om our Special CorresponJeni.) 

The Dutchess County (N. Y.) Medical Society 
AND THE New York Code. — At the annual meeting 
of the Dutchess County Medical Society, held at Pough- 
keepsie on January loth, it was 

Resolved, That the Medical Society of Dutchess 
County instruct its delegates to vote in favor of repeal- 
ing the Code passed at the last meeting of the State 
Society. 

TROY, N. Y. 
(F^om our Special Correspondent.) 

Rensselaer County (N. Y) Medical Society and 
THE New York Code.— At the annual meeting of the 
Rensselaer County Medical Society, held January 9th, 
the following resolutions were adopted by the Society : 

Resolved, first. That this Society affirms its loyalty 
to the Code of the American Medical Association. 

Second, That it directs its delegates to vote for the 
restoration of the Code of the American Medical Asso- 
ciation. 

CHICAGO. 
(^(MPi our Special Correspondent.) 

Preliminary Examinations.— It has been known 
for a number of months that after the present course of 
lectures our State Board of Health would not recognize 
the diplomas of colleges which do not require an en- 
trance examination of its students. Hereafter, gradu- 
ates from colleges which do not have this requirement 
will be obliged to undergo a special examination before 
the State Board in order to be admitted to practice in 
Illinois. The four regular schools here require pre- 
liminary examinations. 

Training School for Nurses.— This organization, 
now only about two years old, has become so much of 
a success at the County Hospital, that citizens have 
contributed funds enough to buy a lot and commence 
the building of a permanent Home for the school, 
within half a block of the college. Probably no good 
organization, touching in its work the practice of our 
profession, has ever been started among us which has 
worked more quietly and modestly than this, and cer- 
tainly no other has, in so short a time, established 
itself on so firm a foundation of public confidence in 
its value and usefulness. 

A New Chair of Laryngology.— Rush Medical 
College has just created a special chair of laryngology 
and elected Dr. E. Fletcher Ingals to fill it, with the 
title of Professor of Laryngology. 

NEW ORLEANS. 
{From our Special Correspondent^ 

Health of New Orleans. — This city is not as 
healthy as it usually is at this time of the year. One 
hundred and sixty-three deaths occurred last week. 

The most serious diseases prevailing are pneumonia, 
some of the eruptive fevers, andcerebro-spmal menin- 
gitis. It is reasonable to suppose that the holidays are 
m part chargeable with this increase of mortality. The 
festivities of Christmas and New Years bring such fruits 



as pneumonia and cerebro-spinal meningitis from_ ex- 
posure to cold ; and the eruptive fevers by disseminat- 
mg their special poisons throughout those assemblages 
which hilarious occasions bring together. 

The deaths firom smallpox average about ten a week ; 
scarlatina is much less prevalent. Four cases of 
cerebro-spinal meningitis have been admitted to the 
hospital within the past ten days. One of these, which 
was apparently the most furious at date of admission, 
suddenly abated, and the patient has been discharged, 
well. It is a well-known fact that in some autopsies of 
patients who die from cerebro-spinal meningitis, no 
lesions are found to indicate that the inflammatory 
process had gone beyond the stage of engorgement. 
We may from this understand how it is that well- 
marked and threatening -symptoms may sometirnes 
stop short of death, or of such an amount of effusion 
as to make recovery slow. Two of these cases were 
under your correspondent's charge. They were treated 
by bromide, potash, and ergot in the first stage : by 
' iodide-potash in stage of effusion. 

Pneumonia is a fatal disease in all large hospitals. 
It becomes still more so if the hospital be located in a 
place where malaria is so rife that every case treated 
IS complicated by its presence or influence. But in 
spite of these difficulties which we have to meet, the 
mortuary reports of the hospital show very favorably 
when compared with the death-rate of the city. 

Death of Dr. Warren Stone. — The early days 
of the present year instanced the death of Dr. Warren 
Stone, the son of the late Prof. Warren Stone. He 
was very largely endowed with the talents and noble 
traits of character which distinguished his father. The 
medical profession of New Orleans and a large circle 
of non-professional friends deplore his loss. 

TORONTO. 
(From our Special Correspondent.) 

Moral Insanity. — At the December meeting of the 
Toronto Medical Society, the veteran Dr. Workman, 
late Superintendent of the Toronto Asylum for the In- - 
sane, read a long and very interesting paper on moral 
insanity, in whicn he said : " The term moral insanity 
was introduced into alienistic literature by Dr. Pritch- 
ard, an English writer, in 1835. Previously, Pinel, of 
Paris, to designate cases apparently identical, had 
styled them ' manie sans delire.' His pupil, Esquirol. 
preferred the term 'manie raisonnante.' This, to the 
vast majority of lay readers, must have appeared a 
very absurd designation, for the vulgar conception of 
insanity is that its subjects are incapable of reasoning, 
a belief which has been found very erroneous by many 
visitors of asylums who have ventured to address the 
inmates as if regarding them all as utterly mindless 
beings. Pinel's manie sans delire was a term quite 
applicable to a large proportion of all the insane, that 
is, in certain phases or intervals of the malady, but it 
would certainly be found to fail to cover the whole his- 
tory of his cases. Insanity almost invariably has its 
inception in a change of the feelings or moral senti- 
ments of its destined victims. This is its usual pro- 
drome ; but it is only when abnormality of the intellect 
has become manifest that the real disease is recognized 
by the friends of the patient, and too often, even then, 
it is not admitted by the neighbors, or the community, 
for outside of his own domestic circle the patient's 
language or actions may appear quite rational. When 
the insane commit crime, in almost all instances, the 
quality of the offence is judged of, not according to 
their actual mental state, but according to its nature or 
enormity ; and it is very well known that the crimes of 
the insane are sometimes shockingly enormous. Why 
should they not be so ? 



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"Pritchard's moral insanity might, with more pro- 
priety, have been z^tdiinsane morality . Of the seven- 
teen cases adduced by him, hardly one will bear the 
test of strict analysis. Some degree of intellectual 
debility or impairment may be detected, by an expe- 
rienced reader, in every one of them, and several 
exhibited very palpable defects; one, indeed, perhaps 
bis most accentuated, terminated in general paralysis, 
an invariably fatal form of insanity and one which, 
in its early stage, is often characterized by gross de- 
partures from moral propriety." 

Dr. Workman, in the latter part of his address, gave 
the history of several cases of the so-called moral in- 
sanity which had come under his own observation, or 
had been recorded by his alienistic confreres. The 
details were very instructive. He concluded by ear- 
nestly admonishing his professional brethren, when un- 
fortunately they might have to appear in Court as 
expert witnesses, never to fall into the inadvertence of 
ssing the term moral insanity. 



International Medical Congress, Eighth Ses- 
sion; Copenhagen, 1884.— Prof. P. L. Panum, Presi- 
dent of the Organizing Committee of the Congress, 
and D. C. Lange, Secretary -General, announce that, in 
accordance with the desire expressed by the Interna- 
tional Medical Congress at its seventh session in Lon- 
don, 1881, that the eighth session of the International 
Medical Congress will be held in Copenhagen during 
the days from the loth to the 16th of August, 1884. 

Fees of the Guiteau Trial Experts.— The De- 
partment of Justice has decided on paying the experts 
summoned by the Government in the Guiteau trial at 
the uniform rate of $25 a day, with the ordinary wit- 
ness fees in addition, but no 6ther allowance for ex- 
penses. It was felt that the Government could not 
undertake to distinguish between experts according to 
their supposed rank in the profession or their compara- 
tive eminence, but must be governed by the length of 
their service. The bills ranged all the way up to |ioo 
a day. The whole amount to be paid to the experts, 
exclusive of the ordinary witness fees, will be between 
$12,000 and (13,000. 

Mr. Brewster Cameron, who has the matter specially 
in charge, intimates that any experts who were especi- 
ally connected with the preparation of the case may 
receive an additional allowance on that ground. There 
were four of these — Dr. Gray, of Utica; Drs. Macdon- 
ald and Allan McLane Hamilton, of New York, and 
Dr. Kempster, of Wisconsin. 

A Training School for Nurses is to be attached 
to the Kings County Hospital, on the plan of the one 
at Bellevue. 

National Association for the Protection of 
the Insane and the Prevention of Insanity. — The 
annual meeting of the National Association for the 
Protection of the Insane and the Prevention of Insanity 
will be held at the hall of the College of Physicians of 
Philadelphia, on January 25, 1883, at 3 and 8 p.m. 
The address of welcome will be made by Dr. S. D. 
Gross. Papers will be read by Drs. Traill Green, J. S. 
Jewell, Charles K. Mills, Milner Fothergill, and others. 

The Monthly Bulletin of the Mortality and 
Sanitary Condition of Lowell, Mass., differs from 
most of its contemporaries, which are strictly statisti- 
cal, in containing short but excellent articles intended 
for popular education in sanitary subjects. The issue 
for December discusses "Preventable Disease" and, 
"School Hygiene." 



The Johns Hopkins University. — President Gil- 
man has just issued his seventh annual report, cover- 
ing the session of 1881-82. The University is stated 
to be in a flourishing condition. There has been con- 
siderable original work accomplished during the year 
in the different departments. 

Dr. Remsen's attention seems to have been confined 
principally to analyzing the drinking waters of Balti- 
more and Boston with a view of remedying their dis- 
agreeable taste and odor. His work has been very 
successful, particularly at Boston, where he showed 
the cause of the trouble to be a fresh water sponge, 
spongilla lacustris. In addition to the general course 
in biology, there is a course preliminary to the study of 
medicine which has been well attended. It is hoped 
that the time is not f^r distant when the medical de- 
partment in connection with the Johns Hopkins Hos-, 
pital will be organized. The work accomplished here 
in biology has been extensive. Dr. Martin, since his 
connection with the University, has paid special atten- 
tion -to researches in physiology, and has devised a 
new method of studying the mammalian heart. He 
has succeeded in keeping the heart alive for five or six 
hours after the death of the animal, and now any ex- 
ternal influences upon this organ can be investigated 
much more satisfactorily than heretofore, when biolo- 
gists had to confine their experiments io the hearts of 
batrachia. 

The appendix to the report contains a full list of 
Fellows since 1876, and a complete bibliography of all 
articles and books published by members of the Uni- 
versity. 

When it was determined to build the two new labora- 
tories, the board of trustees was divided on the question 
of location, some favoring Clifton, others the present 
situation in Howard Street. As they are being built in 
the city, it would seem that the University will be per- 
manently located in Baltimore, and not at Clifton, as 
was the founder's intention. 

The Johns Hopkins Hospital is about a mile directly 
east from the University. The towers of the adminis- 
tration buildings can be seen from all prominent parts 
of the city. The buildings most needed at present are 
virtually completed. Seven of the twelve wards are 
almost ready. Five of these are free, and can accom- 
modate with the greatest ease 156 patients. The other 
two are pay-wards and furnish room for thirty-two beds. 
These wards are to be supplied with all the modern 
improvements. The construction of the elaborate sys- 
tem of ventilation has been directed by Dr. John S. 
Billings, United States Army. Fifteen buildings have 
up to this time been erected, the ground inclosing them 
being a plot of fourteen acres. In addition to the wards 
the administration, nurses' kitchen, autopsy and med- 
ical school buildings are completed. All are of the 
Queen Anne style. 

West Virginia State Board of Health. — Gov- 
ernor Jackson in his biennial message to the Legisla- 
ture, dated January 10, 1883, refers to the Health 
Board of the State as follows : 

"The law establishing the State Board of Health 
and regulating the practice of medicine and surgery, 
as amended and re-enacted last winter, has proved a 
wise act of legislation. It is admirably adapted to se- 
cure the protection of the lives, health, prosperity, and 
happiness of all classes of the people. It has met 
with the sanction of eminent sanitarians in other 
States, who have become acquainted with its provi- 
sions. The law is now in force in every county of the 
State, and we may reasonably expect that its opera- 
tions will prove of much benefit. The number of 
registered physicians and surgeons to date of report 



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is 1,041. Of these, 958 are residents of the State and 
the residue residents of adjoining States. 

Besides the careful protection of the interests of the 
life and health of the inhabitants of the State, the 
Board is charged with the duty of investigating the 
causes of diseases occurring among the domestic ani- 
mals. The value of this provision of the law was wit- 
nessed in Brooke County last summer, when what is 
known as the Southern cattle fever made its appear- 
ance in that county. The prompt action of the State 
and County Boards arrested the spread of the disease, 
and probably saved large sums of^money to farmers of 
that locality, in the preservation of their stock from 
infection." 

Disinfection by Heat, and its Practical Ap- 
plication. — The superiority of heat over all fumiga- 
tions and other reputed disinfectants is now generally 
recognized, and local sanitary authorities have already 
in many districts set up disinfecting ovens or chambers 
of one or other kind. It is, however, of the utmost 
practical importance that the intensity and duration of 
the temperature required for the destruction of bacilli 
and of spores should be fully appreciated and attended 
to, if such" disinfection " is to be really effective, and 
not a dangerous delusion. Drs. R. Koch and Wolff- 
HUGEL, after a long course of carefully conducted ex- 
periments, find that bacteria are not killed until after 
an exposure of one hour and a half to a temperature of 
100° C. {212" F.). Spores of fungi require a greater 
heat, viz., 110° to 150° C. (230° to 300° F.), for at least 
as long ; while nothing less than a temperature of 140° 
C. (285° F.), continued for three hours, suffices to kill 
the spores of bacilli, as those of anthrax. These are 
the germs with which we have to deal in practical dis- 
infection. Such a temperature will, in three hours, in- 
fallibly kill these spores, but since it takes that time to 
penetrate to the centre of even small bundles of clothes, 
or of pillows,- a further exposure of like duration will be 
required for their complete disinfection, and few articles 
of clothing or bedding; will bear such treatment without 
serious damage. It is to be regretted that Drs. Koch 
and WolfThugel did not repeat their experiments with 
moist air, for there seems to be no reason to fear that 
the presence of a proportion of vapor not amounting to 
saturation can detract from, if indeed it do not actually 
enhance, the efficacy of the heat ; while it is known that 
the most delicate fabrics, as ostrich feathers, dyed silks, 
etc., are uninjured by a temperature of 300° Fahr. under 
these conditions, and if the moist air be forced in under 
pressure, as in W. Lyon's apparatus, the penetration of 
the heat is greatly facilitated. The general conclusion 
to be drawn from these experiments, which are de- 
scribed in detail in the Millheilungen des k. Gesund- 
keitsamte, Bd. i., seems to be that nothing less than 
a three hours' exposure to a temperature little short 
of 300° Fahr., with precautions to insure the penetra- 
tion of every part of the articles subjected to it, is 
sufficient. How this is to be attained is a question 
of detail, but at present it certainly appears that pref- 
erence is to be given to the particular apparatus above 
named. — Medical Times ana Gazette, Nov. 4, 1882. 

Smallpox in Southern Africa.— Reports recently 
received from Cape Town state that the epidemic witti 
which the city and neighboring villages have been 
scourged during the past few months is now abating. 
There were admitted into the Lazaretto from the com- 
mencement of the outbreak until October 30, 1,015 P^' 
tients, but these constitute only about one-eighth of the 
whole number who have been affected. Of the 1,015, 
253 were white, and 762 colored. Of the whites, 183 
had been vaccinated at some previous time, and 70 were 
unvaccinated. Of the colored, the corresponding num- 



bers were 180 and 582. Among the whites 49 deaths 
took place, 23 of the patients in these fatal cases hav- 
ing been vaccinated, and 26 unvaccinated. Among 
the colored people 252 fatal cases occurred, 31 having 
undergone previous vaccination, and 221 never having 
been vaccinated. 

Admitted. Died. PercentaKe. 

Vaccinated, 363 54 14.87 

652 



Unvaccinated, 652 



247 



37.88 



1,015 30' 29.65 

Difficulty was experienced in procuring reliable vac- 
cine virus. 

At St. Paul de Loundu the disease is progressing. 
During the month of October 150 cases of smallpox 
were registered, of which 80 proved fatal. The popu- 
lation is estimated at 12,000. The sanitary condition 
of the town is represented as of the worst possible 
character. 

Cholera, Prevention and Cvkk in China. — ^The 
United States Consul at Foochow, China, in a recent 
official report, gives information derived from native 
physicians concerning the cause and treatment of 
cholera. The disease is conceived to arise from un- 
seasonable weather and a lack of harmony between 
the upper and nether worlds, so that men living be- 
tween the two are exposed to and suffer from noxious 
influences ; or it is caused by wraiths badly laid or of 
evil intent, who are boldly exorcised from houses and 
passages by nightly processions bearing the images of 
proper spirits. The villages quarantine against each 
other. Among the precautions to be observed in times 
of danger, we find mat nothing must be eaten or taken 
into the stomach which is liable to cause diarrhoea or 
vomiting. Fats and oils must be avoided, and salted 
provisions used instead. Tea should be replaced by 
ginseng infusion. Exercise in the heated part of the 
day should be avoided. If all precautions fail, and 
the individual become affected, ginger, cassia, and 
aconite are administered, the black - blood is let out 
ii-om under the iinger-nails by needle punctures, coun- 
ter-irritation is applied to the arms by heated seeds, 
and finally, the umbilicus is burned to warm up the 
stomach and start the circulation of the blood. 

Health in Michigan. — Reports to the State Board 
of Health for the week ending January 6, 1883, indi- 
cate that consumption, erysipelas, measles, pneumonia, 
and bronchitis nave increased, that diphtheria and 
neuralgia have considerably decreased, and^that inter- 
mittent fever, whooping-cough, inflammation of brain, 
remittent fever, and influenza have decreased in area 
of prevalence. 

Including reports by regular observers and by others, 
diphtheria was reported present during the week end- 
ing January 6th, and since, at 18 places, scarlet fever 
at 15 places, and measles at 12 places. Smallpox was 
reported in Richmond, Osceola County, January 2d, 
and in Royalton, Berrien County, January 4th. 

OFFiaAL list of CHANCES OF STATIONS AND DtTTIBS 
OF officers of the MEDICAL DEPARTMENT, U. S. 
ARMY, FROM JANUARY 8 TO JANUARY I5, 1883. 

MUNDAY, Benjamin, First Lieuieitaiit ondAstistani Surg-een. 
— Assigned to duty at Fort Klamath, Oregon. — Par, j, S. O. igs. 
Department of the Columiia, December 39, 1883. 

Skinner, John O., Captain and Assistant Snrfeon. — Granted 
leave of absence for one month. — Par. 3, S. O. j, A. G. O., Jan- 
uary 6, 1883. 

Johnson, R. W., First Lientenant and Assistant Surgeon. — 
Granted leave of absence for one month. — Par. 2, S. O. 4, De- 
partment of Dakota, January 5, 1883. 

Wood, Marshall W., Captain and Assistant Surgeon. — 
Granted leave of absence for one month. — Par. j, S. 0. 4, De- 
partment of tie Bast, January 8, 1883. 



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THE MEDICAL NEWS. 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



Vol. XLII. 



Saturday, January 27, 1883. 



No. 4. 



ORIGINAL LECTURES. 



ESMARCH. ANTISEPSIS, AND BACILLUS. 

TIU Aititual Address, before the Philadelphia Academy of Surgery, 

delivered at the Hall of the College of Physicians, 

January S, iSSj, 

By WILLIAM HUNT, M.D., 

SBMIOR SUKCBON TO TH« riMNSYLVANIA HOSPTTAU 

Gentlemen : How does the statement, so often made 
in these times, that everything is practical and demon- 
strative, and that the days for didactic teaching and 
oratory are past, agree with the fact that there not 
merely lingers, but actually exists, an intense desire on 
the part of most people to hear something said by 
somebody, it too often seen^tng to be a matter of indif- 
ference whether what is said be good or bad, so that 
the desire is fulfilled ? Does not the reason lie in the 
fact of the vast superiority of the sense of hearing, 
over every other sense, as a means of intellectual cult- 
tu-e? Science demands demonstration, but demon- 
stration requires explanation; pantomime alone will 
not do, otherwise the deaf and dumb should be our 
intellectual superiors. They are, however, shut oflF in 
a much greater degree than the blind from that capacity 
of association with their fellow-men which is so essen- 
tial to high degrees of mental cultivation. We can 
demonstrate to deaf mutes, but we cannot do so to the 
blind. These sav "tell us all about it;" the others, 
" let us see it." "fhese will ponder with the subjective, 
and show that, hearing, they have understood, while 
with the others there is reason to believe the objectivity 
of objects remains without analysis, and for the most 
part seeing, they see not. The modern introduction of 
lip language promises a great compensation to these 
unfortunate ones. I can see no reason why a deaf mute 
with a healthy brain, one who simply cannot speak 
because he has never been able to hear, having learned 
the language of speech, instead of his own, which is 
essenti^ly a foreign one of signs, should not become 
the peer of any of nis fellow-men. It may be said that 
deaf mutes have all the requisites for cultivation in 
books, after they have learned to read. But reading 
of a high order, to one who only knows the language 
of signs, must be a labor indeed, and I should argue 
without having made practical inquiry that it would be 
very exceptional, and in most cases an impossibility. 

In studying, then, the respective merits of the didac- 
tic and the demonstrative, the blind and the deaf give 
OS the most striking contrasts. Great contrasts, also, 
teachers most sadly know, exist among those who pride 
themselves on the full possession of all of their senses. 
Dumb talkers and deaf hearers thrive in such num- 
bers as to almost justify Carlyle's estimate of popula- 
tion being " mostly fools." It may be that a tacit 
acknowledgment of this by the wise ones of the world 
i:> the foundation of the immense advance of demon- 
strative teaching over the other and older method. 
The teacher seems to say, if I cannot talk a fact into 
your head, I can at least show it to you ; and if with 
ears and eyes both you do not take it in, it is your fault 
and not mine! Who knows but what these proud 
demonstrators, who now so largely'occupy the field of 
knowledge, may, when the concealing veil of truth is 
lifted, have to realize that they have been engaged in 
a Att!dtig show ; while the dialectician, by contempla- 



tion led, is enabled to reveal that to which their work 
is as nothing and vanity. 

And now I, who have always been a demonstrator, 
being forced for the first time, by the appointment of 
our unrelenting President, into a didactic position, 
must cast about for a theme with which to occupy the 
allotted time this evening. 

Biography is justly the favored resort on such occa- 
sions, for what is more interesting and instructive than 
the following of the footprints of the great and learned 
ones of the past? Our two great leaders have 9-lready 
indulged us in this way. John Hunter and his pupils 
iand Baron Larrey have been most vividly pictured to 
us. It is most tempting to follow the example, and I 
might take up Par6, or Cheselden, or Cooper, and dis- 
course on the ligature, or lithotomy, or luxations, until 
my task was done. I might also go back, almost into 
the " night of time," and query as to what was then 
done for human ills, and show that medicine and the 
knife and fire wu-e then, as they are now, at the com- 
mand of those who had the skill, or the boldness, or 
the assumption to use them. But I shall choose none 
of these subjects, for my discourse will be devoted to a 
few of the occurrences of the past year, partly hack- 
neyed and partly, I hope, fresh enough to interest you. 

On the 2a of February, 1882, the distinguished Prof. 
Esmarch delivered a lecture at Kiel upon the "Treat- 
ment of the Wound of President Garfield." He was 
so kind as to send me a copy of this lecture. The 
high standing of the author and the lecture itself were 
looked upon as matters of such importance that, you 
will remember, they were made the subjects of a cable 
telegram to this country, and doubtless also to other 
places. A short statement of the opinions of Esmarch 
was given in the telegram. In his lecture the Professor 
states that he is led to select his subject from having 
noticed, through many English and American publica- 
tions, that the widest difference of opinion exists among 
most distinguished American surgeons, both as to the 
wound and as to its treatment. 

Short comments on five of the critics form the intro- 
duction to his paper. These, in the order named, are 
myself, from whom he opens the discourse with quite 
a lengthy quotation, from my letter published in The 
Medical News, for Nov. 1881 , which he characterizes 
as an attack upon antisepsis. Then follow the conclu- 
sions of Drs. Wm. A. Hammond, Marion Sinie, John 
Ashhurst, Jr., and John T. Hodgen, taken from the 
celebrated and widely read article contributed by these 
four gentlemen to the North American Review for De- 
cember, 1 88 1. 

In his concluding paragraph Dr. Hammond says, 
"it is denied that the wound was necessarily a mortal 
one," and that " the President did not have all the ad- 
vantages of treatment which modern surgery is capable 
of affording." This much of that paragraph Prof. 
Esmarch quotes, and further on he says, "I must, 
upon the whole, adhere to the last proposition of Dr. 
Hammond, but, indeed, from an entirely contrary 
standpoint." He then takes the history of the case 
furnished by Dr. Bliss to the Medical Recorti of the 8th 
of October, 1881', and from it, and from the report of 
the autopsy, he seeks to establish his points. 

I have never met Prof. Esmarch personally, but he 
roust be a capital example of the effect of climate on 
character. His work has the snap of a Norseman in 
it, and is very different from the tedious disquisition 



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ESMARCH, ANTISEPSIS, AND BACILLUS. 



[Medical News, 



of many German writers. He was bom at TSnningen, 
on the North Sea, but most of his life appears to have 
been spent at Kiel, on the Eastern shore — "by the 
wild Baltic's strand." In considering his subject, he 
gives a synopsis of the case from the materials at 
band, and with abrupt, short, and sharp, if not always 
decisive, running comments, in the shape of foot-notes, 
he makes his thrusts. The reader who is not fond 
of foot-notes would miss the gist of the matter if he 
avoided them here. It would be interesting to know 
how they were managed in the lecture, as this, surely, 
could not have been delivered as printed ; for, if so, 
much of its spice must have been lost. 

The main point of the illustrious critic is, that true 
antiseptic treatment was not practised. The whole 
story IS so familiar to us that I shall confine myself 
mostly, and therefore often abruptly, to the exact 
places where these pithy notes occur, and also, adopt- 
ing the same style, I shall take the liberty of occasion- 
ally throwing in a note of my own, designating it with 
an H. The order will be a translation by me, back 
into English, of the parts of Esmarch's synopsis of 
Dr. Bliss's record, which are the especial subjects of 
his strictures; then Esmarch's notes; then my H's. 
After the record has been gone through with, only E. 
and H. will appear. 

To begin: "The first physician who saw him (Dr. 
Townsend) carried his finger immediately into the 
wound ; nevertheless, without finding the ball.'' 

Note, " It is not stated that before this he washed 
and disinfected his hands." ' 

H.: Railroad stations, as a general thing, do not 
keep twenty to forty per cent, solutions of carbolic 
acid on tap. 

"The patient complained of a feeling of weight and 
numbness, later of pins and needles, and pain in the 
lower extremities." 

Note, " Shock of the spinal cord." 

" Dr. Bliss immediately examined the wound." 

Note, "Nothing is said of antiseptic precautions." 

" Then he carried the little finger of his left hand into 
the wound." 

Note, " A dangerous operation without the spray." 

"Thereupon he carried in a bent silver probe." 

Note, ""That it was previously satisfactorily washed 
and disinfected, is not stated." 

H. : Clean hands and clean probes are at least as 
common in America as in Germany or Denmark. That 
" something is rotten in the State of Denmark," is a 
matter of common information. 

" As the President was very desirous of being taken 
to the White House, a temporary dressing" — 

Note," What is that ?" 

H. : Why that is just what it says, a temporary dress- 
ing put on to last during transportation. 

" In answer to questions, the President stated that the 
movement of the wagon did not cause any unpleasant 
feelings." 

Note, " From which it is to be concluded that the 
spinal column was not separated." 

H. : His attendants surely knew that much. 

"As there was suppression of urine until six o'clock 
in the evening." 

Note, "Urethral spasm." 

H. : Better, insufficient or disturbed innervation from 
admitted spinal shock. 

" A catheter was introduced and six ounces of clear, 
not bloody — " 

Note, "Therefore, no injury to the kfdneys." 

H. : A good point in diagnosis 

" "The carbolized-cotton dressing had become dis- 
placed and must be renewed." 

Note, " An antiseptic dressing could not have been 
so easily displaced." 



"During the night the outflow of dark blood con- 
tinued, and made frequent renewals of the dressing 
necessary." 

Note, "The dressing could not have been very 
thick." 

H. : I find nothing about frequent renewals at this 
time in Dr. Bliss's report, but if they were made, how 
thick should the dressings have been ? It appears to 
me that the abundant first and wet organic discharges 
would soon, in the hot weather especially, have be- 
come a true outward nest for infecting germs, instead 
of theoretical ones in the room. 

Drs. Agneyv and Hamilton arrived July 4th. " The 
temperature was 37.8° C, pulse 104, respiration 19." 

Note, " Therefore the whole condition was very sat- 
isfactory. In spite of this a renewed examination 
was made with probes, flexible bougies, etc., in order 
to determine the course of the ball." 

Note, "What for? According to his report. Dr. 
Hamilton disclaimed any probing. It is not stated 
whether the instruments were properly disinfected or 
whether other antiseptic precautions were observed." 

H. : Here is a question of fact, and here is an ex- 
tract from a letter of Dr. Agnew's, dated December 
5, 1882. I wrote to Dr. Agnew on account of remem- 
bering what he told me on his return from Washington 
after his first visit there. He says : " You are right ; no 
examination was made by the consulting surgeons at 
the time of their visit. They were informed Aat care- 
ful explorations had been made at the time of the 
shooting by Bliss and by Wales. Bliss admits that 
he committed an error on this point, writing as he did 
in New York and without any notes to refer to." Of 
course. Prof. Esmarch is excusable, as Dr. Bliss's re- 
port was his source of information. But one of his 
severest strictures is thus swept away, and the ex- 
pectant treatment, as we will find further on, which he 
so ardently advocates in such cases, and with which I 
am in full accord, was carried out to the letter. 

To proceed : " They were convinced that neither the 
liver, nor the kidi).eys, nor the intestine, nor the peri- 
toneal sac were injured, and refrained from any oper- 
ative interference. 

Note, "They might have known this without this 
examination." 

H. : As the exan)ination was not made, they appear 
to have been a fairly bright set of mtn, with average 
reasoning faculties. ^ 

"On the 2 1st of July a pus collection was discovered 
in the general integument which passed below the 
twelfth rib, towards the erector spins muscle, and 
underneath the latissimus dorsi; and the pus, with 
every change of the dressings, was carefully (Dr. Bliss 
says gently ) pressed out towards the wound of entrance 
(Schussbffnung)." 

Note, "Stromeyer and myself (references given) 
have most energetically spoken of the dangers of 
pressing pus out of wounds, especially, or namely, if 
splinters of bone are within." 

H. : A very important thing to protest against, but 
I will again refer to this further on. 

August 6: "A flexible catheter was passed down- 
wards through, the wound seven inches, towards the 
crest of the ilium. This was now done twice daily in 
order to rinse out the pus with an irrigator (hand 
fountain) filled with a solution of permanganate of 
potash." 

Note, " In any case an obsolete and ineffective disin- 
fection method." 

H. : Whether this was done too often or not, those 
who were in attendance were the best judges of the 
requirements; also they were at perfect liberty to select 
their disinfecting fluid, and the permanganate of potash 
is a good one. 



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January 27, 1883.] 



ESMARCH, ANTISEPSIS, AND BACILLUS. 



91 



" In conclusion, Dr. Bliss remarks that the most ap- 
proved antiseptic dressings were used during the entire 
progress of the case." 

Note, "That, certainly, does not amount to much. 
There is a great difference whether one treats a wound 
with antiseptic dressings, or whether he treats it ac- 
cording to antiseptic principles. Against these much 
that is bad has been manifestly done here." 

H.: Here are questions of fact, and the record to 
appeal to. Each one will have to judge for himself, 
though I hope not so harshly as the Professor has 
done, as to whether principles were subordinate to 
technic in the case. 

Here follows a synopsis of the autopsy, illustrated 
by the familiar drawing of the perforated vertebra and 
fractured ribs. How any surgeon can, look at that 
drawing and reflect upon the surrounding structures, 
which, if not directly, were by contiguity involved, and 
then say, not that it is nxA possible for a man so wounded 
to recover, but that he <mght to recover, through mod- 
em methods properly applied, it is hard to conceive. 

Then follow the conclusions of the Holstein Pro- 
fessor, thus : 

E. : "1. President Garfield did not receive an abso- 
lutely deadly wound. The liver was not injured ; the 
peritoneal sac was not injured; there was no peri- 
tonitis; altogether there was no important organ in- 
jured, with the exception of the vertebral column! 
The injury of the vertebral bodies was not of itself 
mortal. Healing might have readily occurred if putre- 
factive ichor (verjauchung) had not set in. In military 
surgery there are examples enough of recovery from 
similar injuries." 

H. : Instead of giving any such examples, here fol- 
lows a long foot-note about deer shooting, thus : 

Note, "Every hunter knows that the stag mostly 
survives a peculiar shot, the so-called hohlschuss. 
This is a shot by which neither the viscera, nor the 
great bloodvessels, nor the spinal cord are injured. 
As the great vessels lie directly below the faces of the 
vertebral bodies, and the spinal cord directly above 
them, the ball, in this case, must go difectly through a 
vertebral body itself. If the cord is wounded, the stag, 
on account of the paralysis of his hinder extremities, 
cannot take to his heels when the hunter comes to 
give him the final stab. 

" If the descending aorta or the inferior vena cava is 
injured, he does not fall immediately, but very soon 
after the shot, on account of the great hemorrhage. 
The ' Hohlschuss ' is considered to be a bad one by 
the hunters, because by it they do not secure the game. 
It is also of no great consequence, because no surgeon 
comes to the rescue with fingers and probes, which 
carry corrupting causes into the wound." 

H. : Allow me to suggest also that neither spray nor 
antiseptic dressings are at the service of the poor stag. 
" Pity tis, 'tis true. This is a point for the open method. 
To go on : 

" Equally also the game is not killed or secured 
when it receives a shot that only wounds the spinous 
processes. In this case the stag falls because the hinder 
extremities are paralyzed momentarily by spinal shock. 
When the hunter approaches, however, the stag strug- 
gles forwards for some distance like a seal, with his 
forelimbs, and then suddenly springs up, and on all 
fours he runs away and is quickly out of sight." 
, H. : If the deer is so soon out of sight and if also those 
who have received the Hohlschuss escape, how do you 
know whether they die or not ? Are they not as likely 
to suffer, and to languish, and to die in their solitudes, 
with such injuries, as human victims do in the open 
day ? The laborious preparers of anatomical speci- 
mens, both human and comparative, so numerous in 
Germany, should be able to show some specimens 



illustrating recoveries of the kind the Professor men- 
tions. I believe they would be very rare from the 
stag. 

As toman, the matter has been gone over so thor- 
oughly by most competent authorities that it is unneces- 
sary for me to burden you with the tedium of statistics. 
Museums have been ransacked and records have been 
searched. I have done something at it myself, and 
notwithstanding the Professor's assertion that there are 
examples enough of recoveries from such wounds as 
that of the President, I feel no hesitation in here chal- 
lenging him to produce a single human specimen un- 
questionably proving a recovery from a perforating 
gunshot wound of the body of a vertebra. This deer 
note also requires further criticism. A shot is spoken 
of by which neither the viscera, nor the great blood- 
vessels, nor the spinal cord, are wounded. What does 
the Professor call the splenic artery two and a half 
inches from its origin at the coeliac axis, where it was 
wounded ? I call it a great bloodvessel. I have pre- 
pared and mounted many a one, and we all know 
what a striking idea of great vascular supply to the 
spleen and neighboring parts is given by specimens of 
it. This artery wound was enough of itself to determine 
a fatal result. 

To go on with the conclusions. E. : " 2. The putre- 
factive ichor (verjauchung) cannot be laid to the ball, 
as it appears to have carried no septic substance into 
the wound, for it was already encapsuled and the 
neighboring part of its track was obliterated, that is, 
healed. 

" 3d. Therefore the foulness, the putrefying causes of 
the wound, must have been brought in from without, 
and for this, different points in the treatment are to be 
accused!" 

H.: Is it logical in the search for the causes of phe- 
nomena, to abandon obvious and all-sufficient ones, 
and to substitute those which are vague, unproved, 
and theoretical? What a blessing it is to live and 
learn ! In 1868, in the Pennsylvania Hospital Reports, 
in a paper called a " Contribution to the History of 
Toxaemia," I give an account of how I was poisoned 
and made seriously sick, from suddenly inhaling the 
fumes from an outburst of ichor, that gushed forth when 
I plunged my knife into a huge gluteal abscess. Inno- 
cently thinking that inward causes, possibly germs, 
may have been at the root of the trouble, I say, " we 
may imagine a micro-photograph taken of the material 
just as it gushes forth, picturing myriads of spores rising 
to a certain height and then falling dead like melting 
snow-flakes. The hapless victim who chances to be in 
the first part of the stream, catches up the living ma- 
terial, and affords a bed for its nourishment and propa- 
gation. Who knows, but what we may some day see 
such a photograph ? Stranger things have hap- 
pened." 

My hopes of ever seeing such a picture have vanished, 
for I find I was altogether wrong. The spores were 
going the other way I I am told that, without having 
taken antiseptic precautions, the moment I made my 
cut, a myriad host of cocci rushed for the wound, and 
that some cowardly divisions as they passed me by, 
sought refuge in my mouth and air-passages, and in- 
sidiously poisoned me with their foulness. The invisi- 
ble contest with the main army must have been fearful 
and altogether without the ramparts, and without quar- 
ter, for the gluteal sortie was successful, as the parts 
healed kindly and there was no evidence of prisoners. 
Notwithstanding my enlightenment, I have still a lurk- 
ing belief that it was what came out of that man, and 
not what went into, or tried to go into him, that defiled 
both him and me. 

To continue, E. : " The different points in the treat- 
ment that are to be complained of are : 



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ESMARCH, ANTISEPSIS, AND BACILLUS. 



[Medical Nevs, 



" 1st. The immediate examination of the wound with 
button probes and fingers, which were probably not 
disinfected (without antiseptic precautions). 

" 2d. The repeated examinations on the third day by 
several of the surgeons (probably so)." 
H. : We have already dealt with this point. 
" 3d. The entirely insufficient antiseptic treatment of 
the wound (deficient in the technic of dressing). 

"4th. The squeezing out of the wound undertaken 
from the 21st of July on." 

H. : Nowhere, my dear Esmarch, in your synopsis of 
the record, nor in the record itself, does the word 
squeeze occur, but you take the deliberate liberty of 
substituting, in your summing up, " Ausquetschen " (to 
squeeze),- for " Ausdrucken " (to press), and Bliss says, 
gentle pressure in one place, and pressure in another. 
Now, if you knew our beloved Dr. Agnew as we know 
him, you would know that he would not allow himself 
to squeeze any kind of wound, to work harm ; nor would 
he allow others to do it if he could prevent it. In 
practice and in precept, he is most earnest against 
roughness of any sort. Shall 1 tell you, though, what 
I know he thinks? He thinks that, for a first-class 
squeezer, there is nothing equal to an Esmarch band- 
age, and it is on account of this very squeezing prop- 
erty that I have often heard him utter warning caution 
as to its use. 

E. : " 5th. After this the daily probing and syringing 
out of the wound with unsatisfactory antiseptic fluids 
(obsolete disinfection methods)." 

"6th. The neglect of a radical division into the pus- 
cavity (8th August)." 

H. : Krom Dr. Bliss'-s account, it was in my opinion 
radical enough, and Dr. Agnew writes to me, Decem- 
ber 27, 1882, " free incisions had been made, on^five 
inches in length, opening up freely the post-peritoneal 
space of the lumbar region, in order to favor drainage, 
which was also assisted by means of drainage-tubes." 
What more the Professor would have I cannot imagine. 
He appears to find fault here for not doing enough, 
and later on we will find him blaming the attendants 
for doing too much. 

After noting the metastatic inflammation of the pa- 
rotid, which he says did not advance to a regular 
metastatic pyxmia, the Professor goes on to say that 
"The President did not die of pyaemia, but of a rela- 
tively small hemorrhage, after his powers had become 
exhausted by septic fever, by decubitus, by bronchial 
catarrh, and by hypostatic pneumonia. The hemor- 
rhage followed a laceration of the splenic artery, which 
perhaps may have been caused by the ball, or by a 
splinter of bone; but probably it gradually formed 
later, under the influence of the ichorous degeneration 
acting upon a place contused by the ball, or against 
which a splinter of bone had been squeezed (geguetsch- 
tt-n Sielle). Before the fatal hemorrhage, probably, a 
spurious aneurism had formed, which burst under the 
influence of the ichorous degeneration. If suppuration 
had not set in, the injury to the artery might not have 
produced any evil consequences." 

H. : Why depreciate the hemorrhage by calling it 
relatively small ? The record states that, besides some 
bloody fluid, the coagula which were gathered meas- 
ured nearly a pint. Is it likely that a wound four- 
tenths of an I inch long in so large an artery as the 
splenic would have healed spontaneously under any 
circumstances ? Who of us here to-night, apparently 
in full health, would give much for his chance of life 
if he knew that there was suddenly thrown into his 
abdomen a pint of blood from an ulcerated splenic 
artery ? Of the two, I would rather take my chance 
from a perforating gunshot wound of a vertebral body. 
Either would be enough to kill; our poor President 
had both conditions to contend with, and yet there are 



those who say he ought to have got well if he had had 
a fair chance. 

I notice that the Professor does not say the blood 
was pushed out of the arteries after death by the em- 
balmers' injection. He knows better than that ! 

To go on, E. : "It appears, therefore, that our col- 
leagues on the other side of the ocean have not re- 
garded our admonition as to the leading principle in 
the first treatment of gunshot wounds: ' Do no harm !' 
and the beautiful observations of Pirogoff', Klebs, 
Reyher, Bergmann, and others, upon the healing of 
the most serious gunshot injuries without suppuration, 
have made no impression upon them." 

H.: That is fine! All we have to say is, that we 
have had a few gunshot wounds on this side of the 
water, and that we have made most beautiful obser- 
vations upon them, and the outcome of those observa- 
tions is that some get well and some do not. 

E. : " The public, indeed, think that the ball is the 
most dangerous thing, and the soldier is happy when 
the ball which has been cut out of him is placed in his 
hand. The surgeon, however, should know that the 
ball itself in most cases does no harm. The real in- 
jury is what it has inflicted in its course, and what is 
superadded comes mostly from the fingers of the ex- 
aminer." 

H. : This is somewhat strongly put as to the last 
proposition, or else German fingers must be peculiar. 
With the other part I, and I think most of us, are 
in full accord, both as to practice and precept. I have 
written and taught in almost precisely the same words 
and to the same efl°ect. 

E. : " Practising American physicians seem, under 
the pressure of public opinion, to have assented to the 
proposition that much too ti/tle was done. But, accord- 
ing to my view, they did not do too little, but much loo 
much I" 

H. : It would be a fair logical sequence that, between 
these two extremes, just enough was done and no more ! 

Here is the climax and conclusion of this remarkable 
address : 

E. : " If they had left the search for the ball entirely 
alone, and immediately after the injury treated it with 
true antiseptic dressings, the President probably might 
have been now alive, even as our Emperor, of whose 
numerous shot grains Langenbeck did not cut out a 
single one.'.' 

H. : Now, my dear Esmarch, is not this «i«^ durch- 
sichligf Is it not most uncommonly diaphanous? 
For one moment to compare the bird-shot peppering 
of the Emperor with the frightful, deadly wound of the 
President ! Is it your regard for the " divinity " that 
" doth hedge a king" that makes you do this ? As I 
write, I have before me German newspapers, and an 
extra of the day, containing full accounts of the at- 
tempt on the Emperor and the after-history. On the 
2d of June, 1878, towards three o'clock in the afternoon, 
the Emperor, whilst taking a drive, was wounded by 
two discharges from a double-barrelled shot-gun , loaded 
with shot, and fired from the second-story window of 
house No. iS; Unter den Linden. 

Many of the shot were warded off" by the Emperor's 
helmet, of which he soon afterwards affectionately said, 
" How often, old helmet, hast thou done this duty for 
me ! and now again thou hast protected my life." Never- 
theless, there were wounds in the face and both arms, 
but none of any gravity whatever. A quarter of an hour 
after the outrage the Emperor took a cup of strong tea, 
and at half-past three Count Perponcher appeared upon 
the landing-place of the palace, and communicated to 
the assembled officers and cadets the facts that his Ma- 
jesty had received three wounds from grains of shot — 
one upon the left temple over the eye, a second upon 
the cheek, and a third in the hand. He gave also to 



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ESMARCH, ANTISEPSIS, AND BACILLUS. 



93 



the feverishly excited masses the comforting assurance 
that there was no danger to the life of the Emperor. 

The royal patient kept his bed for a very short time, 
and on the loth of June, 1878, the eighth day after the 
injury, at 9.30 o'clock in the evening, the following 
bulletin was issued by his medical attendants, Drs. 
von Lauer and von Langenbeck and Dr. Wilms : 

" His Majesty the Emperor feels himself strengthened 
by a night's rest, and after the dressing was finished he 
left his bed for his arm-chair. Most of the wounds are 
healed. The arm, however, is still swollen, but is not 
so painful on being moved." The case went on with- 
out a drawback to complete recovery. 

To compare this case with the President's ! Full 
well you know, Dr. Esmarch, no one better, that if two 
mortals of the baser sort, wounded respectively as these 
two great men were, had been brought together into 
your hospital, that the one, after the requisite exami- 
nation and dressing, and possibly after a few days' de- 
tention, would have been consigned to the care of the 
merest tjrro in the out-ward; while the other would 
have claimed all of your knowledge and skill as a sur- 
geon, and all of your sympathy as a man ; and, although 
you may have appeared like impassive steel at his 
bedside, your heart would have bled at his imploring 
looks for that aid, which you were powerless to give, 
beyond mere temporary help; and some morning, 
coming and finding his place empty, you would have 
thanked God that relief had come for both of you at 
last. 

When I said my discourse would be devoted to a few 
of the occurrences of the past year, I had no idea that 
one of them would take up so much of your time. The 
great event of the year, as important, if true, to sur- 
gery as to medicine, was the announcement that Koch, 
in Berlin, had discovered the origin of tubercle to be a 
bacillus, which he named the l)ac1llus tuberculosis. 
This event also was heralded by cable and wires the 
world over. I had intended to give the discovery 
more than a passing notice, and I might dwell upon 
the excitement which it caused among all classes, 
scientific and lay, especially though in Germany. 

No one has more graphically pictured the story than 
Dr. Formad, in his lecture before the County Medi- 
cal Society, on October 18, 188^. The bacillus was 
discovered. The emperor saw it and fled. Virchow 
was driven back. We are told by an imperial order 
that in military hospitals phthisical patients were iso- 
lated. The community was in a lerment. Koch's con- 
clusions are, however, not unchallenged, as the mas- 
terly labors of Formad prove. 

More interesting and instructive reading than his 
lecture, I do not know. Formad admits the bacillus, 
but denies the claim for it as a cause, and right well, 
by experiment and reason, does he sustain his propo- 
sitions. 

And now there is another antagonist at hand. One 
whom some of us know well. Dr. H. D. Schmidt, 
a former close colleague of Dr. Leidy and myself, in 
this city, but now of New Orleans. When one sees 
that man, broken in health, lame, and with hands 
terribly crippled with rheumatism, through exposure 
in the field (for this was his condition on his last visit 
here), one is lost in wonder at his enthusiasm, and at 
the way in which he produces his beautiful work. He 
writes me, under date of October 20, 1882, in a tone 
of apology, for not having sent certain preparations 
for the Mutter Museum : "Just now 1 am very busy in 
preparing a paper on the bacillus tuberculosis of Koch, 
with which I have been occupied the last three months. 
I have made very extensive microscopic researches on 
this subject, during which I prepared and examined 
several hundred sections of tuberculous lung tissue 



taken from a dozen fresh cases, besides other fresh 
sections which 1 had on hand from my studies of the 
miliary tubercle during last fall and winter, and I can 
say now that Koch's bacillus tuberculosis appears to be 
nothing else but a fat crystal iaxmsA from the fat glob- 
ules in the degenerating tubercular cells. I have found 
this pseudo-bacillus even in pathological neoplasms 
containing fattily degenerated cells. But my paper 
will tell you all about it." Here, then, is a man who 
has the temerity to deny the very existence of the 
bacillus which the emperor saw. 

1 would suggest whether it can possibly be the same 
thing that all of these men are looking at ? Koch's 
and Formad's bacilli increase and multiply rapidly 
under nurture and cultivation. Schmiiit's, if they are 
fat 6rystals (pseudo-bacilli), cannot surely do this. 

And now I hear some specialist say, after the abrupt 
manner of Esmarch, " So vow had intended to take up 
and discuss Koch's bacillus ? What do you know 
about it ?" My friend, did I say 1 knew anything 
about it ? What do you know f I have a right to an 
opinion, have I not? I, who long ago put in a most 
touching appeal for maggots ! Having noticed wounds 
healing kindly under masses of maggots, I reflected, 
that they were scavengers, eating only dead material, 
and so converting harming matter into harmless living 
substance. We have to get rid of them, it is true, 
because they will persist in getting into wrong places, 
and so give an infinite amount of trouble. Now are 
the plaguing micro-organisms of which we hear so 
much any more than consumers of dead material, 
ser\'ing (as we find them everywhere), a beneficent 
end, so long as they do not get into the wrong places ? 
Molecular death is going on continuously in all living 
tissues. In the nice balance of perfect health, the 
results are removed so completely through the blood 
and lymph-channels (so beautifully described by 
Formad), and by other means, that there is , no accu- 
mulation. When, however, disturbances arise, as in- 
flammations, for example, from any cause, abundant 
necrotic products are the consequence, and these 
accumulate faster than they can be removed. Then 
come in the migratory micro-organisms. It is a ques- 
tion of food, and is consonant with what we know of 
the movements of hosts of higher animals, possibly 
also of plants, and sometimes of man himself. As 
these organisms get into the wrong places, they, accu- 
mulating with great rapidity, help to choke further and 
irritate what has already started on an evil course, and 
so they become secondary and very fruitful causes of 
disease. We may comprehend, from Formad's views, 
how scrofulous subjects with narrow lymph-channels, 
are more readily affected than others. To my mind 
there is no positive proof as yet of the organisms being 
SPECIFIC AND PRIMARY in tkcir Operations. I must say, 
if they are so, I do not comprehend how any of us are 
alive. 

There is none the less reason to get rid of them, 
or to keep them out, in disease or injury. The prac- 
tice of antisepticism does not require a theory of a 
fixed character to make it good, as Esmarch seems 
to think, nor need it be limited to one method. From 
the germicide sprays and liquids and the cumbersome 
details of the dressings of Lister, we may come to the 
use of simpler methods equally as effective. 

It is truly astonishing how the medical, and the Ger- 
man medical mind especially, is impregnated with this 
subject. It really does seem to be a bacillary craze. I 
have before me as I write, the November, 1882, number 
of Volkman's Klinische Vortrdge, containing an essay 
by Theodor Kocher, " Upon the Simplest Means of 
Obtaining the Healing of Wounds by Agglutination 
Without Drainage-tubes." 

This writer discusses in a very thorough manner 



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ESMARCH, ANTISEPSIS, AND BACILLUS. 



[MKiiiCAL News, 



the various articles used in antisepis. The merits 
of carbolic acid, iodoform, salicylic acid, and the 
chloride of zinc, are reviewed. His own purpose is 
to advocate the use of the subnitrate of bismuth 
(wismuth), which he does with great care and de- 
tail, and gives experiments and illustrative cases. It 
is not my intention to consider the matter here, but 
I hope to give this substance a trial. Kocher says 
that it is undisputed that a great number of wounds 
heal by Lister's carbolic antisepsis process, perfected 
by Volkman, but it is also certain that this often does 
not happen. " I have seen," he says, " colleagues 
who tenaciously hold to the spray, with all the attributes 
of the Lister-Volkman technique, here and there, have 
the most grave cases of infection, after complicated 
operations." Again, and here is a refinement to worry 
us! "As it is proved that with different forms of in- 
flammation different micro-organisms come into action, 
that simple septic occurrences upon the wound and 
suppurations are not to be laid to the same cocco- 
bacteria, so it is to be inferred that by recent wounds 
and by already existing suppurations, the same anti- 
septic measures are not to be used." 

What are we going to do about it ? Different kinds 
of game, different kinds of ammunition. Buckshot for 
one. No. 12 for another. Before the surgeon can go 
to work, he must know the season, and what kind of 
germs are about, before he can select his germicide. 
The strict antiseptist is most skilled in strategy. He 
takes care of his base, and keeps the country behind 
him open. The theorj' must stand, and whatever mis- 
hap occurs is not due to it, but to incompetent officers, 
or failure in details. 

It is the fashion now for writers and thinkers to ex- 
press their ideas by epigrammatiogeneralizations, thus : 
Formad (agreeing with most recent pathologists) — " No 
inflammation, no tubercle." Koch — " No bacillus, no 
tubercle." I shall venture one which is much wider 
in its application, as it is not confined to tubercle alone, 
and according to the ideas I have expressed, it will 
meet the very great majority of cases, NO microne- 
CROSis, NO MiCROMAGGOTS ; that t's, food mostly in the 
shape of necrotic products, precedes the advent of the 
micro-organisms, however these may originate, -whether 
animator vegetable, and in disease these necrotic prod- 
ucts first, plus the organisms second, play havoc with 
their environment. I know these views will be re- 
garded as obsolete by some, and was disinclined to 
express them, until I was delighted to find that Formad, 
and I think also Dr. Joseph Leidy — and if so, I wish 
no higher authority — essentially hold them. Thus, 
Formad says, " The presence of bacilli (so far as our 
present research goes) is secondary, and appears to 
condition the complete destruction of the tissue already 
diseased and infested by them, and this destruction is 
in direct proportion to the quantity of the organisms, 
which thus regulates the prognosis. The tubercular 
tissue seems to serve merely as a nidus for the growth 
of the bacillus." 

What do I know about this, indeed ? Please remem- 
ber, friend specialist, I have put away my microscope 
for the present, and have turned dialectician. I am 
much further and much deeper than you ! You, surface 
searcher, go on with your mucous membrane ; I have 
reached the inner consciousness, and through it, sit- 
ting, like old Teufelsdreck, "alone with the stars," I 
may yet reveal a bacillus that will make you tremble. 

No one can feel more relieved than I am at having 
pasbcd safely through with the didactic. Now, do not 
despise me if I turn traitor at once, and return to my 
old love, the demonstrative. As soon as our President 
has dismissed us, the west room of the museum down- 
stairs will be thrown open. There, among other ob- 



jects of interest, you will find vertebra and vertebral 
bodies, and models illustrating the line of the Presi- 
dent's wound; also photographs of it sent to me by 
Dr. Reyburn immediately after the autopsy. You will 
see splenic arteries, human and comparative. Judge 
whether, if wounded, a hemorrhage from one of them 
would be a trifle. You will also find Esmarch's por- 
trait' and an Esmarch bandage — remember that this 
is a good thing, a very good thing; but how it can 
squeeze ! — try it. I am sorry I have nothing to illus- 
trate the wound of the Emperor. If it were reed-bird 
season, I could easily have had a boy up from the 
hospital, but reed-bird season is past. 

Scientifically speaking, these objects are coarse com- 
pared to what is prepared for you in the east room of 
the library. There, under powerful miscroscopes, you 
will see Koch's bacillus by Formad, Schmidt's pseudo- 
bacillus, which I understand him to say is identical 
with Koch's. It does not appear to me to be so, but 
the special microscopists will have to settle this. You 
thus find that, even with them, seeing is not always 
believing, a point in favor of the didactic. The slides 
of Schmidt only arrived on Saturday evening, and 
have not been seen here before. You will also see 
live bacilli and other forms of bacteria. The micro- 
scopic exhibition will be almost entirely illustrative of 
the germs which are now considered to be such fruitful 
causes of disease, but which, as you have learned, some 
of us think are secondary. 

Some of you of the laity may smile at scientific en- 
thusiasm when you come to look at these minute rod- 
like lines, averaging, say the four-thousandth of an 
inch in length. But when you reflect what importance 
has been given to them by pathologists, and what in- 
fluence they have already had, on German social life 
especially, you will understand the great interest taken 
in them. Some of the most noble and tender traits of 
humanity threaten to be undermined. The consump- 
tive who has been heretofore lavishly loved and cared 
for, and nursed with tears and parted from with an- 
guish, is to be isolated and shunned as a leper, if such 
doctrines as those of Koch prevail. Is it any wonder that 
some of us wish to look further before we adopt them ? 
Note. — There is authority enough for one in an ad- 
dress of this kind to allow the fancy some play, instead 
of keeping strictly down to the dry detail of science. 
In fact, the imagination in a right direction may be a 
great aid in developing scientific truth. 

Tyndall has fully recognized Lucretius, and Goethe 
was prouder of his science than his poetry. Dr. J. 
Gibbons Hunt had under two microscopes at this meet- 
ing, what he called the " dance of life," and the 
"dance of death." Under one glass were swarms of 
bacteria (bacillus, and other varieties), fairly seething 
with life. Under the other were inorganic particles, 
which had been kept sealed up for two years, and yet 
they were in very active movement. A curious obser- 
vation made by Dr. Hunt was, that these atoms were 
getting smaller and smaller as time went on. When- 
ever 1 see this life movement, and death in life, I think 
of the spirit lines in Faust. Goethe threw science and 
poetry into the same crucible, and subjecting it to the 
heat of his imagination, he poured out immortal ingots : 

In the sea of life, and the storm of deeds 

To and fro I rave. 

Entwine in commotion 

Birth and the grave. 

An eternal ocean, 

Webbed fabric of change. 

Life's glowing range. 

So on time's humming loom the warp I receive. 

And the living garments of Godhead I weave. 

• Ueber Land und Meer, zweiten Heftes, 1883, No. 4. 



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OPTICO-CILIARY NEUROTOMY. 



95 



ORIGINAL ARTICLES. 



OPTICO-CILIARY NEUROTOMY, UNDER THE 

ANAESTHETIC INFLUENCE OF THE 

BROMIDE OF ETHYL. 

IN WHICH ETHYLIZATION AND OPERATION DID NOT 
OCCUPY MORE THAN TWO MINUTES. 

By JULIAN J. CHISOLM, M.D., 
ntorassoK of bvb and bar sukcbrv in thb univbhsitt of hartlamo, 

BALTIHORB. 

For many months I have been using the bromide 
of ethyl daily for all operations which I could 
speedily complete, and, having experimented with 
this new agent over three hundred times in the past 
year, I am beginning to feel that I know how to 
use it and what to expect from it. I have found 
that its action is so very evanescent that it can never 
take the place of chloroform or sulphuric ether for 
any surgical operation which requires some time 
for its performance ; but for all quick work, which 
can be done in one or two minutes, the use of this 
anaesthetic agent leaves nothing to be desired. For 
this purpose it is very far superior to any other 
known anaesthetic. As the result of my every- 
day experience — for I use this agent now in every 
case in which ptain enters as a factor — a drachm of 
the bromide of ethyl, when properly used, will put 
any patient into deep narcosis in less than a minute 
by the watch. Some of my patients have been 
narcotized fully in twenty-two seconds. This deep 
anaesthetic sleep will not last more than from one 
to two minutes. From this narcosis the patient 
awakes suddenly, as if from ordinary sleep, with 
brain as clear as before the inhalation, and with 
neither nausea, headache, nor heaviness of any kind. 
I find the use of this anaesthetic a great saving of 
time in my office surgical practice, and have often 
had patients ethylized, operated upon, restored to 
consciousness, and leaving my office, feeling per- 
fectly well, within ten minutes from the time they 
entered the office door. 

These really magical effects must be obtained from 
the first inhalation, and what J will call primary 
anasthesia. Should the operation be protracted and 
a second, and even a third dose of the bromide of 
ethyl be inhaled, then I find nausea, vomiting, and 
heaviness in all respects, as if chloroform of ether 
had been used. Under this repetition the bromide 
of ethyl loses all of its advantages. To use it suc- 
cessfully and take advantage of this evanescent 
narcosis, one must be methodical and have every 
preparation for an operation made in advance. 
Should the surgeon have to seek instruments, even 
from a contiguous table, he may find the patient 
wide awake on his return. The report of the fol- 
lowing case is constantly repeated in my daily ex- 
perience with the beautiful working of this wonder- 
ful agent. 

Mr. C, aged 55, consulted me with a letter from 
his family physician, who lives 200 miles from Bal- 
timore. For five months he has from time to time 
suffered fearfully with his head and his left eye, the 
sight of which he has entirely lost, no appreciation 
of light even remaining. From the severity of his 



suffering often with nausea, the case was called a 
cerebral lesion, and the most serious results feared. 
I found the case one of acute glaucoma not recog- 
nized, and with all of the distressing symptoms 
secondary to the disease in the eye. Had an iridec- 
tomy been performed five months since, ppssibly 
the sight would have been saved and all of the suf- 
fering prevented. Now either the eyeball had to be 
sacrificed to end the frequent attacks of pain, or a 
division of the eye nerves made as they enter the 
back of the eyeball. This latter o[>eration was 
recommended to him and he accepted it. 

The patient was put on the table with the intent 
of being chloroformed, but thinking that I could 
manipulate rapidly enough to give him the benefit 
of the bromide narcosis, I determined upon the use 
of this anaesthetic, which I had just administered to 
a lady for the removal of a tarsal cyst. 

The instruments necessary for the operation were 
all placed on the table in the order which they were 
to be used. The patient was told to take full 
breath when the inhaler was placed over his face, 
and was made to practise full inspiration in ad- 
vance. A towel, between the folds of which paper 
had been put, was made up into a small nearly air- 
tight cone. Into this was poured about a drachm 
of the bromide of ethyl and immediately inverted 
over the nose and mouth of the patient. Notwith- 
standing the stifling sensation from this saturated 
atmosphere of ethyl vapor, he commenced full in- 
spirations. By the time he had taken the eighth 
inspiration I found his conjunctiva insensible to 
reflex action. He had not been inhaling the ethyl 
more than thirty seconds when deep narcosis was' 
fully established. 

The operation was at once commenced. The 
lids having been separated by the stop-wire specu- 
lum, an incision was made in. the conjunctiva on a 
line with the lower border of the inner rectus 
muscle, extending from the edge of the cornea to 
the caruncula. A second clip with the scissors 
divided the fascia and made a free opening between 
the inner and lower recti muscles. Into this open- 
ing the heavy curved scissors was introduced . Using 
it as a probe, the resisting optic nerve was soon 
found. Drawing outward the point of the scis- 
sors, the blades were widely opened, the optic and 
all contiguous ciliary nerves were caught between 
them and severed. A second opening and closing 
of the scissors, then again using it as an explorer, 
its unrestrained movements in the muscular cone 
behind the eye showed that all the structures enter- 
ing the back of the eyeball including ciliary nerve, 
arteries, and veins, had been divided. With the 
withdrawal of the scissors blood welled up from the 
wound in the conjunctiva. The speculum was im- 
mediately removed, a firm cotton compress applied 
and tightly secured by a bandage, and the opera- 
tion was completed. It took much less time to 
manipulate the instruments than it has taken me to 
describe the process. From the beginning of the 
ethylization to the tying-up of the eye the whole 
operation had not occupied a minute and a half. 
During this period the patient had been sleeping 
undisturbed, with a strong pulse, quiet respiration. 



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and a good color of face. I had hardly laid down 
his head, after securing the compress, when he 
awoke, and was very much surprised to find his 
head bandaged. He got off from the table at once 
and within three minutes from the time that the 
ethylization was commenced he was walking with 
a firm tread, unassisted, from the operating-room 
of the hospital to the contiguous ward, from which 
he seemed to have just come out. 

To eihylize efficiently, a saturated vapor must be 
used, and the inhaler must not be taken from the 
patient's face once the apparatus has been put over 
the nose and mouth. Hold it down firmly for a 
very few inspirations, and your patient will be in 
condition to have any painful manipulation carried 
out. 

In twenty-two seconds and with six inspirations 
I have established deep narcosis. 

In no one case of the three hundred has it re- 
quired more than 60 seconds. 

In no case did deep narcosis from a primary in- 
halation exceed two minutes in duration. 

In the midst of* a large surgical practice, as a 
specialist in eye diseases, I find constant daily use 
for the deep and very evanescent narcosis of the 
bromide of ethyl. I use it for the passing of nasal 
probes, splitting of the canaliculi, scraping out the 
contents of tarsal cysts, opening lachyrmal ab- 
scesses, cutting defective muscles in squint, remov- 
ing the elliptical piece of skin of the lid in ptosis 
or entropion, performing iridectomies for glaucoma, 
or for the making of artificial pupils, and, as in the 
case just reported, for optico- ciliary neurotomy. 

It needs confidence in the safety of the ancesthetic 
to push it in its concentrated form ; and I am con- 
vinced that in no other way can the best effects of a 
primary anasthetic be produced. 

It also requires quick movements on the part of 
the surgeon to complete the operation before the 
narcosis j>asses off. I have frequently performed 
the operation of squint before the medical class at 
the University of Maryland clinic in less than 
sixty seconds, this period including the whole time 
occupied from the beginning of the ethyliz^ion to 
the completion of the tenotomy. In all of the 
special operations which I have enumerated, the 
operative procedure must have beeit completed 
within two minutes to have protected the patient 
from all knowledge of what had been done, so that 
he should feel nothing of the painful manipulation. 



THE MICROCOCCUS OF GONORRHCEAL PUS- 
INFECTIVE VIRULENCE NOT DUE TO THE 
PRESENCE OF THIS PARASITIC 
MICRO-ORGANISM. 

By GEO. M. STERNBERG, M.D., 

SURGION, U. S. A. 

(Ccncludtd from f. 70.) 
REMARKS UPON MORPHOLOGY, DISTRIBUTION, ETC. 

The method which I have found most satisfactory 
and convenient for demonstrating the presence of 
micro-organisms in blood, pus, or culture-fluids, is 



the following. A small quantity of material is 
spread out upon the surface of a perfectly clean 
glass cover, so as to form a uniform and . extremely 
thin layer ; this may be conveniently done with the 
end of a clean glass slide. This is allowed to dry, 
spontaneously or by the aid of gentle heat, and is 
then stained with one of the aniline colors. Methyl 
violet i^ the staining reagent which I most frequently 
employ; a very good solution for this purpose is 
the common violet ink, for sale at every stationer's. 

A drop of this, applied to the thin glass cover, 
will stain the micro-organisms attached to it in a 
very brief time. A few seconds will usually be 
sufiicient. The staining fluid is then quickly washed 
away in distilled water, and the specimen is ready 
for examination under the microscope. 

A little gonorrhoeal pus, taken from the meatus 
urinarius of a recent case, treated in this way pre- 
sents the appearence shown in Figure i. The am- 

FlG. I. 




plification in this and in the other figures illustrat- 
ing the present paper, is one thousand diameters. 

The pus corpuscles adherent to the thin glass 
cover are flattened, and present a more or less ir- 
regular outline, as the result of the manipulation — 
spreading and drying — to which they have been 
subjected. The nuclei — so called — are deeply 
stained, and appear as violet-colored masses, often 
elongated, and presenting the aspect of a proto- 
plasmic mass undergoing division. 

That these masses are composed of living proto- 
plasm, and the unstained portions of the pus cor- 
puscles of "formed material" (Beale), seems prob- 
able 'from the fact that they are stained by carmine 
and the aniline colors. But it is difficult to accept 
the statement of the author named, that "The 
white-blood corpuscle is one thing; the pus cor- 
puscle a very different thing,'" after having exam- 
ined a specimen of pus, and a drop of blood from 
the finger, by the method above described. The 
red corpuscles lose their color, and can scarcely be 
seen after being subjected to this treatment; but 
the white corpuscles become conspicuous on account 
of their deeply stained nuclei, and resemble ex- 
actly pus corpuscles treated in the same manner. 

In addition to the stained nuclei, a certain num- 
ber of the pus corpuscles are seen to contain small 
spherical or slightly oval bodies, stained even more 



• The Microscope in Medicine. 
London, p. 304. 



4th ed. J. & A. ChurchhiU 



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THE MICROCOCCUS OF GONORRHOEAL PUS. 



97 



deeply than the nuclei, grouped in pairs, in fours, 
and, rarely, in chains of three or four. A majority 
of the pus corpuscles are free from these parasitic 
micrococci ; some contain them in small numbers 
as in the centre of the field in Fig. i ; and occa- 
sionally a corpuscle is completely filled with them, 
as shown on the left of the same figure. 

A little pus containing these micrococci intro- 
duced at the moment of its escape from the meatus 
into a flask containing a suitable culture-fluid, ster- 
ilized, and subsequently placed in the culture-oven 
for twenty-four hours, or less, at 100° Fahrenheit, 
causes this fluid, which was previously transparent, 
to assume a milky appearance. Microscopical ex- 
amination shows that this is due to the presence of 
micrococci, joined mostly in pairs, as shown in 
Fig. 2, which pervade the fluid to such an extent 
that the smallest drop contains a multitude of them. 




The fact that they are joined in pairs and that 
they are found throughout the culture-fluid, shows 
that they are in active growth and are multiplying 
rapidly by spontaneous fission. 

Later, when they have exhausted the material in 
the limited quantity of culture-fluid required for 
their nutrition, their active life ceases and they sink 
to the bottom of the flask, where they are seen en 
masse as a white deposit, while the supernatant 
fluid is again transparent. The same phenomena 
occur when, instead of pus containing Micrococcus 
urea, we use a drop of blood from a septicsemic 
rabbit, just dead, to inoculate our culture-fluid. 
But in the latter case, instead of assuming a njilky 
appearance during the active growth of the septic 
micrococcus, which now pervades our culture fluid, 
we have an opalescence sufliciently distinct, but pre- 
senting to the eye a recognizable difierence when 
compared with the other. This difference doubtless 
depends upon the fact that the septic micrococcus 
has more nearly the same refractive index as the 
culture-fluid in which it is contained, or, in other 
words, is more transparent than Micrococcus urece. 

A microscopical examination shows very decided 
morphological diff'erences in the two organisms, 
which, being constant, furnish specific characters as 
definite as are presented by many plants much 
higher in the scale. The septic micrococcus, as it 
appears when in active growth in a culture-fluid, is 
seen in Fig. 3. 

It is impossible in a woodcut to represent the 
aureola of transparent material which is a marked 
character of this micrococcus. This is well shown 
in the photo-micrograph illustrating my paper on 
septicaemia {loc. cii.) This aureola is more pro- 
nounced in the blood, and in cultures made in 



blood -serum than in those in rabbit-bouillon, which 
is the fluid in which I have commonly cultivated 
this organism. 

Fig. 3. 




The most important distinguishing character of 
the two species of micrococcus under consideration 
is found in the fact that one — the septic — divides 
in one direction only, thus forming a linear series 
of two or more oval elements attached to each 
other in the direction of their long diameter; 
while the other commonly divides in two directions, 
the elements being arranged in pairs, as seen in 
Fig. 2, or in groups of .four, as shown in Figs, i 
and 5, resulting from the transverse division of each 
of the oval elements, arranged side by side, consti- 
tuting a primary pair. 

These micrococci are not so easily distinguished, 
the one from the other, when, having exhausted 
the nutritive material necessary for their active 
development, they sink to the bottom of the cultiure- 
flask. 

Under these circumstances, microscopical exam- 
ination commonly shows little groups of spherical 
bodies, having about the same dimensions, and 
which resemble each other so closely that, as in the 
case of the seeds of higher plants (<?. g., turnip and 
cabbage), an expert might easily be at fault m at- 
tempting to distinguish one from the other. But 
by the experiment of planting in proper soil, the 
fact that essential diff'erences exist is readily es- 
tablished in both cases. And, as in the highei" 
plants, it may be shown that, after the material re- 
quired for the development of one micrococcus has been 
exhausted in a certain quantity of culture-fluid, the 
other species wtll develop abundantly in the same fluid 
upon the introduction of seed-m\CTOcocc\. This fact 
I have recently demonstrated experimentally. 

My observations show that the microscopic plants 
under consideration vary considerably as to size in 
the same culture-fluid, and in different media present 
marked differences in this respect, due to nature and 
amount of pabulum, temperature, etc., in short, to 
conditions in the environment, and favorable or 
otherwise to the growth of the plant. 

These diff'erences, when we consider the compar- 
ative size, are as well marked as in higher plants, 
and give ample scope for the development of varie- 
ties and species, under the operation of the laws 
of "natural selection." 

In Figs. 4 and 5, this diffierence in size is very 
apparent. In Fig. 3 we have Micrococcus urece, from 
urine which has undergone alkaline fermentation ; 
and in Fig. 4, the same organism derived from gon- 
orrhceal pus (third culture). 

A mere inspection of these figures might lead to 



4» 



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THE MICROCOCCUS OF GONORRHCEAL PUS. 



[Medical Nkws, 



the conviction that we have here two different mi- 
cro-organisms; but extended observations and the 
experiments already detailed, have convinced me 
that such is not the case, and that, within certain 
limits, differences in size cannot be accepted as 
specific characters among the micrococci, any more 
than in the case of turnips and cabbages. 



Fig. 




Fig, 




By the use of high powers and staining reagents, 
these differences become very apparent, and micro- 
cocci from the same source and in the same field of 
view may differ in diameter as much as one-half. 
Measurements, therefore, .have only a comparative 
value and it is easy to understand how Pasteur has 
given the diameter o( M. ureee as 1.5 /<, while Cohn 
has placed it at 1.3 to 2/1.' 

The limits of variation are even wider than stated 
by the writer last named. In Fig. 6 we have what 

Fig. 6. 




I believe to be the same micrococcus from a differ- 
ent source, viz., from a culture in acid malt-extract 
inoculated with human saliva. (**---— 

This micrococcus is found very constantly in the 
buccal secretions, where it is often seen in groups 
attached to or parasitic within the shed epithelial 
cells. I have also frequently observed it in the sputa 
of tuberculous patients, and, indeed, my studies 
lead me to believe that it is one of the most abun- 
dant and widely distributed of micro-organisms. 
That it does not, under ordinary circumstances, 
multiply in the blood or tissues of a living animal, 
and consequently is not a pathogenetic species is 
shown by the experiments already recorded, and by 
the fact that when human saliva containing it, as 
well as many other micro-organisms, is injected 
beneath the skin of a rabbit, it is not found asso- 
ciated with the septic micrococcus in the blood of 
the animal examined immediately after death. This 
experiment, therefore, affords a ready means of 
obtaining a pure culture of the septic micrococcus, 
while from gonorrhoeal pus we may obtain an una- 
dulterated stock of Micrococcus urea, the associated 
micro-organisms commonly found in normal saliva, 
or upon the mucous membrane of the healthy 

> The Bacteria. Littte, Brown & Co., Boston, 1880, p. 75. 



urethra, being excluded in one ca.se by cultivation 
in the body of a living animal, and in the other by 
some peculiarity of the pus which favors the devel- 
opment of this particular organism. 

The photo-micrograph from which Fig. 6 is 
drawn was used to illustrate my paper upon "Bac- 
terial Organisms Commonly Found u|)on Exposed 
Mucous Surfaces," etc. (Joe. cit), and I then de- 
scribed it under the generic name of " sarcina," 
with an interrogation point as to the species. This 
determination was made in actordanf-e with the 
definition given in Magncw's work (-'The Bac- 
teria," loc. cit.), whi« h is as follows : " The sarcina 
can be considered as bacteria in which the division 
occurs by two per|)endicular partitions, in such 
manner that multiplication takes place in two direc- 
tions.'' 

I have already stated th.it this mode of division 
occurs in the microco<Tus ofgowirrlioeal pus, which 
I have shown to be identical with M. urea Cohn. 
This organism may also multiply bydivi-ion in one 
direction, only so a>i to form chaplrts of five or six 
elements. It is evident then th-«t the character re- 
ferred to — divis'on in two directions — does not 
belong exclusively to sarcina, or that Cohn was mis- 
taken in referring the organism in question lo mi- 
crococcus, to which genus he gives the following 
characters : 

"Cells colorless, or scarcely colored, very small, 
globular or oval, forming by transverse division fiia- 
me- ts of two or several articles, in form of chaplet, or 
united in cellular families, or in gelatinous masses, all 
deprived of movement." 

INFLUENCE OF TEMPERATURE, ETC. 

As the result of a consi<leral)le number of experi- 
ments 1 have fixed the thermal death-point of these 
two species of micrococcus at 140* Fahr., the time 
of exposure being ten niinutt-s. A lower tem|)er- 
ature and longer exposure is, however, destructive 
of vitality. Tnus M. urea failed to multiply in a 
sterlized culture-fluid after being exposed to a tem- 
perature of 130" for thirty minutes in one experi- 
ment, and to the same temjierature for fifteen 
minutes in a second. But both sjjecies survived a 
temperature of 130" for ten minutes (experiment 
several times re|>eaied, with the same result). 

These results correspond very nearly with those 
obtained by other observers who have ex|)erimented 
with different micro-organisms protiiiied these were 
in an active growing condition, and no spores were 
present. 

Thus Cohn found that bacillus nuptilis multiplies 
freely at 45* to 50° C. (1^3° to i2»° Fah.), while 
at a ten perature of 50** to 55" all reproduction and 
development cease, and the filaments are killed.' 

Chauveau, in a recent communication to the 
French Academy upon "Attenuation of Virus by 
Heat (method of Toussaint)," says that nine or ten 
minutes' exposure to a temperature of 54° C. (129.2" 
Fah.) is sufficient to kill completely the bacilli in 
anthrax blood.' 

' The B.icteria, loc. cit. 

' C. R. Ac. des Sciences, June a6, 1883, t. xciv. p. 1694. 



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THE MICROCOCCUS OF GONORRHCEAL PUS. 



99 



Pasteur, as the result of numerous experiments 
upon "diseased ferments" — bacterial organisms — 
which injure the quality of beer, found that "alco- 
holic ferments heated in beer <an endure a tem- 
perature of 55" C. (iji° V.) without losing the 
powc-r of germination ; but the a< lion is rendered 
somewhat slower and more difficult. Diseased fer- 
ments, however, existing in the same medium, 
perish at this temperature, as they do in the case of 
wine.'" 

The author last named has shown that the re- 
action of the fluid in which micro-organisms are 
contained influences greatly the ther nal tleath-point 
of these organisms, and that this is considerably 
less in an acid than in an alkaline medium. 

From 98' to 100' Fa'i. is an extremely favorable 
temperature for the. active growth of both of the 
species of micrococcus which are umler spet ial con- 
sideration in the present paper. I'he limits above 
and below this point at which active growth is pos- 
sible 1 have not found time to determine, but my 
observations lead me to l)elieve that the sejitic mi- 
crococcus is a more del icaie plant than the other, 
and that comparatively slight variations as regnrds 
temperature and composition of nniritive medium 
may arrest its development. My efforis to cultivate 
this micrococcus for successive generations in beef 
tea have not been successful, while a fioui/lmmsAt 
from the fle-.h of the rabbit furnishes a nutritive 
fluid in which it multiplies abundantly. I first re- 
sorted to the use of this culture-fluid upon a hint 
furnished by Pasteur in the report of his experiments 
relating to the etiology of fowl cholera. A bouillon 
made from the flesh of fowls was found to be the 
most favorable medium in which to cultivate the 
micrococcus peculiar to this disease. This sensi- 
tiveness as to the temperature and composition of 
the nutritive media in which they are placed seems 
to be a common characteristic of pathogenetic micro- 
organisms, and, doubtless, is the main reason for 
the marked diflercnces as regards susceptibility to 
their pathogenetic action observed among animals of 
different species. 

The same phenomenon is a mafer of common 
observation among the parasitic fungi which infest 
different plants, -producing the diseases known as 
smut, rust, mildew, etc. We may even have a 
marked difference as regards susceptibility to the 
attacks of a certain fungus among varieties pro- 
duced by cultivation, which originated from the 
same stock. 

In the case of the septic micrococcus this sensi- 
tiveness as to composition of medium has, never- 
theless, rather wide limits, for I have been able to 
-cultivate it both in acid and in alkaline bouillon 
(from rabbit), and also in acid urine. 

Micrococcus urfce seems to be a hardy plant which 
thrives in a variety of organic liquids, and is not 
very sensitive as regards tem|>erature or the presence 
of various salts in considerable quantity, which, d 
priori, might have been suppo^ed to be prejudicial 
to its development. I have found, however, that a 

• Studies on Fermenlation. MjcmiUan & Co., LonJon, 1879, 
p. ao. 



temperature of 60° Fah. is not sufficient to promote 
its active growth, and that steiilized urine to which 
a culture- fluid containing this micrococcus has been 
added, remains acid and transparent for a consider- 
able time at this temperature. 

The writer has for some time past been engaged 
in an experimental study of the action of various 
germicides upon these micrococci and upon other 
micro-organisms, but this is an investigation involv- 
ing a large amount of labor, and some time will be 
required (or its completion. 

in conclusion I beg leave to call the attention of 
any who may be inclined to under-estimate the 
value of studies of this nature to the fact that, aside 
from questions of professional interest relating to 
the role of micro-organisms in the etiology of in- 
fectious diseases, and the best methods of combating 
I)athogenetic bacteria within or without the living 
body, biological problems of great interest are best 
approached by stu<l)ing the vital (chemical?) reac- 
tions of ihese extremely minute unicellular organ- 
isms, which offer the simplest possible conditions 
for such studies, and which may be manipulated by 
the biologist by modern scientific methods with as 
much certainty as regards definite and constant re- 
sults, the conditions being the same, as is possible 
lor the chemist in his operations with non-living 
material. 

Notf. — Since the abive was written, I have 
stimiWed upon the following in The Medical Record, 
of Sept. 23. p. 359. 

" The Gonococcus — Meisser in Breslau, who in 
1879 published the discovery of a micrococcus 
which was to be found in every case of specific 
blennorrhcea, either of urethra orof eye, but nowhere 
else, has recently recorded his conviction that this 
"gonococcus," as he calls it, is the specific agent 
in producing the disease; and quotes Aufrecht, 
Ehrlich, and Giffkey, the opthalmologists Leber, 
Sattler, and Hirschberg in support of his statements. 
But until recently the expenmentum crucis — suc- 
cessful inoculation of the micrococci — had never 
been performed from the simple fact that animals 
are not susceptible to the gonorrhceal contagion, 
and human subjects have always preferred to acquire 
theirs in another way. Recently, however, Bokai, 
in Pesth, was so fortunate as to find six philan- 
thropic students who placed their urethras at the 
disposal of science. With the 'gonococci' which 
Bokai had cultivated artificially from gonorrhceal 
discharge, the six were inoculated ; and three had 
the satisfaction of exhibiting a week later a classical 
gonorrhoea. For one familiar with natural history 
of medical students, the experiment would have 
been far more convincing if the dauntless three had 
been kept in solitary confinement for a week before 
and after the inoculation." — IV. T. Belfield, in 
Chicago Medical Journal and Examiner. 

PosTSCRirTVU.—Expfrtm<n/ No. /j (Oct. 5. i88i) : 
A pure culture of the micrococcus from gonorrboeal 
pus (ihe thirtieth culture (?) or above) was introduced 
into the urethras of two healthy men by means of pledgets 
of cotton wool, soaked in the fluid, which were left ift 
silu for fifieen mintes. 

Result entirely negative. 



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MEDICAL PROGRESS. 



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MEDICAL PROGRESS. 



Bacteria and their Presence in Syphilitic Se- 
■ CRETIONS. — Dr. Morison, of Baltimore, who is at 
present working in Prof. Neumann's laboratory in Vi- 
enna, has published in the January number of the 
Maryland Medical Journal an account of the patho- 
genetic organisms found in the lesions of syphilis and 
of the non-spocific venereal ulcers. The organisms 
supposed to be specific for syphilis were found in sec- 
tions of the hard chancre, and in numerous syphilitic 
skin affections, always' at the seat of disease and never 
in the genieral blood circulation; in this they agree 
with the bacilli of tuberculosis and of lepra. They 
are only visible when stained, and the method of stain- 
ing is rather complicated ; but doubtless this method 
will be so modified in the course of time as to be much 
simpler, as Koch's original method for staining the bacil- 
lus tuberculosis was subsequently modified by Ehrlich. 
The bacilli described by Dr. M., are short cylindrical 
rods. In the lithograph we notice that some of them 
are slightly bent, and have in places the appearajice of 
lying together in paiiis ; in point of size we shbuTd say, 
judging from the plate, drawn under a power of X 850, 
that they are somewhat smaller than tubercle bacilli. 
The bacilli found in non-specific ulcers (chancroidj) 
are longer than the syphilitic, are extremely thin and 
in the plate represented as curved; from which we 
would suppose that they belong rather to the group of 
spirpchaete, and not to the true bacilli. We must dis- 
agree with the author when he says that they closely 
resemble the bacillus anthracis. The number of germs 
discovered by various observers in syphilis are many, 
most of them being found in the blood as well as at 
the seat of the lesion. No special method of staining 
was used to demonstrate them and subsequent inves- 
tigation failed to confirm them. By this last discovery 
of Morison's, we see that only by the employment of 
the most complicated methods of staining, and the use 
of the now indispensable Abbey's illuminator and oil 
immersion glasses, can they be seen. At best, how- 
ever, we fear that, although the bacilli may be cuiti 
vated with success, strict proof of their causal connec- 
tion with syphilis will always be wanting, owing to the 
impossibility of infecting lower animals with the dis- 
ease. The experiments which the author mentions 
— those of Martineau and Hamonic on young pigs — are 
so utterly at variance with former experiments, that 
they must be confirmed. We can only hope that this 
latest bacillus in the field will not share the same fate 
at the hands of the great New Orleans microspopists 
as did the bacillus lepiae and b. tuberculosis. 

Elongation of Nerves.— M. Tr^lat, at the meet- 
ing of the .Soci6'6 de Chirurpie held December I3lh, 
read a report on a work of M. Badal, of Bordeaux, 
on this subject. Recently M. Badal has stretched the 
external nasal nerve in three cases of circum-orbital 
neuralgia, and in all three cases a cure resulted. The 
operation is very readily performed by making an in- 
cision hear the angle of the eye, and exposing the 
nerve between the tendon of the orbicularis and the 
great oblique muscle. — Gaz. Med. de Paris, Decem- 
ber 23, 1882. 

Simple Method for Detecting Tubercle-ba- 
cilli IN Sputa. — The following plan is followed in 
the pathological laboratory of Prof. Rindfleisch, in 
WiirEburg. A portion of ihe sputum is pressed between 
two covtr-glasses, which are then separated and dried 
in the air. A staining fluid is prepared according to 
Ehtlich's foimula ; the cover slip is then passed three 



times rapidly through the flame of a spirit-lamp, the 
sputa being on the upper side, and then floated in the 
staining fluid, which Is contained in a watch glass, and 
the latter held over the flame until the fluid commences 
to vaporize. The cover-slip is then removed, washed 
in a stream of water, and laid in absolute alcohol 
which has been slightly acidulated with nitric acid, 
when the color will be removed in about ten seconds. 
The slip is then taken out of the alcohol, again washed 
in water, dried, and mounted in balsam. — Wiener Med. 
fresse, December 24, 1882. 

Jequiriti in the Treatment of Granulation of 
the Conjunctiva. — At the meeting of the Soci6t6 de 
Chirurgie held December 13th, M. Terrier read a 
report on a memoir of M. Jos6 Cardosa, of Rio Ja- 
neiro, on the employment of this drug. The jequiriti 
is a leguminose plant; an infusion made of the seeds 
and employed as a lotion to ihe conjunctiva in cases of 
granulations, sets up an acute inflammation, and may, 
in large doses, even cause severe accidents. M. de 
Wecker has employed Uie preparation with satisfac- 
tory results, while in the only case in which M. Terrier 
employed it an intense purulent conjunctivitis was set 
up, which was cured without the granulations under- 
going the least improvement. So while in certain cases 
It may be used with success, it should always be em- 
ployed with caution. M. Desprfes maintained that the 
only justifiable treatment of this disease was excision 
of the granulations when chronic, while, when inflam- 
matory, they may be cured by cauterization with sul- 
phate of zinc or nitrate of silver. — Gas. Med. de Paris, 
December 23, 1882 

Dislocation of the Liver. — At a recent meeting 
of the Society of German Physicians in Prague, Prof. 
Pribram reported a case in which, on account of a 

f>yopneumothorax of the right side, the diaphragm and 
iver were displaced downwards. The liver had en- 
tirely left its normal situation in the right hypochon- 
drium, and was so twisted that, while the left lobe was 
only slightly displaced downwards, the remainder of 
the liver lay with its long axis vertical, and its nor- 
mally inferior surface looking to the left. As a conse- 
quence of this dislocation, the transverse colon was 
bent on itself, and displaced downwards nearly as far 
as the symphyses. This condition had been recog- 
nized during life, and caused a certain amount of ob- 
struction during life, particularly to the escape of blood 
from hemorrhage from a large tubercular ulcer in the 
duodenum. — Wiener Med. Presse, December 3, 1882. 

Treatment of Hydrocele. — The following is the 
treatment of hydrocele employed by Dr. Cattaneo 
in the hospitals at Pavia : 

1. Puncture of the hydrocele with a capillary trocar 
of an aspirator, and evacuation of the fluid. 

2. Injection of a solution of hydrate of chloral in 
quantity proportionate to the volume of the hydrocele 
and age of the patient ; one to two grms. of chloral tor 
children, four grams, for adults, and occasionally more 
in old men. The solution is made by dissolving equal 
parts of chloral in cold distilled water. 

3. Cold applications to overcome the pain produced 
by the injection. 

4. The injection is repeated if the absorption occurs 
too slowly. 

The patients are kept in bed during this treatment 
and wear a suspensory bandage for some time after- 
wards. It is claimed by Dr. Lampagnani, who reports 
this treatment, that the effusion has not returned in 
any one of seventeen cases so operated on, nor have 
there been any complications in any cas^.—Joum. de 
Med. de Paris, December 9, 1882. 



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A WEEKLY JOURNAL 
OF MEDICAL SCIENCE. 



Communications are invited from all parts of the world. 
Original articles contributed exclusively to THE MEDICAL NEWS 
will be liberally paid for upon publication. When necessary to 
elucidate the text, illustrations will be furnished without cost to 
the author. Editor's Address, No. 1004 Walnut St., Philadelphia. 

SirascRipTioN Price, including Postage, 

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be made at the risk of the publishers, by forwarding in registered 
letters. 

Address, HENRY C. LEA'S SON & CO., 

Nos. 706 & 708 Sansom Street, 

Philadelphia, pa. 

SATURDAY, JANUARY 27, 1883. 

HATIOVAI. PUBLIC HEALTH LEOISLATIOK. 
During the present session of Congress but three 
bills have been introduced which have any special 
relation to sanitary matters. These are : 1, a bill 
introduced by Mr. Hardenbergh in the House, 
Dec. 19 (H. R. 7,085), " To prevent the importa- 
tion of adulterated teas;" 2, a bill introduced in 
the Senate by Mr. Harris (S. 2,259), "To repeal 
the tenth section of the Act approved June second, 
eighteen hundred and seventy-nine," etc. ; and, 3, 
a bill introduced in the Senate by Mr. Conger (S. 
2,284), and in the House by Mr. Rich (H. R. 7,121), 
" To provide for the sanitary inspection of immi- 
grants." 

We shall probably have occasion to refer to Mr. 
Hardenbergh's bill hereafter, in speaking of adul- 
teration of food and drugs legislation ; at present we 
shall only consider the bills of Senators Harris and 
Conger. The bill of Senator Harris repeals the 
tenth section of the Quarantine Act of June 2, 
1879, which reads as follows, "Sec. 10. This Act 
shall not continue in force for a longer period than 
four years from the date of its approval ; " and also 
repeals the clause of the appropriation bill of last 
year which restricted the operations of the Board 
to cholera, yellow fever, and smallpox. It also pro- 
vides that, of the unexpended balance remaining to 
the credit of appropriations made for the National 
Board of Health, 1 124,000 shall be available for 
the u-se of the Board during the next fiscal year, 
and that an additional sum of 1 100,000 from the 
unexpended balance of moneys to be used only in 
cases of epidemic shall in like manner be available 
for the same purpose during the coming year. 



Senator Conger's bill provides for an appropria- 
tion of $25,000 "To enable the National Board of 
Health to cooperate with State and local boards of 
health*, and local quarantines; and to continue dur- 
ing the remainder of the current fiscal year the san- 
itary inspection of immigrants, for the purpose of 
preventing the introduction of smallppx and other 
contagious diseases into the United States, and 
their spread from one State to another." It will 
be seen that this last bill simply provides funds to 
carry on the iiispection work until the 30th of June, 
the appropriation made last year being insufficient 
for this purpose. So far as we can learn, there is 
little probability of the passage of either of these 
bills in a separate form by the present Congress, 
owing to the fact that this is the short session, and 
that there is a vast amount of legislation pending 
in which members of Congress are much more ac- 
tively interested than they are in health mattere. 
It is, however, possible, that the substance of one 
or both of these bills may be incorporated as a 
clause in the appropriation bill, although the hos- 
tility of the chairman and other members of the 
House committee of appropriations to the National 
Board is such, that any such clause must probably 
be put in as an amendment, in the face of their op- 
position. 

Since the publication of the editorial on the Na- 
tional Board of Health in our issue for Nov. 11, 
1882, page 546, we have received an unofficial letter 
from Dr. Hamilton, Surgeon-General of the Marine- 
Hospital Service, in which he expresses a general 
concurrence with our views as to the essential func- 
tion of a national health organization, and incloses 
the following extract from a communication made 
by him to a member of the Public Health Com- 
mittee of the House, dated March 6, 1882 : 

"It may be asked what there would be left for 
the board of health to do [after the loss of the na- 
tional quarantine]? In answer, it is only necessary 
to point out the scores of questions yet undecided 
as to the causation and prevention of diseases and 
epidemics, as well as the consideration of the dif- 
ferent problems connected with public and domestic 
hygiene about which a board of health might be 
reasonably supposed to concern itself. The dignity 
and usefulness of the Smithsonian Institution have 
never yet been impaired by the fact of its complete 
severance from executive work, and I am sure that 
the board of health would grow in popular favor 
and largely increase its usefulness by a slight change 
in its constitution, a more proper direction of its 
work, and its complete disconnection with executive 
work for which it has evidently neither adaptability 
nor facilities." 

In his letter to this journal. Dr. Hamilton still 
further defines his position in the following words : 



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I02 OSSEOUS AND ARTICULAR LESIONS IN LOCOMOTOR ATAXIA. [Medical News, 



" I have and shall continue to oppose the transfer 
of sick sailors to the National Board under the 
guise of a national quarantine, but I do not oppose 
the Board or its legitimate work. The work of this 
service is the health and hygienic interests of 
sailors and boatmen, but if we are to have a na- 
tional quarantine at all, I claim that the Treasury 
Department, which not only has metiical o^ctn,, but 
the customs officers and coast guard at its disposal 
as well, is the proper department. . . . Now 
it is more reasonable that the commercial interests 
shall be consulted in the disposition of this matter 
than that a few office- holding 'sanitarians ' should 
disturb the ordinary channels of business for the 
sake of bestowing a few offices upon their favorites. 
Now if offices are to be created de novo, we do not 
concede that the National Board of Health has any 
better facilities for procuring them, or that their 
system of appointment affords any better, guarantee 
that they shall be competent than the method now 
pursued by the other branches of the public med- 
ical service ; on the contrary, while the Board does 
not examine its appointees, the Army, Navy, and 
Marine-Hospital Service require theirs to pass a 
rigid professional examination." 

We have quoted thus fully from Dr. Hamilton, 
because we desire to have his views fully and fairly 
represented. It is much to be regretted that there 
is a certain degree of hostility existing between the 
Marine-Hospital Service and the National Board, 
and the more so since this hostility appears to us to 
be almost entirely groundless. We cannot under- 
stand, on the one hand, why the National Board 
should object to the transfer of all quarantine execu- 
tive work to the Treasury Department, nor, on the 
other hand, how it can in any way interfere with 
the work of the Marine- Hospital Service to have 
the work of aiding State and local boards in quar- 
antine work performed through the National Board, 
as at present. 

Dr. Hamilton is rather unjust in his sneer at sanita- 
rians and their motives, as we think he would admit 
upon reflection, but it must be remembered that 
his letter was written just after the meeting of the 
American Public Health Association, where some 
of the sanitarians were disposed to speak harshly of 
his services, and it will be observed that he dis- 
claims all hostility to the Board itself. Since our 
last editorial on the National Board, Dr. Folsom and 
Mr. Phillips, the Solicitor-General, have withdrawn 
from it, and some criticism has been made of the 
remaining members, in that they have not also re- 
signed, and have appealed to physicians and san- 
itarians to influence Congress in their behalf. 

It seems to us, however, that the question as to 
propriety of resignation is purely a matter of indi- 
vidual view as to what is becoming and to the best 



interests of the Board under the circumstances; and 
there is plenty to be said on both sides. We can 
see no impropriety in their having appealed to 
physicians and sanitarians; there is, in fact, no 
other class to xvhom they can properly appeal for a 
competent judgment as to whethei; they have done 
well or ill. The question must be settled in some 
way very soon, for if Congress at its present session 
does nothiiig, the present Quarantine Act lapses on 
the second of June next, and the Board remains 
under the constituting act alone. Whether the 
lapsing of the present quarantine act revives the 
one which preceded and was annulled by it, and 
which put the matter in charge of the Marine- Hos- 
pital Service, is a legal question, not yet decided; 
but probably it does not. 

As indi'-ated in our previous editorial, this ques- 
tion of quarantine, and who is to act as almoner for 
the United States with regard to it, seem to us 
questions of secondary importance as compared 
with the question whether we are to have a National 
Health Commission, to carry out investigations 
into the etiology of disease, and furnish authorita- 
tive and reliable advice and information when they 
are required. It is probably impossible during the 
present session of Congress to obtain legislation 
which will put the National Board of Health upon 
a proper footing, but, at all events, an effort should 
be made to prevent its abolition, or the leaving it 
entirely without means or duties. 



OSSEOTTS AKD ABTICTTLAIl LESIOITS IH LOCOKOTOB 
ATAXIA. 

The advantages which the wide experience of a 
large hospital afford in the study of disease are es- 
pecially well seen in the accumulation of many cases 
of .comparatively rare disorders, or of unusual re- 
sults of the more common. Such cases gravitate 
naturally toward these centres. And when to the 
great hospital is added a man of uncommon force 
and acumen like Charcot, this centripetal force is 
still more marked. Many of us have seen isolated 
cases of fractures and other bony lesions in ataxia, 
but at la Salp6tri6re Charcot has had them by the 
score, and his accumulated facts are so much the 
more valuable.. 

In a recent number of the Archives de Neurohgie, 
FfeRfe presents an elaborate description of the speci- 
mens from eight cases not previously related, col- 
lected by Charcot since 1876, besides others which 
have been given to the Mus6e Dupuytren, the 
Hunterian, St. Thomas' Hospital, the Manchester, 
and other museums. Eighteen excellent woodcuts 
illustrate the paper. 

One of these patients furnished the first complete 
ataxic skeleton ever examined, and with the result 
not only of verifying numerous lesions of bones and 



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THE TREAXMRNT OF TYPHOID FEVER. 



103 



joints recognized during life, but of discovering a 
fracture of the right ilium and left fibula, which 
had passed unperceived. For the first time also an 
arthropathy of the temporo-maxillary articulation 
has been observed post-mortem. In this series the 
hip-joint and the shoulder were chiefly affected, 
especially the first. The head of the femur and 
humerus had frequently disapi>eared, and in some 
cases the entire upper end was gone, leaving only a 
conical stump-like extremity, rough, porous, eroded, 
and corresponding to an equally diseased cotyloid 
cavity. Dislocation was not uncommon, and a strik- 
ing full-length figure of a woman is given, in whom 
the end of the left humerus presented under the 
clavicle, and the upper end of the left tibia and fibula 
were dislocated backwards and upwards four inches 
above the condyles of the femur, stretching but not 
rupturing the crucial ligaments. 

The now well known frequency of fractures in 
ataxics finds several illustrations here. Some are 
re united firmly, others by fibrous union, and in one 
case the fragments of the ilium, though united on 
the internal surface by bony callus one centimetre 
thick and four wide, showed not the slightest trace 
of any effort at repair in the exterior. In another 
case the fractured head of the femur, instead of 
uniting with its shaft, had consolidated with' the 
ilium in an acetabulum so eroded that the femoral 
head could be seen from the pelvis. Moreover, the 
head of the femur and the floor of the acetabulum 
projected as a bulging tumor into the pelvic cavity. 

It is of not a little interest to observe that the 
very first hint of the spinal origin of these joint 
diseases was given by the late Prof. J. K. Mitchell, 
of this city, in the American Journal of the Med- 
ical Sciences so long ago as 1831 and 1833, and that 
his son. Dr. S. Weir Mitchell, in the same Journal, 
in 1873 *°d 1875, ^*s made some of the late and, 
we regret to add, rare American additions to our 
stock of knowledge in reference to such articular 
and osseous lesions. To Charcot, however, more 
perhaps than to any other one author, do we owe 
our knowledge of the subject. He has. insisted, as 
opposed to Volkmann and others, that the lesions 
are not traumatic but spinal in their origin and 
trophic in their character, and, again, that the joint 
disorders are totally distinct from ftiose of ordinary 
dry arthritis. 

Certainly specimens and cases, such as these and 
others which he has described in his Lefons, seem 
to prove both of his points to be well taken. The 
period at which the troubles occur, long before the 
incoordination of the later disease ; the absence of 
prodromata; the malignancy of the disease, as evi- 
denced by the rapid and complete erosion and even 
disapp)earance of the whole upper end of so large 
and stout a bone as the femur, with other almost as 



striking characteristics, are primi facie evidence of 
the correctness of his view. Moreover, the pecu- 
liar articular lesions following injuries to the 'pe- 
ripheral nerves, as well as of the cord, first pointed 
out by Weir Mitchell and his colleagues during the 
late civil war, and now well recognized as clinical, 
facts, are very strong evidences in favor of the neu- 
rotic origin of such osseous and articular lesions, 
even though of so extraordinary a character. 



THB TBE&TKSITT OF TTPHOIS FEVEB. 

In a recent discussion before the Acadhnii de 
Midecine, Dr. Dujardin-Beaumetz passed in re- 
view some of the methods now most employed in 
the treatment of typhoid. These methods may be 
referred to two categories: the antipyretic; the 
antiseptic. The antipyretic consists chiefly in cold 
baths and massive doses of quinine. The bath 
treatment is not without danger in the way of caus- 
ing congestion of the lungs, and the use of quinine 
in the large doses now employed would produce 
toxic effects if it were absorbed, but the greater part 
of it may be recovered from the stools. Salicylic 
acid causes stomach trouble : and if well borne does 
not modify in any way the severity of the disease, 
or lessen its duration. Carbolic acid is a dangerous 
medicine, which may induce collapse or.set up pul- 
monary congestion. In the estimate made of any 
plan of treatment, the type of the epidemic must be 
taken into account. 

Rejecting thus in turn the various novelties of 
treatment. Dr. Dujardin-Beaumetz maintains the 
superiority of that which he styles "the classical." 
It consists in the occasional administration of purga- 
tives, a proper alimentation, careful attention to the 
hygiene of the patient, and the use of means to 
combat unfavorable symptoms as they arise. In 
other words, except the use of purgatives, his method 
is that entitled "expectant" in this country. 



STSAW IK THE STBEET CABS. 

Notwithstanding the comparatively recent in- 
troduction of street passenger cars, there remain 
certain usages connected with their service which 
are relics of the barbarous past, and which are totally 
void of excuse. Notable among these barbarisms 
is the condition in which our horse-cars are kept 
during the winter months. 

While cars transported by steam are models of 
comfort, and even luxury, the comfort and health 
of those multitudes who are compelled to use the 
street-cars of our large cities are treated with abso- 
lute contempt. Nay, there would seem to be a 
reckless disregard of the comfort and health of 
those who patronize these vehicles. 

Let any one fresh from reading a description of 
Koch's investigations on the "bacillus tuberculo- 



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THE QUALIFICATIONS OF A HEALTH OFFICER. 



[Medical News, 



sb," enter a street car on a wet, muddy, winter 
afternoon. Let him glance at the damp, soggy, 
straw or hay which covers the floor, and notice the 
frequent expectoration in the material thus care- 
fully provided for the cultivation of germs, and we 
defy him to avoid the ardent hope that Koch is in 
error, and his bacillus imaginary. No wonder that 
so many prefer to take their chances of pneumonia 
and pickpockets upon the rear platform. 

Should the day be cold, and the door and win- 
dows be carefully closed in consequence, the street- 
car traveller may reflect upon the scars adorning 
his neighbor's face, and amuse himself by estimat- 
ing how many as yet undetached variolous crusts 
still adhere to his person, or he may pursue his re- 
flections so far as to speculate how many may be- 
come detached and find a resting-place in the lux- 
urious hay carpeting at his feet. 

We need not follow the investigator into his 
speculations concerning the whole list of contagious 
diseases. Of one thing we may rest assured, that 
he will arrive at the conclusion that the ingenuity 
of man has not devised any one thing better fitted 
to both concentrate and disseminate morbific poi- 
sons than the average horse-car in winter. Such a 
state of things is a disgrace to our civilization, and 
results from an utter absence of progressive spirit 
on the part of the managers of these corporations. 
It comes from simply allowing things to remain as 
they were in the beginning. In this case there is 
every reason why they should not so continue, and 
there is no excuse for street cars not being both 
properly w'armed and ventilated, since numerous 
efl&cient devices to this end are in the market. 

The enormous power wielded by street railroads 
makes it difficult to deal with the matter by muni- 
cipal legislation. Nevertheless, the evil is a great 
one, and is worthy of most careful consideration by 
all who are interested in the health of the public. 



THE QXrALUnCATIOHS OF A HSALTH OFFICZB. 
The rapid advance in sanitary knowledge, and, 
as a consequence, the more exacting demand for a 
careful and wise administration of sanitary law, re- 
quires a rigid scrutiny into the qualifications of all 
executive oflicers of health. So varied and respon- 
sible are the duties entrusted to the health officer of 
a large town or city that, without s[>ecial knowledge 
and training, and good administrative ability, the 
holder of the position cannot successfully discharge 
the obligations of the trust. Recognizing the sound- 
ness and wisdom of this principle, the local govern- 
ment of England has long since, required that all 
health officers shall be medical men, who, by educa- 
tion and training, are especially fitted for the work 
of investigating the causes and prevention of dis- 
eases, the management of epidemics, supervision of 



sanitary inspections, and the intelligent administra- 
tion of the laws of health. 

It happens too often in this country that the 
position of health officer is one of political reward, 
without consideration of personal and professional 
qualification. The result is an inefficient, haphazard, 
and automatic execution of the laws, and a failure 
to judiciously and efficiently carry out the duties of 
the office, through ignorance of the fundamental 
principles of public and private hygiene. 

A health officer should be an experienced sani- 
tarian, and a physician of thorough education. He 
should be capable of advising the sanitary authori- 
ties in all matters afiecting the health of the people, 
and he should be competent to intelligently inquire 
into the causes, origin, and distribution of diseases, 
to ascertain to what extent they are capable of re- 
moval or mitigation, and to make use of all the 
means at his disposal for the preservation of the 
public healtJi. He should give his entire services 
to the position; he should receive a liberal com- 
pensation, and should have the assurance of con- 
tinuance in office so long as the duties of it were 
judiciously and efficiently discharged. The present 
uncertain tenure of office is a bar to an eligible ap- 
pointment, as none but a professional office-seeker 
is willing to throw aside the advantages of a perma- 
nent avocation for an office of uncertain tenure. 

The recent selection of a health officer for Phila- 
delphia ignores the fact which we have endeavored 
to set forth that special knowledge and training are 
preeminently the qualifications required for such an 
important office. 

Leiter, the well-known instrument maker of 
Vienna, has introduced an apparatus for the local 
application of heat or cold. It consists of a flexi- 
ble metal tube, which may be made to adapt itself 
to any surface. Thus, if it is desired to apply a 
given temperature to the abdomen, the tube is 
coiled on itself until it has the proper size, and 
moulded to fit the surface. The entrance tube is 
connected with a vessel containing water at the de- 
sired temperature, and the exit tube empties into 
any suitable receptacle. The principle is by no 
means new, but the adaptation of flexible metallic 
tubes which can be moulded to any unequal surface, 
is the point of novelty. At Billroth's clinic these 
tubes have been employed by Dr. Mikulicz in joint 
inflammations, in phlegmon, in traumatic delirium, 
in erysipelas, in rapidly growing sarcomata, and in 
neuralgia. Sometimes heat, sometimes cold, is 
found to be more effective. They are applied with 
equal facility, of course. The ordinary rule for their 
application is equally operative in the use of these 
tubes — the sensations of the patient being the true 
guide to the degree of heat or cold respectively. 



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SOCIETY PROC EEDINGS. 

NEW YORK ACADEMY OF MEDICINE. 

Stated Meeting, January 18, i88j. 

The Vice-President, Robert F. Weir, M.D., 
IN THE Chair. 

The Secretary read a letter frcmi Dr. Charles Mill, 
in which he presented an elaborate engraving of John 
Hunter to the Academy. Enclosed was a printed slip, 
taken from Harper's Magazine, descriptive of the en- 
graving. The engraving was the work of Mr. William 
Shaw, a celebrated engraver of the last century. 

Dr. Adams said that the original portrait, from 
which this engraving was made, was in St. George's 
Hospital. He moved that the thanks of the Academy 
be extended to the donor for his generous gift. 

The first paper of the evening was by Dr. Paul F. 
MuNDi, and was entitled, 

SECONDARY PUERPERAL HEMORRHAGE. 

While the occurrence of more or less alarming 
uterine hemorrhage immediately after or during the 
first twelve hours following delivery is by no means 
uncommon, and has been thoroughly discussed in all 
the text-books and in the current medical press, the 
subject of metrorrhagia at a later period of the puer- 
peral state, so-called " secondary hemorrhage, has 
received comparatively little attention. 

The author reported the case of a woman twenty- 
five years of age, whom he had seen in consultation m 
her fourth labor, which was very tedious, and after it had 
lasted for twenty-one hours, the forceps were applied, 
but slipped. After a short time delivery was effected 
by perforating the cranium and applying the cephalo- 
tribc. The cause of the difficult labor was hydro- 
cephalus. On the sixteenth day she was taken with 
profuse hemorrhage, which soon threatened her life, 
but from which, by appropriate treatment, she ulti- 
mately recovered. 

The subject of secondary hemorrhage occurring at 
a late date was then considered, and the paper con- 
cluded with the following brief rules for the manage- 
ment of the third stage of labor, and the early puer- 
peral state : 

1. Always keep the supporting and compressing 
hand on the fundus uteri from the moment the head 
appears at the vulva until the placenta is expelled. 

2. Do not hasten the expulsion of the placenta too 
much, but by steady, gentle friction of the fundus en- 
deavor to obtain its total spontaneous detachment, the 
occurrence of which can easily be detected by the uni- 
forir» firm outline of the contracted utei-us on palpa- 
tion. 

3. Always watch the uterus with the hand, using 
gentle friction for at least an hour, at intervals, before 
leaving the patient. 

4. Always give ergot (one drachm or more of the fl. 
extr.) by the mouth, immediately after the birth of the 
child. If chloroform has been given for an operation, 
or if the labor has been unusually tedious, give the 
ergot hypodermically, injecting a syringeful of the fl. 
extract to the depth of one inch, near the umbilicus. 
It is always advisable to have the syringe filled with 
ergot, and to see that it is in good working order, before 
the conclusion of the labor. 

5. Always have ice on hand ; and if the uterus shows 
a reluctance to remain contracted, rub the fundus 
gently with a piece of ice, or insert a cone-shaped 
piece into the cavity. (As a rule, the injection of hnt 
water, while a powerful styptic, is less agreeable to the 
patient at this time, and will scarcely be employed 
unless actual hemorrhage occurs.) 



6. Always make sure by palpation and compression 
that the uterus contains no coagula, and if such still 
form at once express them. 

7. Aid in securing permanent contraction of the 
uterus by an early application of the child to the 
breasts. 

8. If the labor has been tedious or instrumental, or 
the uterus contracts badly, or the patient is not to 
nurse the child, or is constitutionally feeble, it is wise 
to guard against sub-involution and a long continuance 
of the bloody lochia, by giving the patient a pill con- 
taining one or two grains of Squibb's aqueous extr. of 
ergot, two grains of quinine, and one-third of a grain 
of extract of nux vomica, three times a day, for ten 
days or two weeks, or longer, beginning on the day 
after delivery. If the stomach is irritable, this combi- 
nation may be given in rectal suppositories, the quan- 
tity of ergot being doubled. 

9. Before leaving the patient, an equably tight binder 
should be applied, and if there be tendency to hemor- 
rhage, a pad should be placed under the binder over 
the fundus, to secure its steady compression. 

10. Examine the cervix and vagina with the finger 
immediately "after dehvery, and if there be a laceration 
of either, be prepared to check possible future oozing 
by mild astrmgent injections, or, if need be, applica- 
tions through the speculum. (Immediate suture, as 
recommended by some, appears to be rarely feasible.) 

11. Do not allow a lying-in woman to make rapid 
motions in bed, strain, sit up suddenly or very long, or 
to leave her bed before, the tenth day. 

12. Keep watch of the bladder, particularly during 
the first twenty-four hours, and assure yourself by pal- 
pation and percussion that it is empty and is not inter- 
fering with uterine contraction. 

13. Instruct the n.urse not to insert the nozzle of the 
syringe too far, or to use too much force in giving the 
customary cleansing injections, for fear that the cervix 
may be bruised. 

Dr. Polk thought that the causes of secondary 
uterine hemorrhage were not dissimilar to those of 
hemorrhage occurring elsewhere. Hence, it has been 
his rule, when he had found slight hemorrhage, to be 
on his guard against those conditions which were 
generally supposed to predispose to hemorrhage. If 
uterine contraction takes place in the first instance and 
coagula are formed and are permanent, there will be 
no hemorrhage ; but if, in consequence of disease, 
lymph is not exuded, and the vessels do not contract 
properly, and the proper organization of the tissue 
does not take place, the clot is absorbed and the 
mouths of the vessels remain open. Now, the condi- 
tions which will interfere with the proper closure of 
the vessels are very numerous. Among these should 
be mentioned, first, those included under the term of 
pueperal fever. These prevented the contraction of 
the uterus, and at the end of four or five days we 
would find the fundus of the uterus in the nfeighbor- 
hood of the umbilicus. The other conditions are 
mainly constitutional, and may be summed up under 
the head of any of the cachectic states, such as malarial, 
or those conditions due to the poisonous effects of min- 
erals, such as lead or mercury, or any substances that 
might interfere with the plasticity of the blood. He 
believed there was a ^arge number of conditions, any 
one of which might give rise to hemorrhage, provided 
we have a certain amount of interference with the 
organ itself, such as washing it out, premature inter- 
course, retention of urine, etc. He was sure that he 
had seen a good deal of prostration in consequence of 
the prolonged use of cold in this condition, and also 
that he had never seen any ill effects from the use of 
hot water, which should be as warm as the hand could 
readily bear. 



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PROCEEDINGS OF NEW YORK ACADEMY OF MEDICINE. [Medical News, 



Dr. Partridge agreed with Dr. Polkas to the causes 
of secondary hemorrhage, and if he were asked to 
point out a woman who would be likely to suffer from 
secondary hemorrhage, he would select one with flabby 
muscles, irregular cardiac action, and such symptoms 
as were attributable to defects in the circulatory system ; 
also, those suffering from derangement of the sympa- 
thetic system. He once had an alarming case of second- 
ary hemorrhage occurring on the ninth day after labor. 
When he reached the patient, she presented symptoms 
of extreme loss of blood, her face was pallid and she 
was in a state of syncope. The uterus and vagina were 
filled with clots, and the bed-clothes were saturated 
with blood. Upon examination, it was found that there 
was an annular slough of the vaginal end of the cervix, 
from which a profuse hemorrhage had occurred. In 
this case there was an early rupture of the membranes, 
owing to the frequent pains and great pressure of the 
head. In studymg this subject, he had found that in 
cases where there was resistance to the downward 
coining of the head, there was more tendency to uter- 
ine hemorrhage. 

With reference to treatment, he thought there was 
very little more to be said ; when such a condition of 
the general system as he had pointed out could be 
recognized, he thought it was of importance to watch 
the patient with exceeding care. In regard to local 
treatment, if the hemorrhage depended upon lacera- 
tion, he would say use iodine applied to tne bleeding 
surface with cotton. Septic absorption wafs not com- 
mon before the tenth day, but it sometimes occurred 
earlier. In most cases of laceration the separation of 
the slough occurred on the seventh day, but in those 
cases where the laceration was of very considerable 
extent, the separation of the slough did not take place 
so soon. In such cases, the use of the tampon was 
particularly to be avoided. He could not use the tam- 
pon unless other methods had proved useless. He 
concurred in the opinion as to the non-desirability of 
sewing up the cervix at such time. 

Dr. Hanks remembered a patient coming under his 
observation who suffered from excessive uterine hem- 
orrhage occurring fourteen days after confinement. 
In this case, the cause of the hemorrhage was un- 
doubtedly due to malarial poisoning. Though the 
patient was thoroughly exsanguinated, yet after washing 
out the cavity of the uterus with warm carbolized water, 
she finally rallied. He had had another case undoubt- 
edly due to malarial poisoning, which came on nine 
days after confinement. In this instance the hemor- 
rhage was controlled by intra-uterine injections of hot 
water. He did not usually make use of the tampon, 
and would not recommend it on account of the diffi- 
culty of applying it under such circumstances. He 
thought that the application of iodine could generally 
be relied upon to arrest the hemorrhage. He begged 
to differ from the author in the use of ergot in all cases 
after labor. He did not think this practice was neces- 
sary. What was necessary, however, was to watch the 
patient carefully, and if there were any signs of danger, 
then to use ergot. 

Dr. Muno6 preferred the introduction of a conical 
piece of ice into the cavity of the uterus to the iniec- 
tion of hot water, as he thought it would be as effica- 
cious as the latter, and more agreeable to the patient. 
The subject of chronic lochial dfscharge, or, as it has 
been termed, hemorrhagica lochiilis, he thought was 
of sufficient importance to demand separate considera- 
tion. These cases of profuse lochial discharge might 
continue for months. They were due to want of 
uterine contraction, and to the formation of healthy 
mucous membrane. As to the use of the tampon, 
he would not recommend its introduction into the 
vagina after the delivery of a full-grown child. In the 



use of ergot he saw no evil effects beyond the slight 
nausea, and he thought it was a safe practice to use it 
in all cases. He would, however, consider ite use 
hypodermically as unnecessary, except where it was 
especially called for to arrest hemorrhage. 

The next paper was by Dr. Edward B. Bronson, 
and was entitled 

ECZEMA, ITS PATHOLOGY AND PRINCIPLES OF TREAT- 
MENT. 

The author referred to the importance that is gener- 
ally attached to the changes that take place in the vas- 
cular layer 'of the skin, in eczema. The part played 
by the epidermis in this disease was commonly re- 
garded as secondary and subordinate. He maintained 
that the epidermic lesions were rather of a primary 
and initiative character, and considered the epidermis 
to be the focal point of the eczematous process. The 
researches of Velpeau and others had shown that the 
cells of the rete Malpighii took an independent part in 
the disease that was analogous to that of the endoge- 
nous formations that characterize inflammation of other 
non-vascular structures, such as cartilage tissue, the 
cornea or the epithelium of the epiploa. The forma- 
tive changes that took place in these structures when 
inflamed, originated in the normal, endogenous cells of 
the part and not in cells that had wandered from- the 
bloodvessels. But though the pathological process was 
initiated in the cells of these structures, the adjacent vas- 
cular tissue soon sympathized. The papillary vessels 
responded to an irritation in the epidermis, as did the 
subconjunctival vessels in irritation of the cornea. 

Next the qualifications of the epidermis for initiating 
an irritative process in the skin were considered, and 
in this connection, reference was made to recent re- 
searches concerning the cutaneous nerves — more espe- 
cially the nerves of the epidermis. Of these researches, 
the most important were those of Pfitzner and Unna. 
These investigators had shown that each prickle cell 
in the rete mucosum was provided with two nervous 
filaments which penetrated the cell wall and terminated 
within the cell by bulbous extremities. It was urged 
that this extraordinary nervous supply to the epidermis 
could not but have an important bearing upon the 
pathology of eczema. 

The most constant and essential factors in eczema 
were sensory disturbance and trophic change in the 
epidermis. The trophic changes that took place in the 
derma were regarded as secondary and contingent. 
Impairment of the integrity of the epidermis was the 
necessary condition of every form and phase of eczema. 
It, more than any other feature of the disease, distin- 
guished it firom the erythematous diseases. The des- 
quamation that occasionally occurred in the latter was 
the result simply of nutritive impairment due to vas- 
cular disturbance beneath, but in no wise corresponds 
to the degenerative lesions of the epidermis in eczema. 
It was probable that this trophic change of the epider- 
mis in eczema was under the influence of the epidermic 
nerves. 

Furthermore, it was claimed that the sensory_ dis- 
turbance so characteristic of the disease, viz., the itch- 
ing, was owing to disorder of these nerves. Evidence 
was adduced to show that the diseases of the skin 
which are attended with pruritus always implicate, in 
a marked degree, the mucous layer. In urticaria, the 
lichens, prurigo, scabies, and vesicular diseases in which 
the vesicle was deep seated, sensory disorder ^as an 
important feature, and in all of them the mucous layer 
was markedly involved. 

No great importance was attached to the different 
lesions of the nerves that have been described as as- 
sociated with eczema. They simply served to show 
the intimate relation of the disease to the nervous 



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system. The initial motive of the morbid process — 
exciting cause — ^might be developed from various 
sources: direct external irritation of the epidermis, 
reflex irritations, central nervous derangement, or 
diseases of the nerves, either in their contmuity or at 
their periphery. 

Eczema, then, was a disease the main factors of 
which were a cutaneous inflammation of a catarrhal 
character, seated primarily in the mucous layer of the 
epidermis, involving the derma incidentally to a 
greater or less extent, and accompanied with marked 
disorder of the tactile sense. 

Ordinarily there is but little tendency to spontane- 
ous recovery. 

The obvious therapeutic indications are, first, to 
allay irritation, and second to assist repair. 

The first requires the elimination, as far as possible, 
of all sources of irritation, whether extraneous or in- 
herent, together with the protection of the damaged 
epidermis. The second indicates the use of such 
stimulants as will combat the tendency to chronicity. 
Measures of rest and measures of stimulation consti- 
tute the whole treatment of eczema. Two methods 
are possible — mediate and immediate — the first by in- 
ternal, the second by external medication. The ac- 
cessibility of the suffering tissue in eczema, would 
naturally suggest the method of direct application, 
which was first considered. 

The agents used in the local treatment of eczema 
are either mechanical, chemical, or dynamic in their 
action. Mechanical agents are chiefly valuable for 
protection, answering the same purpose as the simple 
dressing in the treatment of a wound. They include 
various inert powders, lotions, simple ointments, and 
emollient applications generally. The indications for 
the different varieties of this class are not precisely 
identical. As a rule the highest grade of inflammation, 
as in the acute erythematous form, is best treated by . 
wet applications. These abstract local heat by evapo- 
ration, and prevent local desiccation of the superficial 
epidermis — a harsh, dry condition that tends to in- 
crease the irritability of the subjacent nerves. The 
lotion may either hold in suspension powdery sub- 
stances that collect upon the epidermis and supply a 
soothing envelope, or it may contain chemical materials 
that exert a slight modifying influence, such as mild 
astringents or alkalies. Lotions, however, if employed, 
should be used continuously. Alternate wetting and 
drying of the inflamed skin increases the irritation. 
A small quantity of glycerine generally improves the 
wash. Undiluted glycerine is an irritant. Emulsions, 
also, are well suited to this stage of the disease. When 
the inflammation is less intense (acute papular eczema), 
the insoluble powders are the best application. Between 
. lycopodium, starch powder, talc, calamine, oxide of 
zinc, bismuth, and the like, there is little to choose, if 
only the applications be copious and frequent The 
effect is increased by first smearing the skin lightly 
irith cold cream, glycerine and water, or some soothing 
emulsion, thereby aflfording a surface to which the 
powder will better adhere. A little later comes the 
period for the use of ointments. The skin has become 
rougher and harsher, the cuticle brittle and ragged, the 
surface covered with scales, crusts, and abrasions. 
Vesicles appear here and there, or, more commonly, 
minute punctate excoriations. From this time forth 
the cure is usually hastened by the continuous pro- 
tection of an appropriate ointment, until the epidermis 
is sufficiently regenerated to perform its protective 
functions unaided. Such an ointment should be ab- 
solutely non-irritating, smooth, homogeneous, and free 
from ran' idity. It should not be so greasy as to be 
easily displaced ; it should not soften the cuticle so 
much as to render it more vulnerable ; but should be 



of a proper consistency to afford a perfect shelter to 
the exposed and irritable structures, and at the same 
time prevent undue desiccation. It is difficult to find 
any application that better meets all these requirement» 
than our common zinc ointments. Rarely is any other 
preferable. Under its protection and control, stimula- 
tion may be produced by certain measures, intermit- 
tently, or, if desired, more constantly, by modifying 
the ointment by the addition of various medi<aments. 

But eczema has certain phases to which ointments- 
are not suited. As already indicated, they should not 
be begun at a very acute stage of the disease. Further- 
more, where the surface is eroded and exudes a copious 
and ichorous discharge, the effect of all ointment i* 
generally unfavorable. An astringent wash or, better, 
an absorbent powder is preferable. Gypsum, if free 
from gritty particles, added in the proportion of one to 
four or one to eight, increases the absorbent power of 
the powder. 

A class of agents, the action of which is far more 
complex and obscure, is the group that acts as modifiers 
of vital action. By far the most important of these are 
the alkalies. Their value in almost every stage of the 
disease has long been established. In fact, inflamma- 
tions of cutaneous and mucous surfaces, almost with- 
out exception, are beneficially affected by their use. 
Their sedative influence is an important element in 
their action. No more certain anti-pruritic exists, and 
no remedy affords greater relief for the heat and burning 
of an inflamed skin than external alkaline applications. 
The virtues of the alkaline bath are rather under than 
over-estimated. Although medicinal agents are prob- 
ably unable to penetrate the intact cuticle, yet whtn 
applied over an extensive surface they gain sufficient 
access to produce decided effects. Employed over a 
small surface the alkaline effect is very marked when 
the corneous layer is abraded and the nervous struct- 
ure of the epidermis exposed. Dilute alkaline washes 
answer well for the acute stage of eczema. Later, 
when pathological products, difficult to dislodge, accu- 
mulate on the surface, alkaline soaps are preferable. 
In old chronic cases with decided thickening and thick 
laminae of adherent scales, the stronger potash soaps 
are indicated, as the "Schmierseife" of the Germans, 
or, better, the " Sapo Oliva Prseparatus " first brought 
into notice by Dr. G. H. Fox. When the stales and 
crusts are thinner, the milder soda soaps should be 
used, preferably those made with glycerine and a smalt 
proportion of alkali. Lang's, Rieger's, or Pears' soap» 
are the best. 

In squamous eczema, the " soap treatment," which 
we owe to Hebra, if thorough, has no equal, and the 
relief is almost immediate. The frictions themselves 
would cause useless irritation did they not remove the 
source of greater disturbance. In squamous eczema 
there are almost always vesicles deep down in the 
rete. imprisoned by desiccated epidermis or dried se- 
cretion above. The epidermic nerves are intensely 
irritable. The soap clears away the irritating patho- 
logical products, evacuates ichorous fluid formed in 
the vesicles, and brings the liberated alkali into direct 
contact with the diseased tissues, thereby modifying 
the pathological processes, and exerting a direct seda- 
tive influence upon the adjacent nerves. Moreover,, 
the stimulating effect doubtless promotes absorption 
and assists reparative effort. Seldom is any stronger 
alkali than that contained in soap required. For sim- 
ple caustic effect, agents that act more superficially are 
preferable, as carbolic acid or nitrate of silver. The 
latter, or its solution, is generally most useful in cir- 
cumscribed forms of moist eczema, in which there is a 
pyogenic condition. Hot water is of value to allay the 
pruritus of eczema. It accomplishes this by first sub- 
stituting the sense of smarting for the itching, and 



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later by its direct sedative action. The hot water 
should not be stopped too soon, if the full benefit of its 
■use would be derived. Violent scratching temporarily 
relieves the itching, the " paraesthesia " of pain pre- 
vailing over and excluding the paraesthesia of pruritus. 
Carbolic acid is a very useful remedy in eczema ; when 
strong, it annihilates vital action ; moderately concen- 
trated (from X to >i)> 't allays local excitement and 
produces sedation ; dilute, it acts similarly to the tarry 
remedies. Irritable fissures are benefited by strong 
applications. Moderately strong solutions have de- 
cided anti-pruritic virtues. They are especially adapted 
to cases in which the area involved is small and the 
itching intense, as in eczema of the anus. Dilute solu- 
tions are useful in those cases benefited by tar and its 
congeners. Tar in cutaneous affections probably acts 
as do terebinthinate and balsamic substances in dis- 
eases of the mucous membrane. They are generally 
most useful after the acute stage has passed, when the 
nerves have lost some of their preternatural irritability, 
and the condition is one of impaired energy, of relaxa- 
tion, and of congestion, more or less passive in char- 
acter. They improve vascular tension, and check 
excessive secretion. They should be employed at a 
•comparatively later period in eczema than the corre- 
sponding remedies in inflammation of the mucous 
membrane ; perhaps because in the latter case, when 
the drug reaches the seat of trouble, it has become 
less irritating by dilution or modification of its ingre- 
dients. It is a good rule in eczema, that during the 
stage of active exudation in the mucous layer, tar is 
contra-indicated. 

• Little need be said of narcotics. Certain of them, 
however (notably camphor), because of their volatility 
are useful adjuvants in case there be pruritus. 

Mercurials, though sometimes beneficial early, are 
chiefly of value in the latest stage, when acute inflam- 
mation has subsided, but 'when nutrition is interfered 
with by_ the products of inflammation accumulated 
mostly in the cutis and subcutaneous tissues. Mer- 
cury is especially useful in removing surh products, 
fibrous or cellular, because of its hostility to living 
organisms. It attacks first recently formed and im- 
perfectly formed tissues, impairing their vitality and 
predisposing them to rapid subinvolution and resorp- 
tion. Besides this — its peculiar, it? pathognomonic 
action — it has also a stimulant and substitutive effect. 

The " impermeable dressings," more especially the 
rubber applications, are decidedly advantageous in ad- 
vanced eczema with marked thickening. They macer- 
ate desiccated and thickened cuticle, the removal of 
which enables the deep vesicles to discharge. They 
also cause a substitutive inflammation, which, by coun- 
tervailing the chronic eczematous process, assists re- 
pair. When the artificial inflammation becomes severe 
the dressing must be removed. 

Though the agents enumerated embrace a wide 
range in therapeutics — emollients, sedatives, astrin- 
gents, irritants, excitants, and alteratives — they are 
divisible into two classes corresponding to the two 
main indications for the treatment of the disease. To 
one class belongs the function of protection : to the 
other that of aiding and directing reparative effort. 
Early, before the morbid habit is confirmed and the 
natural reparative power seriously impaired, protective 
measures alone may suffice. Furthermore, they are 
indicated during the later stages, to prepare the way 
for stimulant or modifying agents, and to control their 
action. It is upon the proper apportionment of these 
two opposed, but virtually cooperating, therapeutic 
measures that success in the treatment of eczema will 
mainly depend. 

The indications supposed to call for internal medi- 
cation maybe divided into four sets: (i) For the relief 



of internal disorders that affect the skin by reflex irri- 
tation. (2) To remedy general debility or special 
systemic diseases that are accompanied by defective 
innervation or innutrition of the skin. (3) To rein- 
force the local resources of repair by the administration 
of drugs that either act directly on the skin by selective 
affinity ; or, else (4), To set up internally a transpositive 
irritation to divert a share of the cutaneous excitement 
to other organs. 

Sometimes eczema appears to be due to internal 
causes, because of the absence of any unusual source 
of external irritation. Oftener it results ■from the com- 
bined effect of an irritation acting from within, and 
another acting from without. Reflex irritation, such as 
disturbance of the digestive or generative functions, 
rarely suffices alone to cause the disease ; but when it 
is prolonged, the cutaneous nerves become so irritable 
and debilitated that they can no longer tolerate such 
external influences as, under ordinary circumstances, 
would be insignificant. Moreover, in systemic diseases 
attended with a general debility, gout, rheumatism, 
lithaemia, uraemia, diabetes, and the like — the nutrition 
of the skin suffers in common with that of other tissues, 
and these develop a predisposition to disease. Still 
further, back of the predisposition arising from condi- 
tions that affect the general health, it is necessary to 
infer the existence of a special cause that determiries 
the cutaneous outbreak in that limited class of individ- 
uals known as the eczematous. The French school of 
dermatologists attribute this special cutaneous suscep- 
tibility to a special dyscrasia. Eczema is the expres- 
sion of a systemic malady which at certain periods and 
under various influences becomes intensified, betraying 
itself by the appearance of the characteristic lesions of 
the skin. Of this peculiar diathesis, " /es dartres" con- 
stitute the sole manifestation and evidence. 

But is this the only possible explanation ? Is no 
consideration due the inherent nature of the skin af- 
fected, its peculiarities of organization, the measure of 
its tolerance of irritating influences? Why should not 
the skin in different individuals differ as widely in its 
constitution and morbid tendency as do their other 
organs, their nervous, digestive, pulmonary or muscu- 
lar systems ? Some weaknesses arise from defects of 
.anatomical structure; in others, defect of organization 
is less patent, but is betrayed by frequent derange- 
ment of function and proneness to disease. Thus in the 
eczematous subject, though his general health is not 
necessarily impaired, at every departure from health 
the skin is quick to take offence. Whatever may have 
been the original internal or external exciting cause 
the cutaneous effect is often a wholly disproportionate 
one, one that could only be produced upon an organ 
capjfcle of but feeble resistance. The eczematous 
usually, but not always, have dry, harsh, irritable, itch- 
ing skins; moreover they differ in degree of vulnera- 
bility and in disposition to recover from the outbreaks. 

The external manifestations are constant because 
eczema is the natural expression of a simple inflam- 
ntatory action of the mucous layer of the epidermis. 
When an irritation can no longer be tolerated by this 
tissue, its vital ty succumbs, and the legitimate outcome 
is eczema. Its physiognomy is not always the same, 
and it is possible that there ma)r be allotropic forms 
depending on individual peculiarities. These may so 
differ from the simple type as to present the features 
of a different disease. 

Therefore, whatever causes in the economy at lar^e 
may predispose to eczema, the most essential predis- 
position is in the skin itself. Eczema, then, is essen- 
tially a local disease, and the most rational treatment 
is that which addresses itself most directly to the 
offending part. Oblique methods, however, are of 
value, and should not be ignored. At the outset, and 



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in obstinate cases generally, powerful internal diver- 
sion will often so allay the cutaneous excitement as to 
determine the success of the local treatment. Tonics, 
regimen, diuretics, purgatives, alkalies, in discreet 
hands are invaluable adjuvants. Internal medication 
must always be subordinate. There is no " specific " 
for eczema. It will not do to depend on the " selective 
affinity" of internal agents for the tissues affected in 
the disease. Narcotics should be mentioned, but to be 
condemned. Manifest derangements of special or- 
gans or of the general system should be appropriately 
treated. In chronic eczema the original cause has 
usually long ceased to be operative. In the majority 
of cases local treatment is well able to cope with the 
disease single-handed. 

Dr. Taylor remarked that we have cases where 
the whole skin is involved, and in some cases the sub- 
cutaneous tissue beneath it, so that if the author would 
include this in his description of the pathology, he 
thought it would make his paper more complete, 
though he conceded its excellence in its present form. 
The principles of treatment. Dr. Taylor believed, 
could be formulated somewhat as follows : In the 
first or erythematous stages of the disease, soothing 
applications in the form of powders, starch, oxide of 
zinc, arsenic, calomel, with the addition of camphor as 
a slight stimulant, or a lotion, as lead and opium 
wash ; later in the disease stimulants should be resorted 
to. He thought that the proper use of stimulation was 
one of the cardinal points in the treatment of this 
affection. Protective agents should first be used, and 
then stimulants. He agreed with all the author had 
said with regard to the use of soaps. In many cases 
he thought that we could go a step further, and even 
make use of strong solutions of potash. Soaps would 
sometimes fail where potash in strong solutions (say a 
drachm of caustic potash to an ounce of water) would 
succeed. The production of additional inflammation 
should be avoided. He was glad to hear the author 
take the ground that he did in regard to the nature of 
eczema. He believed that, whatever the general con- 
dition of the patient was, the disease itself was a local 
trouble. There was one point which he thought was 
not well brought out, and that was that patients not 
infrequently apply for treatment with eczema who have 
had it for a long time. In these cases, if we go back 
into their history, we find that in early life the patient 
bad suffered from repeated attacks of local eczema. 
In this way the tissues had been rendered more vul- 
nerable all through life than they otherwise would have 
been. He thought it could be stated that, as a rule, 
the more frec^uent the attacks in early life, the more 
liable the patient was to late attacks. In regard to the 
use of internal remedies, he agreed with the author as 
to the desirability of administering alkalies. He thought 
that one remedy had been neglected by the author of 
the paper, and that was arsenic. Arsenic would assist 
the internal treatment very much. The golden rule in 
handling cases of eczema was to look after the local 
treatment. Arsenic had a good effect upon the skin. 
If he were to indulge in a theory as to its action, he 
would say that it stimulates the capillaries, giving them 
tonicity, thus enabling them to hold their own. 

Dr. Bulkley thought that the subject of alterations 
in the cellular layer of the skin was an exceedingly im- 
portant one, and of late years had received insufficient 
attention. He had been much interested in noting the 
effects of tobacco in this disease. His attention had been 
called to a case of eczema of the anus by Dr. Frank 
H. Hamilton, in which the patient had a recurrence of 
the disease each time he used tobacco. He had 
watched the influence of this practice upon this class 
of cases in a number of instances. One case had come 
under his notice where an attack was brought on by 



smoking a single cigar. These facts, he thought, had 
a bearing in the direction of the nervous origin of ec- 
zema. Dr. Bulkley thought that in the majority or 
instances it would be found that patients suffering with 
eczema were not otherwise perfectly healthy. He had 
great confidence in the use of the tonic treatment com- 
bined with alkalies. It has been said that there is no 
specific for eczema, and he himself had made such a 
statement. He had, however, reported several cases 
of the disease recurring in children where the use of 
arsenic internally, without any local treatment what- 
ever, had resulted in a rapid cure. 



PATHOLOGICAL SOCIETY OF PHILADELPHIA. 

Stated Meeting, December 28, 1882. 
The President, James Tyson, M.D., in the Chair. 

TUBERCULOSIS OF SPLEEN, LIVER, AND KIDNEYS. 

Dr. Shakespeare exhibited these specimens without 
a history of the case. They showed exuberant vege- 
tations in pericarditis, abundant miliary tubercles of 
the pleura, of the liver, of the spleen, of the kidneys, 
and of the lymph giands in the region of the head of 
the pancreas. They were brought to the notice of 
the Society mainly Because the members had not had 
many opportunities of examining such perfect exam- 
ples of extensive and diffuse tuberculous infiltration 
without more serious involvement of the parenchyma 
of the lungs. 

Autopsy (six hours after death). — C. J., colored, aet. 60. 
Diagnosis: Pericarditis and pleuritic effusion, with 
strong bands of adhesions between parietal and vis- 
ceral pleura. Thorax : left pleural cavity completely 
obliterated by adhesions; right pleural cavity con- 
tained a large amount of straw-colored serum. The 
lobes of this lung were compressed against the spinal 
column, and were stalactitic. The lower lobe was- 
firmly adherent to the diaphragm, and the three lobes 
were strongly united by adhesions. The parietal pleura 
was thickened and everywhere studded with minute, 
gray, semi-opaque miliary tubercles ; the visceral 
pleura was in a similar condition, except that the tuber- 
cles were less numerous. The cut surface of the right 
lung presented nothing abnormal, save absence of air, 
but the sense of touch showed beneath and near the 
pleura a few scattered minute points, much smaller than< 
millet seeds. The pleura of the left lung was also studded 
with numerous miliary tubercles, and the tissue of this 
lung was similar to that of the right ; it was, however, 
crepitant. The pericardial sac contained 2}i ounces- 
of straw-colored serum. The whole heart was covered 
with an exuberant crop of vegetations. The cardiac 
walls were perhaps slightly softer than usual, otherwise 
normal. Abdomen, peritoneum, normal; no effusion ; 
liver slightly enlarged, with surface here and there 
raised by flat elevations ranging in size from a hemp- 
seed to that of a hazelnut ; capsule normal. The nod- 
ules were firm and of a yellowish tint; the intervening 
tissue was of a dark red. Deep section of the organ 
revealed similar nodules diffused through its substance, 
which seemed otherwise firm and normal. The spleen 
was slightly enlarged, firm, and extensively infiltrated 
with tubercles. The pancreas was normal, but the 
lymph glands near it were much enlarged, but neither 
softened nor caseous ; no caseous focus was anywhere 
detected. The kidneys appeared normal, except for 
one or two more or less pyramidal yellow points. The 
case presents several points of interest: i. Former 
history unknown. 2. Several aspirations, removing 
considerable pleuritic fluid. 3. What was the origin of 
the numerous tubercular irruptions, and if there was- 



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TRANSACTIONS OF PATHOl6gICAL SOCIETY OF PHILADELPHIA. [Mwmcal Ntos, 



auto-infection, what was its probable source? Dr. 
Tyson then gave a risume of the ante-mortem history. 

Uk. Tyson said he regretted having to admit that he 
was less familiar with the history ofthe case than he 
should have been, since the patient was in his own 
wards in the I'hiladelphia Hospital. Thoracentesis 
had heen performed more than once. The patient was 
a. colored sailor, aged 60 years. When Dr. Tyson took 
•charge of the ward in September, the man presented 
the physical signs of double pleuritic effusion, orthop- 
ncea, and feebly transmitted heart sounds, but no car- 
-diac murmur. There was cedema of the legs. He was 
tapped with great benefit, and under a restorative treat- 
ment he rapidly improved, so that he soon became one 
'Of .the walking cases in the ward, attracting little atten- 
tion. About December 1, he became very much worse. 
The orihopnoea and other signs of accumulating fluid 
returned, and so did the cedem i of the legs. His urine 
•was repeatedly examined for albumen, with negative 
results. He was tapped upon the right side and three 
. pints of fluid removed, with but partial relief. The 
other side was also aspirated without success. A car- 
diac friction sound was noted, which seemed to be 
pleuro-pericardial, but in the light of the autopsy it 
was probably pericardial. He died on the 13th of De- 
cember, He was unacquainted with the temperature 
record. 

Dk. Musser said that a relationship between pleurisy 
and pulmonary tubercul^isis could not be denied, but 
whether the pleurisy or the tuberculosis be antecedent, 
was diflicult of solution. Th.it the former is primary 
may be inferred from the fact that persons are con- 
sidered as threatened wiih phthisis who have sub- 
clavian arterial murmurs, due to the pressure or pulling 
on tlie artery of organ zed lymph. Likewise are the 
various friction sounds and exocardial murmurs noted 
to precede tuberculosis, and especially to occur in those 
tuberculously predisposed. Examples of boih cases 
faave come under his observation. It seemed to him 
that a primary acute pleurisy is a rarity, occurring in a 
non- tubercular subject. The last series of cases of 
what wduld be called primary pleurisy he had seen 
were in persons predisposed to tubercle, and in some 
of the cases tubercle subsequently developed. In 
short, so called primary plastic pleurisy occurs only in 
tuberculously disposed mdividuals; other forms are 
secondary to some other process, as Bright's disease, 
septicaemia, rtc. Trousseau calls attention- to latent 
pleurisies with effusion, as being often ari expression of 
a tuberculous diathesis, while also a latent pleurisy 
may occasion development of that diathesis. Two 
c ises illustrating these views have lately come under 
his notice. 

Dk. O'Hara said that although he had not had 
much experience with l.-iient pleurisy, he recalled a 
case of a young man >een five years ago, where exten- 
sive effusion into one side of the chest had unex- 
pectedly occurred, and when detected had been 
removed by tapping. App.-irent recovery then ensued, 
to be followed in a few weeks by copious eflfusion into 
the other pleural cavity. Tapping was again resorted 
to, the effusion never recurred, and the p-itient remains 
tiealihy and free from tubercle at the present time. He 
would like to ask if when the term "all the serous 
membranes were affected" was used, those of the 
brain were included. 

Dr. Tyson replied that there had been no head 
symptoms in the sailor's case. 

Dr. Shakespeake closed the debate by referring to 
the causes of tuberculosis in general and its mode of 
diffusion through the organism. He called attention 
to the failure in discovering any caseous focus, while 
admitting the possibility of such, if minute, escaping 
the most painstaking search. In this and similar cases 



all that could be safely said was that the caseous point 
was not found. Assuming, for illustration, that the 
point in the kidney might have been the origin of the 
auto-infection in this case, he referred to the communi- 
cation between the left renal vein and the inferior mes- 
enteric vein, and the direct communication with the 
portal system thus effected. As to the point raised by 
Dr. Musser, he believed in plastic pleurisies distinct 
from tuberculosis. He had examined very many 
microscopic sections of pleuritic adhesions, and very 
many had proved to be free from tubercle. Authors 
who have made original investigations on man and 
the lower animals, have also as distinctly recognized a 
plastic pleurisy without tubercle, as they have one as- 
sociated with Utis formation. He thought tapping in a 
person not predisposed to tubercle was no more likely 
to produce this disease than tapping an anasarcous 
limb. He was well aware of the facts dwelt upon by 
Drs. Musser and Formad, viz., the association of tapping 
with tuberculosis and of plastic pleurisy with tubercu- 
losis, but he believed that the frequency of this asso- 
ciation had been exaggerated. He thought that in view 
of the well-grounded belief that in certain classes of 
animals, as well as in certain families of men, inflam- 
mation tends to linger, to produce accumulations which 
are prone to degeneration, and to excite local or gen- 
eral tuberculosis, it is more logical to conclude that in 
such cases as above mentioned there is at the outset a 
tainted constitution — a soil already sowed with the 
dormant seeds of disease waiting to be awakened to 
their active processes of destruction by the stimulation 
of an exciting cause. The more frequent the action of 
the exciting cause, the more certain is this dormant 
tendency to be aroused. 
Dr. J. H. Musser exhibited ' 

TWO CASES OF CARCINOMA OF THE STOMACH. 

Case I. — Scirrhus of the pylorus ; general prolifera- 
tion of the connective tissue; interstitial nephritis. 
Malignant disease of the pylorus and of the lesser 
curvature of the stomach was diagnosticated when the 
patient applied at the Medical Dispensary of the Uni- 
versity Hospital, May 14, 1882, for treatment, on ac- 
count of the physical signs especially, and of some 
points in the clinical history. Palpation and percus- 
sion revealed a firm, non-pulsatile, immovable, slightly 
painful tumor in the miadle of the epigastric region, 
one inch to the left of the median line, about the size 
of a turkey egg. When lying down the abdomen was 
slightly scaphoid, but the left upper quarter was dis- 
tended. A curved line extending downwards from the 
umbilicus to the flanks, represented the lower limit of 
this swelling, which was soft and resistant, tympanitic 
on percussion, and with care could be discerned as 
starting from the hard tumor in the epigastrium. In 
short, it was due to a distended stomach. Although 
the tumor was not in the position of the pylorus, and 
although the patient had never vomited, yet pyloric 
disease was determined upon because of the gastric 
distention. On account of absence of marked ob- 
struction, the position and the occurrence of pain in 
the /«'/«(5ar region, disease of the lesser curvature and 
the posterior wall was decided upon. The autopsy 
revealed that the malignant growth surrounded the 
stomach at the pyloric end, but being greater in extent 
in the lesser curvature. An adhesion to the left lobe 
of the liver explained the position of the tumor. The 
patient first noticed the localization of the disease in 
November, 1881, by the occurrence of pain in the epi- 
gastrium following ajar. She noticed that* her health 
had failed three months before, and that menstruation 
had ceased six months previous to the epigastric pain. 
Note here the failure of health before any local evi- 
dences of disease, not even dyspeptic symptoms. She 



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JAMUARY 27, 1883.] TRANSACTIONS OF PATHOLOGICAL SOCIETY OF PHILADELPHIA. 1 1 1 



was a widow, set. 40 years, with one child, her health 
had always been very good, her circumstances moder- 
ate, and her habits exemplary. In addition to a con- 
stant burning pain increased by food, her appetite was 
poor, tongue pale, with enlarged papillae ; flatulency 
was marked, and the bowels constipated. She pre- 
sented a sallow, cachectic appearance, was somewhat 
emaciated, extremely anaemic, with cardiac, arterial, 
and venous blood murmurs, and accentuated second- 
sound. She was under observation until her death, 
October 17, 1882. The pain and constipation were re-: 
lieved by treatment, but the course was only down- 
wards. In addition, I may note the cachexia became 
more marked, and the classical appearance of the face 
was wonderfully depicted — transverse and vertical 
lines on the forehead and semi- circular lines around 
the mouth from the aiae of the nose to the chin, and 
vertical lines on the chin and lower lip. The hue of 
the countenance changed — growing darker and darker. 
This peculiar hue of the face Dr. Musser considered 
the most reliable symptom of approaching dissolution. 
It was noted one month before death. During the last 
two months of her illness she suffered much from sore- 
ness of the mouth and tongue without visible lesions ; 
from burning in the fauces; difficulty of deglutition, 
ac'dity, vomiting taking place every third "or fourth 
day of a clear acid fluid, coagulated milk bile-stained, 
and " coffee-ground material." A painless watery 
diarrhoea occurred frequently, with tarry masses. 
CEdema of the feet and ankles took place six weeks be- 
fore death. The tumor grew in size and changed posi- 
tion, falling downwards. Three days before death it 
was noted to pulsate, was tender, and was three inches 
long, extending from the median line to the left on a 
level with the umbilicus. Autopsy (twelve hours after 
death). — Extreme emaciation; rigor mortis marked; 
oedema of feet. Heart slightly enlarged, the left ven- 
tricle walls S^ lines in thickness; heart weighed 7 
otinces. Aorta i inch 1^ lines in diameter, and 
slightly atheromatous. Deposits of fat along the sep- 
tum were noted, and the muscular tissue itself was 
fatty. The stomach was in the position defined a few 
days before death, was greatly dilated, with the disease 
at the pyloric end extending along the lesser curvature 
four, along the greater curvature two, inches, and com- 
pletely encircling the organ. The stomach walls be- 
came thickened, with much hypertrophied muscular 
coat, as they approached the diseased area. The in- 
ternal surface of the tumor was flat, elliptical, and de- 
fined by an everted lip of varying thickness about 4 
lines high. The surface was uneven, some nodules 
being half as thick. The most central portion pre- 
sented distinct evidences of ulceration. The liver was 
rather larger than normal, seemed fatty, and was not 
indurated. The kidneys were small, hard, and the 
capsule peeled off with difficulty. Microscopic exam- 
ination of the stomach, liver, and kidneys. Dr. W. E. 
Hughes assisting, showed abundant irregularly shaped 
epithelial cells packed closely in a fibrous stroma, but 
Slightly developed in and containing numerous nuclei. 
Liver-cells fatiy and pigmented. Proliferation of the 
connective tissue around the hepatic and portal veins 
was noted, many nuclei proving its recent origin. 
The kidney was markedly cirrhotic, the connective 
tissue being not of recent formation. Note the gen- 
eral proliferation of connective tissue in. the organs. 
No albumen was detected during life in the urine, nor 
were any renal symptoms noted, yet there was un- 
doubted interstitial nephritis belonging to the variety 
described by Gull. Sutton, and Mahomed. The mal- 
assimilation consequent upon the gastric lesion was 
the predisposing factor in the production of this gen- 
eral change. 

Cast /A— Scirrhus of the pylorus ; symptoms simu- 



lating idiopathic anaemia. F. R., aet! 54, white, Ger- 
man, resident of a healthy locality, but much exposed 
as lumberman during the winter. Addicted to con- 
stant use of spirits, malt liquors, and tobacco. Had a 
fever of six weeks' duration at the age of sixteen years, 
and eight years ago some pulmonary inflammation. 
Never had malaria or syphilis. Does not know cause 
of mother's death ; seven brothers and sisters healthy ; 
father died of old age ; his own three children living 
and healthy. Admitted to University Hospital De- 
cember 20, 1878. During the previous winter had 
numerous gastric attacks, as shown by pain and loss 
of appetite. In the spring and summer he lost flesh 
and strength, and was subject to pain in the bowels 
and in the hepatic area, flatulence, pyrosis, and con- 
stipation, but never vomiting. On account of saliva- 
tion in June, he became especially debilitated. At 
time of admission, weight 118 pounds, usual weight 
170. Lies on left side, perfectly apathetic, with the 
physical and mental processes slow of action. Ex- 
tremities cold, very anaemic, conjunctiva and mucous 
membrane very pale ; sclerotics pearly white ; com- 
plexion of a sallow, dirty hue. Palpitation of the heart, 
dyspnoea, and subjective ear-noises were noted. Tem- 
perature irregular; appetite poor; flatulence and py- 
rosis, pain and tenderness in epigastrium ; no defina- 
ble tumor, but a sense of induration. Hepatic and 
splenic areas of dulness normal. No venous hum. 
Heart sounds weak. Urine, sp. gr. 1018. neutral reac- 
tion, albumen one-sixth ; no casts, bile, or sugar ; 
phosphates not in excess. Blood, white corpuscles 
m excess, red greatly decreased in number. Ophth.il- 
moscopic examination; slight retinitis. O. D. pallid; 
central artery dilated. Venous blood paler than usual. 
Absorption of choroidal epithelium, allowing choroidal 
circulation to be seen. Macula healthy ; no hemor-. 
rhage throughout fundus. Both eyes present the same 
appearances. A low typhoid state soon developed, 
with diarrhoea and excessive flatulence. For three dnys 
prior to death vomiting occurred. He died December 
30, 1882. Autopsy. — Stomach alone examined. It is 
to be regretted that the full record was lost. Stomach 
adherent to liver and transverse colon. Lesser curva- 
ture from pylorus halfway to cardiac orifice, infiltrated 
with cancer, extending two inches over the anterior 
wall, and at the pylorus, encircling the organ. Pan- 
creatic and biliary ducts pervious. Microscopically, the 
growth was found to be scirrhous carcinoma. 

Remarks.^P'Si account of the profound anaemia and 
the absence of tumor and vomiting, idiopathic anaemia 
was considered. The examination of the blood, and 
condition of the eye-ground, contra-indicated such a 
diagnosis. The normal size of liver and spleen, and 
the non-glandular involvement excluded leucocythe- 
mia. It is to be regretted that the exact numerical 
blood-count was not recorded. In this case the lesser 
curvature was very much involved, and a distinct 
tumor was absent ; quite the opposite of Case 1. 

Dr. a. p. Brubaker exhibited for Dr. H. Leahan, a 

TUMOR OP BRAIN. 

Jolin J., aet. 53, laborer. When first seen, the pa- 
tient was lying on his back, with head drawn back- 
wards into the pillows, and complaining of stiffness 
and soreness in back of the neck. The mouth was 
widely opened and parched, and the breathing deep 
and heavy. He was in a semi-unconscious condiiion, 
from which, however, he could easily be aroused, but 
soon relapsed into his former state, which was attended 
by stertorous breathing. Speech and deglutition were 
both interfered with, out not abolished. There w 'S 
involuntary passage of urine, but the bowels were 
constipated. Venereal ideas were excessive, but ac- 
companied by complete impotence. Voluntary move- 



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ments of the extremities and also the power of 
coordination were considerably impaired. Pulse and 
temperature were normal. Liquid food was taken with 
difficulty. His condition had been as described four 
days previous to my first visit on September 4, 1882. 
The symptoms gradually increased and coma super- 
vened, which ended in death, September 17, 1882. 
Following history was obtained from the family : 
Twenty-six years ago, the patient was confined to bed 
with "nervousness," for a period of two years, when 
he passed a calculus about the size of a date-seed; 
again a month later, another smaller one. His blad- 
der continued to give him more or less trouble up to 
death. He had his clavicle broken nineteen years 
ago, but there was no injury to the head. About six- 
teen years ago he was suddenly seized while at work, 
with a severe headache, and became totally blind, 
which lasted for twenty-four hours. This was relieved 
by wet cups to back of the neck. From that time, he 
was subject to what they called "shaking spells" — 
when standing there would be a violent trembling of 
the knees and shaking of the arms. These attacks 
occurred about once a month, and occasionally three or 
four times a day. They increased from yfear to year 
in frequency and severity, and appeared to be excited 
by high winds and storms. In February, 1882, he was 
seized with paralysis, beginning in the left little finger, 
thence gradually extending to the ring and middle 
fingers, until the hand became powerless, but was able 
to move his arm. Then followed a numbness in the 
outer side of the left side, attended by impairment of the 
power of coordination, so that, on attempting to walk, 
he was compelled to run to keep from falling. He fre- 
quently fell in the street, and had to be carried home. 
Last February, loss of speech supervened, which lasted 
for one month; the patient then began to speak in 
monosyllables, after which speech gradually returned. 

Autopsy. — Congestion of the entire brain. On re- 
moving it, four or five ounces of serum ran from the 
cranial cavity. Brain substance seemed to be normal 
throughout. In the right fissure of Sylvius was em- 
bedded a tumor about one inch and a half in diameter, 
which was almost entirely concealed from view by the 
convolutions. It rested upon the convolutions of the 
island of Reil, completely disorganizing them. The 
inferior extremities of the ascending frontS and parietal 
convolutions were normal. The upper surface of the 
temporo-sphenoidal lobe was somewhat disorganized. 
The tumor apparently sprang from the pia mater. 

Report of the Committee on Morbid Growths. — ^A 
section made from the tumor presented by Dr. Bru- 
baker, and examined microscopically, showed that the 
growth was tubercular. Its histological structure is 
-seen to consist of fibrous tissue constituting a reticulum, 
the meshes of which are filled with lymphoid cells. 
These appearances are very distinct at the peripheral 
zone of the tumor, while the centre and inner zone are 
in a state of retrograde metamorphosis, presenting a 
very granular appearance, scarcely stained by the car- 
mine. The bloodvessels are mostly obliterated, their 
lumen being filled with coagulated blood or grantilar 
dibrv. 

Dr. W. H. Parrish exhibited specimens of 

ENLARGED LYMPHATIC GLANDS. 

I show five lymphatic glands removed from the axilla 
of a patient whose breast I amputated about nine 
months ago. The case was then reported to the Ob- 
stetrical Society and was published in The Medical 
News of July 8, 1882. The specimen was referred to 
a committee, and Dr. Beates made a microscopical ex- 
amination, and concluded that the growth was an ade- 
noma that had undergone carcinomatous change. Of 



the enlarged glands presented this evening, three about 
the size of an almond were removed from the axilla, 
a fourth of. smaller size from just below the clavicle, 
and the fifth from the side of the neck about an inch 
from the clavicle. The patient presents no cachexia. 
The specimens were referred to the Committee on 
Morbid Growths. 
Dr. Parrish also exhibited 

POLYPI FROM THE UTERINE CERVIX. 

I also present this evening two small growths, each 
'about the size of the last phalanx of the thumb, re- 
moved to-day with a wire 6craseur. On Christmas 
eve, I saw for the first time a patient of French birth, 
a teacher, apparently about 35 years old. When 1 en- 
tered her room she was in a state of syncope from 
hemorrhage from the genitals. The hemorrhage had, 
however, ceased. With the application of hot wet- 
cloths over the front of the chest, and by hypodermic 
injections of whiskey, and aromatic spirits of ammonia, 
she in a few minutes revived so as to be able to tell me 
that she had not menstruated for three months, when 
suddenly bleeding' began from the womb, and con- 
tinued during the day with an exacerbation just before 
sending for me. As the patient's condition was evi- 
dently a critical one, I asked the direct question, if she 
had not had, or was not having an abortion. She said 
it was impossible. I then learned that she was single 
and 42 years old. A digital examination showed an 
intact hymen, and a substance in the vagina that at 
first touch felt very like an embryo of about three 
months. But I soon recognized that it was a growth 
attached to the lower part of the cervical canal, and that 
there was another distending the cervical canal. The 
latter felt still more like an embryo or ovum, and, in 
fact, in the absience of the one in the vagina might have 
at first misled me into thinking that the patient was 
aborting. Slight traction on it soon showed that it was 
attached. There was no return of the bleeding, and 
to-day, with the assistance of Dr. M. O'Hara, I re- 
moved both the growths with the wire, and without 
etherization or the use of a speculum. A remarkable 
feature of the patient's history is that she had always 
menstruated scanty, and at intervals of five or six 
weeks. Never before had she evinced a tendency to 
uterine hemorrhage. I am confident that the patient 
was not pregnant. I presume that, being virginal, she 
is approaching the menopause. 



NEW YORK SURGICAL SOCIETY. 

.Stated Meeting, December 26, 1882. 

The President, T. M. Markoe, M.D., in the Chair. 

INTESTINAL OBSTRUCTION. 

Dr. Weir presented a specimen which illustrated 
intestinal obstruction occurring in the splenic flexure 
of the colon. The cause of the constriction was cancer. 
It was removed from the body of a woman 33 years of 
age, married, who entered the New York Hospital 
November 28, 1882, in the medical service. She had 
had complete obstruction for nine days previously, 
associated during the last few days with stercoraceous 
vomiting. The history was that she had had, some 
time last spring, an attack of intestinal obstruction, but 
not very severe, and from that time had suffered from 
attacks of constipation. The cause of the last obstruc- 
tion could not be readily elicited, nor was any light 
thrown upon the subject by examination of the dis- 
tended abdomen. It was recognited that there was 
great distention of certain coils of intestine, apparently 
in the site of the colon, though this could not be posi- 



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113 



tively made out. Examination with the rectal tube 
showed that the gut could be penetrated to the depth 

of twenty-eight inches ; this was accomplished several 
times when large enemata were administered. These 

latter also established the fact that about one hundred 
ounces of water could be received each time into the 
bowel without unduly distressing the patient, when 
placed in the knee-elbow position. Prior to her ad- 
mission to the hospital, which was on a Tuesday, she 
had received a great deal of treatment, the exact 
naturefof which could not be determined. At the in- 
vitation of the visiting physician, Dr. Draper, Dr. 
Weir saw the case on Wednesday afternoon, at which 
time the patient had a temperature of 102° F., pulse 
120. These symptoms, together with the stercoraceous 
vomiting, the duration of the case, and the history of 
constipation of marked severity, led him to the con- 
clusion that delay should not be continued much 
longer, and he therefore proposed a preliminary rectal 
examination. It was determined,, however, to repeat 
the injections, and to wait until the following morning, 
and if no relief was obtained, to then resort to surgical 
interference. Relief was obtained, the injections 
bringing away a certain amount of fecal material, and 
the discharge was followed by two additional fecal 
evacuations of a creamy, muddy color and consistence. 
The vomiting ceased, and the general condition of the 
patient was so much improved as to encourage post- 
ponement of the proposed surgical interference. On 
Friday the symptoms of obstruction again appeared, 
except the vomiting. The abdomen became more dis- 
tended than it had formerly been, the temperature rose 
higher, and there were nausea and cessation of fecal 
discharge and flatus. On Saturday Dr. Weir again 
saw the patient, and it was then learned that her gen- 
eral condition had very much depreciated within the 
last two days. Dr. Weir then proposed that rectal 
examination be made, which was assented to, and be 
then introduced his hand (of 9X inches circumference) 
slowly into the bowel, but was unable to carry it up 
beyond the upper rectal pouch ; though he could carry 
one finger sufficiently far to enable him to sweep over 
the caecal region. This, however, could not be recog- 
nized. He had proposed to perform a right lumbar 
colotomy if it had been determined by rectal exploration 
that the caecum was distended ; or, if unable to deter- 
mine this point, to perform enterotomy. The patient, 
however, was so much prostrated by the ether and 
examination as to forbid a resort to further surgical 
procedures. She did not rally, as was hoped, but 
gradually sank, and died twenty-four hours afterward. 
The autopsy revealed cancerous disease of the splenic 
flexure of the colon, so slightly perceptible externally 
as scarcely to be recognized, There was also a most 
minute secondary involvement of the liver. No injury 
had been done to the rectum by the manual explora- 
tion. The point of obstruction was twenty-three inches 
from the anus. The caecum was apparently in the nor- 
mal position, and not distended with fluid, but with air. 
To inis point Dr. Weir wished to direct the attention 
of the surgeons, because he had heretofore felt con- 
siderable confidence that in cases of obscure intestinal 
obstruction a rectal exploration might be available as 
a means of diagnosis, and, by the recognition of a dis- 
tended caecum, might enable the surgeon to act with 
freater accuracy. In this instance such exploration 
ad failed. The experience of Dr. Halstead, also, 
who would follow him in the presentation of a speci- 
men, had led to the conclusion, that when the caecum 
was distended with air it might not always be readily 
recognized by the touch. Another point to which he 
would like to ask attention was the diagnostic value of 
injections of water, and of the rectal tube. Hereto- 
fore he had placed much reliance upon the rectal tube, 



especially when the French black tube was used, be- 
cause this latter more readily showed on withdrawal 
any twisting or sharp bending that might have taken 
place. In two instances he had proved by operation 
or by autopsy, that the site of the obstructions had been 
quite accurately determined in this manner. He had 
found some difficulty in carrying the tube beyond the 
sigmoid flexure in the cadaver in four recent trials by 
Dr. Peabody, but in the living subject it could be 
quite easily mtroduced. This difficulty could be easily 
understood because of the difference in the condition 
of the parts. During life the intestines yielded to 
pressure more readily than in the rigid cadaver, and 
perhaps the end of the tube itself produced spasmodic 
contraction, and the gut consequently changed its 
position or that of the end of the tube. As to the in- 
jection of fluids, there was a fallacy in that means of 
diagnosis, because the opening in the large intestine 
might admit the passage of fluid beyond it. That error 
was committed in one instance where there was a 
narrowing of the transverse colon, in which case he 
had performed right lumbar colotomy. Prior to the 
operation large quantities could be injected, with but 
little return. In one trial of a large turpentine enema, 
the matters vomited were strongly impregnated with 
the odor of the injection, showing that the ileocolic 
valve had been forced. A final word might be added 
which would bear also on the case to be subsequently 
narrated. It was that the pathologist of the hospital 
had, in remarking on the difficulty that would have 
been encountered in recognizing the site of obstruction 
by a laparotomy, said that in six autopsies of intestinal 
obstruction he had lately made, he believed that in 
nearly every one from a similar cause, relief would 
not have resulted from an operation. . 

CASE OF INTESTINAL INCARCERATION. 

Dr. W. S. Halstead presented a specimen with the 
following history: Anna B., aet. 35; Irish; widow; 
well nourished; mother of eight children (youngest 
five years old) ; was admitted to Charity Hospital, De- 
cember 16, 1882, complaining of constipation, colicky 
pains, distention of abdomen, and vomiting. She 
states that she has, since her infancy, been subject to 
similar, but less severe attacks, and remembers five 
previous ones distinctly — the last having occurred in 
March of this year. Heretofore, has been promptly 
relieved by "medicine," her symptoms having per- 
sisted on only one occasion for as long a time as two 
days, and their subsidence being always coincident 
with. the escape of much flatus. Constipation had at- 
tracted patient's attention for several days prior to 
present seizure, whidi developed suddenly, about one 
week before admission, while she was drinking a cup 
of tea. Since then, nothing has passed from her 
bowels. She vomited on the 15th, for the first time, a 
little mucus, and has continued to eject, at intervals of 
several hours, frothy muQus and possibly bile, but at 
no time stercoraceous matter. House physician gave 
a cathartic soon after admission. My attention was 
called to the case on the following day, Decepiber 19. 
The recorded history being incomplete, I will recite it 
as accurately as possible fitm memory : Found pa- 
tient tossing from side to side, moaning loudly, and 
apparently in great distress. Countenance slightly 
flushed, but not anxious. Respiration 27; pulse 08; 
temperature 98.5°. Thighs flexed, abdomen much dis- 
tended and unevenly so, everywhere tympanitic, and 
in no one region especially sensitive to pressure. 

Diagnosis. — Intestinal obstruction. Prescribed mor- 
phine, hypodermically, and directed that enemata, as 
large as possible, should be administered with the 
longest available tubes. 

December iS. — Patient confident that she is conva- 



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[Medical Nkws, 



lescing, assures us that she is free from pain, and has 
passed "wind" per anum. Respiration 22; pulse 
104; temperature 98.5°. Cannot ascertain positively 
how much urine has been voided, but the nurse guesses 
four ounces in twelve hours. House physician states 
that hard oesophageal tube was introduced last evening 
to its fullest extent (about twenty inches), and that 
only one quart of fluid could be injected, which, when 
evacuated, brought with it mucus, but no gas, and not 
a trace of feces. Repeated the injection myself, with 
like result, and noticed that the tube was in several 
places most singularly bent and twisted. 

jgth. — 5 P.M. Pulse 120, and intermittent. 6p.m. 
Patient anaesthetized. Assisted by Dr. Weir, pro- 
ceeded to operate under carbolic acid spray {1-40). 
Incision in median line, from umbilicus to pubes. The 
peritoneum being divided, a small quantity of serous 
fluid escaped through the wound. The large intestine 
very much distended, and presenting a few small 
superficial ecchymoses, occupied the entire field of 
view, being folded upon itself longitudinally. The 
separation of the folds exposed the quite normal small 
intestine. After a somewhat prolonged and unsatisfac- 
tory search for the cause of the obstruction, which was 
evidently below the flexura linealis, there could be felt 
with the right hand a dense cylindrical band, about 
t^e size of one's little finger, very deeply situated, and 
stretching from near the promontory of the sacrum, 
obliquely upward and outward, to the parietes of the 
left hypochondrium, not far from the tip of the twelfth 
rib. The abdominal incision was then extended to 
within about two inches of the xiphoid cartilage. The 
obstructing cord being exposed, it could be seen to 
have its apparent origin from the transverse colon, 
and was divided between two stout catgut ligatures,' 
which were passed around it by means of an aneu- 
rism needle. Below the band, and clearly compressed 
bv it, were two tubes of large intestine, one of which 
filled with air as soon as released, while the other did 
not. The patient's condition was too bad to justify 
much further investigation, although it was evident 
that the disposition of the sigmoid flexure was most 
puzzling, and possibly offered another obstacle to the 
escape of intestinal contents. The distended colon, 
which had been protected throughout the operation by 
towels warmed in a solution of carbolic acid (1-40), 
was replaced without very much difficulty, and the 
wound united by a double row of sutures ; the deep, of 
silver, included the peritoneum. 

3oth. — 7 P.M. Patient has just died. Ever since the 
operation was observed by internes and nurses to have 
passed large quantities of gas from the bowels. 

3ist. — 12 M. Autopsy: Quite firm union all along 
line of incision. Transverse colon slightly adherent to 
wound a little below umbilicus. Large mtestine reached 
to fourth intercostal space on left side. Attached to the 
anterior surface of transverse colon at about its mid- 
dle, and having its origin in the great omentum, was 
one portion of the divided bowel with its catgut ligature ; 
the other part being intimately blended, and appar- 
ently continuous with the diaphragmatic peritoneum 
between the eleventh and twelfth ribs. The specimens 
before you show the attachments of the band. 

Figures i and 2, drawn in the light of the autopsy, 
are intended to illustrate what presumably existed 
before, and immediately after the operation. The xxx 
designate sigmoid flexure looped and twisted upon 
itself from right to left. The sigmoideo-rectal junction 
was sufficiently narrowed in the bight of the volvulus 
to prevent the ready escape of flatus per rectum. This 
constriction was evidently one of very long standing, 
and intensified somewhat by the underlying falciform 
fold of its mesocolon, which normally extends from 
the mesentery to the upper end of the rectum, and 



which, in this case, was unusually strong and promi- 
nent, with its concavity directed ventrally. 

Fig. I. 




ittb rib. 



Rectum. 



T\\^ pathogenesis xt\Ay \)w.n have been: ist. Non-jn- 
flammatory adhesion in intra- or early extra-uterine 
life of a considerable portion of large omentum (meso- 
gastrium) to parietal peritoneum — adhesions of this 
nature being incidental to development, as urged by 
Sanger and verified by Soldt. 2d. Embarrassed growth 
of sigmoid flexure, giving rise to a rotation of same, 
which was permitted by the great length of the free 

Fig. 2. 




mesocolon at that early period, or by its coincident de- 
velopment. 3d. Narrowed sigmoideo-rectal junction; 
its growth having been somewhat restrained and its 
lumen reduced by pressure from without. 4th. Acute 
symptoms due, as suggested by Busch, to sudden dis- 
tention of gut above and retraction of mucous mem- 
brane from below omental band, possibly preceded by 
further intrusion of descending colon under the site of 
constriction. I would suggest in similar cases the ad- 
visability of operating early, not only that the patient » 
may survive the shock, but to anticipate a degree of 
hyperdistention of the intestine from which it can never 
recover. If there is reason to suspect the existence of 
a further source of obstruction, or if the tension within 
the distended gut cannot be decidedly relieved by sim- 
pler measures, I believe that laparocolostomy or en- 
terostomy, as the conditions may dictate, to be indi- 
cated. 

Dr. Sands remarked that, in Dr. Weir's case, the 
failure to recognize distention of the caecum was prob- 
ably due to the existence of a band at the upper part 
of the rectum, which prevented the hand of the opera- 
tor from making the usual excursions. In one case he 
had been able easily to ascertain, by manual explora- 
tion of the rectum, a distended state of the caecum, 
the patient having a stricture situated in the sigmoid 
flexure. 

Dr. Weir remarked that he had heretofore regarded 
manual exploration of the rectum as a reliable means 
of determining whether or not the cascum was dis- 
tended. 

Dr. Sands further remarked that in inserting the 
tube with the view of determining the presence of a 
stricture, it should be remembered that the constric- 
tion might be sufficiently close to cause abdominal ob- 



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"5 



struction, and yet not be so narrow as to prevent the 
passage of the tube. This condition was exemplified 
in a case he had already narrated to the Society, in 
which the ordinary black French tube was passed a 
distance of eighteen inches without encountering any 
obstruction. When the patient died a cancerous strict- 
ure of the rectum was found between six and seven 
inches from the anus, just large enough to allow the 
passage of the tube. Dr. Sands said that Simon had 
shown conclusively that it was impossible to pass an 
elastic tube beyond the splenic flexure of the colon, 
and that in cases where a great length of tube has been 
introduced the end of the tube had been arrested at 
the splenic flexure, the mesocolon allowing the tube to 
curve toward the right side. 

Dr. Weir asked Dr. Sands concerning the value of 
exploration by means of the tube in any portion of the 
large intestine below the splenic flexure. He himself 
had already attached considerable value to such ex- 
ploration if properly and repeatedly performed. 

Dr. Sands regarded such exploration as very valua- 
ble. 

Dr. Gerster had observed a case somewhat similar 
to the one related by Dr. Halstead. In his case, how- 
ever, he was able to detect at the operation the site of 
the obstruction. The patient was a boy, thirteen years 
of age, who had suffered from peritonitis eight weeks 
previous to his last sickness. The peritonitis had sub- 
sided under the ordinary plan of treatment, and the 
patient had recovered to such an extent as to be able 
to go to school. Two weeks afterward he was attacked 
bysomething which appeared like peritonitis. Mor- 
phine was administered, and he seemed to improve 
under the treatment so far as to permit the physician 
to attempt to evacuate the bowels by means of an 
enema. From the moment the enema was admin- 
istered, very violent and alarming symptoms of intes- 
tinal obstruction developed. The chief reason why 
the effort was made to evacuate the bowels was the 
complaint of fulness of the abdomen, and entire ab- 
sence of pain upon pressure. The symptoms which 
developed after the administration of the eneriia were 
intense vomiting and depression of the general system, 
with severe pain. The attending physician proposed 
to administer quicksilver to overcome the mtestinal 
obstruction. A second physician was called, who 
found marked depression of the general system, feeble 
pulse, continued vomiting, and clammy perspiration 
' despite the narcosis which had been produced by 
morphine ; marked tympanitis also existed. The child, 
when aroused from his semi-comatose condition, always 
pointed to the left side of the belly as the seat of the 
pain. Dr. Gerster saw the patient in consultation, and 
proceeded to surgical interference for his relief. He 
made an incision which extended from the umbilicus 
almost to the symphysis pubis. Immediately upon 
opening the abdominal cavity the distended bowels 
rushed out through the incision, and filled it so full 
that it was impossible to form any adequate idea with 
reference to the position or condition of the abdominal 
contents. lie extended the incision sufficiently far to 
admit of a full view of the abdominal contents, and 
then introduced his hand and felt most of the intestines 
to be movable, except one bunch consisting of four or 
five loops, which were anchored in the right iliac fossae. 
Separating the loops of intestines constituting this 
bunch, he found they were bound down by a band one- 
fourth of an inch in width, which passed across one 
loop of the mass and formed the true cause of obstruc- 
tion. Upon closer examination it was also ascertained 
that this apparent band was the vermiform appendix, 
which had evidently become attached to the abdominal 
wall during the previous attack of peritonitis. It had 
passed across a portion of the ileum about five inches ' 



from the caecum, and its apex had become attached to 
the mesentery of the ileum upon the other side. The 
upper portions of the ileum and small intestine were 
intensely distended and hypersemic, and the lower 
portion was pale and normal, a^ was also the large in- 
testine. There was no evidence of acute peritonitis at 
the time of the operation. He applied a stout double 
catgut ligature to the band, or vermiform appendix, 
and divided it between the ligatures, whereupon the 
intestinal contents immediately rushed from the supe- 
rior to the inferior portion of the ileum. Dr. Gerster 
then experienced great difficulty in attempting to re- 
place the intestines within the abdominal cavity. 
Hoping to diminish their distended condition, he in- 
troduced the smallest size hypodermic needle, but the 
escape of gas was so slow that he withdrew the needle, 
intending to perform a large number of punctures, but 
when the needle was withdrawn, he noticed that one 
minute drop of intestinal contents followed, and ap- 
peared upon the external surface of the gut. He wiped 
the surface of the gut very carefully, and then intro- 
duced an elastic catheter into the bowel through the 
anus and administered an enema; his idea being that, 
the obstruction being removed, probably a portion of 
the intestinal contents could be removed in that way. 
The plan proved to be perfectly successful. The in- 
jection of hot water through the catheter brought away 
feces, and a large quantity of gas also escaped, fol- 
lowed by solid fecal masses. After the evacuation 
had occurred, the intestines collapsed so much that no 
serious difficulty was experienced in restoring them to 
the abdominal cavity, and the wound was closed. The 
abdominal cavity was not exposed longer than twenty- 
five minutes, but the patient died of collapse about 
eleven hours after the operation. 

Dr. Halstead remarked that he also introduced a 
fine hypodermic needle into the distended intestines in 
his case, and observed precisely the same thing which 
Dr. Gerster had mentioned, namely, the exit of a small 
drop of intestinal fluid upon the withdrawal of the 
needle. Only a small amount of gas escaped, and that 
very slowly. Furthermore, Dr. Weir retained the in- 
testines in position to a considerable extent by means 
of towels which had been dipped in warm, carbolized 
water, and after some manipulation they were returned 
to the abdominal cavity. 

ENCYSTED NEEDLE IN THE LEG. 

Dr. Post presented a portion of a large needle en- 
closed in a cyst, which he had removed from a woman's 
leg about a hand's breadth above the internal malleo- 
lus. The patient was forty-five years of age, and gave 
the history that the portion of needle had been in this 
position during the last twenty-five years. The point 
of special interest in the specimen was that the needle 
was firmly encysted, the cyst, as exhibited in the 
specimen, almost completely surrounding it. At first 
it caused but slight irritation, and subsequently gave 
the patient no trouble whatever until a short time be- 
fore she applied to him for relief. The needle was a 
large one, and the portion removed was two centi- 
metres in length. 



WEST PHILADELPHIA MEDICAL SOCIETY. 

Stated Meeting, Monday, January 8, i88j. 
S. S. Stryker, M.D., President, in the Chair. 
Dr. R. M. McClellan read a short paper, entitled 

NOTES ON THE NOVEMBER EPIDEMIC OF DIPHTHERIA. 

The discussion was opened by a question from the 
President as to the experience of the members of the 



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Society in the treatment of diphtheria with large doses 
of calomel. 

Dr. Bartleson said he had, in several cases, used 
twenty-grain doses every three hours, till two drachms 
had been taken. One of these was a case of mem- 
branous croup in a child seven years old. The child 
did not recover. Another was a child five years old, 
who got well. 

Dr. Dulles said he had first used calomel in large 
doses in the treatment of diphtheria last October. Soon 
after reading a strong recommendation of this method, 
he was called to an infant of six months, whose throat 
was full of membrane, so that it was hardly able to 
breathe, and could not nurse. He ordered five grains 
of calomel, to be given hourly, and in the intermediate 
half-hours, so as not to make black wash of the calo- 
mel, a teaspoonful of lime-water. After ten doses had 
been given, he saw the baby again, and to his great 
surprise found it very much better. The next day, he 
put his little patient upon sulphate of cinchonidia, and 
m a few days more she was entirely out oi danger. 
After this, he had three more cases in the same row of 
houses, and all but one were treated similarly —the ex- 
ception was an adult who had a very light attack. 
These.did as welt as the first case. In the case of the 
infant first mentioned, the calomel did not produce 
any purging ; in the othecs it brought on three or four 
characteristic stools. With his limited experience, and 
with what was already on record, he was inclined to 
use again this method. 

Dr. J. H. MussER said that his own experience in 
the recent epidemic was that the cases were of a mild 
type, so that they got well almost without treatment. 
He used stimulants and spray of carbolic acid and 
lime-water. He had one case, however, which was of 
a different character. In this, a child, when first seen, 
had a sore throat like that of scarlet fever, with other 
symptoms of this disease, and, on the second day, a 
characteristic rash. Two days later, a diphtheritic 
membrane began to form in the fauces, and extended 
down into the larynx, and up into the nares. Appar- 
ently, this was a case of scarlatina, followed by diph- 
theria; or did the scarlatinal condition predispose to 
the infection with diphtheria? or were the two diseases 
developing at the same time? He had another case 
where all the pharyngeal symptoms of diphtheria were 
present, but m two days a scarlatinal eruption ap- 
peared, and the child died with the coma of scarlatina. 
As to the question of a distinction between diphtheria 
and membranous croup, he thought they were apt to 
be associated in the same epidemic, or one would fol- 
low the other. In all cases of membranous croup 
which he had seen, he could trace a connection with 
diphtheria, and therefore he thought membranous 
croup to be but a laryngeal diphtheria. Then, again, 
death is almost sure to take place from stenosis of the 
larynx before a septicaemia develops, and hence before 
the contagious period of the disease has arrived, thereby 
preventing the infection of other members of a family. 

Dr. M. B. Musser said, in reference to the relation 
between diphtheria and membranous croup, that he 
had never seen two cases of membranous croup in 
the same family at the same time; while in diphtheria, 
where one case occurs there are usually others simi- 
larly affected, or, at least, they have sympathetic sore 
throat. In regard to treatment, he had some time ago 
seen a case in which Dr. Meigs, whom he had called 
in consultation, suggested the use of the hyposulphite 
of calcium. Other remedies had been used without 
apparent success, but when this was tried, a most de- 
cided improvement took place within twenty-four or 
forty-eight hours. Since then he has had equally good 
results from its use. He uses, in nearly all cases, qui- 
nine by suppositories, and the tincture of the chloride 



of iron and chlorate of potash, together with stimulants. 
Locally he applies the persulphate of iron, dissolved 
in an equal quantity of glycerine. 

Dr. Bartleson said that he used boracic acid in a 
solution of two drachms in half an ounce of glycer- 
ine and half an ounce of water. After its employment 
he has seen the membrane melt away. For internal 
treatment he uses iron and potash, adding hydro- 
chloric acid, so as to give the mixture a little firee 
chlorine. 

Dr. Mullen had seen ten cases of diphtheria in one 
family ; five were severe, and five were not. As a 
diagnostic point, he called attention to a peculiar and 
very offensive odor about the breath and flatus. In 
treatment he uses locally lime water, the vapor of 
slaking lime, and insufflations of sulphur, together 
with a general tonic and stimulant course. He has 
seen dropsy follow diphtheria as well as scarlatina. 

Dr. Rockwell thought there was a difference be- 
tween membranous croup and diphtheria. In the 
former he had seen patients die very soon of asphyxia 
without adynamia. In diphtheria he had seen admir- 
able results from the local application of lime-water 
by means of the atomizer. 

Dr. Stryker inquired whether, in the sore throat 
of scarlet fever, there was any destruction of tissue with 
'the formation of membrane. 

Dr. J. H. Musser replied that in such cases there 
was often sloughy tissue, which, however, was different 
in appearance from the membrane of diphtheria. He 
thought there were cases where diphtheria existed as a 
complication of scarlatina. 

Dr. Anderson said he had had, last year, a case of 
this sort. A child had had scarlet fever, and diph- 
theria followed. A week or so later, a brother of this 
child had apparently scarlet fever, with characteristic 
rash, and no membrane in the throat. But three or 
four days later a diphtheritic membrane formed, with 
high continued fever, which, after convalescence, was 
followed by most persistent paralysis. He inquired 
whether paralysis was more apt to follow mild or severe 
attacks of diphtheria ? 

Dr. J. H. Musser inquired of Dr. Dulles whether 
the occurrence of the rash in diphtheria had any anal- 
ogy to the occurrence of a scarlatinal rash after sur- 
gical operations. 

Dr. Dulles said that after surgical operations there 
is not infrequently a scarlatinal eruption, which is usu- 
ally mild, and in regard to the etiology of which nothing 
is certainly known. It is probably a coincidence, and 
yet may be hastened in its development by the opera- 
tion. A similar rash is observed in the diphtheria of 
puerperal women, which may also be considered anal- 
ogous. But the frequent occurrence of rash, like 
that of scarlatina, with well-pronounced diphtheria, 
and of a sore throat, like that of diphtheria in unmis- 
takable cases of scarlet fever, suggests something more 
than coincidence. It suggests a relationship between 
these two diseases, which is all the more probable 
when we consider how generally they are associated 
as epidemics. 

CORRESPONDENCE. 



OVARIOTOMY STATISTICS. 

To the Editor of The Medical News : 

Dear Sir : Last summer I wrote to Mr. Knowsley 
Thornton, of London, begging him to be so kind as to 
furnish me with an account of the latest statistics of 
ovariotomy in Great Britain, including his own, for the 
new edition of my Surgery. When his communica- 
tion reached me, it was too late for me to avail myself 



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117 



of his kindness, and I therefore wrote to him at once, 
asking permission to publish the statistics in The Medi- 
cal News, to which he promptly consented. As show- 
ing the latest triumphs of ovariotomy, these figures 
cannot fail to be of deep interest to the ovariotomists 
of this country. Mr. Thornton has great reason to be 
satisfied with his own results, reflecting, as they do, 
great credit upon his methods and operative skill. 
I am, very truly, yours, 

S. D. Gross. 

Elivsitth and Walhot Strbbts, January 17, 1883. 

33 PORTUAN Strbbt, Lonoon W., November 30, i&Sa. 

Dear Dr. Gross : I fear you will think I have for- 
gotten my promise. At last I send you the statistics. 
I have found it very difficult to get them. I can get 
nothing later as to Clay's and Dr. Keith's, only up to 
October, 1881. The others are almost to date. 

Mortality 
Cases. Recovered. Died, percent. 

Dr. Clay,' of Manchester, 93 64 29 31. 11 

Mr. Spencer Wells,' .1088 847 241 22.15 

Dr. Keith,* . . . 381 340 41 10.76 

Mr, Knowsley Thornton,* 328 293 35 10.67 

Mr. Lawson Tail,' . . 226 199 27 n.94 

Dr. Peaslee -(page 276) credits Mr. Clay with two 
hundred and fifty cases; recovered, 182; died, 68; 
mortality, 27.2. I have not been able to verify these 
results, and therefore have not given them in the above 
table. The discussion in the British Medical Journal, 
in 1880, failed to' elicit any statement from Clay him- 
self as to results. He then said that he had performed 
four hundred before he ceased to operate. I think, 
under any circumstances, his results should hardly be 
given in comparison with those of Wells, Keith, Tait, 
and myself, as ours are thoroughly authenticated by 
published tables ; Clay's never have been. 

I think my own mortality answers your question as 
to the value of the spray. I did not know until I be- 
gan to look up the matter for you that I actually have 
got slightly the lead. 

Trusting that, though late, the figures may be of 
some use to you, believe me, with much esteem. 
Very truly yours, 

J. Knowsley Thornton. 

Or. Gross, PaiLACiLrHiA. 



THE EARTH DRESSING. 
To the Editor of The Medical News. 

Sir : The editorial article in your issue of December 
30th, " Ejirth Dressing in Germany " gives an incorrect 
notion of the material used in dressing wounds at 
Prof. Esmarch's clinic, and I beg to be permitted %» 
call attention to it. The writer describes the material as 
" earth," and " earth-mould," and claims for Dr. 
Addinell Hewson the credit of having introduced it as 
a surgical dressing. But it is quite a different thing. 
Dr. Hewson used " the yellow subsoil " " from deep 
diggings " (to quote from his monograph) after drying 
and sifting it ; whereas the dressing introduced by 
Neuber into Esmarch's practice is the ordinary peat 
(" Torf"), which is generally used for fuel in North 
Germany. After being dried it is ground up into a 



I Mr. John Clay's tnmslation of Kiwiich's Qinical Lectures, 
i860. 

* Tables in book and persona! communication to me on Novem- 
l>er 29, 1882. 

» I^etterto Mr. Wells, October 17, 1881. 

* My own are down to date. 

* Paper published in Birmingham Medical Review and British 
Medical Journal. Total number of operations down to August 
5, 1882. 



coarse granular and fibrous mass, which is enclosed in 
bags of gauze, and sprinkled with some antiseptic 
solution (5 per cent, carbolic acid, or corrosive sublim- 
ate I to 1,000), or mixed with 2>^ per cent, of iodo- 
form, and applied to wounds by means of "crinoline" 
bandages. 

I had the opportunity in May, last, of observing the 
application of this dressing and its gratifying results at 
Esmarch's clinic ; and have, since July, employed it 
frequently at the New York, St. Luke's, and Chambers 
Street Hospitals in this city. It has proven the most ' 
satisfactory and cheapest form of antiseptic dressing 
that I have tried ; and in six years I have used the 
carbolized gauze and jute, the salicylated and borated 
cotton and " antiseptic irrigation." 

The peat may be obtained from Mr. J. Neuber, P. O. 
box 1410, New York City. Two hundred kilogrammes 
cost, delivered here, about $25. This quantity fills a 
case a little larger than the average dry-goods box, and 
will be sufficient for an active surgical service of fifty 
beds for the period of three or four months. 
Respectfully yours, 

William T. Bull, M.D. 

2 East Thirtt-Third Strict, 

Nrw York, January 15, i88a. * 



NEWS ITEMS. 



BROOKLYN. 
(Ptom our Special Correspondent.) 

The Medical Society of Kings County held its 
sixty-second annual meeting oh the i6th inst., and the 
following were elected as officers of the Society for the 
ensuing year : President, G. G. Hopkins, M.D. ; Vice- 
President, F. H. Colton, M.D.; Secretary, R. M. 
WyckofT, M.D. ; Treasurer,]. R. Vanderveer, M.D. ; 
LAbrarian, T. R. French, M.D. ; Censors, Drs. A. 
Hutchins, C. Jewett, J. S. Wight, B. F. Westbrook, and 
G. R. Fowler. Two delegates to the State Medical So- 
ciety, Drs. E. N. Chapman and L. S. Pilcher 

A lively discussion arose over a resolution offered by 
Dr. Skene, rescinding the vote of the November meet- 
ing, instructing the delegates of this Society to the 
American Medical Association and to the State Society 
to vote against the so-called " new " Code. This reso- 
lution was carried, under a call for the yeas and nays, 
by a vote of 49 against 26. This action leaves the 
delegates uninstructed upon the Code question, but 
does not affect the vote formerly taken expressing the 
Society's sentiment of opposition to the new Code. 

The Staff of the Kings County Hospital has 
been somewhat unsettled lately. The Commissioners 
of Charities made some appointments, December 23, to 
the consulting staff and then constituted that staff a 
visiting staff. On January 20, however, the matter was 
reconsidered on the request of members of the old con- 
sulting staff, and it was ordered that the former status 
should be restored. 



BUFFALO. 
{From our Special Correspondent.) 

The Erie County (N. Y.) Medical Society and 
the New York Code. — At the annual meeting of the 
Erie County Medical Society, held on the 8th inst., the 
following resolution was adopted : 

"Resolved, That the Erie County Medical Society 
disapproves the action of the State Medical Society, at 
its last meeting, in adopting the report of the special 
committee revising the Code of Medical Ethics.' 



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CHICAGO. 
(From our Special Correspandent.) 

County Hospital. — Chicago is having much trouble 
with its great public hospital, the Cook County Hos- 
pital. The Board of County Commissioners, under 
whose control it is placed by law, has been in more or 
less of a turmoil for many months among themselves 
regarding its management. Meanwhile the county is 
spending nearly or quite a quarter of a million dollars 
in erecting two additional brick pavilions and a cen- 
tral executive building, which will be ready for occu- 
pancy some time next summer. 

The troubles of the hospital have not, however, been 
confined wholly to the secular management, for within 
two years there have been three successive medical 
boards. As soon as a member of the medical staff 
has any difficulty with the management, and the fact 
reaches the official ears of the Board of Commis- 
sioners, the remedy for the difficulty — the Board seems 
to practise a specialty in the use of a single remedy — 
appears to be to turn out the whole corps of doctors, 
and the remedy is promptly administered. Such fre- 
quent changes are a little disturbing to the regularity 
of clinics, and somewhat to their efficiency, although 
it is always found that the staff are ready and glad to 
give clinical instruction to students. 

For the outlook for medical teaching at this point 
there is satisfaction in the fact that the county hos- 
pital is increasing in importance, and in the number of 
cases treated every year, and the further fact that there 
are now so many medical colleges near it that it must 
be largely used in the years to come as a centre for 
clinical instruction. It now has nearly four hundred 
patients constantly ; this number cannot be expected 
to decrease so long as the present rapid growth of the 
city continues. • This growth is now about thirty thou- 
sand annually. The municipal census of 1882 (re- 
quired by law to be taken every two years) showed a 
population of sixty thousand six hundred over the gov- 
ernment census of 1880. 

The County Hospital occupies a large block of land — 
over twelve acres. There are four medical colleges so 
near the hospital grounds that they are simply sepa- 
rated from it by a street — they "surround" it. Three 
belong to the regular profession, and two of them 
are for the education of men — the " Rush " and " Phy- 
sicians and Surgeons'." One, the "Woman's," is for 
the education of women exclusively. The fourth school 
belongs to the persuasion of minute pellets. 



MONTREAL. 



{From our Special Correspondtnt.) 

McGiLL College. — The students of the first and 
second years have petitioned the Faculty and Board 
of Governors for the removal of Dr. Wright, the Pro- 
fessor of Materia Medica, on the plea that his lectures 
are diffuse and unpractical. They resolved to absent 
themselves from his lectures after Christmas, but a 
compromise has been made, and the trouble tempo- 
rarily arranged for the session. 

Parasites in Canadian Pork. — Mr. A. W. Clement 
examined at the city abattoirs one thousand hogs, and 
found four trichinous, seventy-six "measley," and 
thirty-seven with echinococci. "The proportion infested 
with trichinae is considerably smaller than in American 
hogs, as shown by the Chicago and Boston examina- 
tions. Trichinosis is a very rare disease in Canada ; 
only twelve cases have been recognized, three in Ham- 
ilton, Ont., in 1868, and nine in Montreal, in 1870. 
Four post-mortem and dissecting-room cases have been 
recorded. 



The Health of Massachusetts. — The annual re- 
port of the State Board of Health, Lunacy, and Charity, 
has just been submitted to the Legislature. The report 
states that Massachusetts is more exposed to smallpox 
than any other State, and that in 1881-82 the disease 
appeared in about thirty cities ; but the deaths from 
this disease in 1882 were less than in Chicago in one 
week. The year 1882 was one of average health, and 
no disease can be said to have prevailed excessively. 
Malarial fever has not appeared in so many of the 
towns east of the Connecticut as in the previous years, 
but in the western part of the State it seems to have 
been more prevalent than ever. The number of i n 
people in the State is at least 5, 100, a net increase of 
about 200. During the year 52,416 immigrants arrived 
in the State by sea. Probably 30,000 of these remained 
in (he State, and as many more came from other quar- 
ters. 

GuiTEAu's Remains. — The Rev. Dr. Hicks, the spir- 
itual adviser of Guiteau, has executed a legal instru- 
ment transferring to Surgeon-General C. H. Crane, 
U. S. A., all his right and title to Guiteau's body. The 
paper recites the clause of the will by which Guiteau 
bequeathed his body to Dr. Hicks, and it bears evi- 
dence of acknowledgment before a Justice of the 
Peace. In reply to inquiries Surgeon-General Crane 
said he was unable at present to give any information 
with regard to the final disposition of the assassin's re- 
mains. 

Fire in an Insane Asylum. — ^A fire in the Kings 
County Hospital for Incurable Insane, in Flatbush, 
L. I., endangered the lives of fifty lunatics on Thurs- 
day morning of last week. A night nurse while 
making his rounds at 5 A. m., found smoke pouring 
from the sitting-room on the second floor into the hall. 
He gave the alarm, summoning Medical Superinten- 
dent Woodside and six nurses. Half of them set at 
work to put out the fire and the others to remove the 
insane patients in the ward. An alarm was also sent 
to the Flatbush Fire Department. The hose in the 
building was put to use, and, there being plenty of 
water, the fire was speedily subdued, and the firemen 
were not needed before their arrival. Much difficulty 
was experienced in getting the patients out of their 
rooms to a place of safety. Many had to be carried 
out in the arms of the nurses. The fire is believed to 
have been caused by the accumulation of refuse around 
the radiator used to heat the room where it broke 
out. 

Honors to Prof, von Pettenkofer. — Prof, von 
Pettenkofer has received from the King of Bavaria, 
a'p.itent of hereditary nobility in recognition of his 
invaluable contributions to the science of hygiene. 

Dr. H. B. Sands, of New York, was elected a cor- 
responding member of the Soci^t6 de Chirurgie, of 
Paris, at its annual meeting on the 8th instant. 

Autopsy of Gambetta.— The post-mortem examin- 
ation revealed a contraction of the ileo-caecal valve, 
the result of an old inflammation of the bowel and ex- 
tensive purulent infiltration around the caecum and 
ascending colon, with traces of recent peritonitis, thus 
confirming the ante-mortem diagnosis of perityphlitis 
and pericolitis. Under the circumstances a surgical 
operation would have been unavailing. 

Long Island College Hospital. — ^The opening 
exercises of the twenty-fourth session of the Long 
Island College Hospital took place last Tuesday even- 
ing. The annual address was delivered by Health 



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Commissioner Raymond. At the close of the exercises 
a crayon portrait, handsomely framed, of Dr. S. G. 
Armor, Dean of the Faculty, was presented to Dr. 
Armor, in behalf of the students, by Mr. J. W. 
Whitney, of the senior cjass. 

Compliment to Dr. James E. Reeves, of Wheel- 
ing, W. Va. — At a meenng of the West Virginia State 
Board of Health, held on the 13th inst., the following 
preamble and resolutions were adopted : 

" Whereas, This Board has received many very high 
compliments from distinguished sources for the manner 
in which it has performed its difficult labors — notably, 
for its efforts to elevate the standard of medical educa- 
tion in West Virginia ; and, 

" Whereas, It is always just and proper to acknowl- 
edge credit to whom credit is due ; therefore, 

"Resolved, That this Board is fully sensible of the 
eminent services of its secretary. Dr. James E. Reeves, 
to whom belongs, in the main, the credit of directing 
its successful labors, and in all things upholding its 
good name, by his faithful energies and labors alike 
for the State and the medical profession." 

The Board also adopted, unanimously, resolutions 
urging upon Congress the importance of continuing 
and uirthering the work of tne National Board of 
Health. 

Medical Education in Philadelphia. — The Con- 
tinent for January 17, 1883, contains an interesting his- 
torical sketch of the progress of medical education in 
Philadelphia. 

Florida as a. Health Resort. — Dr. R. J. Levis 
contributes an article to the current number of The 
Continent, on the Gulf Coast of Florida, in which he 
points out its advantages as a health resort, particularly 
for subjects of pulmonary disease. 

Dr. Duhring's Work on Diseases of the Skin. — 
A very laudatory review of the French translation of 
Dr. Duhring's treatise on diseases of the skin has just 
appeared in the Annates de Dermatologie et de Syphilog- 
raphie for December 25, 1882. 

Preventive Vaccination in Charbon. — At the 
meeting of the French Academy of Sciences held Dec. 
18, 1882, M. Pasteur read a papec giving the results 
accomplished during the past year in the department 
of the Eure-et-Loir by the farmers who have practi- 
cally applied his method of inoculating live stock as a 
preventive of disease. The number of sheep vacci- 
nated within the year has been 79,392. For the last terf 
years the average annual loss from liver-rot has been 
7,327, or 9.41 per cent. Since the introduction of vac- 
cination this loss has been reduced to 518, or 0.65 per 
cent. Among the flocks which have been only par- 
tially vaccinated, there were 2,308 sheep vaccinated 
and 1,659 '^"t' ^'^^ ^^ '°ss among these was only eight 
for the 2,308 vaccinated sheep, or 0.4 per cent., while 
it was sixty among the 1,659 unvaccinated sheep — 3.9 
per cent. It is worthy of note that these sheep were 
brought from different parts of the department, and 
that the vaccinated and unvaccinated ones were all 
fed and treated in the same way, and subjected to ab- 
solutely identical influences. The veterinarians of the 
Eure-et-Loir have vaccinated during the year 4,562 
head of cattle, and there have been only eleven deaths, 
the rate of mortality being thus reduced from 7.03 per 
cent., at which it stood a year ago, to 0.24 per cent. 
Horses were not vaccinated to so general an extent as 
cattle and sheep, on account of the swellings which 
follow vaccination in these animals ; but of the 524 so 
treated only three died. M. Pasteur emphasizes the 



importance of these results, and adds that in the last 
six weeks 13,000 sheep, 3,500 cattle, and 20 horses 
have been vaccinated, without a single accident hav- 
ing occurred in these 16,520 animals. — Caz. Med. de 
Paris, Dec. 30, 1882. 

Adulteration of Quinine in Paris. — M. Laborde 
stated, at the Soci6t6 de Biologie [^Gas. des Hop., De- 
cember 19th), that the quinine used in the Paris hos- 
pitals contains sometimes as much as forty-three per 
cent, of cinchonine, and that the two substances differ 
much in their actions. He has proved this by experi- 
ments of injecting both substances hypodermically in 
guinea-pigs, when death is produced much more 
rapidly by the adulterated than by pure quinine. 
Some pharmaciens, he observes, under the mistaken 
idea that the action of both substances is alike, sub- 
stitute, either pardy or wholly, cinchonine for (quinine. 
This is very important to be known, especially in 
typhoid fever, which predisposes to some of the acci- 
dents resembling those produced experimentally by 
cinchonine. — Med. Times and Gaz., Dec. 30, 1882. 

Proceedings of the Illinois State Board of 
Health. — The annual meeting of the Illinois State 
Board of Health was held January 11, 1883. Dr. Rauch 
presented the quarterly report of the secretary, from 
which we make the following extracts : . 

Smallpox. — With the advent of cold weather a few 
scattering cases of smallpox have appeared in the 
State, but without creating excitement or manifesting 
any tendency to become epidemic. At three points 
in Cook County, and in Aurora, Kane County, the in- 
fection is attributed to Chicago. At Marshall, in Clark 
County, the disease was brought from Cincinnati, and 
at Cambridge, in Henry County, it was brought from 
Pennsylvania. So far as the history of these cases 
has been ascertained, it is found that the victims were, 
in every instance, either unvaccinated or not vacci- 
nated since infancy or childhood. 

There have been no cases among immigrants during 
the quarter — none, in fact, since the single case in the 
early part of June last, soon after the sanitary inspec- 
tion of immigrants was begun. Strenuous efforts have 
been made to secure the continuance of these inspec- 
tions, or, at least, their prompt resumption at the open- 
ing of the immigrant season. The secretary thinks it 
is demonstrated — from the history of smallpox in 
Chicago during the past thirty-two years ; from the 
consensus of statements of leading health officials 
concerning the origin and spread of the recent epi- 
demic ; and from the results of the operations of the 
Immigrant-inspection Service — 

1. That the immigrant is a prime factor in the origin 
and continuance of smallpox in the United States. 

2. That State and local boards of health, acting in- 
dependently, cannot suppress the disease, when once 
introduced, so long as the influx of unprotected immi- 
grants continues. 

3. That the immigrant-inspection system, in addition 
to furnishing a practical mode of cooperation by the 
various State and local boards of health, has proved 
entirely adequate to remedying the defects arising 
from want of international quarantine laws and of 
uniformity in the administration of our own maritime 
and boundary quarantines. 

Immigrant-inspection Service. — My final report to the 
Secretary of the National Board of Health, in which 
are summarized the operations of the Service in the 
Western district during the season, shows that a total 
of 115,057 immigrants were inspected in the district 
during June I and December 31, 1882. Of this num- 
ber, 57,302 were found to have been satisfactorily vac- 
cinated before sailing or during the voyage, and 3,127 



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were found to have had smallpox — making about 53 
per cent, of the total number protected. There were 
28,408 of the remainder vaccinated or revaccinated 
after arrival and before reaching this district; and 
21,618 similarly treated by the Western inspectors, 
leaving 4,602 unaccounted for, including those whom 
it was deemed inadvisable to vaccinate. 

At the close of August, I made a table of the results 
obtained up to that time. There had then been an 
aggregate of 63,962 persons inspected, of whom it was 
found that 54 per cent, were imperfectly or entirely 
unprotected against smallpox on arrival, and that only 
22 per cent, were vaccinated on shipboard. These 
figures have been changed by the pressure and influ- 
ence of the Inspection Service upon the steamship 
companies and their surgeons, so that, for the whole 
season, the percentage of "susceptible" was reduced 
to 47, while the proportion of ship- vaccinations was 
increased to 29, in the hundred. 

This latter figure (29 per cent.) represents an actual 
increase of fully 42,000 vaccinations secured on ship- 
board by this means, during the latter, as compared 
with the first half of the season ; and indicates the in- 
creasing value, efficiency, and influence of the Service, 
both directly and indirectly, at the time when its opera- 
tions were suspended. 

Prior to the preliminary steps taken to secure this 
Service (including the notification of Dr. Smith, Health 
Officer of the port of New York, to the steamship com- 
panies last spring), vaccinations on shipboard — except 
in rare instances — were confined to the occasions of 
the actual appearance of smallpox cases on board. So 
that, as a matter of fact, an aggregate of about 174,000 
vaccinations on shipboard have been obtained among 
the arrivals at all ports, simply as a result of the exist- 
ence of the Service, and independently of those per- 
formed by the inspectors after arrival. 

Medical Education. — The exposure of the Boston- 
Bellevue Medical College, and its consequent disrup- 
tion, of which the members have already been advised, 
have been followed by some unlooked-for develop- 
ments. As a result of the correspondence carried on 
from this office, the most convincing proof was secured 
that the so-called " college" sold diplomas and degrees 
to individuals grossly ignorant of any medical knowl- 
edge, and either with or without attendance upon its 
alleged course of instruction. Its officers were arrested 
for using the United States mails for fraudulent pur- 
poses, and, on trial, admitted all that was charged 
against them, except violation of the postal laws. To 
this charge they pleaded that they were legally incor- 
porated, and were empowered by the laws of Massachu- 
setts to issue diplomas and confer degrees without any 
restriction as to course of study or professional attain- 
ments. The United States Commissioner held the plea 
to be valid, and dismissed the case with the following 
remarks : 

" The State has authorized this college to issue de- 
grees, and it has been done according to legal right. 
. . . The law makes the faculty of the college the sole 
judges of eligibility of applicants for diplomas. There 
is no legal restriction, no legal requirement. If the 
faculty choose to issue degrees to incompetent persons, 
the laws of Massachusetts authorize it. This is, there- 
fore, not a scheme to defraud under the statute. The 
defendants are dismissed." 

Since fhis decision was rendered, that is, within a 
fortnight, the "American University of Boston," presi- 
dent. Dr. Buchanan (familiar name in this connection), 
and the " First Medical College of the American Health 
Society," located at Boston, have been incorporated, 
and Dr. Alfred Booth, the first president and one of 
the incorporators of the " Boston Bellevue," has given 



notice of his intention to start the " Excelsior Medical 
College." 

Thirty-one individuals have been detected in falsely 
swearing to be graduates of foreign universities, their 
pretensions exposed, and the impostors driven from 
the State through the Act to Regulate the Practice of 
Medicine. 

School Vaccination. — The school population of Illinois 
is now quite well protected against smallpox. 

National Boara of Health. — The following preamble 
and resolution were unanimously adopted : 

Whereas, The Act of Congress, appoved June 2, 1879, 
by which the National Board of Health is charged with 
the duty of cooperating with and aiding State and local 
boards of health in the enforcement of their rules and 
regulations to prevent the introduction of contagious 
and infectious diseases into the United States, and into 
one State from another, will expire by limitation on 
the 1st of June, proximo ; and 

Whereas, The said National Board of Health has 
discharged this duty with so much of success, honesty 
of purpose and regard to economy, as to conclusively 
demonstrate the value of a national agency for the 
protection of the public health ; therefore, be it 

Resolved, IhaX. the Illinois State Board of Health 
earnestly urges upon the Senators and Representatives 
from this State to obtain, during the present session, 
the legislation necessary to secure an extension of said 
act, pending the creation of a permanent national 
health organization — such legislation to include a 
provision whereby the unexpended balances of the 
original appropriations may be reappropriated and 
made immediately available for the purposes of said 
Act. 

Health in Michigan. — Reports to the State Board 
of Health, for the week ending January 13, 1883, indi- 
cate that diphtheria, neuralgia, rheumatism, and scar- 
let fever have increased, and that consumption has 
considerably decreased in area of prevalence. 

Including reports by regular observers and by others, 
diphtheria was reported present during the week end- 
ing January 13, and since, at 21 places, scarlet fever at 
17 places, and measles at 14 places. Smallpox was re- 
ported at Detroit, January 13. 

Obituary Record. — In New York, on the 23d inst., 
George M. Beard, M.D., aged 43 years. Dr. Beard 
was born in Montville, Conn. ; he received his classical 
education at Yale, and graduated in medicine at the 
College of Physicians and Surgeons, New York, in 
1866. He was one of the originators of the National 
Association for the Protection of the Insane and the 
Prevention of Insanity, and was a frequent contributor 
to the literature of the diseases of the mind and ner- 
vous system. His death is said to have been due to 
pneumonia. He leaves a wife and daughter. 

official list of changes of stations and duties 
OF officers of the medical department, u. s. 

ARMY, from JANUARY I5 TO JANUARY 22, 1883. 

Spencer, William G., Captaut and Asiislant Surgeon.— The 
leave of absence on surgeon's certificate of disability, granted 
September 20, 1882, is extended three months on surgeon's cer- 
tificate 'of disability.— /"ar. 4, S. 0. t6, A. G. O., Jan. 19, 1883. 

The Medical News will it pleasti to rictiv* tarty inttlli- 
genet of local tvtnts of ^tntral mtdicat inttrest, or of maUtn 
which U is dtsiraitt to tnng to tkt notict of tkt profession. 

Local papers containing reports or news items should be maried. 

Litters, whether written for pnilicaiion or private information, 
must it OMthenticaUd by the names and addresses of their writers — 
of course not necessarily for publication. 

All communications relating to the editorial department qf the 
News should be addressed to No. 1004 Walnut Street, PhUadelphie, 



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THE MEDICAL NEWS. 

A WEEKLY JOURNAL OF MEDICAL SCIENCE. 



Vol. XLII. 



Saturday, February 3, 1883. 



No. 5. 



ORIGINAL LECTURES. 



ON INTRA-LARYNGEAL GROWTHS. 

A CltHical Lecture. 

By CLINTON WAGNER, M.D., 

ntOFBSSOR or DISBASSS of THB NOSB AMD THROAT. NSW YORK FOST- 

CRADUATB MBDICAL SCHOOL ; SURGBOH-1N-CH1BF TO THB MBTRO- 

POUTAM THROAT HOSPITAL. 

Gentleme*): In the pre-laryngoscopic period the 
presence of laryngeal growths was rarely recognized, 
owing to the want of means of making an accurate 
diagnosis. The first case of which we have any record 
is that of Koderik, in 1759. Brauers, Ryland, Ehrman, 
Rokitansky, and Horace Green have all published 
reports of cases before the introduction of the laryngo- 
scope into general practice. But the most interestmg 
of the several treatises are those of Ehrman, in 1850, 
who published a record of all the well-authenticated 
cases, twenty-six in number, all of which proved fatal 
except three. In 1859, Dr. Horace Gr^en, of New 
York, in an able monograph, g^ves the entire number 
of recorded cases as forty ; thirty-seven of which re- 
stilted fatally. Seven or eight of this number occurred 
in this country ; four in his own practice. 

The symptoms show themselves in an alteration of 
voice, or disturbance of the function of respiration, the 
act of swallowing, and in some cases cough and pain. 

The alteration of the voice may range fi-om slight 
huskiness to complete aphonia. It will depend upon 
the size of the growth and its location. If sessile and 
upon the superior surface of the cord, the voice may 
undergo no change whatever. If it is attached to the 
free edge, or overlaps the free edge of either of the 
cords sufficiently to prevent approximation, there will 
be complete aphonia. If attached by a pedicle to the 
under surface of the cord, it may produce aphonia by 
being thrown upwards and between the cords during 
phonation or attempted phonation, approximation wiU 
be interfered with, and no voice will be produced. The 
voice sometimes has a peculiar vibratory tone or 
metallic ring which the ear of the skilled laryngo- 
scopist may frequently detect at once and suspect the 
presence of a growth, even before making the exam- 
ination with the mirror. If the growth is in either of 
the ventricles of the larynx or attached to the ventric- 
ular bands, voice may not be interfered with. 

Breathing is interfered with in those cases in which 
the growth has attained sufficient size to lessen materi- 
ally the calibre of the larynx. The location of the 
growth may have much to do with the disturbance of 
respiration. If in the upper part of the larynx on or 
above the ventricular bands, it is less apt to produce 
dyspnoea than if lower down and in the glottis proper. 
A growth which does not ordinarily produce much dis- 
tress in breathing may seriously impair it if the patient 
^ould catch cold, producing congestion of the mucous 
membrane to any extent. Inspiration is more labored 
than expiration. If the growth is attached to either 
of the cords, the respiration is very stridulous and at- 
tacks of spasm of the glottis more or less frequent. 

The act of swallowing is interfered with should the 
growth be of large size and attached to the epiglottis 
or to the posterior wall of the larynx, or overhanging 
or adjacent to the pharynx. 

Cough is not always present, and when it is the 



growth will probably be found attached by a pedicle 
and interfering with the movements of the glottis. 

Pain is rarely present, and when felt, the growth is 
usually of malignant character. 

A succession of colds which keep up a chronic con- 
gestion of the mucous membrane — chronic laryngeal 
catarrh — is one of the most common causes. Syphilis 
and tuberculosis have no agency in the production of 
new formations in the larynx. The professional use, 
or rather the abuse, of the voice may be assigned as a 
cause of laryngeal polypi. Persons between the ages 
of 35 and 50 are most prone to new formations in the 
larynx. They are sometimes congenital. Dr. Eddis 
reports a case of an infant that died thirty-seven hours 
after birth from strangulation produced by a laryn- 
geal polypus. Dr. Causit thinks they are most frequent 
in, infancy, while Dr. Bruns reports a case occurring 
in a subject seventy-four years old. In my own prac- 
tice, my youngest case was a boy five years old, from 
whom I removed a large papilloma ; my oldest case, 
a man sixty-three. 

Varieties of growth : benign and malignant. 
Benign : papillomata, fibromata, myxomata, cysto- 
mata, lipomata, angiomata. 

Malignant : sarcomata, epitheliomata. 
Papillomata are most frequently met with of the sev- 
eral forms of laryngeal polypi or growths. They are 
generally multiple, and vary in color from a whitish- 
pink to a deep red. If thoroughly removed, they are 
not apt to recur. Sometimes a mere crushing with the 
forceps will suffice to produce a sloughing or disinte- 
gration of what remains. It is claimed that this variety 
may recur or reappear as a malignant variety if not 
thoroughly removed. I have had several cases in my 
own practice which somewhat support this theory. A 
case whom you have all seen at the Metropolitan 
Throat Hospital, first came to me in January, 1881, 
nearly two years ago. At that time there was a growth 
about the size of a large pea on the right cord, near 
the anterior commissure. I regarded it as a papilloma, 
and suggested the removal by the forceps, which could 
have been done at that time without difficulty. The 
patient declined, and sought treatment elsewhere. 
Twelve months later he again consulted me, at which 
time the whole box of the larynx was almost completely 
filled with growth. Several large pieces were removed 
by means of tlie forceps, but as the growth was found 
to extend downwards below the cricoid cartilage, and 
as- dyspnoea was becoming more urgent each day, 
tracheotomy and thyrotomy were performed, the growth 
removed, and the patient discharged in a few weeks 
from the hospital. The tumor was submitted to Dr. 
Heitzman, of this city, for examination, who pronounced 
it a benign growth of the variety known as papilloma. 
But in his report he stated that it had grown from a 
highly inflamed base, and if it recurred it would most 
likely come as a malignant growth. A few months later, 
in June, just before I left for Europe, the patient came 
to me, suffering from great dyspnoea. A large amount 
of growth had reappeared in the larynx, on the right 
side. During my absence a canula was introduced 
into his trachea by a surgeon in Brooklyn ; and upon 
my return I again operated. This time I removed an 
enormous amount of growth. It involved the whole 
of the right side of the larynx, and extended below the 
cricoid' cartilage. I found it necessary to remove also 
several portions of the thyroid cartilage, in order to 



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ON INTRA-LARYNGEAL GROWTHS. 



[Medical News, 



secure thorough extirpation of the growth. Its attach- 
ments were destroyed by the galvano-cautery. A por- 
tion of the tumor which was submitted to Dr. Heitzman 
for microscopic examination, was pronounced to be 
epithelioma; thus supporting the theory that a per- 
fecdy benign growth may degenerate into a malignant 
variety, and also confirming the opinion of the micro- 
scopist in this particular case, that if a recurrence took 
place, it would come in a malignant form. Fourteen 
weeks have now passed since my last operation, and 
not the slightest trace of the growth can be seen. It 
is to be hoped, for the patient's sake, that my friend 
Dr. Heitzman has committed an error in his diagnosis 
of the tumor. I might add another interesting feature 
of this case ; ossification of the thyroid had taken place, 
and also of the right arytenoid. In performing the first 
operation, in using the curette upon the anterior sur- 
face of the right arytenoid, I probably destroyed the 
raucous membrane over the arytenoid by the force it 
was necessary to use, and also dislocated it from its 
cricoid attachment. Sloughing must have supervened, 
for about three weeks after the operation, during a 
severe fit of coughing, the right arytenoid, completely 
ossified, was expelled through the mouth. The speci- 
men which I exhibit to you is that of the ossified ary- 
tenoid. 

The specimen which I exhibit to you in this bottle is 
a papilloma removed from a child five years of age. 
The littlt fellow was admitted into the Metropolitan 
Throat Hospital about four and a half years ago. He 
was suffering from alarming dyspnoea, with frequent 
attacks of spasm of the glottis. An examination re- 
vealed a large papilloma attached to the right cord and 
almost completely filling the box of the larynx, and 
between the cords posteriorly could be distinctly seen 
what appeared to oe a web of membrane stretched 
from cord to cord. The child was much reduced in 
flesh and strength, and thyrotomy was at once decided 
upon. Tracheotomy was first performed, and imme- 
diately afterwards thyrotomy. This growth was re- 
moved, the false membrane cut away with the scissors, 
and the patient put to bed. The membrane was prob- 
ably the result of an attack of- croup wlfich he had had 
some time before. The boy recovered perfectly and 
gained rapidly in strength and flesh, and was dis- 
charged five weeks after the operation. I saw him 
some two years later ; he was in perfect health and there 
had been no recurrence of the growth. 

Fibromata are the next in frequency. We have the 
hard and soft variety, the former the most common. 
Their growth is very slow. They are usually attached 
by a pedicle, and arise from the submucous cellular 
tissue or perichondrium. 

The specimen which I exhibit to you was removed 
from a stout, muscular man, aged thirty-six, by occupa- 
tion a butcher. This growth was attached by a pedicle 
to the under surface of the right cord at about its junc- 
tion with the middle and anterior thirds. During quiet 
breathing, the tumor would drop below the cords and 
almost disappear from view, hut during the act of 
phonation it was forced upwards and lay upon the sur- 
face of the cords or between them. I made several un- 
successftil efforts to seize this tumor during quiet respira- 
tion. Finally I directed him to make the " ah " sound 
loudly and forcibly, during which I rapidly introduced 
the forceps, and caught and severed the entire growth. 
The specimen in mis bottle is a small fibroma which 
I removed several weeks ago from a gentleman at my 
office. It was attached to the free edge of the left cord 
at its junction with the middle and anterior thirds. His 
voice was a squeaking falsetto. Immediately upon re- 
moving the polypus he recovered his natural deep bass 
voice. 
Myxomata are very rare. Very few cases are on 



record. Mackenzie, in bis extensive practice, has not 
met with a single case. In the Archives of Laryngology 
for January, 1881, I reported a very interesting case 
occurring in my practic^. The tumor was pronounced 
by Dr. Heitzman to be a true myxoma, agprowth rarely 
found in the larynx, 

Cystomata are of more frequent occurrence. They 
are usually foutid upon the epiglottis, sometimes upon 
the true cords. A cystic growth on the epiglottis wliich 
occurred at my clinic at the Metropolitan Throat Hos- 
pital, was removed without difficulty by the forceps. 

Lipomata, or fatty tumors. There is but one case on 
record. It occurred in the practice of Dr. Bruns and 
grew by pedicle from the ventricle, and was of a yel- 
lowish-white color. 

Angiomata, or vascular growths, are very rare. 
They resemble a papilloma excejjt in color, which is 
black. They are very benign in character and not apt 
to recur if thoroughly removed. 

In malignant growths (carcinoma and sarcoma) there 
is usually more pain, the growth is more rapid in its 
development, dysphagia and dyspnoea, especially the 
former, are more marked than in the benign varieties. 
In the later stages the neighboring submaxillary glands 
become involved, and after ulceration has taken place 
there is fetor of the breath, and the expectoration is 
mingled with a muco-purulent secretion. In the early 
stages of the malignant form of growth we cannot 
always diagnosticate them as such. If we could, the 
operation for removal of the larynx could be performed 
at a period when the chances of success would become 
much greater. In my lecture upon syphilis and tuber- 
culosis of the larynx, I mentioned that it was some- 
times extremely difficult to differentiate in a £^ven case 
between syphilis, tuberculosis, and malignant dis- 
ease of the larynx; even the most experienced may 
be at a loss to decide. A man called at my oflSce for 
treatment during my absence in Europe in the ^sum- 
mer of 1880, and consulted Dr. Howland, who had 
charge of my practice. The whole of the anterior 
surface of the epiglottis was covered with an angry- 
looking, nodulated, fungoid vegetation, On the left 
side near the free edge there was slight ulceration, 
which showed a disposition to extend. The man was 
fifty-three years of age and had had primary syphilis 
some thirty years before. The trouble was regarded 
by Dr. Howland as specific, and he was given iodide of 
potassium. The ulceration rapidly increased under 
this drug, which fact, together with the peculiar nodu- 
lated appearance of the growth unlike any case of 
tertiary syphilis that had ever come under my obser- 
vation, satisfied me that the disease was malignant. I 
removed the epiglottis by the sub-hyoidean incision 
and submitted the growth to Dr. Heitzman for micro- 
scopical examination, who pronounced it cancer of the 
epiglottis, of the variety termed epithelioma. The dis- 
ease returned, and the man died nine months after the 
operation. This case presents another point of interest, 
from its being the first operation for the removal of the 
entire epiglottis of which we have any record. A re- 
port of the case was published in the Medical Record, 
May 21, 1881. 

Sarcomata of the larynx are not as frequently met 
with as epitheliomata. They resemble in appearance 
very much the papillomata, and vary in color from a 
deep red to yellow, or the pink of the mucous mem- 
brane. This specimen, which I have called sarcoma, was 
so pronounced by an eminent microscopist of this city. 
Another gentleman of equal eminence, to whom the 
specimen was submitted, called it a papilloma. And 
still another an epiihelioma-papilloma. It began as a 
small sessile growth on the right cord, the greater por- 
tion of which 1 removed with the forceps. The patient 
returned to me in about six months, at which time bis 



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ON INTRA-LARYNGEAL GROWTHS. 



1*3 



larynx presented the appearance already described. 
I performed tracheotomy, followed immediately by 
thyrotomy, and removed the growth thoroughly, ap- 
plying the galvano-cautery. Two months later I was 
compelled to perform another thyrotomy for the re- 
moval of the tumor, which had reappeared. I proposed 
to him at that time to remove the entire larynx. He 
objected, and in all I did thyrotomy seven times. He 
lived two years after the performance of the first. I 
might add that several months before the end, he ex- 
pressed a willingness to submit to the removal of the 
entire larynx, but at that time owing to the engorge- 
ment of the cervical glands and the extension of the 
disease to the trachea, the operation was not consid- 
ered feasible. 

Surgery has taught us that whenever a tumor or new 
formation interferes with the function of an organ, our 
duty is to remove the growth if the operation is at all 
practicable. If the laryngoscope had done nothing 
more than to enable us to diagnosticate the presence 
of intra-laryngeal growths, it would rank as one of the 
greatest of boons to modern surgery. 1 stated that 
Dr. Horace Green, in his monograph published in 
1859, gave the entire number ' of recorded cases as 
forty, thirty-seven of which proved fatal. With the 
aid the la^ngoscope has g^ven us, there is now no 
reason why a case of benign growth should not be re- 
moved, and the functions of the larynx wholly restored 
before life has become in the slightest degree endan- 
gered. Growths may be removed by the endo-laryn- 
geal or the extra-laryngeal method. The former 
consists of removal by evulsion, by cutting, or crush- 
ing. I usually employ Mackenzie's forceps, which 
I here exhibit to you. They are cutting and crush- 
ing, and the blades open either antero-posteriorly 
or laterally. There are a number of sizes, and about 
fourteen or fifteen forceps comprise the entire set. I 
wish to divest this operation (by evulsion) of the mani- 
fold risks and dangers supposed to be incurred by the 
patient and exaggerated by the advocates of so-called 
conservative surg^ery. It is an operation attended with 
little or no danger, and which any one who can intro- 
duce a brush properly into the larynx, guided by the 
mirror, can perform. Preliminary training in the ma- 
jority of cases is futie unnecessary. In Vienna it is the 
custom, or at least it was some years ago when I was 
in that city, to submit the patient to training. That is, a 
laryngeal sound of silver or other metal neatly covered 
with leather was introduced into the larynx and brought 
into contact with the growth for many days before the 
professor attempted the operation. About twelve hours 
■ust preceding the operation, applications with the 
>rush of a strong solution of morphia, alternating with 
chloroform, were made about every half hour. And 
with all this preparation, I have seen the attempt to 
remove the growth fail and deferred for another sitting. 
Bromides internally and locally are also given, and 
produce an anaesthesia, or rather an insensibility, of the 
larynx. I hold that if a brush can be introduced into 
the larynx, the forceps may also be. 

1 rarely submit the patient to any preliminary train- 
ing other than introducing the mirror for from' five to 
ten minutes for several days, provided there is irrita- 
bility of the pharynx. I have frequently removed 
growths at the first and only introduction of the for- 
ceps. My method of introducing them is as follows : 
I take the largest size laryngeal mirror in my left hand, 
and in the right hand a pair of forceps adapted, as far 
as possible, to the particular case in hand. That is, as 
the distance from the arch of the tongue to the larynx 
will, of course, vary in different individuals, I employ a 
pair of forceps longer or shorter in relation to that dis- 
tance. After introducing them into the mouth, and hav- 
ing the point well back of the epiglottis, I carry them as 



i,^ 



quickly as possible into the larynx. In other words, I try 
to surprise the organ ; that is, to anticipate the spasm 
which surely follows the introduction of foreign bodies. 
It is not always possible to watch the course of the for- 
ceps after they have entered, but you must have well 
in your mind's eye the exact location of the growth. 
If It is anterior, near the commissure, you direct your 
forceps to that point. If posterior, you carry your for- 
ceps to that part ; and so, whether it is on the right or 
left cord, you give the proper direction. With a little 
practice — and delicacy of touch can always be acquired 
by practice — you will be enabled to tell whether or not 
you have the growth within the grasp of your forceps. 
Force should never be employed, as it is wholly un- 
necessary. The instrument is introduced closed and 
opened after it has reached the glottis. The larger 
the growth the more easily will removal be accom- 
plished. In regard to the evil results which it is as- 
serted are apt to follow the introduction of the forceps, 
such as perichondritis, necrosis of the cartilages, ulcera- 
tion, paralysis, I have never met with such accidents. 
But I can easily understand how such consequences 
may be brought about. The forceps should never be 
introduced for more than three or four times at one 
sitting, and then, failing to seize the growth^ the patient 
should be sent away, and no further attempt made for 
several days. A congestion of the mucous membrane 
may be produced, and a too fi-equent introduction of 
the forceps while in that condition may lead to un- 
pleasant results. For that reason I recommend you 
to be in no haste in the treatment of these cases. I 
have never seen any good results follow the applica- 
tion of astringents or caustics to intra-laryngeal growths. 
I have no doubt that many of them could be dissipated 
by the stronger caustics, sufh as nitric acid, London 
paste, caustic potash, chromic acid, etc., but it is im- 
possible to localize the effects of these agents, and con- 
sequently their introduction into the larynx is out of the 
question . The milder caustics, such as nitrate of silver, 
zinc, iron, or copper salts, are useless. If a patient 
consults you for hoarseness, and you discover a small 
growth upon one of his cords and you rely upon brush 
applications for its removal, you will surely fail. Your 
assurance to him that the growth will not be apt to 
increase in size, will not be apt to affect his general 
health, or interfere with his respiration, will not satisfy 
him. He will probably seek a surgeon who has the 
skill to remove it, and you, through your want of con- 
fidence in your skill, will lose the treatment of the 
case. > 

The extra-laryngeal method, thyrotomy, should never 
be performed except in those cases in which respira- 
tion is seriously impaired. And even in those cases 
where the growth almost entirely fills the box of the 
larynx, every effort should be made to remove it 
per vias naturales. It is a capital operation, and is 
always attended with more or less risk of life. The 
operation is easy of performance except in those cases 
in which ossification of the thyroid has taken place, 
and this usually occurs after forty-five years of age. 
If tracheotomy is considered necessary previous to 
thyrotomy in a given case, it should be followed im- 
mediately by thyrotomy, and not wait as recommended 
by some authorities for several weeks. You will only 
be subjecting your patient to the dangers incurred from 
two capital operations instead of one, as is the case 
when both are performed at the same time. Until 
my last operation for dividing the ossified thyroid 
I hdd always used the Hay's saw, but the operation 
is tedious owing to the difficulty of fixing or steady- 
ing the larynx, and it is by no means easy to keep 
it in the exact median line. In the case of a man 
upon whom I operated several weeks ago, at the Metro- 
politan Throat Hospital, I employed a small file-cut 



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'CASE OF ECZEMA OF THE FACE. 



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wheel made to revolve by means of the dental engine. 
I divided the ossified thyroid in an incredibly short 
space of time, the line of incision was very clean, and 
the superiority of this instrument over the Hay's or 
small metacarpal saw, upon which we have been com- 
pelled to rely, was clearly demonstrated. I have here 
a number of instruments; forceps of various kinds, 
cutting and crushing ; as well as a guillotine or circular 
knife, such as are employed by the throat specialists 
in Vienna. I consider them inferior in every way to 
those of Mackenzie, and for that reason I never em- 
ploy them in my operations. Prof. Rossbach, _ of 
Wurtzburg, has suggested an operation which consists 
of introducing a sharp-pointed narrow knife through 
the median line of the thyroid into the larynx, and then 
by aid of the mirror introduced into the patient's 
mouth any growth which may be upon the vocal cords 
is to be cut off. This operation has been described as 
a simple one attended with no hemorrhage, and we are 
told that the patient is unconscious of the presence of 
the knife in the larynx, and neither retching^ nor 
coughing is liable to be excited. If the patient is un- 
conscious of the presence of the knife, the larynx cer- 
tainly will not be. You will surely have spasm of the 
glottis, andlnore or less hemorrhage ; it will be utterly 
impossible to hold the mirror in situ from the retching 
which will be produced ; and, in addition to all this, if 
the knife is permitted to remain in the larynx during 
the spasm, I can readily conceive that the posterior 
wall of the larynx and the anterior wall of the pharynx 
may be cut through. I have never attempted this 
operation, and never shall, as 1 consider it wholly im- 
practicable. 

ORIGINAL ARTICLES. 



NOTE ON A CASE OF ECZEMA OF THE fACE 
IN AN INFANT. 

By CHARLES W. DULLES, M.D.. 

SURGICAL RRGISTRAR TO THR HOSPITAL OP TMR UNIVRRSITY 
OP PBNMSYLVANIA. 

About a year ago, H. G., an infant, eight months 
old, fat, but white looking, was brought to me suffer- 
ing with eczema of the face, having a large patch 
on each cheek, and one on the chin. The disease 
was of the papulo-squamous type, the surface being 
rough, somewhat elevated in spots, and of a red or 
brownish-red tinge, according to the temperature 
of the air. It had now lasted some months, and 
the child's parents had little hope of having a cure 
effected. With this in view, I gave a guarded prog- 
nosis, and tried my hand at the little boy. I worked 
away from March 2 to April 28 — nearly two months 
— with diluted iodine ointment, zinc ointment, 
white precipitate ointment, cod-liver oil and cal- 
omel and zinc ointment mixed, locally; and inter- 
nally, with castor oil and rhubarb, till I had the 
bowels in fine condition. But all accomplished 
only temporary and trifling results. At this junct- 
ure, one day, with the child before me, it occurred 
to me to try the effect of removing the cuticle and 
stimulating thi; deeper layers of the skin with the 
tincture of iodine. I at once put this idea into ex- 
ecution, making, on April 28, a limited experiment 
on the chin, to begin with. This worked well, and 
I then, on May 8, tried it on the chin and gne 
cheek. These both did well, and on May 26 I 
painted all three places with equally happy effect. 



After each application of the iodine desquamation 
occurred, and the improvement was marked. By 
June 5 the face was cured, and there has been no 
recurrence of the disorder in the six months which 
have since elapsed. 

I have been led to narrate this case because I 
find, on inquiry of some of my friends who are 
specialists in dermatology, that the line of treat- 
ment last employed, which was novel to me, is 
also novel to them. I am told that a similar method 
is not uncommonly followed in obstinate, long- 
established, and indurated eczemas of adults, but 
that it has not been recognized as applicable to 
eczemas in very young persons. 

It certainly worked admirably in the present 
case, getting rid of the red, dry, rough and scaly 
patches on both cheeks and chin, which had been 
of the most disfiguring character. And when next 
I encounter like conditions, I shall not postpone 
having recourse to it till after I have tried the 
methods usually recommended, but use it at first. 

One of my friends, an experienced specialist, to 
whom I spoke of the treatment while I was employ- 
ing it, said h^ would hesitate to use the tincture of 
iodine undiluted on the face of an infant, for fear 
it would prove too irritating. This fear, however, 
was not realized in my case. The remedy did no 
harm, was easy to apply, required no change of 
dressings or trouble on the part of the mother, and 
it was followed by a prompt and permanent cure. 



THE REACTION OF DEGENERATION. 
By G. BETTON MASSEY, M.D., 

BLBCTRO-THBRAPBtmST AND ASSISTANT PHYSICIAN TO THR PHILADBL- 
PUIA ORTKOPjn>IC HOSPITAL AND INVIRHARY POR NRRVOUS DISBASBS. 

The value of electricity as an aid in the differ- 
ential diagnosis of various forms of paralysis is 
quite considerable, and is largely owing to recent 
investigations into the behavior of muscular tissue 
under the influence of the poles of a galvanic bat- 
tery. Under certain well-determined conditions a 
variation in this response is clearly and readily 
found, and points unerringly to a change that can 
have no higher seat than the trophic centre of the 
affected muscle, thus immediately excluding all 
possibility of a cerebral origin of the malady, and, 
as we shall see directly, being of still further aid in 
narrowing down our inquiry into the probable seat 
of the paralysis. 

This "reaction of degeneration" of muscular 
tissue to galvanism was first observed by Brenner, 
and afterwards by Erb, the latter making quite an 
elaborate study of the subject, and first suggesting 
the name by which it is now known. 

During several years past I have been much in- 
terested in an attempt to verify these statements of 
Prof. Erb in the abundance of material to be found 
at the electric clinics qi the Infirmary. The result 
has been a complete confirmation of the existence 
of the reaction, and of its claims upon the attention 
of the profession. 

In obtaining this reaction a reasonable amount of 
dexterity and circumspection is necessary, but its 



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FEBRUAJIY 3, 1883.] 



THE REACTION OF DEGENERATION. 



"5 



recognition is by no means sufSciently difficult to 
deter the most inexperienced manipulator from the 
attempt. The hazy description of the phenemenon 
by the specialists who have mentioned it, is, there- 
fore, much matter for wonder. 

In this article nothing will be said of the action 
of the faradic current ; it is also assumed that the 
reader will understand that the galvanic current is 
only to be taken into consideration at the opening 
and closing of the circuit, as it is then only, under 
ordinary circumstances, that any contraction of 
muscle occurs. 

First, it is to be clearly understood that the reac- 
tion of nerve trunks and of muscular tissue should 
be sharply distinguished. Quantitative changes of 
excitability (increase or diminution of the response 
without change of the normal formula given below) 
occur alike in nerves and muscles, but it is in mu^ 
cles only that these peculiar changes of a qualita- 
tive character occur ; and it is because we cannot 
eliminate the intra-muscular nerve twigs from a par- 
ticipation in the polarity induced in the surround- 
ing muscular tissue by the superimposed pole that 
we sometimes find it difficult to detect the slighter 
degrees of qualitative change — the true behavior of 
the muscle being masked, as it were, by the greater 
excitability of the nervous tissue. To thus confine 
the influence of the pole whose action we wish to 
test to the tissue of the muscle chiefly, it is evident 
that some attention should be paid to topographical 
anatomy. Similar considerations should also guide 
us in selecting a position for the opposite, indiffer- 
ent, pole. It is usually recommended by those who 
have written on the subject to place the indifferent 
pole on the sternum j this, however, is unwise be- 
yond the fact of its rather painful character, as con- 
tractions of most of the muscles of the limb are 
apt to be produced by the current in its course from 
the chest towards the opposite pole. Experience 
has suggested to the writer that it is far better to 
select a contiguous tendinous or bony spot as the 
position of the indifferent pole. In the examina- 
tion of the tibialis anticus muscle, for instance, the 
patella forms a good point of departure, as also for 
the quadriceps extensor. Some attention to the 
point of departure is absolutely essential to a cor- 
rect examination. 

Having placed one well-moistened electrode over 
the muscle to be tested, and the other in some care- 
fully selected point of departure, it next becomes 
necessary to properly close and open the circuit. 
For this purpose nothing is in any way comparable 
to a pedal rheotome, a simple mechanism worked 
by the foot ; it is, in fact, a necessity whenever the 
services of an assistant cannot be obtained, as a 
steady application of the electrodes is essential in 
many delicate cases — even the slightest movement 
produced by the working of the hand-current- 
breaker being confusing. If the pedal rheotome 
also contains a commutator, worked by the foot, for 
changing the poles while still in situ, its handiness 
will be greatly increased. The clockwork current- 
breakers usually furnished by instrument makers are 
totally unfit for diagnostic'purposes, since the current 



should be completely under the control of the 
operator. 

The normal reaction of the galvanic current in 
muscle is as follows: With a medium strength of 
current (15 to 20 sulpho-chromic cells, or 25 to 35 
bluestone cells, in accordance with the temporary 
condition of the battery), there is a decided con- 
traction at the closure of the circuit with the kathode, 
or negative pole, on the muscle. On changing the 
poles by means of the commutator, thus bringing 
the anode, or positive pole, over the muscle, we 
obtain a slight contraction at the closure. There 
are no contractions at the opening of the circuit 
with either pole. In other words, the normal con- 
dition presents a stronger kathodal closing contrac- 
tion and a weaker anodal closing contraction. This, 
simply stated, is the key to the whole matter; but, 
simple and easily verified as it is, it yet has been 
more than once overlooked or misinteipreted by 
electro-therapeutists. Erb' states that with an in- 
termediate grade of current the kathode causes a 
strong contraction on closure, but none on opening 
the circuit. " The anode, on the other hand, causes 
feeble contraction, both when the current is closed 
and when it is opened, the degree of contraction 
being nearly the same in both cases, though some- 
times the one and sometimes the other may be 
somewhat the stronger, or may show itself more 
promptly." Whether the muscular tissue of an 
American, under the stimulus of anelectrotonus, 
acts differently from the Teutonic fibre or not I 
cannot say; but I am certain that not even our 
German-American citizens present that sort of 
anodal response. I can only explain his statement 
by the supposition that he paid but little attention 
to the point of departure. Dr. Bartholow' has 
fallen into even a more serious error when he states 
that the anode causes contractions chiefly on open- 
ing the circuit. If he had but tested the thenar 
eminence of his left hand, a moment would have 
sufficed to show him his error. The mistaken esti- 
mate of the action of the anode by both authors is 
really unaccountable, as it is clearly evident to any 
experimenter that the anodal closing contraction is 
much stronger always than the anodal opening con- 
traction — in fact, that it is obtained usually by a 
strength of current that will show no motion what- 
ever at the opening. 

To repeat: with a medium current we obtain 
good kathodal closing contraction, slight anodal 
closing contraction, and no motion whatever at 
either kathodal opening or anodal opening. 

The great strength of current required to bring 
the opening contractions in health makes the opera- 
tion a painful one, and is apt to precipitate volitional 
interference with the electro-motility ; but, to make 
the statement complete, it may be added that in 
increasing the current strength to the point of giv- 
ing great pain, it is said that we may obtain an 
anodal opening contraction, and with a still higher 
strength, kathodal opening contraction. 

Now the "Reaction of Degeneration" consists 

' Ziemssen's Cyclop., vol. xi. p. 273. 

' Bartholow's Medical Electricity, p. 117. 



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merely in a more or less perfect reversal of the 
above formula. The anodal closure then causes a 
stronger contraction than the kathodal closure. 
This is readily demonstrated in all typical cases. 
A less degree of degeneration may be present, how- 
ever, and shown in but a slight increase of anodal 
closing over kathodal closing contraction. A still 
less degree may be present and indicated by an 
equality of the two closing contractions, .and yet 
this would still be an unerring sign of the presence 
of the qualitative change in question. 

In recording the notes of cases at the Infirmary, 
it has been found very convenient to use the for- 
mula recommended by Erb, which consists in the 
use of the initials of the German words employed 
to describe the reaction. Thus the formula of the 
normal reaction, kathodal closure: stronger con- 
traction, anodal closure: weaker contraction, may 
be recorded by the letters Ka.S.Z. ; An.Sz. ; Ka. 
and An. representing kathode and anode reispec- 
tively, S. representing Schliessung, closure, and Z. 
Zuckung, contraction. The relative strength of the 
contraction is best represented by a large or small Z. 
Other symbols that may possibly be needed are, O., 
Oeffnung, opening of circuit, and Te., Tetany, or 
prolonged contraction. There are at least two good 
reasons why the initials of the German words should 
be retained in English formulas rather than the 
translated initials, viz., the necessity we would be 
under to assign different meanings to the same 
letter in the translation ; and, secondly, the estab- 
lished usage of the German formula in European 
scientific works, including some British authors. 

It has been found by Erb that this change in the 
response of the muscle to galvanism is accompanied 
by, and coincident with, a change in the nutrition 
of the muscular elements themselves. After section 
of a motor or mixed nerve, an atrophy of the mus- 
cular fibres immediately sets in. It may be seen 
during the course of the second week. It consists 
in a narrowing of the fibres, which may possibly 
reduce them to one-half their width in five or six 
weeks. The transverse striae become less distinct, 
there is a notable increase in the muscle nuclei, 
and it is even said that a chemical change may be 
demonstrated in the contractile substance. It is at 
this time (from two to six weeks after the paralysis) 
that the reaction of degeneration may be found at 
its height. It is accompanied by an absolute quan- 
titative increase of galvanic response, and total ab- 
sence of farado-contractility. From this time on 
the degenerative response lessens in amount and 
distinctness, in accordance with the relative in- 
crease of connective tissue, until finally the trophic 
control is reestablished over the part, with a grad- 
ually returning normal reaction; or, in hopeless 
cases, a sclerotic atrophy, representing the debris 
of muscle, presents a final and permanent obstacle 
to any and all forms of motility. Thus the diflS- 
culty at times experienced in obtaining the degen- 
erative response in cases where it should be found 
may be due to the lateness of the stage of paralysis 
at the time of examination. In such cases an earlier 
examination would have undoubtedly disclosed the 
change. 



As to the diagnostic value of this sign, we have 
alread_y some positive data. It is to be found in all 
cases of traumatic paralysis depending on injuries 
to nerve trunks. In fact, all peripheral paralyses 
of nerves due to neuritis, or other lesions acting 
upon nerves after their exit from the brain or spinal 
cord, such as compression by tumors, extravasa- 
tion of blood, etc., will show the abnormal response 
in the early stages. Of this class may be mentioned 
facial paralysis, the various artisans' palsies, and 
local spasms due to neuritis from over-use, such as 
scrivener's palsy or cramp, telegrapher's palsy or 
cramp, seamstresses' palsy, pianist's palsy, etc., 
together with the worst forms of paralysis from 
compression, as, for instance, the musculo-spiral 
paralysis not infrequently contracted by drunkards 
while sleeping with the head resting on the arm. It 
occurs also in lead palsy, and in infantile paralysis. 

With the exception of the last-mentioned two 
affections, all examples of its presence are strictly 
confined to diseases in which considerable anatom- 
ical changes exist in the nerves. In reference to the 
exceptions — lead paralysb and infantile spinal paral- 
ysis (/. e. , polio-myelitis anterior acuta of either chil- 
dren or adults) it may be mentioned that they con- 
sist essentially of disease of both the gray matter of 
the cord and of the muscles themselves — the relative 
importance of which is still under discussion among 
pathologists — and are accompanied by great trophic 
disturbance. With these exceptions, therefore, the 
occurrence of the reaction of degeneration points 
most positively to a peripheral disease of the nerve 
trunks, or of the conductors of trophic influence 
within the cord, and excludes the possibility of 
brain disease, thus, in most cases, having important 
bearings upon our prognosis. 

In view of the above facts, together with the 
statement that the reaction is normal in progrfessive . 
muscular atrophy as long as any muscular tissue is 
left, I would suggest that the true explanation of 
the phenomenon is closely connected with a study 
of the conductors of trophic influence and the effect 
of interference with or abolition of their functions 
as conductors. 

Some practical hints bearing upon treatment are 
the following: In all cases of paralysis of motility 
showing this qualitative change there is more or 
less total loss of response to faradism. Galvanism 
should therefore be preferred to faradism as a thera- 
peutic agent. Since also the anode or positive pole 
becomes the most active, it should be given the 
choice of position in applications to the muscles. 

1633 Akch Stribt. 

HOSPI TAL N OTES. 

BOSTON CITY HOSPITAL. 
(Service of W. C. B. FiFIELD, M.D.) 

FRACTURE OF THE OS CALCIS OF EACH FOOT; DEATH 

FROM EMBOLISM ON THE TWELFTH DAY; AUTOPSY. 

(Reported by Royal Whitman, M.D., House Surgeon.) 

The patient, a robust (ierman, was brought to the 
hospital September 19, 1882. While being drawn up a 
shaft in a bucket, the rope bVoke, and he fell a distance 
of about eighteen feet, striking upon his feet. 



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137 



Examination showed the following injuries: Several 
incised wounds of the face. Upon the inner aspect of 
the right ankle, immediately below the malleolus, was 
an incised wound about two inches in length. Upon 
the introduction of the finger, a compound, commi- 
nuted fracture of the inner aspect of the os calcis, im- 
mediately below the articulation with the astragalus, 
was detected, the cancellous structure of the bone 
being exposed, but not injured to any extent. Several 
small fragments of bone were removed, and the wound 
was dressed with carbolized gauze. 

The left ankle and lower leg were swollen, dis- 
colored, and tender on pressure. There was indistinct 
crepitus about the ankle, and apparently a slight out- 
ward displacement of the foot. • No change in the con- 
tour of the heel was discovered, and a positive diag- 
nosis as to the position of the fracture was not made, 
though it was thought to be a fracture of the outer 
malleolus. The leg was placed in a fracture-box, and 
hot fomentations applied to tjie ankle. 

During the following week the patient progressed 
favorably. The swelling about the left ankle persisted, 
and several blebs formed upon the leg. There was a 
slight amount of suppuration about the compound fract- 
ure of the right foot, but no pain or swelling. On the 
afternoon of Ocober 20, the swelling of the left ankle 
having subsided, a roller plaster bandage was applied. 

In about one-half hour after its application the house 
surgeon was called, and found the patient in a state of 
extreme cyanosis, pulse rapid, feeble and irregular, 
expression anxious, face covered with cold perspira- 
tion, respiration sixty to the minute, and gasping in 
character. The patient complained of great pain in 
the cardiac region, and said that he was dying. Air en- 
tered the lungs freely. The foot of the bed was raised 
and subcutaneous injections of brandy and ether were 
given, but without effect. The patient rapidly grew 
worse, and died in about fifteen minutes after the first 
symptom. 

Autopsy (eighteen hours after death). — There was a 
fracture of the inner aspect of the right os calcis, as has 
been described, an area about three-fourths of an inch 
in diameter of the cancellous structure of the bone 
being exposed. No injury of the neighboring bones or 
soft parts. 

The left foot was then examined, and the os calcis 
was found to be completely smashed. The superior 
surface, articulating with the astragalus, was firmly 
impacted into the surface to which the tendo Achillis is 
attached. This portion of the bone was also fractured 
in various directions, though the fragments were not 
separated. The remainder of the bone was broken into 
several fragments. The surrounding soft parts were 
considerably lacerated and the adjacent veins filled 
with thrombi. No other bones of the foot or leg were 
injured. 

The lungs were then examined and the main pul- 
monary arteries were found to be almost completely 
occluded by thrombi. 

Remarks. — Fracture of the os calcis of both feet is 
an extremely rare accident ; but two cases of it having 
been reported — one by Malgaigne, and the other by 
Voillemier. 

Malgaigne speaks of the difficulty in making a 
diagnosis of the injury, and says that it is most often 
mistaken for fracture of the fibula on account of the 
pain and swelling about the ankle. Recovery is 
usually slow, and considerable disability often results. 

Embolism, as a cause of death in fractures, is not 
mentioned in the prominent works on surgery. The 
only mention of this complication that I am able to 
find is as follows : 

" Azam, of Bordeaux, first wrote upon this subject 
ia 186$. He has demonstrated that thrombosis, which 



may also accompany a great variety of injuries and 
inflammatory diseases of the limbs, is particularly 
liable to occur about fractures of the leg. The inti- 
mate relations which exist between the bones and the 
tibial and peroneal veins explain the frequency of its 
occurrence. Embolism, the results of which are so 
serious, is a consequence of thrombosis, and is of 
much more common occurrence than is generally be- 
lieved. In all ages, surgeons have noticed cases of 
sudden death, most frequently occurring after fract- 
ures of the lower leg. They have explained these 
deaths by pretended serous or nervous apoplexies, 
convenient and pompous explanations, but devoid of 
sense ; and had Azam done nothing more than to 
demonstrate in a single case the stupidity of such ex- 
planations, he would have accomplished something, 
for the discovery of a positive fact is never in vain, but 
always of practical importance." — Noveau dictionnaire 
de Medicine et de chirurgie. 



MEDICAL PROGRESS. 



Ligature of the Broad Ligaments as a Substi- 
tute FOR Castration in Cases of Uterine Fibro- 
MYOMA. — Dr. Giovani Cosentina reports the case of 
a m irried women aged 36, with an interstitial fibroid 
tumor of the uterus, who suffered from an almost con- 
tinuous uterine hemorrhage, and in whom all the 
ordinary remedies had been tried without success. 
The case seemed to be a suitable one for the removal 
of the ovaries, the operation for which was decided 
upon, and even commenced. From the difficulty in 
detaching the ovaries, which were adherent to the 
uterine walls, and with the idea that perhaps the hem- 
orrhage might be caused by the immense congestion 
of the veins of the ligament, the right broad ligament 
and Fallopian tube were ligated. The wound in the 
abdomen healed readily, and the woman was dis- 
charged. Two months later she returned, and it was 
found that the tumor had greatly reduced in size, and 
the hemorrhages had diminished in frequency and se- 
verity.— y<7«r«. de Mid. de Paris, December 23, 1882. 

The Micro-organism of Whooping-cough. — Dr. 
Carl Burger describes an organism which he has 
found in the sputa of patients with whooping-cough, 
which are so constant in their appearance in this dis- 
ease, while never to be seen under other circumstances, 
that he believes there must be some etiological reason 
for their presence, particularly since the intensity of 
the disease depends upon the number of the organisms 
present. He has not yet reported the results of the 
culture-experiments with which he is at present occu- 
pied. 

These organisms are_ readily detected by simple 
staining with watery aniline solutions, and may be 
prepared in the same manner as employed by Koch in 
the case of the bacillus tuberculosis. Dr. Burger de.- 
scribes them as ovoidal rods, about twice as long as 
broad, with a slight constriction around their middle ; 
occasionally they are met with in chains and groups, 
and by their difference in size and shape can be readily 
distinguished from the spores of Leplothrix buccalis. — 
Berliner klin. W^c^., January i, 1883. 

Removal of Goitre.— In the Deutsche Medisin. 
Zeitung, No. 42, an abstract of a case of extirpation 
of a goitre, performed" by Von Riedel, is given, which 
is unusual in the fact that symptoms supposed to be 
due to some affection of the vagus occurred soon after 
the operation. Aphonia, with rapid pulse and dysp- 
noea, set in within two hours after the operation. 



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Tracheotomy failed to relieve the dyspnoea. Four 
days later, pneumonia was detected, and the patient 
succumbed. At the autopsy the recurrent nerves were 
found to be embedded in blood-clut; there was also 
commencing suppurative inflammation of the medias- 
tinum, and lobular pneumonia. Von Riedel puts the 
vagus symptoms down to the use of a two per cent, 
solution of carbolic acid with which the wound was 
washed out. He has seen one other similar case. 
The facts of the case are interesting, but t/e think the 
explanation not free from objections. — Medical Times 
and Gazette, December 23, 1883. 

Fatty Hypertrophic Cirrhosis with Icterto. — 
Dr. Merklbn reports two cases of the above nature 
which occurred under the service of Prof. Vulpian. 
From an analysis of their symptoms and the lesions 
detected post mortem, he draws the following conclu- 
sions : 

1. The icterus in cases of fatty hypertrophic cirrhosis 
is the consequence of an acute or sub-acute diffuse 
intra-lobular hepatitis, which, by the abundant forma- 
tion of embryonal cells which it causes, arrests the 
flow of bile in the lobule. 

2. The intensity of the icterus is dependent upon 
the integrity of the hepatic cells, and is less marked 
when their fatty degeneration is complete. — Rev. de 
Med., December 10, 1882. 

Treatment of Hemorrhoids. — Dr. Gavoy has 
employed the following plan of treatment in rebellious 
cases of hemorrhoids : it consists in freezing the hem- 
orrhoidal vessels, and so causing an isolated arrest of 
the circulation. To accomplish this the base of the 
tumor is surrounded by a thread so as to arrest the cir- 
culation ; the surface of the tumor is then touched with 
a piece of ice which is held there for some time ; by this 
treatment the tumor becomes greatly reduced in size. 
It is not necessary to anaesthetize the patient; the treat- 
ment is also efficacious in cases of erectile tumors. — 
Journ. de Med. de Paris, Dec. 30, 1882. 

New Operation for Ruptured Perineitm. — At the 
meeting of the Obstetrical Society of London, held 
December 6, 1882, a paper on this subject was read by 
Dr. Wynn Williams. In this operation the sides of 
the rent were first denuded in the usual way ; then a 
flap of elastic tissue about two-thirds of an inch in width, 
about two lines in thickness, and long enough when on 
the stretch to reach as high as the denuded surface on 
the labia, was dissected up from the floor of the vagina. 
Sutures were then passed through the denuded sur- 
faces in such a manner as to keep the edges as well as 
the flat surfaces of this flap in contact with the raw sur- 
face. This being done, the sutures were secured in the 
usual way. When the rupture involved the sphincter 
ani, the flap was made, and the sutures passed through 
it in the same way as in the simpler case, but the rent 
in the wall of the rectum was sewn up with sutures 
made to terminate within the bowel, ana the deep su- 
tures secured before those bringing the flap into posi- 
tion were tied. — Lancet, December 30, 1882. 

Poisoning by Pyrogallic Acid. — Dr. Ernest 
Besnier reports four cases in which friction with an 
ointment of pyrogallic acid in cases of psoriasis pro- 
duced marked symptoms of poisoning. The most 
severe symptoms were produced suddenly in all cases : 
hsemoglobinuria and hsematuria, violent diarrhoea, 
and pulmonary oedema, accompanied by great col- 
lapse ; death resulted in two cases. Dr. Besnier be- 
lieves that the most satisfactory treatment of such 
conditions is to administer hypodermic injections of 



ether, inspiration of oxygen, and the free administra- 
tion of alcohol in small and repeated doses, combined 
with revulsives, such as cold wraps applied to the 
skin. — Ann. de Dermatol, et de Syphilog., December 
25, 1882. 

New Operation for Spina Bifida. — At the meet- 
ing of the Leeds and West-Riding Medico-Chirurgical 
Society ^eld December ist, Mr. A. W. Mayo-Robson 
showed a child, six weeks old, upon whom, when six 
days old, he had performed a new operation for spina 
bifida. The redundant parts removed by the operation 
were also shown. After the removal of these parts, 
and after stitching up the arachnoid over the spinal 
canal, periosteum from a rabbit was inserted between 
the meninges and the skin so as to cover the gap in the 
bones. The wound had perfectly healed ; the skin over 
the lumbar region was quite level ; there seemed to be 
no tenderness on pressure; the child looked strong and 
healthy. The sac, examined by Mr. F. H. Mayo, was 
found to be of the size and shape of half a swan's egg; 
the wall consisting of true skin and subcutaneous tissue 
lined by serous membrane. At one point the sac was 
very thin and transparent, appearing to consist only of 
the serous membrane covered by a thin layer of epi- 
dermis, when fresh minute bloodvessels could be seen 
to ramify over it. Mr. Robson drew attention to the 
following points: I, the operation was performed with 
full antiseptic precautions, eucalyptous air being used 
instead of carbolic spray; 2, the meninges were closed 
by uniting the sef ous surfaces, as in peritoneal surgery ; 
3, the transplantation of living periosteum and its con- 
tinued vitality ; it had not yet, however, formed new 
bone; but already the covering of the canal had a 
greater than mere skin-firmness; 4, the entire absence 
of bad symptoms in the child, operated upon at so 
early an age, was noticed. — British Medical Journal, 
December 30, 1882. 

Pulsation of the Spleen in Aortic Incompe- 
tence. — It would appear that this sign of aortic incom- 
petence has not been previously desciibed. Attention 
has now been drawn to it by Dr. Gerhardt, in the Zeits. 
fiir klin. Med., IV., S. 449, without any attempt being 
made to magnify the importance of the phenomenon. 
We are familiar with pulsation in the smallest vessels 
of many of the visible parts of the body in aortic incom- 
petence, including the bed of the nails; and Quincke 
nas shown how the two factors necessary for its pro- 
duction are, relaxation of the vascular walls, and sud- 
den great variation in the blood-pressure, such as occurs 
in aortic regurgitation. In Gerhardt's three cases the 
spleen was large and the patients in high fever. The 
splenic tumor swelled during cardiac systole, expand- 
ing gradually, and diminished ip size again during 
diastole. A dull double sound was audible over the 
tumor, apparently distinct from the cardiac murmurs 
which could be made out at the upper part of the tumor. 
To the finger the pulsation had not the characters of an 
aneurism, but was of the nature of a soft swelling, very 
much as in pulsating jugulars. The sign appears to be 
not entirely without some prognoptic value, inasmuch 
as it indicates a sound condition of the left ventricular 
walls, and compensation, as far as possible, of the 
valvular ihadequacy. — Medical Times and Gazette, De- 
cember 23, 1882. 

Arterio-venous Aneurism. — At the meeting of the 
Soci6i6 de Chirurgie, held Dec. 6, 1882, M. Pouaiulon 
read a report of a case of an arterio-venous aneurism 
which became purely arterial by the obliteration of the 
vein which communicated with the artery. The dis- 
ease occurred in a man who, when 11 years old, had 



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139 



accidentally cut himself in the bend of the arm with a 
pen-knife. An aneurismal tumor of the size of a small 
nut resulted, and remained without change for forty- 
two years, when it suddenly increased in size, and 
caused intense oedema of the arm and forearm, and 
rupture appeared imminent; the radial pulse could 
not be felt. The arm was amputated and antiseptic 
dressings applied. The operation resulted favorably. 
The examination of the tumor, after turning out the 
fibrinous clots, showed that it had been an arterio- 
venous aneurism, but that the humeral vein had be- 
come obliterated up to the shoulder, while the humeral 
artery was atheromatous ; the obliteration of the vein 
was evidently due to phlebitis and thrombosis. — 
L Union MidicaU, December I2, 1882. 

Purulent Peritonitis; Laparotomy; Curb. — 
Anton Schmidt, of Moscow, reports a case of purulent 
peritonitis occurring in a man, aged 2i years, during 
convalescence from an attack of relapsing fever. The 
abdominal cavity was opened by an incision extending 
from the navel to the pubis, and about five pounds of 
pus removed. Careful drainage was established, but 
no injections were employed; a Lister dressing was 
used. Cure occurred without any complications other 
than occasional attacks of colic. — Centralb.f. Chirurg., 
November 35, 1882. 

Localization of Articulate Speech. — At the 
meeting of the French Academy of Medicine, held 
Dec 12, 1882, Dr. Bilot presented a memoir on the 
seat and direction of the capsular radiations whose 
function is concerned in the transmission of speech. 
The author believes that, according to his researches, 
the opinion of Bouillaud, who accorded no more im- 
portance in this connection to one frontal lobe than to 
the other, is more nearly correct than that of Dax and 
Broca, according to whom the left side alone is func- 
tionally concerned with articulated language. If the 
frontal lobe is not, strictly speaking, the governing 
organ of speech, it nevertheless contains the agents 
charged with its transmission. The memoir was re- 
ferred to a commission, composed of MM Vulpian and 
Mathias Duval. — Gazette Hebdomadaire, Dec. 15,1882. 

Ergot in Diabetes Insipidus. — Dr. Alfred Car- 
ter, in the Birmingham Medical Review for December 
(No. 52), gives a brief account of a trial of ergot of rye 
in' diabetes insipidus. The patient was a little girl 
aged six, who had suffered from her complaint for 
about twelve months, probably, before she came under 
observation. The treatment lasted over a period of 
three months, including a fortnight in the early part 
during which the drug was suspended. The liquid ex- 
tract was the preparation used, at first in doses of fif- 
teen minims taken three times daily, afterward gradu- 
ally raised until no less than nine drachms a day were 
being administered. He arrives at the opinion that 
ergot had no notable effect in diminishing the flow 
of urine for the following reasons : i. The flow in- 
creased for the first three weeks, though ergot was 
taken. 2. Ergot was resumed after its withdrawal for 
a fortnight ; yet the average flow during the four fol- 
lowing days was sixteen ounces in excess of the daily 
average during the period of suspension. 3. Though 
the daily flow during the last two months was materi- 
ally less on the whole than before, yet toward the end 
of this period it increased some sixteen ounces beyond 
the average of the earlier part, though at the same time 
the dose of ergot was systematically increased. 4 On 
the final suspension of the ergot the daily average 
diminished at first, and did not afterwards exceed the 
average flow during the time that no less than nine 
drachms of the extract were being taken daily. 5. 



Such improvement as did occur appeared to be more 
closely related to the improvement of general nutrition 
than to anything else. We think it is evident, then, 
that ergot may be added to the somewhat long list of 
drugs which exert no beneficial influence on this formi- 
dable malady. — Med. Times and Gaz., Dec. 23, 1882. 

New Remedy for Syphilis. — Prof. Liebreich 
brought forward, at the last meeting but one of the 
Berlin Medical Society, a new drug for the treatment 
of syphilis by the subcutaneous method. This drug 
rejoices in the name of hydrargyrum formidatum, and 
is, therefore, merely a different form of the old cure for 
syphilis. The mode of its preparation was not stated ; 
chemically, it belongs to the amide group, in whose 
structure the monovalent amidogen (NH,) plays an 
important part. Liebreich was led to think of this new 
preparation from the notion that the ordinary amides 
of the body, of which urea may be regarded as the 
principal one, pass out of the oi^anism in an unde- 
composed state ; when, however, an amide is in com- 
bination with a metal, decomposition readily occurs, 
and the metal is reduced and deposited. Liebreich re- 
peated his experiments before the Society, and showed 
that these conjectures were quite true for the metal 
mercury. It is supposed, therefore, that the formamide 
of mercury, after the hypodermic injection, undergoes 
disintegration ; and so the mercury is set free, and is 
able to exert its well-known power over the lesions of 
syphilis. The preparation is easily soluble in water, 
is of neutral reaction, does not coagulate albumen, is 
not precipitated by caustic soda, and the presence of 
mercury can be demonstrated by means of sulphide of 
potassium. The drug, when injected under the skin, 
produces its effects very surely and rapidly. This is 
not regarded as a disadvantage, for the medicine is 
said to be easily borne, and has never produced sali- 
vation in Liebreich's hands. There is very little pain 
attendant on the imection, which has never excited 
any inflammation. From a half to a whole of a Pravai 
syringeful (a one per cent, watery solution) may be in- 
jected twice or thrice daily. Liebreich looks on the 
preparation as the best we yet have for subcutaneous 
injection. — Med. Times and Gaz,, January 6, 1883. 

Symmetrical Gangrene of the Extremities. — 
At the Pathological Society of London, on December 
5th. the body of a child, which presented a most re- 
markable example of this rare condition, was shown 
by Dr. Southey. The body was that of a well-nour- 
ished girl, aged two years and a half. A few months 
ago, she had a "feverish attack," which was accom- 
panied by some purpuric spots on the limbs. On No- 
vember 13th, another slight feverish attack occurred^ 
and lasted three days. The child remained in good 
health up to the afternoon of December ist ; she then 
complained of headache ; on the following morning, 
she appeared quite well. In the afternoon, she com- 
plained to her father that she had "hurt her legs." 
He rubbed the backs of her calves, but this increased 
the pain ; and he noticed that the skin in that situation 
was livid ; soon after, she vomited, complained of head- 
ache, and was " feverish." At 6 p.m. on that day (De- 
cember 2d), she was worse, the patches on the calves 
were blacker, and were extending up and down the 
calves ; the parents also noticed, at this time, that the 
backs of the arms were becoming affected in a similar 
way. At 6 a.m. on the following morning, it was no- 
ticed that the buttocks had become livid. At noon on 
December 3d, she was admitted into St. Bartholomew's 
Hospital in a moribund condition ; the pulse at the 
wrist was feeble, somewhat wiry, but could be counted. 
The tibial pulse could not be felt. The patches of 
lividity felt hard and tough; the lungs and heart ap- 



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peared to be quite healthy; liquid nourishment, brandy 
and milk, were taken, but soon vomited as a rule ; two 
doses of nitro-glycerine were also given, but immedi- 
ately vomited. At 7 p.m., a convulsion occurred; up 
to this time, intelligence had been preserved; but, 
after this, convulsions became very frequent, and she 
died at 11.45 p-m., on December 3'd; the whole dura- 
' tion of the case was thus not much over thirty-two 
hours. The necropsy had been made by Dr. Norman 
Moore, but no coarse lesion could be found in the vis- 
cera. He had examined the femoral and other arte- 
ries of the left lower limb, but had found no embolus. 
The parts affected were the legs, in almost their whole 
extent, the buttocks and the neighboring part of the 
back, the backs of the arms, and the cheeks; the le- 
sions were remarkably symmetrical. A theory to ac- 
count for these cases, of which Dr. Southey had seen 
three or four, but none so well marked as this, had been 
put forward by M. Reynaud, who supposed that there 
was a spasm of the arteries, with subsequent migration 
of blood-corpuscles, and transudation mto the skin. — 
Bnt. Med. Journ., December 9, 1882. 

Extirpation of Kidney. — At the meeting of the 
Sheffield Medico Chirurgical Society, held December 
7, 1882, Dr. Keeling showed a large tumor of the 
right kidney which he had removed, at the Jessop Hos- 
pital, by a front abdominal incision from an unmarried 
woman, aged 23, on August 10, 1882. The tumor was 
thought to be ovarian in the first instance, its real nature 
not being ascertained until the peritoneal cavity had 
been opened. The stump of the tumor, consisting of 
the pelvis of the kidney and the renal vessels, was se- 
cured by catgut ligatures, and. a long drainage-tube 
was placed in the track of the wound. The hemor- 
rhage in the latter part of the operation was severe, 
and the patient almost pulseless when carried to bed. 
Convalescence was retarded by profuse suppuration 
and diarrhoea. The wound was finally healed on the 
thirty-eighth day ; the patient had now (four months 
after the operation) completely recovered. The tumor 
was cystic in its character, with strong fibrous walls, 
continuous, apparently, with the capsule of the kidney. 
It was developed on the concave aspect of the ^land, 
and the kidney itself, otherwise but little altered in ap- 

fiearance, was flattened out on the back of the tumor, 
t had been growing for more than three years, but had 
not given rise to any kidney symptoms. — British Medi- 
cal Journal, December 30, 1882. 

Ipecacuanha as an Oxytocic. — Dr. Pitkin con- 
firms the assertion that ipecacuanha administered dur- 
ing tedious labor will augment the energy of the uterine 
contractions, and reports a case in support of his state- 
ment.— /o«r«. de Med. de Paris, Dec. 2, 1882. 

Some Curious Laparotomie.s. — Rosenbach (Gaz. 
Mid. de Strasbourg, No. 11, 1882) reports the follow- 
ing cases : 

1. Extirpation of a cancer of the rectum extending 
high into the pelvis ; detached by abdominal incision, 
and removed through the anus. The abdomen was 
opened directly above Poupart's ligament, the sigmoid 
flexure drawn out, and divided between two ligatures ; 
the upper end of the divided gut was then sutured in 
the abdominal wound, to form an artificial anus, and 
the lower end was disinfected and returned, after di- 
vision of the mesentery, to the abdominal cavity. The 
abdominal wound was then closed, and the rectum ex- 
tirpated through the anus. Drainage was carried on 
through the perineal wound, which was not closed, 
but stuffed with iodoform gauze. Death occurred from 
collapse on the second day. 

2. Operation for a distended gall-bladder containing 



a large number of calculi. The tumor occurred in a 
girl aged seven years ; had existed for two years ; was 
the size of the fist, and was situated in the right half 
of the abdomen ; distinct fluctuation could be detected. 
The abdomen was opened, and the gall-bladder stitched 
to the edges of the abdominal wound. Ten days after- 
ward the gall-bladder was opened, and a large quantity 
of clear, mucous fluid removed, and about forty calculi. 
Cure occurred without any febrile reaction. 

3. Extraction of biliary calculi through an abdominal 
incision. Cure resulted in spite of the fact that several 
calculi were lost in the peritoneal cavity. 

4. Retro-visceral dermoid cyst. Laparotomy to the 
left of the umbilicus. As the cyst could not be re- 
moved, the abdominal wound was closed, and the cyst 
sutiired to it and then opened. Cure took place with- 
out febrile reaction. 

5. Laparotomy for congenital retro-peritoneal tumor; 
neuroma of the solar ganglion. (Result not stated.) 

6. Laparotomy for intestinal obstruction from com- 
pression by an abscess of the pancreas. . (Result not 
stated.)— -/tfKrn. de Med. de Paris, Jan. 6, 1883. 

Litholapaxy in India. — Dr. P. J. Freyer states 
in the Indian Medical Gazette for December, 1882, 
that he has employed this operation in ten cases, and 
he is so thoroughly satisfied with its results in every 
respect that he has now decided on practically aban- 
doning lithotomy in the adult in favor of the new 
operation, except in cases of large and hard calculi, 
and when the case is complicated by stricture. In all 
cases he introduees a morphia suppository immediately 
after the operation, and gives ten grains of quinine in- 
ternally as soon as the patient recovers consciousness. 
He thinks this plan aids in warding off urethral fever. 
He believes that litholapaxy will become very popular 
in India, where the natives are averse to any mode of 
treatment that involves a series of several distinct sur- 
gical operations. 

General Progressive Muscular Atrophy with 
Paralytic Lumbar Lordosis.— Dr. Ludwig Langer 
reports a remarkable case of progressive muscular 
atrophy leading to paralytic lumbar lordosis, which is 
especially interesting from the extreme distonion of 
the skeleton produced, leading to the supposition, at 
first sight, that the case must be one of some disease 
of the bones. It is further clinically interesting from 
the high degree of development of the characteristic 
symptoms, and, anatomically, it brought into promi- 
nence the action of numerous groups of muscles which 
ordinarily are not accessible to study. — Diutsches 
Arch.f. klin. Med., December 18, 1882. 

Diagnosis of Tubercular Ulceration of the 
Larynx. — At a recent meeting of the Berlin Medical 
Society, Dr. Frankel made an interesting communi- 
cation on this subject. He believes that in a large 
number of cases the lenticular tubercular ulcer is quite 
characteristic. The tubercle is found completely be- 
neath the epithelium and sets up an ulceration, which, 
in general, tends to spread to the surface ; the borders 
are not sharp, but they can be always recognized by 
their sloping character from new filtration with recent 
granulations; the bottom of the ulcer is lardaceous. 
The ulcer is surrounded by an inflammatory zone, in 
which deposits of miliary tubercle can also be recog- 
nized. 

In many cases, however, the ulcer does not have 
sufficiently distinct characteristics to permit of a diag- 
nosis without the accessory information drawn from 
auscultation and percussion. — Rev. Mens, de Laryn. 
d Otol. et de Rhinol., January, 1883. 



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STATE BOARDS OF HEALTH. 



»3i 



THE MEDICAL NEWS. 

A WEEKLY JOURNAL 
OF MEDICAL SCIENCE. 



COMMxmiCATlONS are invited from all parts of the world. 
Original articles contributed exclusively to THE Medical News 
win be liberally paid for upon publication. When necessary to 
efaicidate the text, illustrations will be fiimished without cost to 
the author. Editor's Address, No. 1004 Walnut St., Philadelphia. 

SUBSCKiPTioN Price, including Postage, 

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of the undersigned. When neither is accessible, remittances may 
be made at the risk of the publisheis, by forwarding in REGISTERED 
letten. 

Address, HENRY C. LEA'S SON & CO.. 

Nos. 706 & 708 Sansom Street, 

Philadelphia, pa. 

SATURI^AY, FEBRUARY 3, 1883. 



STATE BOABOS OF HEALTH. 
It seems strange that any argument should be 
required at the present time in favor of the estab- 
lishment of State Boards of Health; yet such would 
appear to be the case, if we may judge from the 
hesitancy with which legislators approach the sub- 
ject, and their repeated failures to adopt salutary 
laws, even when endorsed anij urged by those best 
qualified to judge of their character and impor- 
tance. As an example of culpable indifference and 
neglect, in staving off from year to year a measure 
which has elsewhere been demonstrated to be of 
unquestionable advantage to the health and well- 
being of the people, the State of Pennsylvania as- 
sumes an unenviable prominence. 

Annually, for years, the Legislature of this State 
has had before it a bill creating a State Board of 
Health, but it has always failed to enact it into a 
law. At the present time such a bill is again pend- 
ing, the passage of which, in its main features, is 
earnestly desired by sanitarians and philanthropists, 
not only in this Commonwealth, but in the adjoin- 
ing States, many of which have already been pro- 
vided with central boards of health, and have a 
common interest in all measures tending to prevent 
the spread of disease. 

Without a department of public health a State 
government is deficient in its organization. Agri-' 
culture, education, finance, law, fish culture, and 
the like, are all objects of which the State properly 
takes cognizance; but what sufficient reason is there 
for ignoring the equally important obligation to care 
for and protect the health of her citizens ? 
The establishment of a State Board of Health is 



necessary for the collection and preservation of 
vital statistics. Apart from their essential value as 
records for future reference in studying some of the 
great problems of the human family, they will be 
of immediate and indispensable importance as a 
guide in searching for the causes which undermine 
the health and jeopardize the prosperity of the 
people. One of the most important functions of 
such a board is that of sanitary investigation and 
research upon questions affecting the health and 
life of citizens of the Commonwealth. No better 
proof of the advantages resulting from the per- 
formance of these duties need be presented, than 
that furnished by the instructive reports of the 
boards of health of the States of Massachusetts and 
Michigan. 

It should be the duty of the State Board to fostei 
and encourage the study of the preventable causes 
of disease, and the application of the remedies ; to 
discover the needs of the people with respect to 
sanitary laws, and to suggest, explain, and recom- 
mend the appropriate legislation ; to represent and 
guard the interest of the whole State in national 
and inter-state sanitary legislation and conferences; 
and to act as a central bureau for the collection, 
record, preservation, and dissemination of valuable 
information on all subjects pertaining to the health 
and life of the people. 

As a medium of communication and of concerted 
action between local boards of health, and of aiding 
such boards in the suppression of nuisances when 
the cause is beyond their jurisdiction, as, for ex- 
ample, in case of defilement of streams and water 
supplies, such an organization will prove to be of 
the utmost advantage. 

We trust that the members of the Legislature of 
Pennsylvania will recognize the truth of the old 
Latin motto, " salus popuU suprema estlex,^' and that 
they will no longer allpw the State to occupy the 
unenviable position of being one of the nine States 
in the Union which remain without a State Board of 
Health to investigate, supervise, and advise in the 
interests of the life and health of the citizens of the 
Commonwealth. 

AKASABCA ACCOHPAHTIBG TYPHOID EEVEB. 

Anasarca accompanying typhoid fever appears 
to be a rare condition in the hospitals of Paris, for 
M. Leudet has not met a single case in that city in 
a service of six years, while, curiously enough, he 
observed eight in the H6tel Dieu of Rouen, in a 
short space of time ; and Griesinger noted it in 
one- fourth of the cases of a typhus (typhoid?) epi- 
demic in Germany in 1857. It was also noted by 
the earlier English physicians, by Magnus Huss in 
an epidemic in Sweden in 1855, and by Virchow in 
an epidemic in Upper Silesia in 1849. ^^^ occur- 



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[Medical News, 



rence in the hospital service of M. Millard, of a 
case of typhoid fever, in which, after a profuse intes- 
tinal hemorrhage on the seventeenth day, there 
supervened, suddenly, general anasarca without 
albuminuria, has led M. Ch. Eloy, in a recent 
number of L' Union MidicaU, to carefully study 
the entire subject. 

Four classes of cases of dropsy complicating 
typhoid fever have been observed : 

ist. Local and partial oedema, resulting from 
thrombosis. Such are the cases of thrombosis of 
the internal saphenous or other veins of the lower 
extremity, resulting in phlegmasia alba dolens, or 
milk leg, which are by no means confined to typhoid 
fever, but may occur in any cachectic state. 

2d. Anasarca with nephritis, of which Traube 
reported a remarkable case, in which the oedema 
was confined to the hands and feet, accompanied 
by suppuration of the kidney, and believed to have 
been due to typhoid fever. Such an origin was 
denied by Rayer, but Griesinger, Frerichs, Rilliet 
and Barthez, and others still, have observed re- 
markable alteration of the kidney in this disease. 
We have ourselves met an instance of this compli- 
cation — nephritis — which gravely threatened an 
unfavorable termination of the case, but the patient 
ultimately recovered. 

. 3d. Anasarca and serous dropsy with albumin- 
uria, noted by Griesinger, Harley, and others. In 
the experience of the former they occurred in the 
third week, and with the latter on the thirty-fifth 
day after the beginning of convalescence. In the 
last case, febrile phenomena and desquamation ac- 
companied the invasion of the anasarca; and in 
some cases were noted an abundance of sudamina, 
and sometimes a true miliary eruption. The in- 
stance occurring as late as the thirty-fifth day after 
convalescence began, ushered by fever and desqua- 
mation, we should be inclined to consider indepen- 
dent of the typhoid attack, from which it was so far 
separated. Further we can see no reason for sepa- 
rating the second and third categories. Both must 
be the result of a renal complication, and seem to 
difier only in the seat of the dropsy. 

4th. Anasarca and serous dropsy without albumin- 
uria, occurring in the third week, coincidently with 
defervescence — the case related by M. Eloy being of 
this class, which is also the most common, since out 
of eight cases of the dropsy, albuminuria was absent 
in six. It is often preceded by copious perspiration 
or diarrhoea; sometimes by a profuse enterorrhagia, 
as in the case reported ; at others by a pulmonary 
accident, as bronchitis or pleuro-pneumonia, that 
is to say, some debilitating cause; and, in general, 
the subject is a feeble one, and the type of the fever 
adynamic. Usually the approach is sudden, and 
for the most part without fever. The urine is com- 



monly increased in quantity, but otherwise normal. 
The anasarca is not confined to the connective 
tissue, but may, though rarely, invade the pleura or 
peritoneum. Its effect upon prognosis is not, as a 
rule, more serious than to retard convalescence. 

As to the pathogenesis of these conditions, nei- 
ther cold nor geographical peculiarities are sufficient 
to account for them, and it would seem necessary 
to admit a morbid condition of all the tissues of 
the organism, and a dyscrasic state of the blood, 
provoked in some one of the ways alluded to, or by 
unfavorable surroundings, as those of famine, pov- 
erty, and confinement in prisons, etc. That con- 
ditions of the blood have much to do with them is 
proved by the fact that anasarcas have succeeded 
upon repeated bleeding in the course of typhoid 
fever. It is needless to say that a restorative and 
tonic treatment is indicated. 



6AHBETTA— HIS MODE 07 DTIHO. 

The lesions disclosed at the autopsy of Gambetta 
serve to illustrate some interesting and important 
pathological questions. The perityphlitis, colitis, 
and the localized peritonitis, whilst the immediate 
cause of death, were accidents only, arising in the 
course of a constitutional state. His habits of life 
were sedentary, and he was addicted to the pleasures 
of the table. A member of the bourgeoise class, 
whose ancestors were compelled, by the stress of 
circumstances, to adQpt a frugal life, he inherited 
their constitutional j)eculiarities. The changed con- 
ditions of life as he rose into political importance, 
and the indulgences which he permitted himself, 
induced obesity and a depraved condition of his 
fluids and solids. One of the results of these causes 
was the development of glycosuria — of that form of 
the malady associated with a vigorous state of the 
nutritive functions. Such subjects grow very fat, 
eat enormously, and pursue sedentary occupations. 
The condition of glycosuria is not constant, it is 
rather intermittent, and diet and exercise have a 
very pronounced effect in causing the disappearance 
of the sugar. Such subjects, it is now known, may 
continue for many years to present this congeries of 
symptoms. Whilst they may not experience very 
pronounced symptoms from this cause, and may 
continue for a long time fair, fat, and flabby, they 
are peculiarly liable to intercurrent diseases of a 
formidable kind — to serous and parenchymatous in- 
flammations. Such was Gambetta's fate. Confined 
indoors by a wound, and doubtless poisoned from 
this source, he experienced an intercurrent inflam- 
mation. His system was poorly prepared to resist 
the inroads of such a malady. His tissues were 
flabby, watery, fatty, and his vital resources, there- 
fore, at the minimum. 



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FEBRUARY 3. 1883.] NATIONAL ASSOCIATION FOR PROTECTION OF INSANE. 



133 



Such a case is a whole series of moral homilies. 
To the physician the moral is — inculcate the art of 
right-living, for the secret of prevention consists in 
the adaptation of the personal hygiene to the pecu- 
liar state of the social conditions. We leave to the 
moralist the lessons appropriate to such a termina- 
tion of such a life. 



THE KATIOHAL A880CIATIOK FOB THE FBOTECTIOH 07 
THE lUSAHE. 

A SMALL number of eccentrics meet semi-an- 
nually to discuss the problems connected with the 
care of the insane. What purpose, soever, may 
ostensibly claim their attention, the one subject to 
occupy them is, the abuses of asylum management. 
They wish everything changed, but, like iconoclasts 
in general, they are more apt at breaking up than 
constructing. They are more especially concerned 
that admissions to asylums should be more difficult — 
desiring to avoid the incarceration of sane persons, 
which they affect to believe is very frequent. During 
the proceedings of the meeting in which the remark- 
able paper referred to below, was read, a severe 
rebuke was administered to the authors of these 
reckless assertions by a former member of the State 
Board of Charities, who affirmed that, as a result of 
many years' observation of asylums in Pennsyl- 
vania, he had never known of a single instance of 
the incarceration of a sane person. Dr. John L. 
Atlee, of Lancaster, confirmed Mr. Well's vigor- 
ous statements, and twenty-five years' service as a 
trustee of the Harrisburg Asylum surely has given 
him the right to speak authoritatively. 

A very remarkable paper was read by a clerical 
gentleman who may be fitly characterized as a 
"reverend idol." He held forth on the duty of 
the sane to.^e insane. We learn that he belongs to 
the group of sensational preachers — moral teachers, 
who are nothing if not startling j who deal in epi- 
gram, in antithesis, in paradox, in climax and anti- 
climax, in amy rhetorical clap-trap which will startle 
their hearers. His paper was a sensational sermon, 
read in the deepest of clerical bass, and with a 
manner compounded of pertness, self-sufficiency, 
and affected modesty, which he has found effective, 
doubtless, in his congregation of adorers. Too 
wise a man was he to perplex his audience with 
weighty problems. He contented himself with por- 
traying the horrors of asylums, the fatal ease with 
which the sane are incarcerated, and the barbarities 
of the medical profession. He exhibited a sublime 
disregard of facts. He began by asserting that 
insanity was a disease of modern civilization only, 
that it divided with the "ubiquitous malaria" the 
attention of physicians, that asylums were dread- 
fully mismanaged, and that the sane were easily shut 
up in these monstrous prisons without possibility of 



escape, condemned to endure perpetual wrongs. 
He did not instance a single example of a sane 
person confined in an asylum, although he was not 
the less confident of the existence of such cases. 
The chief actors in these iniquitous proceedings 
are the doctors. They give the certificates on 
which the victims are confined, a doctor, as an 
asylum superintendent, holds the hapless subject a 
prisoner, and doctors are willing witnesses to sup- 
port any enormity, if properly paid. 

All this, and much more, did the "reverend idol" 
pour forth with self-satisfied consciousness. When 
his paper was ended interest in the proceedings 
ceased for him, and he retired, leaving the audi- 
ence to digest at their leisure his platitudes, and 
his sonorous but empty paragraphs. The insane 
who need protection have little hope when de- 
fended by such an advocate. "What went ye out 
for to see ? A reed shaken by the wind? " 



CAIIDIACEKTEBIS. 

The inquiring spirit of the times is well exhibited 
in the novelty and boldness which characterize the 
surgical expedients now carried out, or proposed. 
To reach eminence quickly, the young surgeon must 
startle. He must explode, so to speak, under the 
ancient surgical edifice, a cask of dynamite, to 
awaken the inmates of this conservative institution 
to a realization of the tremendous revolution going 
on about them. When these old fellows talk about 
Sir Astley Cooper tying the abdominal aorta, they 
are stunned by the intelligence that Billroth removes 
the larynx, and substitutes a rubber counterfeit, and 
takes out as much of the stomach as happens to in- 
convenience the patient. It has not yet been pro- 
posed to remove a damaged heart, and substitute a 
sound bullock's heart ; but this operative procedure, 
as bold as it may appear, is approximated to by the 
scheme to tap the heart itself, when the venous 
system is overloaded. 

This new operation of cardiacentesis was recently 
advocated by a New York surgeon. The proposi- 
tion is to tap the right auricle, and draw off suffi- 
cient blood to relieve an overloaded state of the 
venous system. The reasons, therefore, are conclu- 
sive. 

" Whatever skeptic could enquire for; 
For every WHY he had a wherefore." 

The small difficulties in the way of this brilliant 
operation are of little moment compared with the 
magnificent coup de thiatre of the procedure itself. 
What matters it if any of the great venous trunks 
are perforated ? It is true, when a needle is inserted 
the movements of the heart must widen the orifice 
made. An inhibiting ganglion might be irritated, 
with the effect to slow the already laboring orgati. 



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THE DANGERS OF SEWER GAS. 



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A motor ganglion might be perforated, suddenly 
cutting off the nervous force generated by it. 

To urge such objections as these, is to indicate a 
woful lack of that progressive spirit exhibited by 
modern surgery. Such objectors are inveterate 
old fogies, who must be abandoned to their idols, 
as incapable of a higher order of surgical achieve- 
ments. There are physicians, also, who object to 
tapping the right auricle, on the ground that the 
venous system may be unloaded by opening a vein 
in the arm. A physician who entertains such an 
opinion is simply incapable of appreciating the 
triumphs of surgery, and may be classed with those 
surgeons who are so hopelessly conservative as to 
prefer some trivial operation to a grand coup, which 
whilst it may end the career of the hapless patient, 
starts the surgeon on a course of brilliant operative 
methods. 

TH£ DAirOEBS OF BEWEB GAS. 
The New York Times of January 24th has an 
article upon the dangers of sewer gas, etc., in 
which Memphis is cited as an example of increase 
of disease following the introduction of sewers. 
This article has been prepared without any regard 
to the facts of the case, very mucH after the manner 
of an anti- vaccination pamphlet. It commences by 
stating that the Memphis system of sewage was con- 
structed under the superintendence of Major Ben- 
yaurd, U. S. Army, when in fact Major Benyaurd 
had nothing whatever to do with the construction, 
which was effected in part under the direction of 
Col. George E. Waring, and part under that of the 
City Engineer. It goes on to say that the result 
has been a settled and apparently consequent in- 
crease of the ratio of mortality, and that the deaths 
from dysentery have doubled, and those from diph- 
theria have more than quadrupled. From this it 
concludes that "it would really seem as if they 
are right who contend that no ingenuity of trap, 
valve, or ventilation, no matter how carefully exe- 
cuted in every detail, can prevent the percolation 
of noxious gases into a dwelling house that- is di- 
rectly connected with sewage mains. It is an as- 
sured fact that since the attention of sanitary 
engineers has been especially directed to this sub- 
ject in this City [New York], tracing back the 
agitation for the last three years, there has been a 
steady increase in the annual ratio of mortality. 
There have been no great epidemics to account for 
this fact, tenement and apartment houses have 
been steadily improving in sanitary provisions, the 
streets have been kept cleaner than before, our 
recent structures have comprised all the requisites 
of good plumbing and good engineering, and yet, 
as in Memphis, dysentery and diphtheria have 
obstinately persisted in str^gthening their hold. . . 



Until the present system of direct connection [of 
our sleeping-rooms with the sewage mains] was 
adopted, diphtheria was infrequent, and dysentery a 
rare disease, and it is fair to infer that their recent 
prevalence is in some manner due to the later mode 
of building." 

The truth is, that diphtheria has been a rare cause 
of death in Memphis. The diseases to which the 
largest number of deaths in Memphis diu-ing the 
last three years have been due, are consumption, 
pneumonia, diarrhoea, and dysentery, and a group 
of dfseases among infants, more especially the col- 
ored, variously reported as debility, marasmus, in- 
anition, etc. The prevalence of bowel diseases in 
Memphis is no doubt connected with its water sup- 
ply, which is very impure. In short, so far as the 
records of deaths in Memphis for the last three years 
have been published, they do not indicate that the 
sewers have caused disease, except in one way — viz., 
that the outlet of the sewerage is so situated with 
reference to the water-works, that at times some of 
the sewerage is probably mingled with the water 
supply. 

With regard to the statement that recent struct- 
ures in New York City "have comprised all the 
requisites of good plumbing and good engineering," 
etc., the reports of the inspectors of the Board of 
Health, and the records of trials of " skin plumbers" 
published in the columns of The Sanitary Engineer 
tell a very different story. 



THE PBICE 07 SAHITAST COSSOHS. 

From the Report on Quarantine for the year 
1882, by Dr. R. M. Swearingen, Health Officer of 
the State of Texas, we learn that to invest the fever 
district and confine the infection to its narrow 
boundaries, a double line of guards were stationed, 
one along the Arroyo Colorado, a stream encircling 
Brownsville on the east and north, and about thirty 
miles distant, and the other reaching along the 
railway between Corpus Christi and Laredo. " The 
expenses of these extensive Ijnes were necessarily 
great. September 30 the Marine-Hospital Service 
had paid out twenty-six thousand eight hundred 
and fifty-five dollars, and the expenses all told, up 
to the date that quarantine was raised, must have 
aggregated sixty-five or seventy thousand dollars." 
Dr. Swearingen continues, "The good accom- 
plished, however, can not be estimated by dollars 
and cents. The fact that the epidemic was con- 
fined to one place in Texas, while it desolated 
ranches and towns for hundreds of miles up the 
Rio Grande on the Mexican side, is strong evidence 
that the money was not squandered uselessly." 

The result may justify the expenditure, but we 
must not forget that at the same time Pensacola 



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was suffering from a similar epidemic, and that the 
disease was confined to one place in Florida with- 
out any expenditure for the payment of guards to 
confine it. In 1879, when a terrible epidemic 
raged in Memphis, and lesser outbreaks existed in 
New Orleans, in the Teche country, and various 
points elsewhere, the disease was confined to these 
numerous foci at an aggregate cost considerably 
less than was incurred at this one locality in Texas. 
It is true that the Texan cordon guarded a long 
line of river, but this was done incidentally. . The 
line did not extend along the Rio Gfande, but at 
snch a distance in the interior as would have been 
necessary had Brownsville alone been under guard. 
The establishment of a close guard is open to the 
objection of shutting up the whole population in an 
infected city, thus precluding the application of one 
of the most rational measures of protection, that, 
namely, of prompt depopulation, while a cordon 
placed advisedly at thirty or more miles distance 
costs sixty-five or seventy thousand dollars. 



REVIEWS. 



Syphilis. By V. Cornil. Translated, with Notes 
AND Additions, By J. Henry C. Simes, M.D., and 
J. William White, M.D. 8vo. pp. 461. Philadel- 
phia: Henry C. Lea's Son & Co. 

The reader of this -book will find that, despite the 
long-continued and careful study bestowed upon syphi- 
lis, there are yet many things very far from being 
settled concerning it. If he has adopted the dualistic 
theory made familiar to American readers by the work 
of the lamented Bumstead, he will receive somewhat 
of a shock when he discovers that, while M. Cornil, in 
common with many other reliable authorities, is a 
staunch dualist, his American editors incline to believe 
in the common origin of chancre and chancroid. It 
will be impossible for him to resist the conviction that 
Drs. Simes and White in presenting their view reflect 
the opinions of a small, but growing number of syphi- 
lograpbers ; and while he will probably conclude that 
the correctness of the position of the unicists is by no 
means established, it will be impossible for a fair- 
minded man to resist the conviction that neither theory 
by itself is adequate to explain all the questions which 
arise. The result of a careful perusal of this volume 
must be to leave the mind of the student in a some- 
what chaotic condition concerning the nature of syphi- 
lis. Indeed, when he observes that M. Cornil is a 
dualist, and that his editors, to say the least, incline to 
the opposing theory, the reader may almost despair of 
himself arriving at'a fixed state of mind in the matter. 
Yet, however disagreeable a state of incertitude may 
be, it is the attitude becoming the true scientist. It 
might be thought that the time devoted to the accumu- 
lation of observed facts had been sufficiently long, and 
that we might now begin to generalize with safety ; but 
a survey of this book will at once convince that the 
end is not yet, and that we must yet be prepared to 
receive further facts, and that the nature of the syphi- 
litic poison, in common with that of tuberculosis, and 
many constitutional affections, is still undetermined. 

_ The additions of Drs. Simes and White are very con- 
siderable, as well as of great importance. The trans- 



lation has been very well done, and the translators 
have made some mo^t judicious alterations in the 
arrangement of the work. A distinguishing feature of 
the book is the attention paid to histological details 
and the visceral lesions of syphilis. We know of no- 
work which is of equal value in either of these respects. 
It is a book which must be studied by every one who 
desires to acquaint himself with the views of the day 
concerning syphilis, a disease which seems to- be of 
ever-increasing importance as a factM: in the history 
and well-being of man. 

It is to be hoped that Drs. Simes and White may see 
fit to prepare an independent work of their own upon 
the subject, which would seem to be warranted by the 
number and value of their additions to M. Cornil's 
lectures, and which would more fully bring their opin- 
ions before the profession, unhampered by their attitude 
of commentators. 



The Busy Physician's Visiting List, Clinical Aid,. 
AND Pocket Ledger. Detroit: Geo.S. Davis, Med- 
ical Publisher. 

This new candidate for professional favor, as an aid 
to the daily life of the doctor, ha'itonuch merit. It is 
adapted to any date, and can be use* both for the daily 
record of engagements and for an account book. It 
has calenders, obstetric and annual, metric tables, and 
rules for the treatment of emergencies, points in differ- 
ential diagnosis, a list of new remedies, etc. Although 
we are generally opposed to pocket-books, which aint 
to provide the physician with medical knowledge, we 
must praise the good judgment and skill displayed ia 
the preparation of this work. We can recommend it 
to our readers, as a most useful pocket-book. 



SOCIETY PROCEEDINGS. 



NEW YORK SURGICAL SOCIETY. 
. Stated Meeting January g, 188 j. 
The President, T. M. NUrkoe, M.D., in the Chair^ 

excision of the knee-joint. 

Dr. C. T. Poore presented three patients upon 
whom he had performed excision of the knee-joint. 
All the operations were performed with the circular 
incision. The antiseptic spray was not used. The 
wounds were thoroughly washed out with a solution of 
carbolic acid, one to forty. The bones were sutured 
together with wire sutures, and drainage-tubes passed 
through the anterior flap around the joint and out 
through the popliteal space. To secure immobility, 
the limb was placed on a posterior splint, and a plaster- 
of- Paris bandage applied from the toes to the groin, an 
interval being left at the point of operation. 

The first patient was a boy, sixteen years of age,, 
with a rather poor family history. He had pulpy dis- 
ease of both knee-joints. In the right, the tibia was 
dislocated backwards and flexed at a right angle with 
the femur. The right knee-joint was excised in 1879, 
and the result was firm union of the tibia and femur, 
with two inches shortening. At the time of dismissal 
from the hospital, he had quite good flexion of the 
left knee, and was able to act as an assistant to a sur- 
veyor, which compelled him to do considerable walk- 
ing. Last summer he fell and injured the left knee. 
This was followed by swelling and pains, and it had 
left that joint stiff in a straight position. Notwitb- 
standing this he was able to walk very well. 

The second patient was a girl, thirteen years of age, 
who fell and injured the left knee-joint six years ago. 



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PROCEEDINGS OF NEW YORK StJRGICAL SOCIETY. 



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The injury was immediately followed by swelling and 
pain, and six weeks subsequently an abscess formed, 
which was opened in Bellevue Hqspital. She was 
subsequently a patient at Roosevelt Hospital, where 
several large abscesses formed about the joint and the 
lower portion of the thigh, and were opened. She left 
there considerably improved, but with the limb flexed 
at nearly a right angle. She subsequently was ad- 
mitted to St. Mary's Hospital, where Dr. Poore oper- 
ated upon her in May, 1882, by removing a V-shaped 
portion of the lower extremity of the femur. There 
was considerable shortening after the operation, and 
there still remained a small external ulceration, but no 
exposed bone. 

The third patient was a boy, who had suffered with 
abscess from Pott's disease, and also had ostitis of the 
head of the tibia, which opened into the joint. Exci- 
sion was performed in the usual way, and there was 
nothing peculiar concerning the subsequent progress 
of the case, except that on the following day the tem- 
perature arose to 105.5° Fm but fell to the normal 
within a few hours, and afterwards there were no un- 
favorable symptoms except the occurrence of a small 
slough upon one side of the joint, for which Dr. Poore 
was unable to account. In this case there still re- 
mained a small si&us, into which a probe could be 
introduced, but be was unable to detect any rough 
bone. 

Dr. Poore had also operated upon another similar 
-case, and expected that the patient would be present, 
but for some reason was absent. In all the cases the 
wounds healed promptly, and all the patients were up 
on the fortieth day. 

FIBRO-SARCOMA OF THE PAROTID. 

Dr. Sands presented a patient who illustrated the 
act that in the case of tumors which are unpromising 
n character, occasionally the disease does not return 
after removal, or, at least, for a very long period. This 
man, now thirty years of age, came under his notice 
in June, 1870. At that time there was a tumor in the 
parotid region, which was believed to involve the 
parotid gland. It was situated upon the right side, 
occupied the entire parotid region, and formed a rather 
low but extensive growth, which caused prominence 
of the ear, was exceedingly firm and entirely immova- 
ble. It had then been growing for about five months. 
The case was regarded as unfavorable on account of 
the rapidity of the growth of the tumor, and the ex- 
tent and firmness of its adhesions to the deep parts, as 
well as to the skin. Dr. Sands decided, however, to 
attempt to extirpate it. When the flaps of skin had 
been raised, a small portion of the growth was re- 
moved, and was examined with the microscope by Dr. 
Delafield, who found it to be a fibro-sarcoma. The 
piece removed contained a large proportion of fibrous 
tissue, with cell elements of a round shape. The diag- 
nosis was confirmed by the subsequent examination of 
the tumor after its removal. The tumor extended into 
the deeper portion of the neck, and was attached to the 
styloid process, and was so incorporated with the ad- 
jacent tissue as to make the operation very unsatis- 
factory. The under surface of the skin was invaded 
by the morbid growth, being completely incorporated 
with the whitish tissue of the tumor. Notwithstanding 
the difficulty of the operation, the patient made a good 
recovery. Some sloughing of the cutaneous flaps 
occurred, but beyond this no accident followed the 
operation, and the patient left the hospital six weeks 
afterwards with the wound healed. Before the opera- 
tion the facial nerve was intact, but immediately after- 
wards the parts supplied by it were found to be 
completely paralyzed. The paralysis still remains, 
although it is hardly noticeable when the features are 



in repose. Dr. Sands had watched the case with a 
great deal of interest, and made his last note about 
one year ago, at which time there was no evidence of 
recurrence of the disease. About three months ago 
the patient discovered some swellings upon the right 
side of the neck, and now there can be felt six or ei^ht 
flat movable tumors extending along the posterior 
edge of the sterno mastoid muscle down to the clavi- 
cle, the largest being about an inch in breadth and 
length, and about half an inch in thickness. They 
are very firm, being in this respect like the original 
tumor. The skin in the neighborhood of the opera- 
tion seemed to be sound. 
DRs McBurney then read a paper on 

TRACHEOTOMY AS A PRELIMINARY TO CERTAIN 
OPERATIONS. 

The operations which are referred to in the title of 
this paper are operations for the removal of the upper 
or lower jaws, particularly when these parts are in- 
volved in the growth of large tumors ; operations for 
the removal of large or vascular naso-pharyngeal 
polypi, or of tumors springing from the tonsils or walls 
of the pharynx, or tongue, or palate ; and. also opera- 
tions which involve the extirpation of the entire tongue, 
or of the larynx and adjacent parts ; in fact, all opera- 
tions in the course of which considerable risk is run of 
having blood or diseased material pass into the lungs 
or stomach. The old method, so frequently made use 
of before the introduction of anaesthetics, and still 
recommended by some, of placing the patient in the 
sitting posture with the head upright, or hanging for- 
ward, offers certainly very slight advantage. Some of 
the blood lost will, to be sure, flow out of the mouth, 
but the tendency of such blood as finds its way back- 
wards to pass down the trachea and cesophagus is 
greater in this position than in any other. Moreover, 
the difficulty of retaining a patient who is under the 
influence of an anaesthetic in this position, and the 
awkwardness of applying artificial respiration, or of 
doing tracheotomy if suddenly demanded in the course 
of the operation, and the greater liability to syncope, 
form very serious objections to it. 

Rose's position, or the hanging head, was an in- 
genious device, undoubtedly applicable to certain 
cases. Rose placed the patient with the head and 
neck projecting beyond the end of the operating table, 
allowing the head to fall so far backwards that its 
vertex pointed to the floor. The naso-pharyngeal 
cavity then becomes a cup placed on a lower level 
than the orifices of the trachea and cesophagus, and 
blood collecting in it flows more readily out of the 
nose, provided the nares do not become plugged with 
clots, than down the pharynx. From this cup-shaped 
dependent cavity blood can be sponged and readily 
removed. This position appears to me to recommend 
itself in cases where hemorrhage will probably not be 
great, and where the seat of the opei'ation is the palate 
or mouth, as in cases of cleft palate, or where portions 
only of the jaws are to be removed without external 
incisions. But in cases where hemorrhage is very 
great, or the disease to be removed involves the naso- 
pharyngeal cavity itself, the Rose position favors the 
accumulation of blood at the very place where it is 
most objectionable. Moreover, patients are not infre- 
quently met with who behave very badly when thus 
placed while under the influence of an anaesthetic, 
the tension of the larynx and trachea apparently pro- 
ducing a spasm of the glottis which becomes danger- 
ous if not relieved. 

Both the upright and hanging head positions are ex- 
ceedingly awkward in the administration of the anaes- 
thetic, it being necessary to remove the cone as soon 
as the operation is begun, and to interrupt the opera- 



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tion at intervals in order to give more anaesthetic. 
This last is a serious objection, for not only is the 
operation much prolonged, but blood is frequently lost 
in large quantities while the mouth and nose are 
concealed from view. The gravity of extensive and 
bloody operations about the mouth and adjacent parts 
has been frequently illustrated in the last few years, 
not a few such operations having resulted fatally to 
the patient, either at the time of operation or within a 
few days thereafter. Moreover, the nature of the dis- 
ease for which most of these operations are undertaken 
requires that they should be performed not only with 
expedition, but with great thoroughness. 

I do not know who first suggested a preliminary 
tracheotomy in the class of cases which I have re- 
ferred to, but to Trendelenburg is due the credit of 
giving to the profession an apparatus complete enough 
to be of very great service in such cases. The original 
device consisted of a tracheal tube, surrounded in the 
tracheal portion with a thin rubber bag, which could 
be sufficiently inflated, by means of a connected bulb, 
to completely fill the trachea. To the outer end of the 
tracheal tube an elastic one, several feet in length, was 
fitted, at the free extremity of which was a reservoir to 
receive the anaesthetic. The objections to this instru- 
ment, as so arranged, are several. In the first place, 
if the rubber bag was overdistended, which might easily 
happen, it might burst, or could force its way down so 
as to close the lower end of the tube. This latter ac- 
cident occurred to me in one case, and gave consid- 
erable trouble. The tracheas of some patients do not 
bear well the lateral pressure of the bag, violent cough 
being induced when it is distended. This I have also 
seen occur. To remedy the first objection, as well as 
to get rid of the outer bulb, and to obtain greater nicety 
in fitting the trachea. Dr. Friedrich Lange devised the 
instrument already shown to this Society. It seems to 
me to fulfil the indications for either temporarily or 
permanently tamponing the trachea better than any 
which I have seen. 

Michael, of Hamburg, surrounds the canula with 
compressed sponge. Over the canula and sponge he 
places a sack of gold-beater's skin, soaked in a solu- 
tion of rubber. A little water having been thrown into 
this sack, the sponge swells and effectually closes the 
lumen of the trachea. Dr. Foulis, of Glasgow, in ex- 
tirpating the larynx, tamponed the upper end of the 
divided trachea with a lead canula which was sur- 
rounded with a rubber ring, thus completely closing 
the air tube and effectually preventing the passage of 
blood into it. 

Dr. Lange recommends in similar cases a leaden 
canula surrounded with punk, which material is light, 
and does not allow of the passage of fluids through it. 
These cases, however, hardly come under the head of 
preliminary tracheotomy, tamponing of the trachea 
being necessarily done in the course of the operation. 
The objects of the preliminary operation are several. 
Firstly, to prevent the passage of blood down the 
trachea. Secondly, to facilitate the continuous and 
safe administration of the anaesthetic. Thirdly, to 
avoid the possibility of being called upon in the course 
of the operation to open the windpipe under forced 
and adverse circumstances. Fourthly, to permit of a 
continuous, rapid, and complete operative procedure, 
and thus avoid much unnecessary loss of blood. 
Fifthly, to secure to the patient after the operation an 
abundant supply of air which is not contaminated by 
the discharges from the seat of operation. 

The passage of blood down the trachea is a dan- 
ger which always threatens in bloody operations 
about the upper air passages, and enough fatalities 
have occurred from this cause to make its prevention 
worthy of consideration, death having been produced 



on the operating table, and pneumonia having been 
produced in other cases from the entrance of blood 
mto the air cells. The unnoticed loss of blood is, in 
some cases, very great, where the operator depends 
upon the sponging out the larynx during the opera- 
tion, blood passing down the trachea, and more espe- 
cially down the oesophagus, in large quantities. When 
the trachea is tamponed so as to permit of a continuous * 
administration of the anaesthetic through the canula, 
this loss of blood can be largely avoided, for continuous 
pressure can be kept up upon the bleeding points dur- 
mg the course of a long operation, which of course can 
not be done where the anaesthetic is being repeatedly 
administered through the mouth and nose. The con- 
tinuous and safe administration of the anaesthetic has 
also the great advantage of not only saving time in 
operating, and, hence, some exhaustion to the patient, 
but of permitting the operator to deliberately carry out 
his dissection. In cases of malignant disease, as of 
the upper jaw, tongue, and pharynx, complete extirpa- 
tion of the disease is far more likely to be attained 
where the tracheal tube is used than when it is not ; 
of course, a less rapid recurrence of the disease would 
then be expected. 

The advantages claimed for the preliminary opera- 
tion can be obtained in a manner somewhat different 
from, and in my opinion better than, that proposed by 
Trendelenburg. Instead of the long and heavy tube 
used by Trendelenburg, one very like an ordinary 
tracheal tube may be used, into the outer end of which 
the tube to conduct the anaesthetic from the reservoir 
can then be fitted. It is not necessary to tampon the 
trachea itself, as the same effect may be efficiently ob- 
tained by packing the lower part of the pharynx with a 
sufficiently large sponge, to which a string is attached to 
facilitate its removal. Kocher recommends this plan, 
but I first saw this method made use of by Dr. George 
A. Peters, and I have seen it used by others and have 
used it myself with complete success. It is not perfect, 
however, for sponge, no matter how tightly packed, 
will permit of the passage of fluid. I would suggest, as 
an improvement on the ordinary sponge packing, a 
sponge covered about half with thin rubber. The 
rubber side being pushed down and covering the whole 
lower surface of the sponge, would prevent any drain- 
age through. 

There are some questions in regard to the prelimi- 
nary operation which 1 am not able to satisfactorily 
answer to myself. Firstly, is there any advan- 
tage gained by doing the tracheotomy some time in 
advance of the primary operation ? Max Schiiller, 
in his monograph on extirpation of the larynx, recom- 
mends that the tracheotomy be done some weeks in 
advance, and claims that by so doing the risks of sub- 
sequent pneumonia and bronchitis are lessened. Out 
of fifteen cases of extirpation of the larynx which 
Schiiller collected, five died of pneumonia, and one 
suffered from severe bronchitis. But I am not able to 
satisfy myself that any real advantage would be gained 
by doing the tracheotomy a long time beforehand, ex- 
cept in cases where the difficulty of breathing through 
the normal passages caused great impairment of 
health. 

In answer to another question, I think a more posi- 
tive reply can be made. How long shall the tube be 
kept in position after the operation ? 

It should of course be left in all cases where there 
is reason to fear that the upper orifice of the larynx 
may become occluded by inflammatory swelling. But 
another reason for retaining the tube in position is to 
enable the patient to obtain a supply of pure air during 
the suppurative stage. Kocher not only keeps the 
tracheal tube in, but also the sponge tampon in the 
pharynx, the sponge being soaked in a five per cent. 



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solution of carbolic acid and removed only to allow the 
patient to feed. This method also enables the surgeon 
to treat the wound nearly antiseptically, the nostrils 
being plugged, the mouth closed though drained into 
a tube, and frequent washings of the whole cavity 
being resorted to. I am inclined to think that the 
comfort and safety of the patient would be increased 
by following this method m all extensive operations. 
Michael, Schuller, and others, also claim that by keep- 
ing up for some time this permanent closure of the 
larynx, patients are much less likely to suffer from 
(Schluck) pneumonia, or foreign-body pneumonia. I 
have myself made use of a preliminary tracheotomy 
but three times. In one of these the Trendelenburg 
apparatus gave me great trouble in consequence of the 
extreme elasticity ofthe rubber bag, which folded over 
the end of the canula when it was distended. In the 
other two cases for removal of naso-pharyngeal polypi, 
I made use of a simple canula, and plugged the lower 
part of the pharynx with sponge. This method gave 
me great satisfaction. 

Dr. Post said he had performed preliminary trache- 
otomy three times; twice upon the same subject after 
a longf interval. In two out of the three times the 
operation was performed without the introduction of 
the tube, according to the method of Dr. Martin, of 
Boston, which he had found very satisfactory. He in- 
troduced a large sponge into the fauces, and only a few 
drops of blood escaped into the trachea. With the 
open trachea he found it very easy to sponge out what- 
ever blood might enter. He had found great facility in 
performing tracheotomy as a preliminary operation, 
and believed that all the advantages which Dr. Mc- 
Burney had attributed to the operation, are derived 
from it, and that there was no additional risk from 
performing it. 

Dr. G. a. Peters had performed preliminary trache- 
otomy three times. In one case he had used Trende- 
lenburg's tube. Having seen the difSculties which 
Dr. McBurney had mentioned concerning the use of 
this tube. Dr. Peters had had the instrument modified, 
and supposed that he had gotten rid of the danger, but 
he then found that another troublesome symptom re- 
sulted ; namely, a persistent coughing the moment the 
bag was distended, although he had taken pains to 
measure the exact amount of air which was necessary 
to distend the bag up to a certain point. After that, 
he threw Trendelenburg's tube aside entirely, and had 
since used only an ordinary tracheal tube, stuffing the 
fauces with sponge. This method had given him much 
satisfaction. The anaesthetic could be administered 
without interruption, and he had had no trouble from 
blood running into the stomach or trachea. In one of 
the cases where he used Trendelenburg's tube the pa- 
tient had a cough which lasted for some time, but he 
attributed it rather to pressure from the instrument 
than to entrance of blood into the lungs. He had, 
however, concluded that the most satisfactory method 
was to use the ordinary tracheal tube and stuff the 
fauces with a sponge. 

Dr. Gerster had performed preliminary trache- 
otomy once, and in a case previous to exsection of half 
of the larynx. In that instance, he used Trendelen- 
burg's instrument, and just after the operation had been 
commenced the India-rubber bag ruptured, and he was 
obliged to remove the canula and replace the bag by 
folds of gauze bound in position by silk. The canula 
was then reintroduced, and answered the purpose very 
well. With regard to one object mentioned by Dr. 
McBurney concerning tracheotomy as a preliminary 
operation, his own opinion was that preliminary trache- 
otomy performed a good while before the secondary 
operation afforded a good many advantages over its 
performance simultaneously with the operation for the 



removal of the disease. He recalled several instances 
where he had been present, and in which considerable 
time was consumed in performing the preliminary 
operation ; thus in one instance half an hour was oc- 
cupied, and it could readily be seen that in an anaemic 
patient the performance of the preliminary operation 
would necessitate the longer continuance of the an- 
aesthetic and therefore an undesirable exposure to 
shock. Tracheotomy upon a grown subject was rather 
an indifferent operation if properly performed, and the 
necessary care was bestowed upon the after-treatment. 
The operation was not very serious, and the patient's 
respiratory tract became accustomed to the tube, and 
he, therefore, believed it to be advantageous to first 
dispose of this liability to accident before the operation 
proper was to be performed. 

Dr. W. T. Bull had had occasion to perform trache- 
otopiy as a preliminary operation in four cases : three 
times for extirpation of a portion of the tongfue, and 
once for removal of a recurrent growth from the side 
of the pharynx. In all instances he had used the 
ordinary tracheotomy tube. He had not seen any ad- 
vantages following the use of the tube with the rubber 
bag. On the contrary he had thought that it interfered 
with expulsion of mucus from the trachea. He had 
not left the tube in more than forty-eight hours. He 
regarded the suggestion made by Dr. McBurney with 
reference to permanent tamponing the trachea after the 
operation as a very valuable one, and as an important 
addition in the after-treatment. 

Dr. Briddon remarked that he had been prejudiced 
against Trendelenburg's tube, and had simply used an 
ordinary tracheal tube, packing the fauces wih sponges. 
The operations which he had performed, however, had 
'always been laryngotomies. He thought it unneces- 
sary to make the operation for the introduction of the 
instrument a tedious one. He believed there was no 
danger from hemorrhage, which always ceased after the 
introduction of the tube. He had been favorably im- 
pressed in the adoption of Nussbaum's method of 
narcosis in these cases, that is, to precede the an- 
aesthetic by the use of a large hypodermic injection of 
morphine, perhaps fifteen drops of Magendie's solution. 
This is to be followed by the use of an anaesthetic, and 
he had employed chloroform, administering it to the 
production of moderate narcosis, and then performing 
tracheotomy. He had been surprised at the small 
quantity of chloroform required to maintain insensi- 
bility. In one operation not more than three and a 
half drachms were consumed, and the patient was able 
to assist at the operation, was sufficiently conscious to 
be able to empty the mouth of blood, etc., and yet he 
was placed beyond sensitiveness to the knife. He had 
not seen Trendelenburg's tube used without the occur- 
rence of some disagreeable accident. 

Dr. Weir had performed preliminary tracheotomy 
in one case with advantage ; using only the ordinary 
tracheal tube, packing the fauces with sponges, and 
maintaining anaesthesia through the mouth of the tube. 
He was led to adopt this method because of havine 
previously resorted to Rose's method in the removal 
of a naso-pharyngeal growth. It was found that the 
stretching of the neck unduly compressed the trachea 
and interfered with respiration. In the second case of 
a similar nature the use of tracheotomy permitted more 
satisfactorily the dependent position of the head. He 
was loath, however, to adopt preliminary tracheotomy, 
because he believed the operation in itself was asso- 
ciated with considerable risk. He had been led to this 
conclusion from studying the cases in which the ope- 
ration had been performed for the relief of syphilitic 
disease of the larynx without much dyspnoea, and for 
rest of that organ. In two such cases pneumonia 
had occurred. He had also seen several instances of 



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139 



cut throat where only the trachea had been incised and 
where the patient's condition was good, and subse- 
quently chest symptoms developed. He would not 
resort to the preliminary tracheotomy unless the sub- 
sequent operation was evidently to be an excessively 
bloody one, and with risks liot to be avoided by posi- 
tion, slight anaesthesia, etc. 

Dr. Sands could recall only a single case in which 
he had used Trendelenburg's tube, and in that instance 
it worked very well. Pains were taken to prevent the 
expansion of the rubber bag over the lower orifice of 
the canula, and the only inconvenience observed was 
the occurrence of coughing, as already mentioned by 
Dr. Peters. He thought that if the instrument could 
be used with success so far as to completely occlude 
the trachea, it would form a very valuable invention. 
He had noticed, however, that it frequently failed to 
accomplish the purpose for which it was designed, as 
it allowed blood to pass down into the trachea. He 
had many times excised tumors of the pharynx and 
tonsils, or had removed the upper jaw without en- 
countering the least danger from the entrance of blood 
into the air-passages. He thought that if these points 
received due attention during such operation, little or 
no danger need arise from this cause. In the first 
place, the patient should be placed in a chair with his 
head inclined slightly forward. In the second place, 
profound anaesthesia should be avoided, as the blood 
will enter the larynx only when it is rendered quite 
insensible, as is the case with deep narcosis. In the 
third place, it was desirable to operate quickly. In two 
cases of naso-pharyngeal polypus which he had re- 
moved years ago, no blood entered the trachea so far 
as he could discover, and the patient made a good 
recovery. The principle of tamponing the trachea was 
important, however, and he would be glad to see it 
realized in practice. His own experience had not led 
him to regard tracheotomy as an operation likely to 
cause pneumonia, yet he was not prepared to deny that 
such might sometimes be the case. 

Dr. Gerster said that the weight of Dr. Sands' re- 
mark was largely in the proposition which he made 
not to carry the anaesthetic too far. He had had occa- 
sion to perform several operations upon the upper jaw, 
and he had always been careful not to place the pa- 
tient too profoundly under the influence of the anaes- 
thetic; only just sufficiently so that he would not re- 
sist violently enough to prevent the finishing of the 
operation. In all these cases he had not seen any 
difficulty whatever, because when any blood entered 
the trachea, the sensitiveness of that tube induced re- 
flex movements which caused an immediate rejection 
of the blood. 

Dr. Stimson remarked that he doubted whether the 
patient could always be depended upon to give evi- 
dence of the presence of blood in the trachea by cough. 
He had one patient whom he had anaesthetized six 
times for the removal of a constantly recurring growth 
in the upper maxilla. The woman took ether badly, 
and complete anaesthesia was never obtained for more 
than one or two minutes at a time. In that case he 
had seen the pharynx so full of blood that air bubbled 
up through it, and yet the patient never coughed. -He 
was not positive that blood made its entrance into the 
trachea, but it was in the pharynx in large quantities, 
and air bubbled up through it. No bad consequences 
followed. 

The President remarked that during the last fifteen 
or twenty years he had performed quite a large number 
of these operations, and he believed that by simply bear- 
ing in mind the suggestion made by Dr. Sands, no dif- 
ficulty need be experienced with reference to a serious 
quantity of blood getting into the trachea. He believed 
that in a large proportion of cases the most bloody op- 



erations could be performed with safety without pre- 
liminary tracheotomy. 

fracture op the calcaneum. 

Dr. Stimson presented a specimen which illustrated 
fracture.of the posterior portion of the head of the calca- 
neum. He believed it to be probably the result of mus- 
cular action. The patient was a man fifty-three years of 
age; who was admitted to Bellevue Hospital in Novem- 
ber last for a disease of the tibia which required ampu- 
tation. Eight years ago, while crossing the street, he 
was knocked down by a wagon and received the injury 
which the specimen illustrated. At the time the injury 
was received, the patient said that the skin was not 
bruised. The fragment was the portion to which the 
tendo Achillis was attached, at least partially. It was 
more than an inch in length, and about three-fourths 
of an inch in breadth. On its outer side the periosteum 
was complete ; on the inner side there was a growth of 
bone which presented the appearance of having been 
the result Of reparatory process. The fragment had 
united with the bone at its upper border, but was about 
half an inch anterior to its original position. The speci- 
men was accompanied by photographs, and a plaster 
cast which illustrated the deformity. 

Dr. Bull thought that pure muscular action could 
not produce this fracture; t^at it was the result of di- 
rect violence. 

Dr. Stimson remarked that there were several cases 
upon record in which the fracture occurred as a result 
of muscular action. 

Dr. Peters referred to a case, and Dr. Weir to 
three cases, m which fracture occurred as a result of 
muscular action. 

melanotic sarcoma. 

Dr. Gerster presented a specimen of melanotic 
lympho-sarcoma, which he removed from the neck of 
a man on the fourth of the present month. Three 
months ago the patient got heated from running about, 
and then sat down in front of an open window and 
was chilled. This was the only fact which he had been 
able to ascertain concerning the cause of the growth, al- 
though he did not attribute much importance to it as an 
etiological factor. Immediately after this occurred, the 
man noticed a slight swelling at the corresponding 
angle of the jaw, which gradually increased in size. 
There was no sore throat following the chilling, nor 
nasal catarrh. The tumor continued to grow and he 
consulted a physician, who proposed to inject into it 
tincture of iodine. At that time it was about the size 
of an Italian chestnut. Considerable reaction followed 
the injection. The tumor did not resume its former 
size and shape, but continued to grow rapidly, and 
after three months it attained the size of a small 
orange. It was situated in the upper cervical -triangle 
below the angle of the jaw. Laterally it was quite freely 
movable, not so vertically, and the skin over it was 
attached to the tumor. Dr. Gerster diagnosed lympho- 
sarcoma of rapid growth, and gave a grave prognosis. 
Removal was advised; the exsection was not difficult. 
Immediately after cutting through the skin it was 
noticed that the mass had a peculiar dark color. On 
account of its appearance, and from the fact that 
through a slight puncture made by a hook introduced 
into its capsule for the purpose of lifting the tumor up, 
a black material exuded, he did not attempt to remove 
the tumor from the capsule, but dissected out the cap- 
sule and all, keeping well to the outside of the growth. 
At the lower and inner part of the tumor, where it ap- 
proached the superior thyroid artery, there was a dense 
mass of connective tissue of recent inflammatory origin, 
which had attached the capsule to the bloodvessel, and 
also enclosed a small bundle of lymphatic vessels. 



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Immediately upon the oozing of the black muddy ma- 
terial, which presented the appearance of graphite, 
through the opening made by the hook, be removed 
the instrument and applied a ligature round the point, 
carefully cleansed the part, and then proceeded to the 
dissection without further assistance of this kind. At 
the upper and outer angle of the jaw, a large number 
of lymphatic glands were found which had exactly the 
characteristics of the tumor itself. They looked like a 
chain of small blue grapes, and burst as soon as 
touched. They were dissected away also with some 
connective tissue by which they were surrounded. 
When the tumor was cut open, it was found to con- 
tain a cavity in which there moved freely a black body 
that was surrounded by the dark fluid material already 
mentioned. Microscopical examination revealed that 
the growth consisted almost entirely of round-celled 
pigmented elements, with a very sparse stroma. The 
mass which was free in the centre, was doubtless the 
original swelling or lymphatic gland noticed first by the 
patient in the neck. The thick melanotic envelope 
enclosing this glandular body apparently represented 
the degenerated glandular capsule. The wound was 
closed by a few silver wire sutures, and healed by first 
intention. Early recurrence of the disease is to be ex- 
pected. 

FIBRO-HYOHA OP THE SCROTUM. 

Dr. W. T. Bull presented a specimen accompanied 
by the following history: H. C. F., forty-eight years of 
age and married, entered the hospital October i6, 1882. 
He gave no specific history, there was no history of 
cancer in the family, there was no history of trauma- 
tism. About twenty years ago, the patient first noticed 
a small, hard lump about the size of a marble in the 
lower part of the right side of the scrotum. There was 
neither pain nor tenderness on pressure, nor discom- 
fort of any kind. This mass gradually increased in 
size until two or three years ago, since which time it 
had grown much more rapidly. On admission he com- 
plained only of the weight and inconvenience. The 
scrotum formed a tumor as large as a child's head, the 
enlargement being on the right side. The skin was 
normal with large veins, the tumor was ovoid in shape, 
and reached upwards as far as the external abdominal 
ring, which was dilated, and filled up when standing 
by a hernial protrusion as large as a goose egg, which 
could be easily returned. The surface of the tumor 
was smooth but uneven, and marked by several 
rounded projections which were semi- fluctuating. The 
right testicle was on its lower end softer than the left, 
and apparently somewhat flattened, but movable in the 
tunica vaginalis. The circumference of the tumor at 
its upper limit was fifteen inches, at its lower part 
eighteen inches, and was of firm elastic consistence, 
and not at all tender. There was no pain either from 
it or the hernia. The patient had worn no support. 
There were no enlarged glands. Removal was ad- 
vised. The parts were washed with a solution of car- 
bolic acid, I to 40, after which ether was administered. 
Dr. Bull was assisted at the operation by Drs. George 
A. Peters and R. F. Weir. The hernial protrusion was 
put back and held, the tunics covering the tumor were 
dissected down to the capsule, and the cord exposed. 
A strong piano string was placed round the cord two 
inches from the tumor, and held by the forceps ; the 
cord was then cut across about one inch from the 
tumor and it appeared normal, but it was evident at 
once that the lower end of the hernial sac, which was 
adherent to the surface of the tumor over a space as 
large as half a dollar, had been cut across with it. 
The bloodvessels were ligated with catgut, the wound 
in the peritoneum was united by continuous catgut 
suture, the irregular portion of redundant scrotum was 



cut off with the scissors, a drainage-tube was intro- 
duced, and the wound was closed with sutures of car- 
bolized silk, sixteen to twenty in number. Iodoform 
peat-bags and absorbent cotton were used in the dress- 
ing. The patient was discharged from the hospital 
cured, November 13th. The hernial protrusion was 
diminished in size, and was retained by a truss. The 
tumor weighed three and a half pounds. It had been 
examined by Dr. Satterthwaite, who reported that it 
was a composite growth, consisting chiefly of ordinary 
fibrous tissue, to a less extent of fatty tissue, and to a 
still less degree of non-striated muscular tissue. It 
was situated behind the cord, which was lengthened, 
but otherwise unaffected, and above the right testicle, 
which was normal, as was also its tunica vaginalis. 
The origin of the growth was apparently from sub- 
cutaneous connective tissue, its outer layers forming 
a sac that was infiltrated with lime salts over most of 
the surface, while where depositions were absent there 
were small hernial protrusions of tumor substance. 



NEW YORK ACADEMY OF MEDICINE. 

Section on Practice. 

Stated Meeting, January 16, i88j. 

Dr. Edward G. Janeway, Chairman. 

Dr. Janeway said that he had made a post-mortem 
examination on a man to-day, who had died of 

abscess of the liver, 
in which a quart and a half of pus was evacuated, 
death being due to peritonitis consequent on rupture of 
the walls of the abscess. Previous to his death. Dr. 
Janeway asked the patient if he had had any hypo- 
chondriacal or melancholiacal attacks. The patient 
gave an emphatic negative answer. This was only one 
of a number of cases of abscess of the liver in which 
no melancholia or hypochondriasis was present. He 
therefore believed that these conditions existing in con- 
nection with abscess of the liver were the exception 
rather than the rule. 

The paper of the evening was read by Dr. Henry 
D. Noyes, and was entitled 

EYE TROUBLES WHICH MAY BE ERRONEOUSLY ATTRIB- 
(TTED TO LESIONS OP THE BRAIN AND NERVOUS 
SYSTEM, 

The author said that the connection which exists 
between diseases of the eye and other parts of the 
body, especially with the nervous system, had come to 
be very thoroughly appreciated. Since it bad been 
demonstrated that the ophthalmoscope could give 
evidence in regard to more distant parts of the body 
than the eye itself, it had been employed largely by 
neurologists and by general physicians. What he had 
to say was not in disparagement of this use. On the 
contrary, he thought it ought to be used more exten- 
sively than it had been in the past. His remarks were 
more in the shape of a caveat against erroneous de- 
ductions. 

Among the objective facts which are observed in the 
eye with the ophthalmoscope were certain ones which 
were capable of misinterpretation. We look at the 
retina with reference to its clearness, and the condition 
of its bloodvessels. As to the optic nerve, it was as- 
serted that its appearance varied greatly within normal 
limits, both as to its color and definition and texture. 
It was very infrequent that optic hyperaemia existed in 
acute brain troubles ; it was, however, frequently pres- 
ent in acute troubles at the base of the brain ; but in 
acute meningitis, or acute inflammation of the cerebral 
tissue, it was very rare to find evidence of its exist- 
ence in the optic nerve. Changes in the optic nerve. 



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141 



when due to brain trouble, were, as a rule, the effect 
of chronic inflammations, or of new growths, or of in- 
terstitial changes which required a long time before 
they made themselves known. If, therefore, there was 
redness of the optic nerve, it was necessary that other 
symptoms should be present before this could be taken 
as evidence of brain disease. Intense hyperaemia of 
the optic nerve was shown more commonly as the re- 
sult of strain, or some defect in the eye itself, than as 
the result of disease of remote tissues. 

One change found in the optic nerve which was sig- 
nificant of brain disease was that of swelling. This 
condition of choked disks might, however, be present 
where there was no other evidence of active brain 
trouble, or the probability of latent brain trouble. In 
such cases the condition of the nerve should be looked 
upon as an anomalous one, which was occasionally 
oDserved. 

The appearance of the retina varies, to a consider- 
able degree, in different individuals. It is frequently 
seen to present a glistening, opaque look, especially 
along the line of the bloodvessels. This should not 
be mistaken for perivasculitis. It does not indicate 
that there is a condition of inflammation. 

Moreover, the general illumination of the fundus 
varies greatly with the size of the pupil and the com- 
plexion of the patient. This could be seen by an ex- 
amination of any of the figures in books illustrating 
the normal variations. Sometimes there is seen a 
bright, opaque striated surface, running out from the 
nerve itself, which might be mistaken for an exuda- 
tion. The speaker remembered a case where he com- 
mitted this error, and supposed it to be indicative of 
inflammation with exudation, whereas it is by no means 
infrequent, and denotes an imperfect development of 
nerve fibres; that is to say, it is a congenital condition, 
which has no influence upon the real function of the 
, eye, or any bearing upon other conditions of health. 

Sometimes the optic nerve is very pallid and the 
retinal vessels small, and there may be a shallow ex- 
cavation. This condition might be supposed to be 
indicative of atrophy, whereas it may be only due to 
the general poverty of the circulation. There were 
many singular anomalies familiar to ophthalmoscopic 
investigators which might be alluded to, but, under the 
circumstances, they were, he thought, apart from the 
subject of the paper. Dr. Noyes said, nowever, that 
be desired to call attention to the fact that an experi- 
enced observer may mistake the appearance in ihe 
eye for evidence of inflammation, as had occurred in 
a case under his observation, in which an English 
ophthalmologist had supposed intracranial mischief of 
some sort to exist. Dr. Noyes found, after fitting the 
patient with appropriate glasses, to correct a marked 
nyperopic astigmatism, that his vision became Jg. 
The other eye was removed, because of a tumor within 
it. and the mental symptoms disappeared entirely. 
This was a case where the mental symptoms were un- 
doubtedly due to the refractive error which had not 
been observed by the physician who had previously 
examined the patient. 

These were some of the objective errors. IHitting 
that subject aside, there were a series of symptoms of 
subj^tive character, which were very likely to be mis- 
taken for troubles of the nervous system. These were 
principally cases of refractive error, such as hyperme- 
tropia, astigmatism, and troubles with the extrinsic 
muscles of either eye. This was not a new subject. 
Its full discussion was perhaps due more to Dr. Weir 
Mitchell, of Philadelphia, than to any other gentleman ; 
but the experience which the author of the paper had 
with these cases, he thought, entitled him to make 
reference to them. Errors in refraction, as far as the 
symptoms are concerned, are the same as simple spasm 



of the accommodation without error of refraction ; but 
the class of cases which Dr. Noyes now signalized 
were those where patients made very little complaint 
in regard to the eyes, and in some cases where there 
was no complaint whatever. The patient has thu& 
impressed the physician with the idea that some 
other portion of the body was affected. The chief 
symptom which manifests itself in these cases is that 
of headache. The headache can be of any possible 
variety, and of any possible degree. It can be frontal 
or temporal ; it can be confined to the vertex, the occi- 
put, or even to one side of the head, although this 
latter variety is comparatively rare. This headache 
may or may not be associated with the use of the eyes. 
The patient may arise in the morning with a headache, 
or it may come on after an increase of any mental 
labor. Connected with the headache will be another 
symptom, which may bfe regarded as more significant — 
namely, nausea. It is not uncommon for nausea and 
headache to be associated together, nausea being pres- 
ent at intervals, while the neadache is exceedingly 
persistent. 

Take a case in which the patient makes no com- 
plaint of any trouble with the eyes, but speaks of 
severe headache, and suppose that you have occasion 
to examine his eyes to see if any information can be 
obtained in them to explain the symptom, and suppose- 
that you find in one eye a deep degree of congestion, 
and in the other eye redness and opacity of the nerve, 
this condition might lead to the belief that these are 
cases of chronic meningial trouble. We might sup- 
pose that this opinion was reinforced by appearances- 
of exudation and a fringy condition of the edge of the 
nerve. The same symptoms can exist without there 
being any refractive error. 

To illustrate this point, Dr. Noyes read a letter from 
a physician, who had sent to him a young lady sup- 
posed to be suffering from slight spasm of the internal 
recti muscles, which contributed towards certain ex- 
ternal symptoms. She complained of certain vague 
symptoms. She experienced a sensation of distress in 
sitting among persons, and disliked to look into the 
eyes of other people. She had loss of sleep, inability 
to sit, and likewise experienced a sense of mental 
fatigue, all of which symptoms indicated a considerable 
degree of disturbance of the psychic system, which 
was presumed to lie beyond the influence of the eyes. 
Hysterical convulsions had occurred, and four years 
previous the patient had a transient goitre. Later she 
fell, striking upon the end of her spine, at which point 
there was much tenderness upon pressure. There was 
no trace of uterine or ovarian disease. 

Upon critical examination of tRis patient it was found 
that a large part of the cerebral disturbance was due to 
intense spasm of the muscles of accommodation. 
Under the free and vigorous use of atropia the spasm 
was much relaxed, but up to the present date had not 
been wholly overcome. The origin of this spasm was 
remote, and doubtless could be explained by the injury 
to the spine which the patient had received. 

Dr. Noyes remarked in passing that he had seen not 
a few cases where serious ocular trouble depended 
upon concussion of the spine ; the latter giving rise to 
a morbid condition of the extrinsic muscles of the eye. 
He said that he would take the liberty of reading a 
second letter in which the particular trouble was due 
very largely to a disordered condition of the muscular 
apparatus of the eye. A young woman, 32 years old, 
was near-sighted, and had divergent strabismus. She 
subsequently developed other symptoms and the ques- 
tion was, whether these were not due to her strabismus, 
the latter being supposed to be of congenital origin. 
She was seen some years ago by an ophthalmic sur- 
geon, who advised no interference. During her teens 



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she suffered from violent headaches. Three years ago 
she had an attack of melancholic insanity of a few 
•weeks' duration, together with other symptoms. The 
last attack resulted from a fall upon her head. The 
physician made the diagnosis of primary curable 
demeniia. The patient had chloro- anaemia, with a 
very marked bruit in the carotid and at the base of the 
heart, and there was probably also present lithaemia. 
The symptoms indicated the condition of impaired 
nutrition rather than congestion, insomnia and dis- 
turbance of vision. She now complains of buzzing 
noise in her ears, and has always complained of hallu- 
cinations. What is especially important is that she 
cannot use her eyes without pain. This, the attending 
physician thought, might be attributed to- the stra- 
■bismus. 

Dr. Noyes said that the case was, in his own judg- 
ment, one in which the symptoms were to be attributed 
to the condition of the eye. He therefore determined 
upon an operation for the divergent strabismus, which 
resulted satisfactorily, not only in relieving the local 
pain, but her health, also, improved materially after- 
-wards. 

This subject of irritation as the cause of disturbance 
of the ocular muscles, is one that has been debated 
considerably, and is one about which there is not a 
perfect consensus. There is no difference of opinion 
about the disturbance of the ocular muscles. While, 
on the one hand, there are assertions which are not in 
accord with experience. Dr. Noyes was of the opinion 
that these muscular disturbances exert a far greater in- 
fluence, not only over the functions of the eye, but also 
over the functions of the health in general. As an il- 
lustration of this, he took pains a few mornings since 
to study the symptoms of a little girl, fourteen years of 
age.who had been brought to him by her mother. The 
•mother stated that the child had suffered from head- 
ache for three years, and that she had made up her 
niind to consult a specialist. The question was, whether 
to go to an oculist or a neurologist. A headache had 
existed for three years,' and had become worse of late. 
When she looked hard at people they seemed to go 
away from her. She has a headache several days in a 
week, and very often wakes with it in the morning. 
In spite of the headache she often continues to read, 
as she says, for the purpose of forgetting it. The pain 
is principally in the occiput. Ajar upon the feet, or a 
slight blow upon the head, is very unpleasant. In her 
personal appearance she is healthy. She has a slight 
tenderness over the supraorbital region, upon the right 
side. She sometimes passes her hand over her eyes, 
to clear away the mist. On testing this patient with 
prisms, he found no important muscular error, but 
when the child was asked to look at a finger held close 
tip to the face, it was noticed that it was difficult for 
her to keep both eyes upon it ; and when it was held 
very close, one eye would deviate to one side. The 
.diagnosis was extreme debility of the internal recti 
muscles, which has given rise to the condition of head- 
ache. 

The symptoms which persons who suffer from this 
disease have, are headache and nausea, and an ina- 
bility to look continuously at an object, and pain easily 
aggravated by the use of the eyes. They cannot ride 
in the cars, or look out of the cars because it excites 
headache. This was a brief statement of this class of 
cases. 

Now, how are these cases to be recognized and er- 
rors to be avoided ? In the first place, errors may be 
committed in using the ophthalmoscope, owing to in- 
sufficient experience with it, the observer not being 
familiar with what is normal and what is abnormal. 
But it is more important, perhaps, that the instrument 
•shall not be employed according to one method only, 



that is to say, by the indirect method, when the mirror 
is held in one hand and a lens in the other. A much 
more valuable mode is the direct method, which con- 
sists in the use of an instrument supplied with glasses 
to correct this vision of the patient as well as that of 
the observer, and showing whether you are dealing with 
a normal or an abnormal eye in regard to its refraction. 
With such an instrument you can get a much better 
idea of the appearance of the eye. 

Finally, under suitable circumstances, the resort to 
atropia is advisable. Now, if one uses atropia in an 
examination of eyes for suspected brain trouble, pre- 
caution is necessary. With the ordinary size of the 
pupil it is necessary for the observer to have consider- 
able expertness in order to get a correct idea of the 
condition of the eye. If you are to examine a patient 
who is liable to become blind from brain disease, and 
you wish to use atropine, it is proper to assure your 
patient that no ultimate trouble can result from its use, 
otherwise disagreeable feelings might be entertained 
on the part of the patient towards the physician. On 
the other hand, when the symptoms are of a subjective 
kind and are due to refractive and muscular errors, 
atropine mav not only help the examination, but may 
remove the headache. This removal of the headache 
may be only temporary, permanent relief coming only 
after suitable optical corrections by means of glasses. 
The difficult refraction cases are those in which there 
is a considerable degree of astigmatism. In a con- 
siderable proportion of cases astigmatism complicates 
the refractive error. . The degree to which subjective ■ 
symptoms make their appearance varies greatly ac- 
cording to the temperament of the patient and his 
general condition. This is especially shown in those 
instances when the trouble is due to uterine disease. 
In muscular errors the treatment consists in fitting the 
patient with suitable prismatic glasses, and sometimes 
m the use of tenotomy, and in the treatment of remote 
discoverable lesions which will have an influence upon 
this trouble. Both refractive and muscular errors may 
be combined together, and sometimes in such a man- 
ner as to make the prescription of glasses exceedingly 
complicated. 

Dr. Mary Putnam Jacobi remarked that the sub- 
ject of the paper was one that interested her extremely 
from a neurological, rather than an ophthalmological, 
point of view, although she believed it was eminently 
proper for one interested on the nervous side of these 
cases to examine into the other side, for it was a neu- 
rologist (Dr. Weir Mitchell), and not an occulist, who 
first called attention to this condition. It was probable 
that it was intimately associated with the anatomy of 
the part. In the cases referred to with functional dis- 
turbances of the eye, spasm of the internal recti mus- 
cles was usually found. She did not know whether or 
not if was the generally accepted view that this spasm 
of the internal recti was dependent on the close a^o- 
ciation of the optic nerve with the corpora quadri- 
gemina. She alluded to the fact that spasm of these 
muscles had been induced by falling on the end of the 
spine. Similarly, concussion of the corpora quad- 
rigemina and the cerebellum would serve to explain 
the curious symptoms of nausea and vertigo which 
have often been observed in these cases. She sup- 
posed that this condition might give rise to a con- 
siderable amount of psychical disturbance. Such 
disturbances may depend upon the constant strain 
produced by the blurring of the objects the individual 
was regarding. She thought it was very extraordinary 
that in insanity, associated with visual hallucinations, 
we did not more often find disturbances of the eyes. 
When she and Dr. Seguin were visiting the Hudson 
River State Hospital for the Insane, the latter ex- 
amined all of the male patients having visual hallu- 



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February 3, 1883] TRANSACTIONS OF PATHOLOGICAL SOCIETY OF PHILADELPHIA. 143 



cinations, and found remarkably few refractive errors. 
She alluded to a case that recently came under her 
observation. The patient suffered from visual halluci- 
nations, without any other symptoms. This condition 
had lasted for several years, and was due to no dis- 
coverable cause, unless to reflex uterine irritation. In 
that case the eyes were examined, and not the slightest 
trouble was found. 

Dr. Beard wished to ask Dr. Noyes whether he had 
watched cases of the character he had described in his 
paper, for a number of years after treatment had been 
discontinued, in order to ascertain whether the relief 
afforded was permanent, not only with respect to the 
ocular trouble, but also to the general condition. A 
second point of much interest to him was, how to tell 
whether this condition of the eye was the result or the 
cause of the disease. He had found it impossible in 
any case to answer the question completely. This 
whole subject, it seemed to him, was to be referred to 
a general condition. The entire body is a bundle of 
reflex actions. The same statements that apply to the 
eyes, are applicable to the stomach, the urethra, the 
rectum, etc., but he had never seen a case in which 
permanent relief had been obtained by the use of 
glasses alone. The result of his observations and ex- 
perience is that the relief of the local irritation was 
only a help, and did not serve to effect a cure inde- 
pendent of other treatment. 

Dr. Putzel thought that an important point had been 
overlooked. Stress had been laid on reflex action in 
these cases. He thought that there was a continual 
outflow of force which must cause a constant strain on 
the nerves, which strain would induce a condition of 
neurasthenia. In regard to the mode in which reflex 
irritation acts, that it is confined to the corpora quadri- 
gemina, he was unwilling to admit. It seemed to him 
probable that it acted more generally than upon one 
local centre of that sort. 

Dr. Birdsall had used the method recommended 
by Dr. Noyes, and with a partially successful result. 
TTie patient was a boy about twelve years old, suffering 
from an intense headache. This was aggravated by 
reading, and particularly by pursuing his studies in 
school. The patient, when seen, was in somewhat of 
a maniacal condition, in which there were hallucina- 
tions, and which at times seemed to take very nearly the 
form of an epileptic or hysterical seizure. The mother 
thought the boy unconscious at times, as he would lie 
in a stupid state. Usually the headache was followed 
by a period of excitement, after which he would lie 
down, sleep for several hours, and wake up relieved. 
Glasses were ordered. The relief they afforded was 
very decided, for a time the patient being relieved 
from headaches. After a few weeks they returned at 
greater intervals, and he was ordered to leave school. 
Subsequently, on resuming his studies, the headaches 
again came on, but the maniacal attacks did not re- 
turn for a time. In the course of a year, however, 
they made their reappearance, though thev were less 
violent. After a time the patient was taken out of 
school altogether and sent to the country. In the 
course of a few months he recovered his health en- 
tirely, and was now apparently a perfectly well boy. 
Dr. Birdsall was inclined to believe that the trouble, 
in this instance, was not due to any disease of the eye, 
but was caused rather by the condition of his general 
nervous system. He had, moreover, seen similar cases 
in which similar attacks had been relieved by correc- 
tion of errors of refraction. He thought the condition 
referred to ought not to exist if the nervous system 
was in a healthy state. 

Dr. Janeway suggested that the class of cases al- 
luded to by Dr. Beard was not the same as that alluded 
to by the author of the paper, and that they were un- 



doubtedly due to error in the development of nervous 
tissues. 

Dr. Webster testified to having seen many cases 
permanently relieved by the correction of error of re- 
fraction. Dr. Birdsall's case called to mind the diffi- 
culties that were sometimes met in treating these cases. 
In prescribing glasses it was proper first to order those 
that would correct only the manifest hypermetropia. 
Such would afford relief for a time, and in some cases 
proved to be all that were necessary. If symptoms 
begin to return the eye should be tested again, and 
another pair of glasses prescribed, which would, in all 
probability, be found to give permanent relief. If not, 
by renewing the glassses every six months all the hy- 
permetropia would be finally corrected. 

In closmg the discussion Dr. Noyes testified in most 
positive terms to having seen many cases permanently 
relieved by simply prescribing appropriate glasses. 



PATHOLOGICAL SOCIETY OF PHILADELPHIA. 

Stated Meeting, January 11, iSSj. 
The President, James Tyson, M.D., in the Chair. 

Dr. E. T. Bruen presented a 

small tumor of the head of the pancreas, 
about two and a half inches in diameter and closely 
adherent to the common bile-duct. The {growth is of a 
colloid nature, but its histological character is unset- 
tled by microscopic examination. There were no 
secondary deposits in any other viscera, as i% the rule 
in colloid g^rowths. The patient was a male, aet. about 
65 years, who, for two years prior to death, had inter- 
mittent attacks of jaundice, attributed to catarrh of the 
biliary duct. The case was under observation for two 
months. At first the symptoms of chills and fever led 
to treatment for malaria, but as the jaundice gradually 
deepened, treatment for the supposed catarrhal state 
of the bile-duct was instituted. The futility of a well- 
directed and usually successful treatment was the spe- 
cial indication of some more substantial cause. He- 
patic trouble or biliary calculi were readily excluded, 
but there was nothing to fasten suspicion on the pan- 
creas. There was constipation with clay-colored stools. 
There was febrile movement of hectic type — the so- 
called hepatic fever, accompanied by irregular chills. 
Intestinal indigestion was not marked. Indeed, with- 
out exception, the negative results of the clinical record 
are of the most discouraging character. The case is 
presented because each case of pancreatic disease 
ought to be recorded, so that many cases viewed col- 
lectively may contribute to the clearness of a future 
distinct picture of pancreatic disease. 

Dr. Formad said that he had notes of the autopsies 
of five or six cases of cancer of the pancreas, with 
marked jaundice. It seemed to him that the jaundice 
was most persistent in primary pancreatic carcinoma 
from pressure on the bile-duct. He did not think that 
the tumor just presented was carcinomatous, as there 
would then probably have been secondary gp-owths in 
the liver. The growth was probably a cystic colloid. 

Dr. Bruen called attention to some forty cases of 
jaundice due to primary carcinoma of the head of the 
pancreas, lately reported by another observer, from 
which it was demonstrable that jaundice was an in- 
variable symptom of primary hard carcinoma of the 
head of the pancreas, while it was uncommon when 
the disease was secondary or affected other parts of 
the organ. 

Dr. James Tyson then presented a specimen of 

diaphragmatic hernia, 
from a German about 27 years of age, who had been 
ailing since February, 1878, when, stretching himself, 



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[MxDiCiU. Nkws, 



his wife suddenly pretended to tickle him. He quickly 
threw down his arms, and at that moment felt a sensa- 
tion of pain on the left side in the neighborhood of the 
heart. At the same time he felt faint and cold. In 
five or ten minutes these sensations passed away, but 
he remained very much frightened. When first seen 
by Dr. Tyson, in June, 1880, he could not even walk 
across the floor without becoming completely out of 
breath, but he said he was not short of breath when the 
accident first occurred. He had also a peculiar puffing 
expiration which did not occur, however, with every 
act of expiration, but once in four or five. There was 
no cough. Physical examination revealed, on inspec- 
tion, almost total absence of movement of the chest- 
wall in the upper half, the respiration being almost 
purely abdominal. The upper percussion border of 
the heart corresponded with the junction of the third rib 
with the sternum, and the right border with the middle 
of the sternum. The apex beat was in its normal posi- 
tion, but was more diffuse than in a strictly normal 
state. Pulmonary percussion appeared normal, except 
below the left scapula, where resonance was less than 
in the corresponding situation on the right side. Vocal 
fremitus was impaired over the whole of the left lung. 
There were no abnormal cardiac murmurs. He was 
treated at various times with digitalis, bromide of 
potassium, chloral, tonics, etc., and even a blister was 
put over his heart, with the view that there was some 
cardiac, or pericardial affection, although the physical 
signs were wanting. There was no improvement, 
although at times the dyspnoea, which was the most 
distressing symptom, seemed sometimes less. . His 
death occurred December 15, 1882, from obstruction of 
the bowels. At the autopsy it was ascertained that 
about 20 inches of the large intestine, with its corre- 
sponding mesentery and almost the whole omentum, 
had ascended through the oesophageal opening of the 
diaphragm into the left pleural sac, encroaching upon 
the space occupied by the left lung until the latter was 
compressed into the apex of the left pleural sac and 
was reduced to a cylindroid mass, about 15 centimetres 
in length and half as many in diameter. There was 
no hernial sac, the opening being that for the oesoph- 
agus. The case was, therefore, technically one of her- 
nia diaphragmatica spuria. The heart was displaced 
to the right, but was otherwise normal ; the liver was 
slightly fatty, but the other viscera were normal. It is 
not unlikely at the moment referred to in the history, 
when the patient threw down his arms, that a small 
portion of the omentum or mesentery slipped through 
th,e oesophageal. opening, and that subsequently and 
more or less gradually the vacuum tendency of the 
pleural sac in each act of respiration caused the re- 
mainder of the mass to be drawn in until the entire 
cavity was occupied. This accounts for the fact that 
there was no dyspnoea at the beginning, but that it 
gradually increased as the thoracic space was intruded 
upon. In vol. 81, 1882, of Virchow's Archiv, will be 
found an exhaustive article on Diaphragmatic Hernia, 
in which 291 cases are collated. In a somewhat hasty 
examination of this paper. Dr. Tyson has been unable 
to discover a single case so long under observation as 
this — nearly four years. Many cases were discovered 
at the autopsy and had been unsuspected, others were 
congenital, and others were traumatic. 

Dr. Bruen asked if there had been any hiccough ? 
If so, was there any dysphagia with solid food ? 
Finally, did the physical signs suggest pneumothorax ? 

Dr. Roberts made some remarks with reference to 
the diagnosis and to the possibility of laparotomy in 
similar cases. He also asked whether the symptoms 
just preceding death were those of strangulation. 

Dr. Davis referred to thirst as a prominent symptom 
according to Lawrence. 



Dr. Tyson replied that Dr. Formad had told him 
that there was decided hiccough. There was no true 
tympany, with the absence of the vocal fremitus. 
Nothing gave rise to any suspicion of its true nature. 
Thirst was marked. There was no dyspha^^a. 

Dr. J. H. MussER then presented the specimens from 
a case of 

ULCER OF THE STOMACH IN THE ANTERIOR WALL; AD- 
HESIONS TO THE ABDOMINAL WALL; HEMORRHAGES 
AND PAIN ; DEATH P^OM MORPHIA HABIT. 

J. J., aged 71 years, millwright. Fourteen years 
before his death he was attended for haematepiesis oc- 
curring after three days of nausea. Over a pint of 
blood was vomited, and considerable was discnarged 
by stool the next day. In ten days he returned to 
work and enjoyed good health for two years, with the 
exception of occasional attacks of indigestion. Then 
a recurrence of nausea, followed by a profuse discharge 
of blood per anum, occurred. He made a full recov- 
ery, but pain after eating was now noticed. Two years 
subsequently he bled very much from a wound of the 
foot; was much prostrated thereby. This was suc- 
ceeded by severe pain after eating, with marked epigas- 
tric tenderness. The constant use of narcotics alone 
gave him relief. November, 1873, he was again under 
treatment for gastric ulcer without any avail, save when 
he exhibited narcotics. He resorted to the use of mor- 
phia, and continued its use during the remainder of his 
life. Change of diet did not influence the pain, and he 
partook of a laborer's fare. In 1877 a small tumor to 
the left of and several inches above the umbilicus, 
hard, tender, and apparently involving the abdominal 
wall was discovered. For several years he worked in 
a country sawmill, using one drachm of morphia a 
month. Heavy lifting aggravated his pain. In August, 
1882, the patient took to his bed. Death took place. 
The only anatomical alteration noted at the autopsy 
was the change in the stomach. The organ was en- 
larged and contracted (hour-glass) towards its fundus. 
The anterior wall, one-third of the distance from the 
fundus, and at the point of constriction, was adherent 
to the abdominal parietes to the left of the median 
line, three inches above the umbilicus. Opposite to 
the point of adhesion in the mucous membrane there 
was a small ulcer two lines deep and six in diameter, 
with clean-cut edges, a healthy floor, and surrounded 
by cicatricial tissue for a radius of one inch. Un- 
doubtedly the ulcer would have healed entirely had 
not the morphia habit cut off the patient. Dr. J. H. 
Musser thought that it was plausible to suppose that 
the first hemorrhage, taken with the profuse foot hem- 
orrhage, was due to the patient having been of an 
hemorrhagic diathesis, and that the second gastric 
hemorrhage was from the same cause, and was at- 
tended by a hemorrhagic infarct, with subsequent de- 
velopment of the ulcer. Especially is this possible, as 
it was only after the second hemorrhage that pain oc- 
curred, and this symptom is never absent, " except in 
cases which run a rapid course" (Da Costa). 



NEWS ITEMS. 



NEW YORK. 
{From our Special Corresfondeni.) 

Drs. Willard Parker and Frank H. Hamilton 
are doing well. The former has suffered for some 
months from a disease of the urinary organs connected 
with advanced life, and his condition has been a 
troublesome one. 

A Reception to Mr. F. Seymour Haden, of 
London, and to Members of the New York 
Academy of Medicine is to be tendered by the Presi- 



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February 3, 1883.] 



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I4S 



dent and Vice-presidents of that Society, upon the 
evening of February the loth, and the invitation has 
been extended to all to "Join in the Loving-cup," that 
relic of the round-table which suggests free-boasting 
and convent-robbing and revelry, which are quite in- 
consistent with the dignity of the gray-haired solons 
of the medical profession of this city, whose deeds of 
daring are ordinarily committed with the blunt-hook, 
or the scarifier. 

It is to be regretted, by the bye, that this body will 
not accept the munificent offer of the Army Medical 
Museum Library, and exchange some of their dupli- 
cate pamphlets and books for an equal number of rare 
foreign pamphlets. 

The New York County Society's Delegates. — 
It is strongly hinted that if the medical delegates from 
the County Society are not supported by the delegates 
from the other county societies in the matter of the 
new Code, that next year they will refuse to go to Al- 
bany. 

BALTIMORE. 
(From our Special Correspondent.) 

The Prevalence of Smallpox. — So much has re- 
cently appeared in the public prints concerning the 
prevalence of smallpox in this city, that a brief state- 
ment of the true history and actual extent of the dis- 
ease in our midst may not be unacceptable to the 
readers of The News. At the outset, it may be well to 
state that the reports have been very grossly exagger- 
ated, and that in no sense cap the disease be consid- 
ered to be epidemic. Indeed, in no single week has 
the mortality equalled one-half of the highest weekly 
death-rate from smallpox recorded in 1872-73, when 
we last had the scourge, and when we escaped the un- 
enviable notoriety that we have lately acquired with 
less justice. Smallpox has prevailed in Baltimore at 
pretty regular intervals of ten years for a period dating 
from early in the century. The cause of this is proba- 
bly to be found in the general neglect of vaccination 
during periods of freedom from the disease, whereby 
the number of susceptible individuals gradually in- 
creases, until a large proportion of the community be- 
comes ready to be infected by the varioloid poison. 
From the cusappearance of smallpox in the spring of 
1873, in consequence of the thorough system of vac- 
cination adopted by the Health Department, smallpox 
found no lodgement in the city until the closing week 
of 1879, ^^^ ^^^^ ^°^ *>"ly * brief period. On Decem- 
ber 27th a man was discovered at the ticket office of 
the Baltimore and Ohio Railroad with an eruption that 
proved to be that of smallpox. He was forthwith sent 
to the quarantine hospitaL 

On January 11, 1880, a man who conducted his 
business in the vicinity of the station, and whom the 
original patient ^Cordes) had engaged in conversation 
before his detection, sickened with smallpox, was sent 
to the hospital, where he subsequently died. On Janu- 
ary 13th, four children of the proprietor of a saloon in 
which Cordes had called upon his way to the station, 
developed smallpox, and on the 15th the wife of the 
proprietor sickened with the same disease. They 
were also sent to the hospital. On January 26th, a man 
who had worked at the saloon at the outbreak, but who 
had moved to another house, was attacked with small- 
pox and was removed to the hospital. No further 
development of the disease was observed in the city. 
On Christmas day, Cordes, the original patient, who 
was apparently a tramp, had called at a tavern on the 
Frederick Road, near the city, and shortly afterwards 
four persons in the house developed smallpox. These 
facts were reported in the Bulletin of the National 
Board of Health by Mr. A. R. Carter, the indefatigable 



Secretary of our own Health Board. They are inter- 
esting as showing periods of incubation in the several 
cases. The active measures adopted probably checked 
the further progress of the disease. In June, 1881, one 
case was reported at Locust Point, the southeastern . 
water front, but no new cases seem to have resulted 
from it. The present visitation dates from November 
4, 188 1, when a colored child, lately arrived from 
Allegheny City, developed smallpox. It resided in 
Franklin Street, in the northwestern section of the city. 
Some relatives of this child carried the disease to Pine 
Street, in a more central location, and other inmates of 
the house on Franklin Street were attacked. The dis- 
ease spread slowly; scattered cases reaching South 
Baltimore, where there is a densely crowded colored 
population, in January and February, 1882. The 
eastern section of the city was not invaded until July, 
when near the water front of the